That’s the question noted ethicist (and pediatric intensivist) Robert Truog asks in a recent opinion piece in the New England Journal of Medicine. And it’s a good question, one that any experienced intensivist has probably asked themselves more than a few times during their career. (Although the journal gives free access to most of their opinion pieces, for some reason they didn’t with this one. So the link is to an extract, but but if anybody wants a full copy, let me know.)

I’ve written before (also in reference to an article by Dr. Truog) about the ethics of futile care — that is, care that is of no benefit to the patient. As a matter of principle, physicians are not obligated to provide such care. The question typically arises when a family asks us to use a potentially toxic or painful treatment in a situation in which a child has no chance (in the opinion of the doctors) of recovering. These are not uncommon situations; I’ve written real-life descriptions of a couple of them in one of my books. Yet even though we’re not obligated to do it, are there times when an attempt to resuscitate a terminally ill child is ethical, even necessary?

Dr. Truog thinks there are such times. Some families simply cannot accept, even after long, painful discussions, that their child will not survive. They cannot “give up,” which is how they may see a decision not to attempt CPR. Like Dr. Truog, I’ve cared for a few patients and their families like that. And, like Dr. Truog, I’ve done CPR on such children. I haven’t prolonged it, but I’ve done it, with the parents looking on, sufficiently long to demonstrate its futility. And the families appreciated that I had done it.

I suppose you could say that when I did that I was treating the family, not the patient. More extreme critics might say I was wasting resources or even being disrespectful of the newly dead. Yet there certainly are times, when their child is beyond saving, that it is appropriate to treat the family in this way. I think any intensivist who doesn’t understand that probably hasn’t practiced pediatric critical care long enough yet.

Bronchiolitis is the leading cause of hospitalization for very young children in the USA. You’ll find various definitions of what bronchiolitis is, but a standard one is a viral illness that starts in the upper respiratory tract with runny nose, congestion, and cough. This is soon followed by symptoms in the lower respiratory tract — the lungs — such as rapid breathing, wheezing, and sometimes the need for extra oxygen. The culprit in half to three-quarters of cases is what we call respiratory syncytial virus, or RSV, but a variety of viruses can do it. Interestingly, 10-30% of children with bronchiolitis and RSV have another respiratory virus, too. Researchers aren’t sure if this combined infection contributes to how severe the symptoms are.

Any child can get bronchiolitis, but children who were born prematurely or who have some preexisting problem with their lungs are particularly susceptible to experiencing severe cases of it. But even otherwise normal children can get critically ill. I just cared for such a child, one who needed a week of a mechanical ventilator for it, and all pediatric intensivists have now and then had similar cases.

Because it’s so common, and because some of the symptoms of bronchiolitis resemble asthma, physicians for many years treated it with asthma drugs. Unfortunately, these drugs rarely help. But the urge to do something, anything, for this often frustrating illness is a strong one, and I still often see full-bore asthma treatment given for bronchiolitis. Indeed, in spite of multiple recommendations by panels of experts, more than a few American doctors seem reluctant to concede that little in the way of drug therapy helps. It’s hard-wired into our nature to treat things. The problem is that no drugs are risk-free, so we shouldn’t use them unless there is a reasonable chance they will do good.

What helps bronchiolitis? For a child at high risk of getting a severe case of RSV we can give a monthly shot of a drug called Synagis that can reduce the chances of getting RSV, or, if it happens, having a less severe case. For the rest, we use frequent suctioning of all the nasal mucus, oxygen if a child’s blood oxygen level shows it to be a bit low, and time. For now, that’s about it.

A recent article in the New England Journal of Medicine examines what would happen to our nation’s health statistics if we succeeded in reducing salt intake. Although I’ve always known, as all physicians do, of the connections between excessive salt intake and heart and blood vessel problems, I was surprised by the magnitude of the findings. An average per person reduction in salt intake of 3 grams per day would have dramatic effects on the incidence of these diseases. The authors estimate that the numbers of strokes and heart attacks would drop substantially: the annual number of deaths from all causes could easily drop by nearly 50,000. The greatest benefit would accrue, over time, to young persons, because the cumulative incidence of these chronic illnesses would fall. Even a more modest reduction in average salt intake — 1 gram per day — would still reap great rewards, since the relationship of salt intake to cardiovascular disease is a linear one.

And where does most of the salt in our diet currently come from? Not from the salt shaker — it comes from processed foods, those convenient boxes on supermarket shelves. The salt in these products can be reduced without consumers even noticing — a 10% reduction was accomplished in England over a 4 year period without complaints.

When I started training in pediatrics, nearly 35 years ago, it was common practice when an infant or child needed something done that was going to be painful, anxiety-producing, or both, the child was often merely held (or tied) down. Looking back on it now, it reminds me of the 19th century, a time when somebody might just be given a stick to bite down on. I wonder how we could have been in the same place with children a century later.

To be fair, there were several reasons we did things that way. Chief among them was the notion — one we now know to be false — that children (infants in particular) did not feel pain in the same way as older persons. The other reason was that we simply didn’t have available many of the medications we have now to counteract pain and anxiety, and the few that we had had not been studied much in children.

Things are much different now. We have a menu of things we can use to prevent pain, ranging from numbing cream we can put on the skin to lessen (or even eliminate) the pain of a needle stick to powerful, short-acting anesthetic drugs we can use to put the child into a deep (and brief) slumber. We have reliable ways of greatly reducing or eliminating both pain and anxiety when a child needs medical procedures as varied as an MRI scan or some stitches in the scalp.

Most doctors who do these procedures are well aware of these things. But if you run across one who doesn’t seem to be, don’t be shy about speaking up and asking what can be done to make your child more comfortable.

An interesting recent editorial in the New England Journal of Medicine asks that doctors be explicit about what they will support and what they won’t. In particular, would we agree to pay cuts? The essay points out that, at least early in the process, drug companies, insurance companies, device manufacturers, and hospitals all agreed to some limitation on their income. (If they still would, of course, is another question.) But doctors have made no such pledge. In fact, as a group, we’ve demanded more of the healthcare pie. Is that fair?

I don’t think it is fair. To me, the biggest problem with physician salaries is that they are so spread out from lowest to highest in a manner that doesn’t really reflect training or expertise — the variance primarily reflects custom. My own family’s experience with medicine spans well over a century, with my grandfather graduating from medical school in 1903 and my father in 1944. Some doctors have always made more money than other doctors, either from being busier or from getting more training. Surgeons and other doctors who do procedures have always made more than those who don’t do these things, but the huge variance in physician salaries we have seen emerge in the past several decades is a new phenomenon. To me it parallels the huge (and recent) disparities we see between what a CEO gets paid and what an the average employee gets paid. Things have gotten out of balance.

If you want to learn more about how medical practice, including how it is paid for, emerged in the last century, there is no better book about it than The Social Transformation of American Medicine, by Paul Starr. The book won a Pulitzer Prize in 1984. And if you’re wondering: yes, I’d give up some salary to get healthcare reform, so long as everybody else would, too. It’s only fair.

That’s the title of an interesting editorial in a recent issue of the New England Journal of Medicine. It’s interesting because how people think about, and act towards, an epidemic is in many ways as important as the medical aspects of the disease. So the emotional epidemiology is important

The H1N1 vaccine became a controversial subject, although not among medical scientists. There were some glitches in the vaccine supply, but these are easily explained by the lack of lead-time in vaccine manufacture. Generally the manufacturers get about a year to produce the next year’s vaccine; in this instance they only got half that time. The interesting thing is that, by the time the vaccine became available in large quantities, the same people who were clamoring for it in mid-2009 (and upbraiding the system for not have it ready) were now suspicious of it, even afraid of it.

Why did this happen? One culprit, of course, is the voracious 24 hour news cycle that demands extreme stories. The “swine flu plague” played right into that. Another is that we physicians lack an appreciation for “emotional epidemiology,” causing a subsequent lack of vigor in addressing influential, but misleading articles, such as this one. (This article has been demolished in many places, such as here specifically and here, more generally.)

I’ve written before (here and here) about the reliable winter time arrival of RSV. This virus is the most common cause of pneumonia and bronchiolitis in children under six months of age. To scientists, RSV is a fascinating virus with several unique properties.

One of these is its behavior in the population. During its annual visitation, RSV is everywhere. Then it suddenly vanishes. There are exceptions to everything in medicine — I have seen sporadic cases during the off-months — but generally RSV arrives with a bang in mid-winter and then leaves suddenly in the spring. It is the only virus that consistently and reliably causes an epidemic every single year. Not even influenza does that. However, RSV epidemics may still have some regional variability. For example, often one city will have a much more severe epidemic than do others in other regions of the country.

Another aspect of RSV that interests medical scientists is how poor a job our immune systems do in fighting it off. Virtually all children are infected with RSV during the first year of life. Not only that, all of us are reinfected multiple times during our lives. Attempts at devising a vaccine for RSV have all been unsuccessful. In fact, early versions of an experimental vaccine seemed to make the disease worse in some infants, raising the possibility that some aspect of our immune response to the virus actually contributes to the symptoms.

RSV has a high attack rate — the term scientists use for the chances that a susceptible person will get the infection if exposed to it. That, plus our generally poor defenses against it, explain the frequent epidemics.

RSV is generally not a serious illness, but for some children it can be life-threatening. These children are very small infants, especially those born prematurely, and those with underlying problems with their lungs or their hearts. For those infants we have a monthly shot that helps reduce the severity of RSV when they get it, and may even prevent a few cases, but this is not ideal.

Since RSV cannot be prevented, the best thing a parent can do is try to postpone it. That is, if you have a newborn infant in the height of RSV season, try to minimize exposure of your child to people with cold symptoms, especially toddlers. And for those who do handle your infant, have them wash their hands first.

By now everybody knows that the Senate passed a healthcare reform bill last week. The House passed such a bill last month. The bills differ in important respects, and of course it is still unclear if the two bills will be reconciled in conference committee to produce a bill that both houses will pass. If a final conference bill does pass, it will have ground-breaking effects on medical care. What might change in the PICU?

My first-blush answer is that it will have important effects for me, my colleagues, and our patients, but not so much as it might for other aspects of medical practice. Why do I say that? First, look at where our current healthcare dollars come from (source is here):

Private insurance: 35%
Medicare: 19%
Medicaid and SCHIP: 15%
Other public funds: 12%
Other private funds: 7%
Out-of-pocket: 12%

These figures are for the entire system. As I’ve written before, the PICU is different — very different. Around half of children in the PICU already are covered by Medicaid, the joint federal/state program for children of poor families. This startling statistic is a reflection of the fact that poor children are far more likely than are affluent children to end up in the PICU.

But even though half the children in America’s PICUs are on Medicaid, half are not, and the healthcare reform bill can have a major impact on them, especially those from families who are presently uninsured. A PICU bill can bankrupt those families. This bill will reduce the number of times that will happen, and I think that is a good thing.

The H1N1 strain of influenza — the “swine flu” — has gotten a lot of headlines this past year. You can find a summary of matters during the first half of 2009 here. That report studied 272 patients who were sick enough to be admitted to the hospital. Of these, 25% needed to be in the ICU. From my perspective, the interesting part was that nearly half were children; unlike usual influenza epidemics, only 5% were older than 65.

I didn’t see any severe cases of H1N1 until this past fall, but then I began to see quite a few of them. Of these, two were so severe that they required prolonged treatment with a mechanical ventilator, a breathing machine. Another child in our region was so severely ill that he required treatment with the most extreme kind of respiratory support, something called extracorporeal membrane oxygenation (ECMO). This machine bypasses the lungs entirely and uses a machine to get oxygen directly into the child’s bloodstream. Using ECMO is a complicated endeavor, one with high risks and high mortality. But sometimes it is all we have to offer.

My conclusion on the H1N1 flu is that it was every bit as severe as the experts predicted. Although the mortality was not anywhere near as bad as the great epidemic of 1918, we also have means of ICU support that physicians didn’t have back then. This year’s flu, like that of 1918, also seemed to affect the very young to a degree I haven’t seen before. To me, the massive campaign to vaccinate as many as possible was justified. Of course we don’t know if it helped reign in the epidemic thus far, but I think it probably has.

Since the beginning of the H1N1 (swine flu) influenza epidemic bottles of commercial hand sanitizer have been flying off the shelves. They’re everywhere in my son’s elementary school, for example, and I’ve seen them sitting on the counter and available for customer use in stores and banks. Is that gel worth it? Does simply washing your hands work just as well?

That question has been studied, quite directly, here. The investigators tested twenty volunteers who had been vaccinated against H1N1 influenza and who had had a blood test that documented that they were immune to the infection. So they couldn’t get sick from the virus. These volunteers then had live flu virus put all over their hands, after which they washed them either with soap and water or one of several hand sanitizers. The investigators then tried to recover live virus from the volunteers’ hands, and compared the results to how much virus they could obtain from the hands of volunteers who did not do anything except air-dry their hands.

The results showed that all methods dramatically decreased the amount of virus on the hands. Seventy percent of volunteers who did not wash with anything still had virus on their hands even an hour later. All of the hand cleaning techniques worked very well, but simple soap and water actually worked the best. So sanitizer is fine if you haven’t got a sink around, but wash your hands the old fashioned way if you do.