Working as a physician in a hospital means being buried with paper — lots of it. A patient’s medical record, the medical chart, is typically a fat three-ring binder that gets rapidly fatter by the day the longer the patient stays in the hospital. Children in the PICU may build up a medical record that weighs more than they do. Old medical records for patients — records that describe their previous hospital stays — are often delivered to the hospital floor from the medical records department in a very full shopping cart. Plowing through these old records can take hours. More importantly, one can miss important things, key nuggets buried deep in the largely unhelpful mass of paper. And, of course, if the patient has had medical experiences at another hospital, those are not even in the chart.

Many believe the answer is an electronic medical record (EMR), with everything stored on a computer. The record can be easily organized and searched for important information. Assuming that systems are standardized (a big if), the record can then be easily portable and travel with the patient on a disk or be sent over the internet.

The whole topic of EMR is a highly emotional one among physicians. Many like the idea, many absolutely hate it, even though the latter group recognizes the EMR is inevitable, really. For hospitals, the start-up costs of implementing the EMR can be huge. Thus far, few have done so. A recent survey in the New England Journal of Medicine found that only 1.5% had done so in a comprehensive way, although many had begun implementation of various portions of the EMR. The Obama administration has proposed federal funds for part of the costs, but inevitably each hospital will have to spend money upfront to initiate EMR systems.

For myself, I happen to work at one of the few hospitals with complete EMR. I like it a lot. For PICU practice, the ability to get important data quickly is key to giving good care to critically ill children. I’ve been doing this for 30 years, long before there were computers on every (or any) desk and the EMR allows me to do my job better. I look forward to seeing it implemented across the nation.

I’ve written before about how drunk driving impacts the PICU. Now a recent tragedy in Texas reminds us that talking on a cell phone while driving can be just as bad. Five children died as a result. Five children.

It’s been known for some time that using a cell phone while driving impairs your reflexes. A study from the University of Utah used a driving simulator to test reaction times of drivers using a cell phone, both against the ear and in so-called “hands free” mode. The results showed that using a cell phone was the equivalent of being legally drunk. Although text-messaging wasn’t studied, I’m sure that has an even worse effect on driving skills.

I am astonished that many parents who would never drive their children around after drinking alcohol think nothing of chatting on the cell phone constantly while their kids are in the car. It appears that this particular driver was both drunk and using a cell phone, compounding the problem.

I’ve written before about how poor children and children without health insurance are far more likely to need PICU care than are more affluent children. For example, although children on Medicaid account for 20 - 25% (depending upon the state) of children in America, about half of all children in America’s PICUs are on Medicaid. Once in the PICU, though, do the poorer kids have worse outcomes than the richer kids? Does their chronically disadvantaged situation set them up for being more difficult to treat and cure?

I’ve been looking for information about this crucial question for some time and recently found some disturbing data about it, in the form of an article in the journal Pediatric Critical Care Medicine (volume 7, pages 2-6, 2006). You need a subscription to the journal to get the article, but I’ll summarize its important findings for you.

First, the study confirmed that children without insurance are far more likely to suffer critical illness: ” . . . far more serious illness and injuries were associated with uninsured children admitted to the PICU.” But did that make it more likely that these children would suffer worse outcomes, or even make it more likely for them to die?

Unfortunately, uninsured children did have poorer chances of survival. In fact, they were three to four times more likely to die in the PICU. Why was that? The answer was not that they received different care in the PICU once they got there; the answer was that they were much sicker to start with. Compared to children with either private insurance or public assistance (Medicaid), the uninsured children came into the PICU in much worse shape, with far worse derangements in their physiological state. Most likely their parents, fearful of the cost, delayed bringing them to the hospital until sometimes it was too late to save them.

What can we learn from this? Lack of health insurance kills children. That is both a tragedy and a terrible indictment of how we presently care for America’s children.

Asthma is on the rise, especially among children. The Centers for Disease Control (CDC) reported a prevalence of asthma in children of 3.6% in 1980; by 2003 this had risen to 5.8%, which represents a 60% rise in the number of cases. The numbers are going up in adults, too, but they are most dramatic in children. From my perspective in the PICU, there is no question that this problem is increasing; we are seeing more and more children with the sort of severe asthma attacks that land them in the PICU.

Asthma is really a clinical syndrome more than a specific disease. By that I mean it represents a tendency of a child’s lungs to respond to a variety of triggers — things like allergies, tobacco smoke, and simple viral colds — in a characteristic way. This response is constriction of the smaller airways of the lungs, increased mucous in the airways, and inflammation around the airways. The result is difficulty breathing, mostly manifested by difficulty getting air out of the lungs. Trouble getting air out with each breath causes a child to have the characteristic wheezing sound asthma produces. Besides wheezing, a severe attack causes the child to have difficulty getting enough oxygen into the bloodstream.

What’s happening? Is it just that we’re noticing (and labeling with asthma) more children these days, or does this represent a real increase in the disease? The experts all agree that these numbers indicate a real increase, not some kind of artifact. They point to several possible culprits. Since many asthmatics react to environmental triggers, a decline in air quality is a leading candidate. In fact, various studies have shown that children living in dense, urban environments, especially near busy traffic areas, have a higer risk of asthma. Body weight also contributes to asthma, and the steady rise in childhood obesity likely contributes, too. The fact that “asthma” is probably not just one thing makes it all that more difficult to figure out what is causing this slow-rolling epidemic.

The good news is that, even though the number of children with asthma is on the rise, the therapies we have now are much more effective than those of thirty years ago, so the number of severe complications from asthma is actually decreasing.

You can get reliable information about asthma here, at the site of the National Heart, Lung, and Blood Institute, and here.