There’s a best-selling book out about how simple checklists can prevent complications of medical treatments. It’s simple, the lowest of low tech, requires no expensive equipment, and it works. It seems a bit sad that we need research to confirm common sense. Now a new study describes how yet another very simple thing can reduced complications — simple, automated reminders.
Medical care in the PICU is quite complicated at times and the pace is often hectic. When we are going from patient to patient we focus on the major stuff — the mechanical ventilator, for example. It’s easy to overlook smaller items; smaller items which, in the longer term, can become much bigger things. Urinary catheters are an example of this.
We use these tubes to drain urine out of the bladder of a patient who is unable to urinate themselves. They’re useful and handy. But urinary catheters do carry some risk of infection, especially if they are left in for a long time.
A recent study showed that simply asking the doctor — prompting them with a small reminder each day — if the catheter was still needed led to a 50% drop in catheter-associated infections. It’s simple, easy, and cheap. It’s something I now have on my daily checklist for each patient.
I’ve worked in hospitals since I was 16 years old — 42 years ago now. I was first an orderly, then a nurse’s aid, then a practical nurse, and a finally a surgical technician before I became a physician.
When I started, female nurses wore caps, the details of which identified which nursing school they had graduated from, as well as a pin that gave the same information. They wore starched, white dresses, white shoes, and white hose. They were never called by their first name except by those who knew them personally. Male nurses were few and far between. We had none in the medium-sized community hospital where I worked.
Of course things have changed a lot from those times. Female nurses no longer have to wear those awful hats and uncomfortable starched dresses. Having everybody in scrubs does improve comfort, although it can make it hard to tell the PICU nurse from the housekeeping person cleaning the PICU.
The most significant change to me is that nurses now expect both patients and doctors to address them by their first names. In fact, they have to: my name badge has my full name on it, but the PICU nurses only have their first names and the first initial of their last name. I’m told that at hospitals which still have a nurse’s last name on the badge, the nurses themselves put tape over it to obscure it.
I’m told the reason for this change is personal safety and security. Nurses have close, intimate contact with patients and families, and they fear stalkers. Yet I’ve also been told by security people that, if somebody really wanted to find out the last name of a particular nurse, it wouldn’t be that difficult. I’d love to see some actual data about this issue.
Medicine has long been rigidly hierarchical. Nurses, whose relationship to physicians for many decades was more or less a master-servant one, have struggled for recognition and respect. The fact that physicians were once overwhelmingly men and nearly all nurses were women compounded this effect. (In pediatrics, at least, this profile is changing — now over half of pediatricians in training are women.)
I have wondered now and then about calling nurses by their first names, but continuing to call physicians “doctor.” Is that fair? Somehow it seems to me it should be all one or all the other — both sides using the first name or neither.
This question crops up from time to time on nursing discussion boards, such as here, and always seems to lead to pro and con debates. Nursing leaders also ponder the implications of this new familiarity, such as here. I’m curious what anybody else thinks about it.
Every patient wants the best care — what is known to work. Certainly nobody wants care that doesn’t work, especially if what doesn’t work carries some risk of its own. But what if we don’t know what treatment is best for a particular condition? Shouldn’t we find out?
It is well known that there are wide variations in medical practice across the country, even for the same conditions. Even in the same region, doctors choose different therapies for the same condition. This is often because the circumstances of patients differ. But what if doctors choose different therapies for no particular reason except personal preference? And what if those therapies, although producing the same outcomes, differ in cost by a large amount?
Enter comparative effective research (CER). The idea is simple: compare two treatments and see which works better. And, if one works only a little better and the cost difference is huge, is the tiny improvement worth the cost. It seems odd to nonphysicians, but this kind research is hard to do, and is in fact rarely done. We often compare some new, experimental treatment with the standard; but it is often hard to compare two standard treatments with each other to see which works better. Why?
A recent editorial in the New England Journal of Medicine examines why CER can be challenging to do. The reason often boils down to money. In the example given in the article, a very expensive drug was being compared with a much cheaper one. Both therapies were covered under the patients’ insurance (in this case Medicare). But one group of patients would have an enormously high out-of-pocket copay fee because the copay is often calculated as a percent of the total bill. How do we deal with that? The guiding principle of a randomized, controlled trial is that the patient groups are similar. It would affect the trial if one group of patients could afford (or was willing to pay) a higher copay than the other.
Another key principle of such trials is that neither the patient nor the evaluating physician knows which group the patient is in — which drug they are receiving. This is called blinding. For experimental drugs blinding is easy; the patient gets an unidentified drug, marked only with a code that will be broken later. But if the drugs being compared are both covered by insurance, the insurance statement shows to the patient what it is.
These problems are solvable. But it is important to realize that comparative effectiveness research, which we very much need if we are to control our exploding medical costs, will not be easy to do in many situations.
We’ve always know that hospitals can be dangerous places for patients. In a landmark study some years ago, the Institute of Medicine, a part of the National Academy of Sciences, demonstrated just how dangerous they can be; anywhere from 50,000 to 100,000 people die annually from preventable errors. How are we doing at reducing that grim statistic? The answer is that we are making some progress, but there remain serious roadblocks.
The deaths studied by the Institute of Medicine came from a whole host of causes, and many of these causes are complex and difficult to address. But it turns out that one cause — serious infections from central venous catheters — can be easily improved. We can’t prevent all of these infections, but we can dramatically reduce them. The way to do this is absurdly simple and the lowest of low-tech: use a checklist that ensures basic procedural steps are followed in the correct order. Hospital safety guru Peter Pronovost demonstrated this some years ago. Checklists for all sorts of procedures are useful. Well-known medical author and surgeon Atul Gawande had even written a best-selling book about them. So what’s the problem? The answer is that the problem is often doctors and our medical culture. A recent editorial by Dr. Pronovost helps explain why. (The editorial is from the Journal of the American Medical Association, which requires a subscription. If anybody wants a copy, let me know.) Here’s the crux of the problem, as described by Dr. Pronovost:
“Although most physicians and hospital leaders genuinely want to prevent harming patients, and many physicians practice good teamwork, this view of not questioning physicians is pervasive. Physicians are often rushed, sleep deprived, and overworked and are offered limited training about teamwork and conflict resolution. The practice setting is not always conducive to completing recommended practice and anything that takes extra time for one patient (eg, searching for supplies) detracts from the care of others. Physicians also may not receive feedback on individual performance or hospital infection rates. Social, cultural, educational, and financial differences between physicians and nurses also may inhibit some nurses from speaking up, even when physicians may welcome such feedback.
Moreover, many physicians have not accepted that fallibilities are part of the human condition. Thus, when a nurse questions them, it causes embarrassment or shame. Clinicians are sometimes arrogant, believing they have all the answers, dismissing team input, responding aggressively when questioned. The line between autonomy and arrogance is fine and nuanced. Society has benefited tremendously from physician autonomy and innovation, producing new drugs, devices, therapies, operations, and anesthetics. Therefore, autonomy and innovation must be continued. However, autonomy becomes arrogance when actions are mindless and not mindful, when something is done simply because a physician demands it, when a clinician does not learn from mistakes, and when experimentation occurs without a clear rationale or testable hypothesis. Too often autonomy is mindless and driven by arrogance. When placing a catheter, reliability not autonomy is needed.
As Pogo said many years ago: “We have met the problem, and he is us.”
Here’s a snippet from the first chapter of my new book, How Your Child Heals. It picks up at the point where you, the reader, have begun a microscopic voyage to see what an infected splinter looks like from the perspective of inside your child’s body.
Now that you have had the full-sized, outside view of what happened to your son’s finger, it is time for you to go inside to places where the ancient physicians could not go. It is time to take a seat in the audience of the microscopic drama. You are about to make the first of several trips you will make throughout this book in a tiny, imaginary, high-tech vessel. Think of it as a cross between a submarine and an all-terrain vehicle; it can swim in the blood stream or leave the circulation to crawl around between the cells of the body. It is well-equipped with spotlights and spacious windows, allowing you to see what is happening all around you. The dramatic setting for your first foray is the time just before you called the doctor’s office to ask what to do about it.
The blood vessels in the body form an immense, self-contained system that is divided into two halves. We need oxygen to live, and one half of the circulation, the arteries, carries oxygen-rich blood out to all the parts of the body, down to the tiniest places. The other half, the veins, brings oxygen-depleted and carbon dioxide-laden blood back to the lungs to get more oxygen, which we breathe in, and dump the carbon dioxide waste, which we breathe out. The two halves of the circulation join in a microscopic meshwork of vessels called the capillaries. This is where the true business of circulation happens, where oxygen and other important nutrients get delivered to the body’s cells.
The capillary bed of your son’s throbbing finger is the key place to visit as you investigate what is causing all the problems, but to get there you must first get inside his circulation. You need a location where the tiniest of blood vessels are accessible, close to the surface. The lining of the eye is such a place.
Imagine you begin by poising your craft at the base of one of his lower eyelashes. You look over the edge into the wet, shiny world below. Your son momentarily pulls down his lower lid, revealing the pink inner lining of his lower lid, called the conjunctiva. You seize your chance, zip over the edge, and find yourself motoring about in the clear liquid of his tears, nature’s way of keeping our eyeballs moist. Here there are blood vessels close at hand, just below the surface. You slide your craft into the nearest one and then drift along with the stream, ever faster, as it takes you toward the heart.
You do not stay in his heart long, though, because nothing does. The blood rockets out of the heart like a fire hose because the heart pumps an enormous amount of blood very quickly. A typical adult heart, for example, sends out about a gallon and a half of blood every minute, proportionately less in a child. The effect on your vessel is the equivalent of taking a trip over Niagara Falls. You get bounced around, but soon find yourself in the aorta, the large vessel exiting from his heart.
The aorta is wide and fast, but it soon divides, then subdivides, into multiple rounds of ever smaller vessels. As this branching happens, the velocity of the stream in each of them slows down dramatically. Within seconds after leaving his heart you are scooting down one of these tributaries, headed for his painful index finger.
Things were moving so fast in the aorta and the first couple of branchings that you could not see any details in the surrounding walls of the blood vessels. Although you are going slower now, your pace is still a brisk one, and the flow still pulses along–now faster, now slower–in rhythm with your son’s heartbeat. Soon the stream slows down enough for you to get some idea of just what kind of pipe you are traveling through. The first thing you see when you shine a light at the walls is that the surface is covered by a bumpy layer of cobblestone-appearing cells. The junctions between these cells make a completely watertight barrier; no blood can leave this sealed pipe, and thus you cannot see what is going on in the tissues outside of it.
You soon find you are slowing down even further as you come closer to the sore on his finger, and you notice a dramatic change in the walls of the blood-filled passage you are passing down. For one thing, the wall of the tube is now translucent; you can shine your light right through and get a hazy view of what lies beyond. There are now some small gaps between the pavement of flat cells that makes up the walls, but the cells still mostly touch one another along their edges.
You have reached the capillaries. In real life there would be millions upon millions of options for you to have chosen on your trip from the aorta as the tubes branched into ever smaller pathways, but for our purposes we assume your miniature craft has the proper instruments to sense the correct path among the myriad of choices to lead you to the sore spot on your son’s finger.
There’s a provocative editorial in a recent New England Journal of Medicine about the explosive rise in high-tech medical imaging. Everyone knows doctors order a lot of CT scans, MRI scans, and ultrasound studies, and that the number of these has been steadily increasing. And the cost is enormous. From the article: ” . . . these costs were the fastest-growing physician-directed expenditures in the Medicare program, far outstripping general medical inflation.”
To be fair, rising use of new medical technology is expected because, well, it’s new. What is unclear is that how much of this increased use has led to improved health to justify the cost. Clearly much of it doesn’t, and unnecessary scans, particularly CT scans, lead to risk with no benefit.
The practice of “defensive medicine,” of doctors ordering tests out of a fear of being sued for missing rare conditions, is often given as a cause for overuse of scans. There is some truth to that: the article cites a Massachusetts study showing that 28% of scans are done for that reason. Lawsuits over failing to diagnose things are common; lawsuits about overuse of tests are vanishingly rare.
Physician conflict-of-interest also plays a part. Through a loophole in Medicare regulations, physicians are allowed to refer patients for scans from which the physician benefits financially. That is wrong and needs to be fixed.
But there are deeper reasons. The root cause may well be “the style and content of clinical education and their impact on medical practice.” In other words, how doctors are trained. We use scans unthinkingly, and, unthinkingly, can cause harm. Again from the editorial: “The greatest risk that patients face with unnecessary imaging is the needless exposure to downstream testing and inappropriate treatment related to misdiagnosis and the overdiagnosis of common but unimportant findings.” I’ve seen that happen more than a few times.
In the PICU we focus a lot on nutrition because critically ill children need good nutrition for them to heal from their illness or injury. We often struggle to provide those needed calories. We usually can manage it one way or another, either with high potency oral feedings, special intravenous feedings known as total parenteral nutrition (TPN), or some combination of both of these. We have formulas we use to calculate what a child’s nutritional needs are.
But what about normal children? Many mothers, and it seems most grandmothers, don’t think their children are eating enough to grow. Aside from charting progress in height and weight, how can we calculate if a normal child is getting enough calories?
Here are some good rules of thumb. It’s simplified, but it works. The first thing you must do is determine your child’s weight in kilograms, since that is how we do the calculations: 1 kilogram = 2.2 pounds. Once you know that, you can calculate the average amount of calories needed to grow this way:
- Age newborn to 3 months: 100 calories per kilogram per day
- Age 3 months to 3 years : 90-100 calories per kilogram per day
- Age 3 years to 8 years: 80-90 calories per kilogram per day
- Age 8 years to 12 years: 60-80 calories per kilogram per day
- Age 12 years to 16 years: 45-60 calories per kilogram per day
These calculations assume a normally active child. A significantly more active child needs more. A reasonable rule of thumb for this extra need is for an active child (defined as an hour per day of sustained physical activity) to have about 1.25 times their baseline calories and very active children (defined as more than 90 minutes of sustained physical activity per day) to have 1.5 times their baseline calories.
What does this work out to be in actual numbers? A normal 6-year-old in first grade weighs about 20 kilograms (44 pounds). For him, the daily need is 1700 calories. How about a 17-year-old girl who is a serious soccer player? The average weight for a girl of that age is 55 kilograms (120 pounds), and she needs about 3700 calories; her baseline need is 2400 calories or so, multiplied by 1.5 for her intense activity.
Here’s another excerpt from my new book, How Your Child Heals. It’s from the chapter on symptoms, and it’s about what causes diarrhea.
Diarrhea, the frequent passage of watery stools, is something with which most parents of small children are well acquainted. It is a common symptom because its most common causes, intestinal viruses, are all around us. There are many of these for a child’s immune system to meet as it matures. Each new encounter usually causes illness, but subsequent exposures often cause few or no problems. These viruses are highly infectious, so they spread easily wherever toddlers gather to share toys and cookies. The result is what doctors call gastroenteritis, a fancy term for an inflamed stomach and intestines.
Other things besides viruses can cause diarrhea, but most of these cause it in the same way intestinal viruses do — injuring the cells lining the intestines so they cannot do their job of absorbing the nutrients passing by them. A wide variety of food intolerances can also lead to diarrhea, often because the absorbing cells, though present in the intestine, are in some individuals unable to deal with a particular food properly. Common examples of this include a deficiency of the absorbing cells that process lactose, a type of sugar in dairy products, or a sensitivity to the proteins present in cow’s milk. Whatever the cause of the poor functioning of the absorbing cell lining, the result is often diarrhea. If there is significant stretching and squeezing going on in the intestine the child will often have cramping pain, too.
When the intestinal lining is injured, it cannot do its job of absorbing food. If a large amount of unabsorbed food makes it to the lower reaches of the small intestine, it draws water out of the intestinal wall. It also becomes excellent food for all the bacteria living there, and the action of the germs gorging themselves on this sudden feast produces even more substances that draw water into the intestine. When this mixture is dumped into the large intestine, the enormous mass of bacteria normally living there magnifies the effect. The large intestine can absorb quite a bit of water, but it can become overwhelmed by the volume of what it is being asked to take in. Plus, its lining cells may themselves be injured by the infection and be less able to do their job.
These things makes the stools watery. Diarrhea also means more frequent stools. The simple increase in the amount of material the intestines must deal with is one cause of the more frequent stools. Another is that most causes of diarrhea also speed up the transit time, the length of time it takes what a child swallows to pass all the way through.
There is another kind of diarrhea, one less common in children. This disorder is of the large intestine, the colon, and is called colitis because that word means an inflamed colon. It is typically caused by one of several varieties of infectious bacteria. Since the colon can become quite irritated and inflamed, the diarrhea of colitis often has blood in it from oozing off the intestinal wall. It is usually a more serious illness than simple gastroenteritis of the upper reaches of the intestine. This is why seeing blood in your child’s stools is a reason to visit or call the doctor, especially if your child has fever as well.
We have several ways to deal with diarrhea, the first of which is to do nothing other than make sure your child is getting enough fluid to replace that lost in the stools. This is how doctors usually handle the situation, because typical gastroenteritis is quite self-limited and will pass soon. When it does, the damaged absorbing cells very rapidly replace themselves on the villi and all is well. If it persists for many days, that is a reason to suspect something else is causing it.
Simple common sense teaches us we should not challenge the intestines of a child with diarrhea with large meals full of complex, difficult to absorb foods, because the poorer the absorption, the worse the diarrhea potential. Parents have known this for generations. This is the rationale for using smaller, more frequent meals of simple starches like rice and bread, or even of eliminating all solids for a day or so. There are several ways of approaching this issue, but many parents find out by trial and error which dietary manipulations work for their children and which ones do not.
We do have several drugs to treat diarrhea, most of which work by slowing down the transit time through the intestines. Lomotil is the brand-name of a commonly used one. These drugs affect the intestinal nerves that control how fast the intestines squeeze the food along, slowing down the process. They work well in adults, although you can easily see how it is possible to overshoot and end up with constipation. However, doctors rarely recommend these drugs for small children because, as with the nausea and vomiting medicines, the potential side effects outweigh any benefit of using them for a condition that usually quickly passes without treatment.
People today use their cell phones a lot — so much so that some folks I know seemed to have them glued to their ear all day long. Is there any risk to that? Some have questioned if the radio waves involved might lead to an increased risk of tumors — cancer — in those who do this. A recent article in the International Journal of Epidemiology sheds some light on the question. (Epidemiology is the study not of individual sick people, but of how disease affects populations.)
The study is what is called a case-control study. This matches people with a particular condition with people who don’t have the condition, but who otherwise are similar to those with the disorder. The investigators then look for things — evironmental exposures, for example — that are present in the patients with the disorder but not in the control group, those without the disease.
In this case, the investigators found no link between cell phone use and the occurance of two common brain tumors. These results need to be confirmed, like all medical research, especially since there was some possibility of a link at very high exposures, but overall the results are reassuring.
Here’s another excerpt from my new book, How Your Child Heals. It’s from the chapter on symptoms, and it’s about what causes cough.
The hallmark of most respiratory illness, both in children and in adults, is a cough. Coughing is a reflex, one difficult to suppress. You probably know this from the experience of sitting in a quiet setting, such as in a lecture audience or in church, when you have a cold. The urge to cough is nearly impossible to deny, even with intense effort.
The upper and middle portions of the airway, meaning the space between the back of the throat, through the vocal cords, and down to the first branching of the windpipe, are thickly sown with sensors. They are particularly abundant right around the vocal cords and down at the area of the first branching of the windpipe into smaller breathing tubes. If anything touches these sensors the response is a cough. The reason this reflex is so powerful is that nature is fanatic about protecting our airways. We need to breathe every minute, and objects that might block our airways are potentially very dangerous. Since the last line of defense for the lungs is at the windpipe’s first branching, it makes sense that touching that spot provokes a particularly explosive episode of coughing.
Infections of the upper respiratory tract cause the mucous-secreting cells that line the walls to make more mucous, sometimes large amounts of it, and this extra material trips the cough sensors. The upshot is that we cough and cough until the mucus is cleared out of the airway via a mechanism doctors term a productive cough, meaning it produces sputum.
Often, however, a cough is dry–it does not produce any sputum at all because the cause for it is not excess mucous. We term this a nonproductive cough. It often comes in spasms of multiple coughs in succession, followed by a period of relative quiet. This kind of cough is caused by inflammation of the walls of the airway, something respiratory viruses do, and the inflammation triggers the cough sensors. In children, asthma is another common cause because asthma inflames the airways. A nonproductive cough can also happen if we inhale anything that irritates our airways, such as dust, smoke, or a noxious gas.
If a cough is from asthma, we have several medicines to treat that, such as inhaled albuterol. If it’s not asthma, specific treatment is more difficult. There are dozens of products sold over-the-counter as remedies for cough. None of them do much to help it, although they may soothe the back of the throat. The things many of them contain cause unwanted side effects in small children, so most doctors recommend not using them, as does the American Academy of Pediatrics. The last thing we want in a medication for children is something that does not help the situation and may actually cause harm.
We have medicines that really do suppress cough. They do not work on the airway; rather, they work on the brain itself to suppress the cough reflex. Codeine, a narcotic, is the one most commonly used, but there are others. We rarely use these medicines in children, especially small children, because they have significant side effects, primarily drowsiness and altered mental state. Additionally, if a cough is being caused by excess mucous or other material in the airway, we can make the situation worse by blocking the child’s ability to clear the stuff out.