What’s your favorite example of the weird way doctors speak?

May 7, 2010  |  General  |  No Comments

Every profession has it’s own jargon. This is often helpful because it lets members of the profession (or trade) communicate with each other efficiently and accurately. Medicine is no different in that regard from a host of other professions. But more than a few doctors get into communication troubles when they use their jargon with patients and families. I can think of many examples of that.

But just as weird are the speech constructions doctors often use, both to patients and to each other. Chief among these is the constant use of passive, rather than active sentence constructions. The passive leaves out who is actually doing stuff, suggesting sometimes that things just happened on their own. For example, instead of saying, “Dr. X did an operation on Mr. Jones,” you often hear “an operation was performed on Mr. Jones.” Or, instead of saying “we decided to do this,” you’ll hear “it was decided to do this.” The actor(s) get left out.

Another very odd construction one often hears, when a particular patient might be helped by treatment X, is that “the patient is a candidate for treatment X.” It sounds vaguely as if the patient were running for office or something.

Most of us have heard odd things like this. I’d be interested in reading yours.

Children and toxic plant poisoning

April 30, 2010  |  General  |  No Comments

As I’ve written about before, we commonly see children in the PICU as a result of some toxic ingestion or other. Toddlers take medicines they shouldn’t, but don’t know any better; teenagers also take medicines they shouldn’t, but usually should know better.

Toddlers also put anything in their mouths, including plants, and some of these are potentially toxic. In fact, between 5 and 10% of calls to poison control centers involve a plant ingestion. Yet hospitalizations of children for plant poisoning or toxicity are extremely rare. Thus, although such exposures are common, serious consequences are rare. Still, it is good for parents to be aware of some of the common plants around the house and garden than can cause problems.

Philodendron leaves, for example, can be quite irritating to the mouth and tongue but don’t cause any systemic effects. At holiday time, the berries of both holly and mistletoe, particularly the latter, can be quite toxic, so it’s important to keep them out of reach of toddlers. Here and here are lists of common indoor and outdoor plants that can cause problems.

What should you do if your child has eaten some plant material that worries you? The answer is to call your local Poison Control Center, the number for which is in the front of most telephone books.

Whooping cough: it’s still very much with us

April 23, 2010  |  General  |  No Comments

Whooping cough, or pertussis, its official medical name, is one of those things we hear our grandparents talk about. It once made many, many infants extremely sick with severe coughing and excessive mucous, and some died from it. The so-called paroxysms of coughing can end with the infant sputtering and blue at the end of the spell, after which he takes a huge gulp of air — the characteristic “whoop.” They tire themselves out so much from coughing that they have little energy left to do anything else, including eating.

We have a vaccine that does a fairly good job of preventing whooping cough, which is why we don’t see much of it these days. But the illness has not gone away. In fact, I just saw a case, one of the many I’ve seen over the years. The protection the vaccine gives tends to fade with age, and studies have shown that a fair number of adults with a persistent, chronic cough actually have infection with the pertussis bacteria that causes whooping cough. If such people come in contact with young infants, typically before those infants have completed (or even received) their vaccinations, the babies can get the infection.

I’ve seen some very severe examples of what can happen then. I described one of these in my first book.

The infection affects children in several ways. Our respiratory tract normally produces mucous every day. This is one of the key ways we protect our lungs from all of the particles in the air, such as dirt, pollen, and dust. When we breathe these particles in, they are trapped by the mucous in our airways, and we then cough the material out, which is why our phlegm looks dark after we have been in a dusty environment. The whooping cough bacteria increase the amount of mucous in the infected child’s airway. In addition to that, the bacteria interfere with how the lungs normally get mucous up from the small airways to cough it out. The result is that a child with whooping couch is nearly drowning and gasping for air between coughs; this gasp at the end of a coughing spell is the “whoop” of whooping cough.

If you are interested in finding out more about this infection, you can find it here and here.

A virtual pediatric intensive care unit?

April 17, 2010  |  General  |  2 Comments

There is a shortage of intensivists in the US, both pediatric ones and those who care for adults. Intensive care nurses are in short supply, too. Yet the demand for intensive care services is growing. Part of the demand for adult intensivists is driven by our aging population, but what about children? Why aren’t there enough pediatric intensivists to go around?

I think the principal reason is that our national standard of care for children has changed over the past decades. When I trained in pediatrics over 30 years ago, only the largest children’s hospitals had PICUs. That has changed. The expectation these days is that medium-sized hospitals provide a much higher level of pediatric care than they did in the past, and that includes care of critically ill or injured children. Sometimes this means having a regional transport system so that such children can be rapidly flown to a larger center. But more and more it means that we need to have PICU capability in more places, and that means we need more pediatric intensivists.

Many have wondered if part of this problem can be solved by spreading the expertise of intensivists over a wider area, by taking advantage of all the communication and monitoring capability we have — that is, by establishing what has been labeled a “virtual ICU.” The idea has been gaining ground in adult practice; here is an example of what it means.

How could that work? What most people mean by a virtual ICU is that intensive care doctors (or nurses) can sit in a room and monitor the vital signs, lab results, x-rays, etc., of patients in ICUs in another location. The monitoring doctor could see the patients with a video camera, too. The patients aren’t alone, of course — there are doctors and nurses at the bedside, just not intensivists. When the intensivist monitoring the situation spots something, or if the doctor on site needs advice, there’s the telephone.

Can this work? I have a friend who is an adult intensivist and who has done this for years. He’s enthusiastic about the concept. I’m not so sure about children, though. Maybe I’m a dinosaur, but there’s a fair amount of research that shows that the best way of determining if a child is really, really sick is to have an experienced person say that child is sick. Tests and monitors help, but the sixth sense that an experienced person brings to the bedside is invaluable.

Still, I think some version of virtual ICUs are in the future for children, too. The technology does keep improving, and we simply don’t have enough pediatric intensivists to go around. Looking at the number of pediatricians training to become intensivists, this situation isn’t going to change anytime soon.

The concept of a virtual PICU can also have another role — that of intensivists exchanging information and collaborating with each other. Children’s Hospital of Los Angeles has been running a site intended to do that for several years now.

Getting medical information from the Internet

April 10, 2010  |  General  |  No Comments

Like all doctors these days, many of my patients’ families search the internet for medical information. Often the day after I’ve had a long discussion with a family they return with fresh questions they’ve obtained overnight from Dr. Google. Some of you reading this right now are likely doing that very thing. There’s an excellent recent discussion here about this brave new medical information age, what it means to doctors and patients.

For myself, I am always pleased when families do this. It provides an excellent starting point for continuing discussions about their child. It helps me a great deal in my communication with families. This is often because, even though I explain what I think is important, I not infrequently misjudge what parents really are wondering about. In addition, some parents are a bit inhibited (or intimidated) in discussions with doctors — an Internet search helps them formulate their questions based upon what they really want to know, and I can more easily give them that.

I think doctors should embrace this newest wrinkle in the doctor-patient relationship. For one thing, it’s a very useful conversation opener. I often ask parents if they’ve been looking for online information, if there’s anything I can do to help them find it, and then discuss it with them. For another thing, pointing patients to reliable websites gives them something they can return to in the future for continuing information.

Doctors can serve as a key interpretive filter for patients and families because, of course, the medical information on the Internet, though open to all, is not infrequently wrong. Or, if not wrong, it is not really applicable to my patient’s situation. And somebody’s blog rant should not be weighed equally against information found on a respected site.

There are many useful sites for parents seeking this kind of information, but here are a few I think are good. Properly used, the Internet empowers patients and parents; improperly used, it can confuse and frighten them. Either way, doctors shouldn’t ignore it. Our patients are using it all the time, so it is best for all if we help them do that in the best possible way.

CT scans and cancer: thinking about the meaning of risk

April 3, 2010  |  General  |  12 Comments

I’ve written before about how to think about the risk of x-rays that we doctors do — here, here, and here. These posts, particularly the first one, are the most read and commented upon ones I’ve done since starting the blog over two years ago. Some recent articles in the medical literature have got me thinking about the subject again, because I order more than a few CT scans for children.

The first thing to understand is that nothing we do in medicine is without risk. All tests have risks. If the test itself is virtually risk free, there is always a risk of obtaining (and acting upon) wrong information, and sometimes that is not a trivial thing.

The next thing to understand is that ordinary x-rays, what doctors often call “plain films” cause a vanishingly small risk to the child. You should not worry about those unless your child has received hundreds of them. You can read a nice comparison of radiation exposure of the various kinds of x-rays, and what it means, here.

CT (computed tomography) scans are different, because their radiation doses are much higher than plain films. And the number of CT scans has risen dramatically: there were 62 million of them done in 2007, 4 million of which were performed on children. In comparison, there were about 2 million done on people of all ages in 1980. This thirty-fold increase has been enough to double the average radiation exposure of Americans. What do we know about the risks of that increase?

CT scans do increase the lifetime risk of cancer, especially in children. But by how much? The answer is — we don’t know for sure, although there are some studies underway to find out exactly. What we can do is calculate the radiation doses that CT scanners deliver to specific organs and combine that information with that we have from atom bomb survivors (who of course got massively greater radiation exposure) to estimate what the lifetime cancer risk is. But understand that is a sort of guesstimate. This graph, taken from this article, is a good summary of what we know.

The chart divides CT scans into the two most commonly done — head (left panel) and abdomen (right panel). It then looks at the increased risk, over a lifetime, of getting cancer that is attributable to the CT scan. For abdominal scans, that’s 0.14%, if the scan happened before the age of one. What this means is that, for all kids who get cancer at some time in their life, about one in a thousand of those cases could be attributable to a CT they had earlier in life. That’s not at all the same thing as saying the scan gives them a 0.14% chance of getting cancer — over a lifetime, all of us have a risk much, much higher than that. Rather, it says that, among the large number of us who will get cancer, as many as one in a thousand of those could be attributable to the CT scan.

How should a parent interpret all this if the doctor says their child needs a CT scan? The main thing to remember, as I’ve said in my other posts on this issue, is that several times a very, very small number is still a very, very small number. So the practical implication is that, although CT scans do increase risk, for an individual child that risk is still very small.

The practical thing for a parent to do is to ask the doctor is what the risk is of not doing the scan, of not getting the information the scan gives. If the risk of not doing the scan, which is often very large, is greater than the risk of doing the scan, which is very small, the calculation favors doing the scan.

There is no question that CT scanning has been an enormous weapon in our war against disease and injury. What we are doing now is finding out ways we can avoid doing them if possible. For example, in children the most common indication for an abdominal CT is to diagnose appendicitis, and CT does a good job at that. Some recent research has focused on determining which children need a CT for that and which don’t. The FDA also has a program to try to do what it can to reduce unnecessary scanning. Because that’s the real issue: if the increase in use of CT scanning continues at the same clip over the next couple of decades that it has over the past, then we will have a much larger problem to deal with.

If you’re interested, you can read several of the articles from the medical literature that I’ve summarized in this post — here, here, and here.

Dehydration in children

March 27, 2010  |  General  |  No Comments

Our bodies are mostly water — about 60% water, in fact. This varies a little with age and sex, but it is a good rough estimate. Of that 60% water, about a third of it is outside the body’s cells, so-called extracellular fluid, and two thirds of it is inside the body’s cells, so-called intracellular fluid. The easiest way to remember this is the “60/40/20″ rule: total body water is 60% of our weight, intracellular water is 40% of total body weight, and 20% is extracellular water. Water can move back and forth between these compartments as needed. Dehydration is a relative deficit of body water, and children are especially prone to developing it.

Dehydration results from loss of body water being greater than replacement of it. Our bodies lose fluid constantly: our kidneys must make a minimum amount of urine to stay functional; we lose water as sweat; and our breath, being fully humidified (saturated with water) takes water from our bodies. These are called obligatory, or insensible water losses. Children have a proportionately higher insensible losses than do adults because their ratio of surface area to body mass is higher. So, compared with adults, children need to take in a relatively larger amount of water to keep all those body compartments full.

What causes dehydration in children? The most common causes are those that increase losses, such as diarrhea, vomiting, or rapid breathing from some respiratory problem. Sick children also tend to take in less fluid, so decreased intake of fluids also contributes.

How can we tell if a child is dehydrated? The most common early sign is decreased urine production, since the kidneys respond to the problem by conserving water. The urine also becomes more concentrated because there is less water in it. As a rule of thumb, the kidneys of a child weighing 10 pounds normally puts into her bladder about 1-2 teaspoons of urine per hour. What a parent can tell, for infants, is if the baby is wetting diapers at the rate she usually does.

As dehydration becomes more advanced, there are other signs we look for. These include a decrease in weight (because so much of our body is water), listlessness, poor color with a doughy feel to the skin, and a more rapid heart rate.

Most cases of dehydration can be treated with increased oral fluids, but sometimes, particularly if the child is too listless to drink, we use intravenous fluids for a day or so until the child is better. We have a good rough guide, based on body weight, about how much fluid a child needs to keep from becoming dehydrated when they are sick.

A common version of the formula divides children into three categories: less than twenty-five pounds, twenty-five to fifty pounds, and over fifty pounds. The first group needs about a half teaspoon of fluid each hour for each pound of body weight. This means a ten-pound child needs five teaspoons an hour, which is a little more than two- thirds of an ounce, or roughly about two ounces every three hours. A twenty-pound child then needs twice that—about four ounces every three hours.

The second group of children, those weighing twenty-five to fifty pounds, need about four to six ounces every three hours. Children weighing over fifty ponds need about six to eight ounces every three hours.

A cup of juice is usually about four ounces and a large glass closer to eight ounces. So offering you child something to drink every three to four hours should keep them well hydrated.

You can read an excellent discussion about dehydration in children here.

How many children seen in emergency rooms don’t have emergencies?

March 20, 2010  |  General  |  No Comments

Everybody knows, especially those who work in emergency rooms, that a sizable proportion of patients there don’t have an emergency. This is true for children as well as adults. The reasons they are in the ER and not somewhere else are also pretty well known:

1.) A lot of children don’t have a regular doctor, so the ER, by default, serves as their doctor.

2.) Even if a child has a regular doctor, often appointments are hard to get and are days or even weeks in advance, something that doesn’t help very much if your child has an acute illness.

3.) Many doctors’ offices aren’t set up to have much capacity to handle walk-ins.

There is a growing number of free-standing ambulatory walk-in clinics, called by some a “doc-in-a-box,” that respond to this need, but a lot of parents end up taking their child to the ER. Of course this tends to clog up the ER, but many parents simply have no other choice. The question is, what proportion of the children being seen in America’s ERs don’t need to be there?

A recent study in Pediatrics, the journal of the American Academy of Pediatrics, tried to answer this important question. (The link is only to the abstract — unfortunately, you need a subscription to get the whole thing. If anybody wants one, let me know.) The study surveyed a national sample of 5,512 ER visits. The demographics of the group — age, sex, race, economic status — were broadly representative of the whole US population. The investigators counted the number of times the children used the ER and for what. Importantly, and a weakness in the data, is that they didn’t have access to the actual patient encounter charts, so the true severity of the children’s problems couldn’t be assessed; all they knew was what the final diagnosis was.

What they found was that yes, many children who, for one reason or another are brought to the ER, don’t need to be there. But the number of such visits — 1671, or 30% — was less than I expected. Like many pediatricians who have worked in ERs, as I did extensively for 5 years, it often seems like well over half the kids don’t really need to be there. But that’s not what the study found. Of course, 30% is still too many, because it diverts the attention of the ER staff from the sickest children and clogs the system. I think if you gave the parents of these children other options they wouldn’t use the ER. I say this because, in my experience, most parents really are excellent judges of how sick their children are.

Age also mattered; children older than two were more likely to be in the ER inappropriately than were younger children. This actually was a good thing. Infants get seriously ill faster, and with potentially worse consequences, than do older children. Those are the ones we want in the ER more frequently.

The data on socioeconomic status were the most interesting to me. Contrary to what you might think, low-income children, especially minority children, were less likely to use the ER inappropriately. Insurance status wasn’t a factor, although children with insurance had higher overall costs. This is likely an artifact of how we pay for medical care in America.

This study was a national average, and I’m sure the numbers would differ among inner-city urban, suburban, and rural hospitals.

Overuse of the ER is definitely something we need to fix if we ever are to bring down the cost of medical care. Because the overhead costs of ERs are so high (they must be constantly ready for anything), the cost of seeing common illnesses there is several times higher than the cost of the exact same thing seen in a doctor’s office or clinic.

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The pulse oximeter: how we measure oxygen in the blood

March 13, 2010  |  General  |  No Comments

If you’ve ever taken your child to the doctor for any sort of breathing problem you’ve probably encountered a device called a pulse oximeter. It’s a little thing with a bright red light on it that we clip to a finger or toe. It then generates a number called the “oxygen saturation” of the blood. Using one doesn’t hurt at all. How do these things work?

The pulse oximeter really represents a breakthrough in clinical care, because it gives us a reliable, simple, and painless way to determine what the oxygen level in the blood is. We had other ways before that (and still have them), but they require sticking a needle into a blood vessel, typically the radial artery where you feel your pulse in your wrist.

The thing the machine measures, the oxygen saturation, is the proportion (percent) of the hemoglobin in the red blood cells that are carrying oxygen. Our red bloods cells are stuffed full of a protein called hemoglobin, which is a carrier for oxygen. The red cells have only one main job — pick up oxygen in the lungs, haul it around to the body where it is needed, and dump it out there. In many ways our blood stream is like a freight train with each red blood cell being one of a long string of box cars. The cars go round and round doing their job, with each red blood cell living for several months before being replaced with a fresh one.

Oxygen saturation represents the number of box cars filled with oxygen. Normally, when the train leaves the lungs, it is at least 95% filled. When it returns to pick up another load, it is still generally at least 70% filled. This provides our bodies with an important margin of error, some reserve supply of oxygen. In fact, if the train returning to the lungs is, for example, only 40% filled, this is evidence of serious problems because the reserves are being used up. The pulse oximeter, the light on your child’s finger, measures saturation of the blood leaving the lungs.

Pulse oximetry is wonderful technology. I well remember when the devices became available, because I trained in an era when we didn’t have them. Sometimes our first sign that a child might need extra oxygen was when they started to turn a dusky color, which doesn’t happen until the saturation drops to around 80%. Now we have early warning of trouble. Plus, of course, we no longer need to stick children with so many needles. That’s wonderful, too.

If you’re interested in more details about how they work, you can read about it here.

Is it always wrong to perform futile CPR?

March 6, 2010  |  General  |  4 Comments

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.