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.
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.
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.
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.Read More Post a comment (0)
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.
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.
Addendum: Recently Kraft Foods announced it plans to reduce the salt in its prepared foods by about 10%. Read about it here.
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.