The continuing issue of what to do with smaller pediatric intensive care units: Is regionalization the answer?

November 15, 2018  |  General  |  No Comments

I spent my early and mid-career years working in a pediatric intensive care unit at a large academic center. We did almost everything except for a few things esoteric at the time — small bowel transplants, a few kinds of experimental surgery. I’m now in my late career (but have no plans to quit anytime soon!) and work in a smaller PICU. I am frequently confronted with the issue of just what a smaller unit should be doing. Some of these questions are easy. For example, we don’t do kidney dialysis in children so any child who might need that gets sent to a larger, academic PICU. We also don’t do heart surgery in children, although we care for children before and after their surgical repairs done elsewhere. But you can easily see how this can get complicated, even murky, as we think about the vast array and spectrum of severity of childhood illness and injuries. For example, I frequently care for children with severe respiratory failure who need a mechanical ventilator. But our PICU does not (and should not) offer the most sophisticated form of respiratory support — extracorporeal membrane oxygenation (ECMO). Deciding when things have deteriorated to such an extent that a child might need ECMO, and hence transfer, is a total judgement call. We don’t want to transfer too early but we certainly don’t want to do it too late, when the child is much more unstable.

When PICUs began they were located in major academic medical centers. Now we have smaller units like mine scattered across the landscape. And “scattered” is the correct way to think about it because where you may find a PICU is a bit random. Essentially what happens is that a larger community hospital decides they want a PICU. I can tell you from personal observation this decision is often made with little detailed planning and without consideration of what having a PICU really means, what specific services you are going to offer or are compelled offer. Several organizations I know of just hired some pediatric intensivists (and never enough of them), bought some ventilators, stuck a PICU sign on the wall, and declared themselves open for business. Several organizations, including the American Academy of Pediatrics, have published guidelines of what a PICU should consist of, but it has no teeth and no one has decided exactly what services are appropriate. Besides, the guidelines are now a decade old. A very crude measure would simply use the metric of number of PICU beds and yearly patient census, but even that’s not done. There are some guidelines for specific procedures, such as liver transplantation, but on the whole it’s whatever people want to do. It’s pretty chaotic.

I’ve seen some bad things happen because of this Wild West approach to PICU practice. In densely populated areas such as the Northeast you find places were PICUs are sitting cheek by jowl and competing intensely with each other for patients. In contrast, in the West the nearest PICU may be hundreds of miles away and the referring physician has no choice at all. The issue, of course, is twofold: it is inefficient, and cruel to families, to transfer children to big PICUs when they could be appropriately cared for closer to home; yet it can be dangerous to keep children in smaller PICUs when they have or might develop problems that require a higher level of expertise. Of course this is not a problem unique to PICUs. It applies to other aspects of acute medical care. Critical care is a flash point for the question because there may not be time for a leisurely referral to a far away specialist. Decisions, sometimes simply based upon best guess, need to be made.

My own modest suggestion toward solving this problem is that every smaller PICU should have a formalized, agreed upon protocol for consultation and transfer of patients. In other words, there should be some type of formal regionalization for pediatric critical care. The PICU I work in is fortunate to have a tight relationship with a major children’s hospital. I can call at anytime on a direct number just to bounce ideas off another intensivist, ask for specific advice, or arrange transfer. I have many colleagues around the country who, when they wish for that sort of help, must go through layers of obstruction to get it. Sometimes when they want to transfer a patient to a bigger PICU they essentially need to “pitch and sell” the patient to the larger facility, who may even refuse the transfer for non-medical reasons. This is not the way to go. I think every PICU that doesn’t offer the complete range of critical care services should have some sort of arrangement with a larger unit. Right now most have only an informal, vague, “this is what we generally do” protocol. It needs to be better than that.

Everything you’ll ever need to know about croup

November 10, 2018  |  General  |  No Comments

Imagine this scenario. Your two-year-old son has had a runny nose for a day or two and an occasional cough, but seemed no worse to you that everyone else in his preschool class. Two hours after you put him to bed you hear him coughing, only this cough is like none you have ever heard from him before. It sounds like a barking seal at the circus–a brassy, honking noise. In between coughs he his making a strange crowing-like noise. When you snap on the light you see him sitting up in his crib, leaning forward, and coughing that strange cough. You also notice the part of his chest below his ribcage is sinking inwards with each breath, backwards from the way it should go. Your little boy has a scared look in his eyes, and you are more than a little scared yourself. He has croup. What is croup?

Croup is a disorder caused by inflammation of the trachea, the main breathing tube in the neck, just below the vocal cords, in an area called the subglottic region. Some say it gets its name for the old Anglo-Saxon word kropan, which means to croak or cry out. If true, such venerable terminology tells us this common childhood ailment has been recognized as a distinct entity by parents for a very long time. Physicians sometimes give it a much fancier name, laryngotracheobronchitis. This learned construction merely describes what croup is: inflammation (hence the “itis”) of the breathing tubes extending from the vocal cords (the larynx), through the trachea, and often down to the lower breathing tubes (the bronchi). Even though the inflammation can stretch up and down the airway, it is in the subglottic region where the symptoms happen. Why this is so is because of a simple law of physics–that is where the airway of a toddler is at its narrowest. The symptoms of croup come from blockage of airflow.

The inflammation of the subglottic region makes the lining of the trachea swell. Since the trachea is more or less round, this swelling makes the diameter of the airway smaller. Sometimes the swelling of the tissues gets so bad the size of the child’s airway is narrowed to that of a small straw. What happens next is simple physics, and is analogous to what happens in cold water pipes if they have their diameter narrowed by mineral deposits in them: flow through a tube is proportional to the fourth power of the radius of the tube. This may sound esoteric, but the principle has important practical implications for small children with croup.

Imagine an adult whose airway has a diameter of twelve millimeters. Then imagine the lining of this tube develops one millimeter of swelling all around its lining, thereby reducing its diameter to ten millimeters. If one does the calculations, this slight reduction in size reduces airflow by about half. Now consider a toddler with a  five millimeter airway who has the same one millimeter of swelling all the way around it, reducing it to three millimeters in diameter. The adult in this example loses about half the airflow, something easily compensated for by just breathing a little harder. In contrast, the toddler has his airflow reduced to only thirteen percent of what it was. This reduction is too much to compensate for, although the child tries. His trying causes the symptoms of croup.

It is air rushing turbulently through a newly tiny airway that causes the crowing sound characteristic of the breathing of a child with croup. It is called stridor, and an experienced person can often make the diagnosis of croup based upon that sound alone, even over the telephone. Additionally, the front portion of a toddler’s ribcage is not yet solid bone–it is still partly cartilage. This means that, since a child’s chest is not yet firm in the scaffolding of the ribs, the increased effort of breathing makes the chest cave in the wrong way with each breath. These are called retractions. They are not specific to croup, but happen in a child with respiratory distress from a variety of causes. The final characteristic finding of croup, the seal-like barking cough, is from irritation of the vocal cords.

One of the characteristic attributes of croup is how sudden the onset of the stridor, the sign of upper airway obstruction, often is. For some reason croup tends to be worse at night; most visits to emergency departments for croup occur between ten in the evening and four in the morning. A typical story is that parents put their child to bed with just a mild cough only to awaken in the middle of the night to the sound of severe stridor. This is a predictable result of the place where the inflammation is happening. Since airflow is dependent upon the fourth power of the radius of the child’s trachea, he may not have much distress during the early stages of the illness. But as the airway gets smaller, subsequent reduction in size becomes critical. The analogy to water pipes is a good one: loss of half the space inside the pipe from mineral deposits causes only slight reduction in water flow when one turns on the tap, but just a little more blockage severely cuts down flow.

Croup is an extremely common childhood illness. Estimates vary, but studies suggest as many as fifteen percent of all children have croup at least once, and five percent have it more than once. Some have estimated croup accounts for fifteen percent of all respiratory tract disease seen in pediatric practice. The peak time for croup is fall and early winter, but it can occur any time of year, even summer. The peak risk age for children to get croup is eighteen months, and boys are one-and-one-half times more likely to get it than are girls.

Croup is caused by infection with a respiratory virus. Although there are a few ailments that resemble croup and are caused by something else (more on them below), standard croup symptoms are brought on by viral infection. There are multiple viruses that can do it, but nearly three-quarters of all cases stem from infection from a single family of three closely-related viruses–the parainfluenza viruses, which are cousins of true influenza. Less commonly croup is caused by the true influenza virus, respiratory syncytial  virus (RSV), or a few others.

All these viruses are spread from child to child in the manner of most respiratory viruses–tiny droplets of infected mucous or saliva. These droplets can fly through the air after a cough or sneeze and be inhaled by someone nearby. Alternatively, virus-laden mucous gets deposited on a child’s hands when she puts them in her mouth or nose and the virus then moves on to someone else when the child touches them. Either way, the first step is for the virus to infect the back of the throat, causing cold-like symptoms of nasal congestion, cough, and low-grade fever. For reasons we do not understand, some children get no more than that. Often, however, and especially with the parainfluenza viruses, the infection moves to the subglottic area of the trachea. There it causes the local irritation and inflammation that leads to the airway swelling and subsequent symptoms of obstructed airflow.

Croup is entirely a clinical diagnosis; there is no specific test for it. This means the doctor decides it is croup based upon a typical story (cough, congestion, stridor, and mild fever). Sometimes, though, a doctor will get an x-ray of the child’s neck, which often shows some narrowing of the airway. The above picture, an x-ray of a child’s neck, is an example of this. Air on an x-ray appears black, bones are white, and tissue is grey. The central black column of this child’s trachea is narrowed abnormally at the point of the arrow. (The bones stacked like coins in the neck are part of the spinal column.) Doctors do not always get such an x-ray, especially if everything points to croup. If the story is atypical, a common reason for getting the x-ray is to make sure the child’s symptoms are not from something else. Those other possibilities are divided into infectious ones and non-infectious ones.

There are other infections besides viral ones that can infect a child’s airway and block airflow. Serious bacterial infection can do this also. The principal one of these is epiglottitis, a severe and rapid swelling of the epiglottis, a structure that sits just above the opening of the trachea at the back of the throat. The epiglottis is what keeps food from going into the trachea during swallowing. When it becomes severely swollen, which is what happens with epiglottitis, it can completely block the airway and cause a life-threatening emergency. Another infection that can mimic croup is bacterial tracheitis, a severe infection of the entire trachea that causes so much infected pus that a child’s airway can become obstructed. It, too, can be life-threatening.

Fortunately, both epiglottis and bacterial tracheitis are rare. Epiglottis was once not uncommon, but near universal vaccination of children against the bacterium Hemophilus influenzae, the main causative organism, has dramatically reduced the incidence of the disorder. Both these serious conditions usually behave quite differently from croup. The main difference is that both cause high fever (croup’s fever is nearly always low-grade) and the children appear quite ill. The key distinction between croup and epiglottis is that the latter not only makes breathing difficult but also makes swallowing painful or even impossible for the child. Thus a child with epiglottis will not only have stridor, but will sit hunched forward and drool, unable to swallow.

An x-ray of the neck can help distinguish croup from these more serious infections. However, if the doctor thinks epiglottis is possible the standard way to proceed is for the child to be given a sedative and have his airway directly inspected using a procedure called laryngoscopy. If this is necessary, it is usually done by an airway specialist, such as an otolaryngologist, commonly called an ENT specialist.

There also are non-infectious things that can cause upper airway obstruction and stridor, since anything blocking the airway gives the same symptoms. Overall, what distinguishes these non-infectious causes of upper airway obstruction from the infectious ones is the lack of any other evidence of infection, such as nasal congestion, fever, or malaise.

If the onset of a child’s breathing problems is quite sudden, the doctor might consider the possibility of a foreign body stuck in the airway. Toddlers put anything into their mouths–toys and bits of food are frequent offenders when this happens. On the other hand, if the progression of a child’s symptoms is progressive over days or weeks, the doctor might think about several kinds of tissue growths that can occur within the airway. If either of these possibilities is likely, the child usually needs laryngoscopy or bronchoscopy, inspection of the trachea and lower airway, for diagnosis.

A few children have recurrent, sudden episodes of croup symptoms without any other evidence of viral infection. These attacks from what is called spasmodic croup also generally happen at night. The cause is unknown, but it may be related to allergies. It is generally treated the same way as viral croup (see below).

The walls of the trachea are stiffened with bands of cartilage; this is what holds them open and keeps them that way. Some children have an airway that is intrinsically less stiffened with cartilage than most, causing it to collapse a bit when the child breathes, causing stridor that can sound like croup. In this condition, called tracheomalacia, the symptoms are chronic and are often worse when the child is lying on his back because the weight of the tissue in the neck compresses the airway more. It requires bronchoscopy to diagnose for certain.

Croup ranges in severity from quite mild to the rare case of near total obstruction of the airway. To help categorize this severity doctors have devised various scoring systems to rate the child’s symptoms. One commonly used of these “croup scores” is the Westley scale. The scale assigns points for various symptoms and groups children into “mild,” (less than three points), “moderate,” (three to six points), and “severe” (more than six points). It uses five criteria to do this: severity of retractions, degree of stridor, how well the air is getting into the child’s lungs as assessed with the examiner’s stethoscope, if the child is dusky-colored from insufficient oxygen, and if the child is becoming poorly responsive from lack of oxygen. Generally mild croup can be treated at home; moderate and severe croup require medical attention, and usually the more ill children will be admitted to the hospital.

Once a doctor decides a child has croup, it is fairly well-accepted how to treat it. Therapy is directed at two things: making the child feel better and reducing the airway inflammation to improve airflow. Mist has been a mainstay of treatment for mild croup for many years. This often gives a child significant relief from the pain and raspy, dry feeling in the throat, although whether it actually helps reduce the inflammation of the airway itself and improves air flow is doubtful. Mist may also help loosen airway mucous and allow the child to cough it up easier. Throat pain and fever are helped by treatment with acetaminophen or ibuprofen. The traditional home remedy for mild croup is to close the bathroom door and run a tap until the room is completely steamy, then turn it off and sit with the child in the mist. A parent needs to be careful with this, of course; children have been burned from scalding water. Exposure to cool night air (since croup happens mostly at night) is also a traditional remedy. Although widely practiced and certainly benign, it, too, has never been validated.

Doctors typically use one or both of two ways to reduce the inflammation and swelling in the child’s airway. Direct application of the drug epinephrine (adrenaline) to the swollen tissues shrinks them by constricting the tiny blood vessels under their surface; it is the virus-induced engorgement of these vessels and leakage of fluid out of them that causes the swelling in the first place. The drug is given by nebulization, blowing high-flow air or a mixture of air and oxygen through the liquid epinephrine and thereby dispersing it into a fine mist, which the child then breathes to carry the drug to the subglottic area. Epinephrine works within minutes and usually gives a child prompt relief from the stridor and retractions. Unfortunately the effects of epinephrine only last a few hours at most. It can then be repeated, although dose after dose of epinephrine can rarely lead to worse swelling when the drug wears off.

The subglottic swelling of croup is from inflammation in the area, so standard treatment of moderate or severe croup also consists of using a drug to reduce the inflammation–a steroid. Steroids are also being used increasingly for mild croup, both to make the child feel better and to interrupt in its early stages progression of the swelling. Steroids can be given orally, by intramuscular injection, or even nebulization like the epinephrine. A commonly used steroid for croup is dexamethasone (Decadron), a single dose of which is usually sufficient to reduce the inflammation. Unfortunately, steroids do not act immediately like inhaled epinephrine–they take four to six hours at least to work.

A typical treatment scenario for a child coming to the emergency department with croup would be to have him breathe some cool mist, followed by a nebulized epinephrine treatment. Usually the best way to do this is to have the child sit in a parent’s lap, since he is most comfortable there and agitation makes the stridor and retractions worse. Then the child receives a dose of steroids. Often by then the child’s symptoms are much better, but it is important to keep the child in the emergency department for at least an hour or two more to make sure the symptoms do not recur after the epinephrine wears off and the child needs more treatment. A child who has continues to have symptoms after  epinephrine or who needs repeated doses of epinephrine needs admission to the hospital. What doctors particularly look for is continued stridor when the child is completely calm; called “stridor at rest,” it is a standard indication for hospital admission.

A child with severe croup needs more complicated management, although this is very uncommon. If the child is clearly not getting enough air to stay alert and keep his blood oxygen levels up he needs immediate placement of a breathing tube, called an endotracheal tube. It is placed by a procedure known as intubation. A child with less severe croup, but who remains in significant distress and begins to tire from the effort of breathing also needs intubation.

Croup usually runs its course in five to seven days, typically with one day of worst symptoms and several more of cough and hoarseness. Since the symptoms characteristically get better in the day, it is common during the middle of the illness for a child to have minimal symptoms during the day but several nights of worse cough.

There is no clear-cut evidence that children who have one episode of croup are more likely to get it again. There is some evidence children who have group are more at risk later to develop reactive airways disease–asthma–than children who never have croup. However, if true, this may not be a cause-and-effect association; the propensity for a child to get croup when infected by a respiratory virus may reflect the same innate tendency to develop asthma. They may be different manifestations of the same thing. There are no long-term after-effects of typical viral croup.

Vaccine denialists mythical unicorn: why they will never accept scientific reality

October 19, 2018  |  General  |  No Comments

I swiped this editorial cartoon by Steve Sack from the redoubtable Dr. David Gorski’s blog, who goes by the nom-de-web of Orac. Recent epidemiology shows reducing the fraction of vaccinated children in the population rather promptly leads to a resurgence of the diseases vaccines protect against. This is the concept of community or herd immunity. Epidemiologists debate the concept around the margins but overall its importance is well accepted. People who deny the effectiveness of vaccines or even think vaccines are dangerous don’t accept it, though, and you can find many examples of this around the internet, some sort of reasoned, some not. Although I’m trained in pediatric infectious diseases, a field that includes a lot of epidemiology, I’m not an epidemiologist. So I’m not going to chew on the whole herd immunity thing. I’m going to write about a particular form of concern trolling common among vaccine denialists: the claim that they would fully support vaccines if only vaccines could be shown to be fully safe and effective, using their own special definitions of what that means. In effect they erect an impossible standard to meet, which is of course how concern trolling works.

A common claim is that, although individual vaccines may be safe, the safety of combinations of vaccines together has never been shown. It’s not always clear what the demand is here, but it often appears to me to mean they want a trial of all the many possible combinations of vaccines compared. If you just do the math on how many vaccine combinations are possible you can see this demand is absurdly impossible to meet. We actually do have ongoing surveillance of vaccine safety happening all the time and the results show them to be the safest medical procedure we have, with around 1 complication per million doses administered. The only thing safer is homeopathy, which does nothing but harms nothing. Vaccine denialists elide this fact by redefining what a vaccine complication is through including nearly anything that happens to a person afterwards, even years afterwards, as vaccine-caused. I’ve read posts by many adults who claim, for example, that their fatigue, difficulty concentrating, and “metabolic problems” stem from vaccines they received as children. Also automobile accidents have been blamed as vaccine complications. The absurdity is truly mind boggling.

And then there is the mythical unicorn vaccine denialists claim is the only acceptable answer: a direct comparison of vaccinated and unvaccinated children, searching for differences in outcomes. Key here is the frequent claim unvaccinated children, on average, are healthier than vaccinated ones. To someone who knows little of clinical research this seems like a perfectly reasonable demand. Just compare vaccinated to unvaccinated children, see who got illnesses or complications and who didn’t. I just saw this one on my Twitter feed today:

Also note this tweet includes the common fallacy the Amish don’t vaccinate — most do. Anyway, there have been some terrible studies of this sort reported, such as this one, which highlight the fallacy of doing such a simple comparison without controlling for any confounders. Fundamental to any proper study like this is that the two groups being compared, in this case vaccinated and unvaccinated, must differ only in the variable being tested. A common way of handling the question is a case-control study, in which each case is matched with one or more controls that, as best as can be determined, satisfy that requirement. But vaccinated and unvaccinated children, by parent choice, are hopelessly self-selected right out of the gate. There are other confounding issues, such as blinding, but that’s the main one.

Well then, as some have actually demanded, we must have a randomized controlled trial (RCT), the gold standard of clinical research. RCTs use random assignment of subjects to one group or the other, in this case vaccine or a placebo (fake vaccine), and ensure both the subjects and evaluation team be blinded to who got what. Think about this for a minute. They are demanding parents agree to subject their child to a trial in which they have a 50/50 chance of getting a fake vaccine. All this to satisfy the concerns of vaccine deniers. It would be incredibly unethical to do such a study, and no institutional review board (aka human studies committee) would ever approve such a thing. For such trials there must be reasonable uncertainty about which group is getting the better treatment and in this case there is none. The bottom line is any vaccine skeptic who demands proof like this is being massively disingenuous. It’s akin to demanding a randomized controlled trial of parachutes.

The enduring mystery in this perennial chestnut of a topic is that vaccine deniers demand a level of safety and certainty from vaccines that they demand from no other medical procedure or treatment. Absolutely every treatment I can think of is riskier than vaccination. Some are far, far riskier. I suppose it’s partly owing to a visceral resistance to injecting something into a healthy person, but vaccine denial in general has deep, deep historical roots.

We’re not doing very well in reducing unnecessary CT scans in children with minor head trauma

October 8, 2018  |  General  |  No Comments

Computed tomography, or CT scanning, is one of the most powerful diagnostic tools to emerge during my medical career. Just look at the detail in the brain images above, taken at 90 degree angles through the brain. And I was there at the beginning. I remember well when I was a medical student taking neurology and the first CT scanner arrived at the Mayo Clinic. By today’s standards it was incredibly crude. It displayed a tiny image on a cathode ray tube that was then photographed with a Polaroid camera. Preservative lacquer was then smeared on the photograph and it was pasted into the patient’s chart with glue. But the crude photographs were amazingly superior to what physicians had previously, which was nothing. They had skull x-rays to look at the bone and the very painful and very indirect imaging technique called pneumoencephalography. So neurologists and neurosurgeons were ecstatic at the new technology because it allowed them to see the brain directly.

Over the years head CT emerging as pretty much a standard test for evaluating any bonk on the head, particularly if the person clinically had a concussion or especially if they lost consciousness. This is because one of the things a head CT does particularly well is identify brain swelling or bleeding inside the skull. But then some concerns began to arise about the radiation that comes with CT scanning. And CT scans do deliver an order of magnitude at least more radiation than do ordinary x-rays like chest, arm, or leg x-rays. So this raised the concern of all these head CT scans contributing to increased cancer risk, a particular concern in children who have developing brains and their life ahead of them. It turns out there is a measurable increase in lifetime cancer risk from CT scans. It’s tiny, but it’s measurable. How tiny? About 2 in 10,000 head CT scans. The risk is higher for abdominal CT scans, but these deliver much higher radiation doses. Radiologists recognized this issue and a decade or more ago instituted protocols for children that reduced radiation significantly (the Image Gently program). But the risk is still there. For small children there is often the additional risk of the need for sedation to do the scan because the child cannot hold still enough to get a sharp image. The point is that we should use the same risk/benefit calculation when ordering a head CT that we use when ordering any other test. If the risk, however tiny, exceeds the expected benefit we shouldn’t do the test. So if the benefit of a head CT in minor head trauma in children is essentially zero we shouldn’t get the scan. But how do we determine that? To help us with that question various professional organizations have issued guidelines regarding when a head CT is needed to evaluate pediatric head trauma and when it’s not. An interesting recent study investigated how we are doing in adhering to those guidelines. You can read one commonly used set of guidelines here.

The authors studied the years 2007-13. The guidelines had been recently put in place at the beginning of that period. Their goal was to see any effect of this; they hypothesized that, over a decade, implementation of the guidelines should result in a reduction in pediatric head CT scans. They used the enormous National Hospital Ambulatory Care Medical Survey database, a resource that includes information on over 14 million children who visited an emergency department during the 9 year study period with a diagnosis of head trauma. Their question was crude but simple: Did rates of CT scan use for pediatric head trauma change over the study period? The simple answer they found was: no change. The below graph shows the proportion of children who got head CTs over the study period. The points of implementation of various guideline initiatives are noted — Image Gently, PECARN Rules (described in the above reference), and Choosing Wisely. But the line is unchanging within the confidence intervals. I suppose we should not be surprised most of this excess CT use occurred at community hospitals rather than academic facilities; up-to-date practice would be more expected to take place at the latter.

So what does this mean? An accompanying editorial to the above study considers the implications.

It is disappointing that US children have generally not benefited from current best practice research and continue to experience unnecessary radiation exposure. This is a reminder that pediatric research and education efforts are frequently not focused where most US children receive their medical care. . . . A recent study of a community ED revealed that a maintenance of certification program sponsored by a children’s hospital was associated with lowered CT scan use from 29% to 17%.

Most discussions of this sort bring up defensive medicine, that is, doing things out of a fear of lawsuits. However, adherence to nationally recognized best practice guidelines is a pretty solid defense against later claims of negligence. In this case, it’s not at all inconceivable that not following best practice guidelines actually puts a physician at risk from being sued.

A mother’s language and voice modulation affects how her newborn infant cries

October 6, 2018  |  General  |  No Comments

unnamedI first posted about this subject a couple of years ago but it’s so fascinating to me I’m writing about it again. I happened to run across this study containing some amazing information. It’s from a publication called The Journal of Voice. The link is to the abstract — the complete article is behind a paywall but I can get it for anybody who’s interested in reading the whole study in detail. Its title is “Fundamental frequency variation in crying of Mandarin and German neonates.” I have always assumed, like most people I suspect, that babies cry the same the world over. When they’re uncomfortable or hungry they let us know by crying. It turns out this may not be the case. If so, then language development is pushed to the very first days of life — even before that, perhaps. There is actually previous work of a similar nature that studies what the authors termed the melody of an infant’s cry and how it varies with the mother’s native language. It’s long been known that from birth infants have a particular recognition of their mother’s voice, something that appears to be associated with the melodic contours of how the mother modulates her voice.

Some languages are tonal. This means the pitch of the speaker’s voice affects the meaning of the words; the same sound can mean something entirely different depending upon the pitch. Mandarin Chinese, spoken by over a billion people, is such a language. There are four pitches that must be mastered to speak Mandarin. I have a friend who spent three years in China and really struggled with this. I don’t recall the details, but as I recall she told me, as one example, the word for “fish” means something entirely different when uttered in a different pitch. There is a language spoken in Cameroon  that is even more complicated, sound-wise. This language has eight different pitches that affect word meaning, and there are further modulations in pitch that complicate things even more.

The particular study cited above was a collaboration between investigators in China and Germany. German is not a tonal language, of course. The investigators recorded the vocalizations of 102 newborn infants, examining in particular pitch, fluctuation, and range. The results, in the words of the lead author, were clear:

The crying of neonates whose mothers speak a tonal language is characterized by a significantly higher melodic variation as compared to – for example – German neonates.

It’s even more interesting when you consider that these are newborns. They’ve only been out of the womb a couple of days. So the clear implication is that they heard their mothers speaking while still in utero and acquired patterns of vocalization that they begin to use immediately after they were born. That’s quite amazing, I think. It has implications even for those mothers who don’t speak tonal languages: that is, your baby can hear what you’re saying, especially during the last trimester of pregnancy, so be sensitive of your tone. So maybe if you are angry and yell a lot your infant may actually be impacted by that, and not in a good way. Something to think about.

Some random thoughts on the evolution of the stethoscope: from vital tool to symbolic regalia

August 31, 2018  |  General  |  No Comments

The stethoscope. Nothings says “I’m a doctor” more than the stethoscope in a pocket or draped around the neck. Forty-five years ago when I got my first one, a gift from my physician-father, the former was more common. Then we were more likely to wear coats — white coats or suit coats — and pockets were available. I had suit coats in which the lining was worn out from the weight of the thing and at the Mayo Clinic back then, perhaps still, the sartorial police didn’t allow white coats. Of course medicine was overwhelmingly male then so suit coats were the norm. These days you’re much more likely to see them draped around the neck like the guy in the picture above. Back then we did put them around our necks sometimes, but that required that the springy metal arms to be around your neck, like this guy.

I found that tended to give me a headache because I think it partly occluded blood flow down the jugular veins in my neck. Interesting to me is the newer fashion statement of draping it around the neck like picture #1 is made possible because the tubing on today’s stethoscopes is much longer. The longer tubing also makes wearing it like the guy in image #2 cumbersome because the end of it bangs on your belt rather than the middle of your chest.

Materials of course have evolved as well. My first one was made of steel with rubber tubing; today’s versions are mostly lightweight plastic. Mine was one of the style called Rappaport-Sprague, named after its inventors, I assume. The very best model was sold by Hewlett-Packard, which, alas, no longer makes it. I wish I could get one again because the one my father gave me was stolen from the hospital doctors’ lounge by some evil weasel. I saw the one pictured below offered on E-Bay for $900.00, so I guess other folks share my nostalgia. It looks just like the one I had. I have to say I think the old rubber tubing gave much better sound transmission than today’s plastic stuff.

Notice the shorter tubing. If you draped the tubing of one of the older versions around your neck the thing could fall to the floor when you moved if you weren’t careful. In contrast, the newer Rappaport-Sprague style on the guy in image #2 has long tubing made for neck draping. The plastic tubing versions made 50 years ago, and there were those, also had shorter tubing; now they are much longer, like the one sported by the guy in image #1. So let’s focus on the interesting matter of tubing length, because I think it tells us something about the sociology of medicine. It requires we consider for a moment the origin of the stethoscope and conventions of how physicians examined patients.

Until late in the 19th century it was common for physicians not to examine patients at all. They would often render a diagnosis based on the patient’s story. The notion of how useful is touching, examining the patient came with the growth of scientific medicine, as well as some changes in social conventions. The stethoscope as a tool to listen to the internal organs was invented by Laennec, who devised a wooden tube like the one below. The traditional story is that he first used a tube made of rolled paper, purportedly because the patient was a women and it was ungentlemanly for him to touch her or place his ear to her chest.

My first stethoscope with its shorter tubing made auscultation a more intimate act than today’s version; you had to lean closer in to the patient. I think that’s a socially signifiant difference. Some might say the longer tubing is there because it makes taking the blood pressure easier, but I don’t buy that. For one thing, blood pressure measurement works just fine with shorter tubing. For another, these days blood pressure is generally taken with an automatic machine rather than manually. In a real sense we’re now more distant from our patients.

The stethoscope itself is becoming less and less used in practice. I still find it very useful in the PICU every day, but it’s not unusual to find on daily rounds that a student or resident hasn’t used one in their daily examination of a patient. I think one thing that keeps it going is not so much its function as a tool but rather as a key part of a physician’s regalia, a badge that proclaims status. Just look at all the stock internet images of people posing with one prominently displayed. But like the white coat that once indicated physician status, but now is worn by everyone, you’ll find a stethoscopes hanging on necks everywhere. What I see now is an interesting sort of countertrend; many senior physicians no longer carry one. When they want one they just borrow one from the dozens available around the PICU.

You can read another take on these trends in this essay from The Guardian. It points out how several aspects of medical practice we take for granted, including the use of the stethoscope, were fostered by the social changes of the French Revolution. I recommend it.

 

 

It’s nuts, but some people still don’t put their children in car seats

August 13, 2018  |  General  |  No Comments

I would think by now that I wouldn’t have to write anything about the importance of child car seats. But I find I do, because I still see as I drive adults holding babies and toddlers over their shoulder, often while sitting in the front seat. This has been illegal in most places for many years, but it is still common and it is still stupid and dangerous. I also still see the results–several children each year come through the PICU who were unrestrained passengers in a car accident, and a few of them die. A recent CDC study found that around 600,000 children ride unrestrained at least once in a given year. Interestingly, and not surprisingly, children riding unrestrained are often in vehicles in which the driver is also not wearing a seat belt.

Here are some recent statistics on car seats and motor vehicle accidents. In 2015 nearly 59,000 children under the age of 5 were injured in motor vehicle accidents, 8% of them seriously, and about 1% died. This amounted to 471 children. Significantly, over one third of the children who died were unrestrained.

Most of us have been lectured to about these things, but I have found many parents have difficulty understanding notions of statistical risk. For example, one study showed 72% of parents were seriously afraid their child would be abducted by a stranger. That is, I suppose, a legitimate fear, but it is not very likely to happen; in fact, it is vanishingly unlikely. It is only one-fourth as likely as you getting struck by lightning.

My point is that parents should do what they can to reduce the chances of their child suffering harm: by all means tell your child about what to do when approached by strangers, but also please buckle them into a car seat, preferably in the back seat, when you drive anywhere with them, even a short distance.

You can find an excellent overview of all manner of car seats and how to use them here.

Don’t let patient care interfere with documentation

August 11, 2018  |  General  |  No Comments

I’m being sarcastic, of course, but that’s often how it seems some days. Those are days when I’ve been busy at patients’ bedsides all day and then struggle to get my documentation done later, typically many hours later. I jot notes to myself as I go along, but it can be hard to recall at 5 PM just what I did and why at 8 AM.

It used to be very much the other way, and that wasn’t always a good thing either. Years ago I spent months going through patient charts from the era of 1920-1950. They were all paper, of course, and the hospital charts were remarkably thin, even for complicated patients. I recall one chart in particular. It was for a young child who was clearly deathly ill. The physician progress notes for her already prolonged stay in the hospital consisted of maybe 2 sheets of paper. Most of the daily notes were a single line. I could tell from the graphs of the child’s vital signs — temperature, pulse, breathing rates, and blood pressure — that one night in particular was nearly fatal. The note the next morning was written by a very famous and distinguished physician. I knew him in his retirement and he was a very loquacious man in person. His note after the child’s bad night was this: “mustard plaster did not work.” If I were caring for a patient like that today there would be just for that day and night multiple entries probably totally several pages on the computer screen.

Patient charts are burdened with several purposes that don’t always work together. The modern medical record as we know it was invented by Dr. Henry Plummer of the Mayo Clinic in the first decade of the twentieth century. Up until that time each physician kept his (only rarely her) case notes really as notes to themselves. When the multi-specialty group appeared, and Mayo was among the first, the notion of each physician have separate records for the same patient made no sense; it was far more logical to have a single record that traveled from physician to physician with the patient. That concept meant the medical record now was a means for one physician to communicate with another. So progress notes were sort of letters to your colleagues. You needed to explain what you were thinking and why. Even today’s electronic medical records are intended to do this, although they do it less and less well.

Now, however, the record is also the principal way physicians document what they did so they can get paid for it. Patient care is not at all part of that consideration. The record is also the main source for defending what you did, say in court, if you are challenged or sued. The result is that documentation, doctors entering things in the record, has eaten more and more of our time. Patients and families know this well and the chorus of complaints over it is rising. Doctors may only rarely make eye contact these days as they stare at a computer screen and type or click boxes. But we don’t have much choice if we are to get the crucial documentation done. That’s how we (and our hospitals) are paid and payers are demanding more and more complex and arcane documentation. I don’t know what the answer is, but I do think we are approaching a breaking point. We are supposed to see as many patients as we can. But the rate-limiting step is documentation.

To some extent we brought this on ourselves. In our fee-for-service system physicians once more or less said to payers: “We did this — trust us, we did it — now pay us for it.” I can’t think of a formula more guaranteed to cause over-utilization or even outright fraud. But there is only so much time in the day. In my world an ever smaller proportion of it is spent actually with the patient.

“This kid looks sick.” Some evidence for the power of experienced observation of patients’ faces

July 22, 2018  |  General  |  No Comments

Anyone who has worked in medicine for a long time well understands the power of the statement coming from an experienced person: “This kid looks sick.” That person could be a physician or nurse. Years of experience does tend to give one a sort of sixth sense for when to worry something serious is going on that just hasn’t shown itself fully yet. Seasoned parents can often provide the same perspective. A fascinating recent article pertaining to this appeared in Critical Care Medicine, the journal of the Society of Critical Care Medicine, entitled “What faces reveal: a novel method to identify patients at risk of deterioration using facial expressions.” It suggests an empiric perspective for studying just how this phenomenon may work. It’s not about children, but the findings could easily apply to pediatric patients.

The authors include experts in empirical evaluation of facial expressions, broken down into something called “action units.” This is a scientific field I have to say I had no idea even existed. They used video recordings of 34 patients identified by nursing as potentially, but not yet, deteriorating clinically. The patients were then followed in time to identify those who ended up in intensive care for deterioration and what their faces were doing just before that. They also used a standard measure in the UK for deterioration termed the National Early Warning Score. This is based on objective measures such as heart rate, respiratory rate, level of consciousness, and other things that can be measured. The video recordings were analyzed by observers trained in this sort of thing but who were blinded to who deteriorated and who didn’t to see if subtle facial signs predicted this. You can look at the paper for the minute details, but some of the most useful distinguishing features were overall head position and what the person was doing with their eyes. I sure have seen that aspect in action. For example, a very useful observation when evaluating a child with respiratory distress is to look into their eyes: Are they paying attention to anything besides breathing? Can you distract them?

The authors provide some visual illustrations of what they are talking about, including this famous painting (the AU categories are some of their analytical tools):

Painters have been capturing face expressions since antiquity. The painting “The Dead Christ Mourned” by Annibale Carracci (1560-1609) is striking in its composition. Carracci showed the same facial expression in the dead Christ and Madonna, clearly displaying . . . AU 15 (lip corner depression), AU 43 (eye closure), AU 51 (lateral position of head), and AU 25 (lips parted).

The authors think their methods might be incorporated into standard evaluation systems. Maybe. What I think is their work validates what we have known for years. When experienced clinicians look at a patient, they unconsciously incorporate into their assessment what they have gleaned after years of looking at sick people and what happens to them.

Here’s another interesting example. Separating the very ill and liable to deteriorate from the not-so-sick is a perennial challenge in the emergency department setting, particularly in pre-verbal children. Untold numbers of research studies have tried to come up with something, anything, perhaps some blood test, that could help in this sifting process. Not surprisingly, it turns out the most useful measure for children is for the most experienced person in the room to say: “That kid looks sick.” When you hear that, believe it.

Anyway, I find this work fascinating as an example of how cross-disciplinary research can work, and I applaud whichever author first thought of it. I believe the article is behind a paywall; if anyone can’t get access to it and wants a copy, let me know via the contact form on my homepage.

Can young physicians be taught empathy, or is empathetic capacity innate.

June 26, 2018  |  General  |  No Comments

(I posted a version of this little essay some years ago at the request of Maggie Mahar, but I think it’s an important issue that’s worth dusting off and putting out there again.)

We want competent physicians, but we also want compassionate ones. How do we get them? Is it nature or is it nurture? Is it more important to search out more compassionate students, or should we instill compassion somehow in the ones we start along the training pipeline? I think the answer lies in nurturing what nature has already put there.

My background is in pediatric critical care, which I have practiced for thirty-five years. Throughout most of my career I have taught medical students, residents, and fellows. So I have seen young physicians as they made their way as best they could through the long training process. I also served on a medical school admissions committee for some years and interviewed many prospective students, so I have had the opportunity to see and speak with them before the medical education system even got hold of them. I think the main principle to keep before us is not so much to figure out a way to teach compassion, but rather to devise ways such that the training process does not reduce, or even extinguish, the innate compassion all humans have toward one another. Unfortunately, our current way of doing things does not do a very good job at that task. But I do not think our present state of affairs is anyone’s fault. We are hobbled by our success. Some historical background is helpful, I think, to explain what I mean.

When my grandfather graduated from medical school in 1901 he had only a few tools to help the sick. He could do useful things to help injuries mend. He had the newly discovered techniques of aseptic surgery, as well as ether to allow him to do it painlessly. Other than that, though, he did not have much – narcotics to relieve pain, powdered digitalis leaf to help a failing heart, and a few other things. Mostly, though, he had bagful of useless nostrums. Some of them were even harmful. Because he had little to offer, compassion figured prominently in whatever therapy he did. It had to.

When my father graduated from the same medical school in 1944, things were better. Surgery had advanced further from his father’s day, although only brave surgeons entered the chest cavity. There was sulfa, and penicillin soon became available, working miracles with previously deadly infections. Streptomycin and later drugs made the scourge of tuberculosis treatable. He soon had some drugs to treat high blood pressure, which by then had killed his father, plus a rapidly enlarging stock of other useful drugs to put in the black bag he took on house calls. But there were still many things for which he could do nothing. For a heart attack he gave some morphine to take away the pain and then waited to see what happened. If a cancer could not be removed surgically, he had nothing to offer. Although my father’s black bag held more than his father’s had contained, compassion was still a crucial part of my father’s armamentarium. As for his father, it had to be.

I graduated from medical school in 1978. If scientific medicine was just spreading its wings during my father’s training, I experienced it in full flight. By then our medical-industrial complex had rolled out nearly all of the varieties of therapies we have still, although of course we have polished and improved them. What has happened, I think, is not that we have become less compassionate on purpose, but that we came to act as if we no longer needed the compassion of my father or my grandfather’s era, now that we had so many really useful and exciting therapies to offer.

I also think one other historical change is key to understanding how our young doctors react to the experience of seeing death and dying. In my grandfather’s era, it was an unusual person, even an unusual child, who had not personally seen someone die. Children and young adults saw how those around them behaved and reacted to death. If they became doctors, both they and their patients had shared this common experience, so both knew how to act. I saw death for the first time when I was sixteen on my very first day working as an orderly in our local hospital. I was giving a bath to an old man; he looked at me oddly, and then he was dead. None of my friends or schoolmates had ever seen such a thing. I still recall it vividly. I also remember well how helpful the nurses, all women in their fifties or sixties, were to me afterwards. I watched them wash the body, a once sacramental task now largely done by nurses in hospitals instead of families in their homes. They were respectful, but matter-of-fact as they went about it. After all, it was a natural thing.

I think compassion for others is innate in all of us, although it is stronger in some than in others. All of us possess an inner light. Perhaps that opinion makes my theology show, but I think it is fair to say our medical school selection process already skews toward selecting students more compassionate than the average person. We need to encourage that quality, certainly, but that is not the key issue in my mind; mainly we need to prevent medical training from driving it into the background, belittling it, or even snuffing it out. So I do not think we need so much to ponder how to teach compassion as we need to find ways of letting students’ natural humanity shine through. For medical educators, that would seem to me to be good news. Framed that way, it ought to be doable – but how?

There are many things in medicine that can be taught with the old “see one, do one, teach one” model that those of us older than fifty remember. We also remember never seeing a faculty attending physician in the hospital at night, because, after sundown, the place belonged to the residents. Even during the day, attending physicians were more likely to be found in their offices or their research laboratories than out and about on the wards. I learned how to intubate a baby and place an umbilical artery catheter from my senior resident, who had learned the year before from her senior resident. But my senior resident was not much help when a premature baby died; she was as much at sea as I was. All she had learned about that from her senior resident was to cultivate a sort of hard-boiled persona. We aspired to it partly because it gave us a mental escape hatch in those situations. But mainly it was because nobody showed us any other way.

How to show that other way? In my mind, there is no substitute for senior, seasoned physicians demonstrating, in the moment, how to let out our own innate empathy and compassion. Good, experienced physicians are comfortable admitting their medical ignorance and failures to families; nothing terrifies residents more than that. When they see it in action, students and residents respond with a version of: “That’s why I became a doctor.” Structurally, medical education has already made great strides in the right direction. We now have rules for resident supervision that involve much more oversight, even at night, than I ever had. This was done mostly for patient safety, I think, with education as a secondary and really unintended consequence.

So the opportunities are there – we just need to implement them better. For example, after an unsuccessful resuscitation and a death, the folks with the grey hair should spend as much time discussing with students and residents the psychic dimensions of the death as they do the sequence of medical decisions. Most of my colleagues already do that to varying degrees, but it should be an expectation.

We should never again send a resident, alone and emotionally at sea, to comfort a grieving family without backup. We do not do that for complicated invasive procedures; we should not do it for this other, equally important task either. Certainly some organized instruction – seminars, discussion groups, lectures and the like – can be part of the process. But the training curriculum is already stuffed with subjects. Taking residents by the hand and leading them through these experiences does not require another fat syllabus. It only takes a little time. If we want to foster compassion in our students we should ourselves show them compassion for the situations we put them in. We should let their innate, inner compassion and empathy find an outlet and breathe free.