Archive for the ‘Medical problems’ category

Child dying? Call your insurance company, first!

January 5, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

The action steps, in any health emergency, are: ABC. Airway, Breathing, Circulation. The airway has to be open, the patient has to be making an effort to breathe, and the heart has to pump blood. In any emergency, health care people are trained to address these, one by one, in order. Fix what you can before moving on, and concentrate on what’s going to kill the child first. Then, arrange transport for definitive care. That’s the core of life support, and how health care people are trained to respond to an emergency.

But in today’s enlightened times, health care isn’t run by people trained in health care. It’s run by bean-counting administrative flunkies who care only about saving costs.

Here’s this week’s true story: A child presented to my office in severe respiratory distress. He was not breathing well. In fact, he was barely breathing at all. We gave oxygen and supportive care, but he still needed more help—so we called an ambulance to transport him to the hospital. There, he was admitted to the ICU and received expert, life-saving care. He’s now doing fine.

Except his family now has to deal with a second nightmare. To get an ambulance to transport him, we called 911, and the county 911 service did what 911 services are supposed to do–they sent an ambulance over right away, with oxygen and trained people to get him quickly where he needed to be. But that specific ambulance company was “out-of-network”—that’s not the ambulance company that the family’s health insurance company wanted him to use. So the ambulance trip goes to “out-of-network” benefits, at a lower coverage rate with a separate deductible. And the family owes $1900 they can’t afford.

Bean-counting administrative flunky: Hello, sorry for the 30 minute wait, can I help you?

Mom: My child is blue and dying. Which ambulance company should I call for in-network benefits? Money is tight.

Bean-counting administrative flunky: Please enter your 15 digit member ID number, or say the numbers out loud.

(Etc, etc. After another 45 minutes Mom gets a straight answer to call Bob’s Ambulance Company. Bob and ambulance arrive 30 minutes later. The child is dead.)

Seriously: even if mom knew the name of the ambulance company that was “in-network”, she doesn’t get to choose what ambulance comes when she calls 911. They send whoever’s closest, whoever can help—that’s what a health provider is supposed to do. Help the patient. Unlike, obviously, the insurance company.

Bean-counting administrative flunky: Hello, sorry for the 30 minute wait, can I help you?

Mom: My child is dead. Which mortuary should I call for in-network benefits?

Bean-counting administrative flunky: Please enter your 15 digit member ID number, or say the numbers out loud.

The Affordable Care Act has helped many more people get health insurance. But the insurers are still in the business of making money, not in the business of providing health care or paying for health care. They don’t make their money by paying bills. They make their money by doing whatever they can not to pay the bills. If you want to get them to actually pay for your health care, you’ve got to know the ins and outs of the contract, and you’ve got to steer services to “in-network” providers– that includes hospitals, docs, pharmacies, and even ambulance companies.

Child dying? Forget the ABCs of airway, breathing, and circulation—your first call, now, is to your insurance company*. Do a crossword while waiting on hold. And maybe give your child a little oxygen, while he waits—just don’t expect the insurance company to pay for it.

*Though this post was 100% true, the advice in the last paragraph was “snark”, for comedic effect and narrative impact. If your child is very sick and you need an ambulance, call 911 right away. Do not call your insurance company. Later, you may have to straighten out some bills—but take care of your child, first, always.

Some bad news about flu this year

December 8, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

We could be in for a rough influenza winter.

First, data just released from the CDC shows that a lot of the flu circulating in the USA isn’t a good match for the strains in this year’s flu vaccines. About 82% of flu since autumn is a type A H3N2, one that historically has been associated with more-severe illness. Of those, only about half are closely related to the A/Texas/50/2012 strain that was chosen in February to be included in the vaccine. Unfortunately, current methods of vaccine production take a long time, and manufacturers have to commit early—months ahead of time—to what will be included in the vaccines. In February, when the World Health Organization made their recommendations for the Northern Hemisphere 2014-2015 flu vaccine, they chose the H3N2 that was then in circulation. Since then, it’s “drifted”, or changed, to a related but non-identical type.

What this means is that the current vaccine is well-matched to only about 40% of circulating flu. The vaccine will probably offer some protection against the other 60%– illness will be milder and shorter—but a lot of people who got their flu vaccines are still going to get the flu, and spread the flu. Now, some protection is still better than none, so I’d still go and get that flu vaccine now if you haven’t gotten it already. An imperfect (or, honestly, far-less-than-perfect) flu vaccine is better than none. But it isn’t looking good this year.

And it gets worse. It’s becoming increasingly clear that Tamiflu, the anti-viral medication we rely on to help treat influenza, doesn’t work very well. As summarized by the Cochrane Collaboration earlier this year, studies show that Tamiflu is only modestly effective in reducing the length of influenza illness, and may be only slightly effective at reducing complications. If it does work for treatment of flu, it works best when started very early in the course of the illness. The FDA labeling calls for it to be started within 48 hours, but honestly it seems to barely work if started that late. Better to get it started within 24, or even better, 12 or 6 or 2 hours.

In practice, Tamiflu really doesn’t seem to do much of anything for most of the flu patients seen in hospitals and doctor’s offices, because we usually see patients too late. It does have a role in helping family members at risk for flu. They can start it immediately, at the first symptoms, and will probably get more benefit.

Tamiflu can also be used as a prophylactic, or preventive, agent in people exposed to flu with no symptoms, though again, the benefits are modest at best. Crunching the numbers, we probably have to treat about 33 people on average for just one person to benefit from prophylaxis. That’s not very good, especially considering that all 33 people will have to pay for it and risk the side effects.

And Tamiflu does have some significant side effects. Nausea and vomiting are quite common, but the scarier reactions are depression, hallucinations, and psychosis. Neuropsychiatric side effects are most common in people of Japanese ancestry.

So: the flu vaccine, this year, will probably offer only modest benefits. And Tamiflu really has very limited usefulness. It looks like we’d better prepare for a rough winter, and keep in mind some of the old-fashioned ways to keep from getting the flu:

  • Stay away from sick people.
  • If you’re sick, stay home.
  • Keep your mucus to yourself—sneeze into your elbow, or better yet into a tissue. And then wash your hands.
  • Don’t touch your own face. Flu virus on your hands doesn’t make you sick until you help it get into your body by touching your eyes, nose, or mouth.
  • Wash or sanitize your hands frequently, and especially before touching your face or eating.

Not everything is an illness

December 4, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

A thought provoking article in the November, 2014 edition of Pediatrics highlights a growing problem with modern medicine: just because we can make a diagnosis doesn’t mean we should.

The article, titled “Overdiagnosis: How our compulsion for diagnosis may be harming our children”, has been made available for free to everyone. It’s fairly dense and technical, but if you’ve been following this blog I think you can handle it. The article challenges a lot of assumptions we’ve gotten used to making. It turns out that early detection and diagnosis of scary things like cancer is not always a good idea, because sometimes these conditions improve on their own. And making these sorts of diagnoses can cause a lot of harm, including the costs and worries and medical risks of invasive testing and the side effects of medications. The drive to finding diagnoses early may be increasing the number of people with health conditions without actually improving anyone’s health.

“Overdiagnosis” is the term used when an abnormality is found, but detection of that abnormality doesn’t actually benefit the patient. Some examples:

Skull fractures after head trauma – Simple, isolated skull fractures have an excellent outcome without any intervention. Yet children who are diagnosed with skull fractures often are hospitalized and have multiple CT scans.

Increased cholesterol – A 2011 guideline suggests screening lipid panels for children starting at age 10. Following those guidelines, about 200,000 children would be found each year who would qualify for treatment, though there are no studies of the long-term risks and benefits of treating most cases of increased cholesterol in children.

Food allergy – About 17% of children, overall, will show “sensitization” to at least one food on testing; but only about 2.5% of children are actually allergic to food. In other words, most children who test positive for “allergy” to foods are not allergic and don’t need to change their diet.

GERD – “Gastroesophageal reflux disease” is very often diagnosed in babies, especially fussy babies, despite their being very little evidence that reflux causes fussiness or that reflux medication helps in most cases.

Neuroblastoma – This scary, potentially devastating cancer of early childhood can be diagnosed very early by screening urine tests. But early screening in this manner picks up lower-stage cancers that can regress without therapy. Studies of mass screenings for neuroblastoma show that screening does not reduce in the incidence of end-stage cancer or mortality.

What’s the harm in overdiagnosis? There are physical effects—the dangers posed by further medical testing and treatment. These diagnoses sometimes lead to a cascade of confirmatory tests and invasive procedures. There’s also the psychological cost of worry, and of children and parents falling into a belief that their family is vulnerable and unhealthy. And the financial strain can be considerable, potentially diverting resources from genuine health needs that should have been addressed.

As I’ve said many times, doctors need to be humble. What we think we know may not turn out to be right, and more and more screening and diagnosing may not always be what’s best for our patients. We’re not the only guilty ones—there are plenty of worthless pills pushed by alt-health providers and pharmaceutical firms, and plenty of “non-diagnoses” being made by quacks eyeing your wallet. Sometimes the hardest thing to do is nothing, and the hardest diagnosis to make is “you’re fine.” That’s why it’s up to physicians to do it right.

Food allergy testing: Do those big panels work?

December 1, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Theresa asked about eczema (see last post), and also asked about food allergy panels. Does all of that testing help?

Well, usually, no.

It turns out that allergy testing (whether done by skin scratches or blood tests) doesn’t even test for allergy. We sort of smudge through that distinction, because it’s complicated. But it’s time for someone to spill the beans about this kind of testing, and here at The Pediatric Insider, we’re all about telling you guys “the real deal”—the inside info that docs typically keep to ourselves. Here’s something you may not want to hear: “allergy” testing is, well, just not very good.

Let’s start basic. An “allergy” is an adverse reaction (a bad thing, some kind of symptom) triggered by an exposure to something, and caused by a reaction of the immune system. It requires symptoms of some kind, and requires the symptoms to be caused by an immune reaction of some sort.

A broader term, “adverse reaction,” includes allergies but also non-immunologic reactions to things. For instance, many people get bloaty and gassey after ingesting milk. That’s typically caused by lactose intolerance, an inability to digest milk sugar that has nothing to do with any allergy. Still, lactose intolerance and gluten sensitivity and many other reactions are sometimes lumped in with allergies. They’re not allergic, and no “allergy testing” of any kind could possibly identify non-allergic reactions.

Also, allergy – an allergic reaction – requires some kind of symptom, and the symptom ought to be reproducible after exposures. Allergy “testing” often reveals “positives” to foods or other things that upon exposure doesn’t actually trigger a reaction. If eating a food you’ve tested positive for doesn’t cause a reaction, you are not allergic to the food. Period. Allergy requires symptoms.

And that’s the biggest issue with allergy testing—because these tests don’t test for allergy. They test for “sensitization”. They show that your immune system has the capacity to react to the substance, but that doesn’t necessarily mean that you will react to the substance.

I can’t tell you how many times I’ve heard from families who tested positive for food XX, though they’ve never had a reaction to XX—and in fact, they used to eat XX all the time. If your child eats peanuts routinely and doesn’t have a reaction, it doesn’t matter what the allergy testing shows. He is not allergic. The test shouldn’t have been done in the first place.

There are other problems with allergy testing. Though individual tests can fairly accurately say who is sensitized, each test does have a chance of a false result. If the rate of an incorrect test is, let’s say, 5%, that might sound pretty good. But what if you do a panel of 40 foods, each of which has a 5% chance of a false result? There’s a 88%* chance you’ll get at least one false positive. If the panel is large, you’re going to get false results. The larger the panel, the more wrong answers you’ll get. What then?

Another problem: there are a lot of ways to do allergy testing, and they’re not all the same, and I most families have no idea what they’re getting into. The current, most reliable blood testing for sensitivity is called a Cap-RAST or ImmunoCap, and it tests for specific IgE molecules. Older tests are far less accurate, and some still in wide use are as worthless as flipping a coin. If you are going to do allergy testing, you should at least do the best one. Skin testing, too, has different reagents and methods, and it can be difficult to know if what’s being done is the most-reliable testing.

About skin tests: they’ll be unreliable if the patient has been taking antihistamines, and they’ll be less reliable if the patient has a skin condition like eczema, which causes high overall IgE levels and a sort of overall hypersensitivity that leads to many false positives on both skin and blood testing. Testing children with eczema is fraught with peril, which is one reason many dermatologists aren’t keen on addressing the possible allergy-eczema connection.

Still, allergy testing can sometimes help, if you keep these points in mind:

  • Consult with a board-certified, genuine allergist. Many companies market allergy kits and tests and things for general practitioners and ENTs and who knows who else. They’re a big money maker, but we really don’t know what we’re doing with them or how well they work. Please stay away from alt-med practitioners who claim to be able to diagnose allergies by holding your hands or waving vials about or using some kind of elecromagnetic hyperscience quantumconfusionating walletemptier.
  • Test only for foods or other allergens that might be causing a reaction. Foods that are eaten routinely without problems are NOT allergies (and testing will lead only to confusion); foods that always do cause a reactions ARE allergies, and don’t have to be tested. Only test the grey-zone, “maybe” foods, or you’re asking for trouble.
  • Test a limited number of foods. Almost all food allergies are to a small number of candidates: milk, egg, wheat, soy, shellfish, fish-fish, peanuts, and treenuts. Tests for mustard and plantain and okra and lamb are unlikely to yield useful results, and might upset the lambs.
  • Think of allergy testing as a starting point, for clues to what might be a real allergy (positive tests), and clues for what are probably not causes of allergy (negative tests.) Under most circumstances, unless there’s been a life-threatening reaction, you have to confirm ‘allergy testing’ with deliberate exposures. And if there has been a life-threatening reaction, you probably already know what the trigger was—so why do the test?

* It has been a long time since I did statistics. What I did was figured the 5% chance of a false result on one test means that 19/20 times the test will be correct. So if you’re doing that 40 times I figure the chance of 40 correct tests in a row is 19/20 raised to the 40th power = ~ .12, and the chance of that not happening is 1-.12 = 88%. Am I even close? At The Pediatric Insider we welcome comments that point out boneheaded mistakes. Be gentle.

Allergies and eczema: Are they related?

November 24, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Theresa wrote in, “I’d be interested in seeing an article about the connection (or lack thereof) between food allergies and eczema. Also interested in the helpfulness (or lack thereof) of large blood panels for food allergy testing.”

Two good topics—and I’ll get to food allergy panels in the next post. First: What’s the connection between allergies and eczema?

Eczema is by far the most common chronic skin condition pediatricians see. It’s present in about 1 in 3 young children, or maybe more if you count the milder cases. In fact, if you look closely enough, just about every child has at least some eczema. It’s usually mild, and improves nicely with good skin care and the occasional use of low-strength topical steroids.

What causes the itchy, scaly, red rash? Many things seem to contribute: dry skin, rough fabrics, and scratching all make eczema worse. It often runs in families, and often occurs in the same children who later go on to have allergic rhinitis (hay fever), asthma, and food allergies (those conditions, as a group, are called “atopic.”) Eczema is also called “atopic dermatitis”—atopic referring to inflammation and sensitivity, typically caused by an allergic trigger. These conditions are all interrelated, and often co-exist. So is eczema, the rash, caused by a specific, identifiable, and avoidable allergic trigger?

There’s the controversy.  If you ask allergists, they’ll say “probably yes.” They stress identifying and avoiding specific triggers, typically one or more foods. Sometimes their advice is guided by allergy testing, or sometimes just by history, and sometimes by trial and error. Just avoid food X, and if that doesn’t work, avoid food Y. If there is an allergic food trigger, it’s probably one of the common food allergies, like egg, milk, wheat, soy, fish, or peanut. Maybe try avoiding those.

But it’s hard to avoid all of those foods—and “testing” will often lead to false positive or negative results. If food allergy does trigger eczema, it does it slowly, so it may take several days or weeks of restrictions and reintroductions of multiple, overlapping foods to figure this out. Meanwhile, Junior is still itchy. So the dermatologists take a different approach.

If you ask dermatologists if eczema is caused by food allergy, they’ll say “probably no.” They stress taking care of the skin (using good bathing techniques, moisturizers, sometimes topical antiinflammatory medications, and sometimes agents to reduce bacterial colonization.) Just treat the skin, that’s the dermatologists’ motto. We can make this better, and quickly, without anyone going hungry.

Now, if you ask pediatricians if food allergy causes eczema, we’ll say “sometimes.” Though some of us are probably more allergy-focused than others, most of us probably favor practical advice: for mild-to-moderate eczema, it’s usually best to focus on good skin care, and treat the eczema, and get Junior feeling better. IF initial, safe therapy doesn’t work, or if the eczema is severe, then we’ll also try to identify food triggers—though we’ll keep up the good skin care at the same time. One approach doesn’t mean you can’t also follow the other. And, in fact, the best dermatologists and allergists will also recommend this kind of middle-of-the-road, practical advice.

What about those food allergy panels Theresa asked about? Short answer: They don’t work, at least not if your goal is to figure out what your child is allergic to. More in the next post.

What belly aches need to go to the Emergency Department?

November 20, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Giving advice over the phone is always tricky. I can’t see your child, I can’t see the chart, and I can’t get a detailed history or any physical exam at all. After-hours calls aren’t really to make diagnoses or give detailed medical advice—they’re really just for me to try to make sure your child is safe to wait until the next day to see us in the office. If not, it’s off to the Emergency Department. Believe me, as long as it’s safe, I’d really like to keep you away from there.

One of the most common “do I need to go to the ED?” calls are about belly pain. Kids get a lot of belly aches, from all kinds of things, and obviously most of them don’t require emergency care. Except those that do: appendicitis tops the list, but also bowel obstructions or ovarian torsion or a handful of other things that really can’t wait until the next day. So how can I know, over the phone, if you really do need to take your child to the emergency department?

Disclaimer: I haven’t talked to you, and I’m not your kid’s doctor, and I’m not giving you specific medical advice here. If you’re thinking your child has a bad belly ache, call your own doctor for specific medical advice. Stop looking things up on the internet—there are too many weirdos out there giving out poor information, and you’re wasting your time. Go pick up your phone and call your own doctor, now. And thanks for visiting my blog!

These are the questions I ask, things I’ve found can help distinguish which belly aches need immediate evaluation:

How does your child look, overall? A child who’s very pale or grey or barely moving needs to go to the ED. If he says it hurts but he’s walking around and looks pretty good, it can probably wait.

If the belly actually tender? Tender means “hurts to touch.” I’ll ask parents over the phone to gently squeeze the belly, here and there. Don’t ask your child if it hurts, just watch his face—if he grimaces in pain or pushes your hand away, the belly is tender. That means: to the ED.

What other symptoms are there? Frequent or forceful vomiting is concerning, especially if there’s yellow or green tint from bile. Really, any combination of serious symptoms along with belly pain are likely to lead to an ED referral.

How long has this been going on? Belly aches that have been going on for many days or weeks or months are much less likely to be an emergency than belly aches that just started, or are intensely worsening over a few hours.

Where does it hurt? Belly aches in the center of the abdomen, near the belly button, are less likely to be caused by something that needs urgent attention than belly pain in the corners, away from the center.

There’s more to phone medicine than these questions, but that’s a pretty good start. Again, if you’re worried, call your own doctor for specific advice about your own child. Most belly aches can be safely managed at home, but every once in a while there’s a serious emergency brewing. Give your doc a call with the answers in mind to these questions, and you’ll be able to get better advice to make sure your child is OK.

The best helmet to prevent football concussions is….

November 17, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Marshall wrote in: “My son has just had his 6th concussion this season in football. What’s the best helmet to use? I want to keep him safe.”

Marshall, football helmets are there to protect the scalp and the cranium—the bones outside of the brain. They prevent scalp lacerations (cuts), and probably prevent skull fractures. But helmets do not protect the actual brain. There is no helmet, and has never been a helmet, and never will be a helmet, that actually prevents brain injury from concussions.

Concussions aren’t caused by the head hitting another head, or a head hitting a wall. They occur inside the skull, when the brain slams into the inside of the cranium during a rapid deceleration. The brain is a soft, squishy, and very important organ suspended in essentially a bowl of water. If you drop that bowl off of your roof, say, the bowl might shatter on the ground (like a skull fracturing). But even if the bowl doesn’t break, the brain suspended in the water will suddenly go from moving very fast to not moving at all as it slams against the side of the bowl. That causes brain damage, and that’s what a concussion is. It’s not a broken bowl. It is a broken brain.

We diagnose a concussion if there’s been a blow to the head immediately followed by a period of altered brain functioning—dizziness, headache, foggy thinking or disrupted memory, or sometimes a loss in consciousness. Most concussion do not knock the athlete out—the immediate symptoms are more subtle. Even without unconsciousness, any concussion means that there has been brain damage. The damage is on the cellular level—you can’t see it on a CT scan or MRI, and those tests are not helpful and not needed after an ordinary concussion unless there’s a suspicion of a skull fracture or other problems.

The brain damage from a concussion will often heal, with appropriate rest and rehab; but repeated concussions or concussions with little time for recovery will lead to permanent brain damage. With more concussions Marshall’s son will develop lifelong problems with depression, fuzzy or easily-distracted thinking, movement disorders, and a genuine, marked drop in IQ. Good sleep and normal mood regulation can become impossible. These symptoms are, by and large, untreatable.

Marshall, your son will probably need his brain to work well as he grows older. If you’re serious about protecting his brain and mental abilities, he doesn’t need a new helmet. He needs to quit football.

Related posts:

Football and your child’s brain

Protecting your child from concussions


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