Stories about: emergency medicine

Science Seen: Poverty and accidental death, 1999-2012

Unintentional injuries are the fifth largest cause of death in the U.S., and these mortalities have been rising over the past decade. At the same time, more people are living in areas with high poverty levels. Are these trends connected?

An analysis published last week in PLOS One gives evidence that the answer is “yes.” Emergency medicine physician Eric Fleegler, MD, MPH, and colleagues crunched U.S. Census Bureau data against mortality data from the National Center for Health Statistics for 1999 to 2012 — providing resolution down to the county level.

Not only did fatalities increase in tandem with the level of poverty in a county, the study found, but this effect worsened over time, especially for deaths from certain causes such as poisonings, shown here. Read the details in our sister blog, Notes. (Interactive image: Erin Horan)

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My work, my life, my innovations: Eric Fleegler, MD, MPH

Emergency medicine physician Eric Fleegler, MD, MPH has been everywhere from Malawi to Rio de Janeiro making an impact and collecting experiences that inform and inspire his work. His insatiable curiosity for the world around him can be seen in the objects that adorn his office as well as in his bedside manner. “I talk to all of my patients about where they’re from because I care, and because nothing connects more than people being interested in who you are, not just your disease.”

Fleegler splits his time between treating patients, co-directing the hospital’s sedation service, developing the disease management system TriVox Health and publishing research on topics such as gun violence. “I feel totally at home in pediatric emergency medicine,” says Fleegler. “The thing I love most is being able to connect with patients who are scared and worried and make them know that it’s going to be OK. How you talk to people is a part of any good doctor’s care. We have to care for our patients holistically.”

Scroll over the items around Fleegler’s office to learn more about his life, work and innovations.

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Injectable oxygen getting closer to clinical reality

John Kheir, MD, first envisioned an injectable form of oxygen eight years ago, the night one of his patients, a nine-month-old girl, died after catastrophic lung failure. Kheir, a cardiac intensive care specialist at Boston Children’s Hospital, spoke last night to WBZ-TV’s Mallika Marshall, MD, about his efforts to try to buy precious time for children whose lungs stop working:

Want to know more? Read Kheir’s own words about his hopes and challenges for intravenous oxygen in a post he penned for Vector.

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Bronchiolitis guidelines reduce ED costs, improve care

chest x-ray
New workflows and protocols reduced chest x-rays by 23 percent, testing for respiratory syncytial virus by 11 percent, albuterol use by 7 percent and time infants spent in the ED by 41 minutes.
Bronchiolitis, a common respiratory illness among infants, is responsible for hundreds of thousands of emergency department (ED) visits each year. Best practices for managing it, established by the Academy of American Pediatrics (AAP), are fairly simple: Offer supportive therapies and let the disease runs its course, as most interventions have little or no benefit for these patients.

But despite these guidelines, bronchiolitis costs the U.S. health care system millions of dollars a year, much of that cost coming from unnecessary diagnostic tests such as chest x-rays and respiratory syncytial virus (RSV) testing.

“When a mother comes to the ED with a baby who is having difficulty breathing, it can be very frightening for her,” says Boston Children’s Hospital’s Ayobami Akenroye, MBChB, MPH,lead author of a study looking at resource utilization of bronchiolitis patients, recently published by Pediatrics. “In many cases, to help alleviate worry and ensure everything is being done to help the child, EDs will order various tests and sometimes give medication to temporarily relieve symptoms, but rarely do any of these steps impact how care is delivered or affect the clinical course of the disease. They’re usually unnecessary.”

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Consistency and cost: Why reducing variability in health care matters

Many doctors still chafe at practicing "cookbook medicine." (Tim Sackton/Flickr)
The argument that 'I do not practice cookbook medicine' still resonates with many practitioners. (Tim Sackton/Flickr)
Mark Neuman, MD, MPH, practices emergency medicine at Boston Children’s Hospital and is director of Fellow Research and Research Education. Vincent Chiang, MD, chief of Children’s Inpatient Services (CHIPS), contributed to this post, adapted from their recent commentary in Pediatrics.

It’s no secret that the U.S. health care system is in the midst of a financial crisis. As a nation, we spend nearly 18 percent of our Gross Domestic Product on health care, and health care costs remain the largest contributor to the national debt. In 2011 alone, the cost of maintaining the nation’s 5,700 hospitals exceeded $770 billion.

If ever there was a time for a societal mandate to reduce health care costs, that time is now.

It’s widely accepted that one of the first steps to reigning in runaway health care costs is reducing variability in the manner in which care is delivered. Well-defined and well-disseminated best practice guidelines can improve the reproducibility and standardization of care. In time, these guidelines may reduce costly and unnecessary tests and hospitalizations, while providing a platform on which to measure and enhance quality. More consistency may also allow providers to be more efficient with their time, space and personnel.

If it’s so costly, why is health care variability so abundant?

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Tourniquets go from combat to kids

(Scott Foresman/Wikimedia Commons)
(Scott Foresman/Wikimedia Commons)
In the aftermath of the Boston Marathon bombings, first responders did whatever they could to help victims. For many of those injured, tourniquets proved to be the difference between saving and losing a limb—or a life.

“There’s no doubt that tourniquets played a key role in treating the bombing victims,” says Boston Children’s Hospital Trauma Center Director David Mooney, MD.

Two children who were later treated at Boston Children’s had tourniquets applied at the site of the tragedy. One arrived with extensive lacerations caused by one of the two detonated bombs. The other was in worse condition, having suffered blood vessel damage among other problems. Both children are doing better, although one will require further treatment.

Dating back to Roman times, a simple tourniquet, encircling a limb just above a wound, was the go-to method to stop bleeding. Since then, tourniquets have been used on the battlefield and in emergency rooms and operating rooms. However, had the bombings taken place 10 or 15 years ago, those wounded might not have been treated with tourniquets, Mooney believes.

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“Could we have given her intravenous oxygen?” Breathing an idea to life

This syringe, containing particles of oxygen gas mixed with liquid, can potentially save the lives of patients unable to breathe — like the infant Kheir was unable to save early in his career.

John Kheir, MD, a physician in the Cardiac Intensive Care Unit at Boston Children’s Hospital, led a team that created tiny particles filled with oxygen gas, which, when mixed with liquid, could be injected directly into the blood. In an emergency, IV oxygen delivery could potentially buy clinicians time to start life-saving therapies. Kheir will recount his journey this evening at TEDMED, during the 5:30-7:30 p.m. session “Welcoming Death Into Life.” To preview his talk, we’re reprising his popular post from last year.

It was an ordinary Saturday night in the ICU at Boston Children’s, in the fall of 2006. One of my patients was a 9-month-old girl who was admitted with pneumonia, and was having trouble breathing. I had gone in to check on her just a few minutes before; although she was not feeling well, she reached out and touched my hand as I examined her. I assured her mother she was in the best possible place for her care.

Five minutes later, the code bell alarmed. Our team rushed into her room to the most horrific sight I have ever seen.

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Strategies for pediatric telehealth: Lessons from TeleConnect

Boston Children's David Casavant, MD, in a mock TeleConnect drill with South Shore Hospital.

Naomi Fried, PhD, is Boston Children’s Hospital’s chief innovation officer. Shawn Farrell, MBA, Telehealth Program Manager at Boston Children’s Hospital, contributed to this post.

Imagine yourself in an emergency department taking care of a very sick child. Should he be transferred to a higher-level care setting? Can he safely go by ambulance, rather than helicopter? As a doctor, you would like to consult virtually with colleagues and experts at remote locations.

Then imagine yourself in a large room in the heart of Silicon Valley, just a stone’s throw from Cupertino and Apple headquarters. In that room are 5,000 of the biggest thinkers in health care and technology, exploring the next major paradigm shift in care delivery: telehealth. You realize that health care is on the brink of a telehealth explosion.

The energy was palpable as I took the stage at the recent American Telemedicine Association (ATA) conference. I was there to share our experiences launching the TeleConnect program at Boston Children’s Hospital,

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Breathing an idea to life: Injectable oxygen microparticles

This syringe, containing particles of oxygen gas mixed with liquid, can potentially save the lives of patients unable to breathe -- like the infant Kheir was unable to save early in his career.

John Kheir, MD, is a staff physician and researcher in the Cardiac Intensive Care Unit at Boston Children’s Hospital. As reported this week in Science Translational Medicine, he led a team that created a method for IV oxygen delivery — tiny particles filled with oxygen gas, mixed with liquid and injected directly into the blood. In an emergency, the injections could potentially buy clinicians time to start life-saving therapies. The technology was reported by The Atlantic, Popular Science, Scientific American, Technology Review and other outlets.

It was an ordinary Saturday night in the ICU at Boston Children’s, in the fall of 2006.  One of my patients was a 9-month-old girl who was admitted with pneumonia, and was having trouble breathing. I had gone in to check on her just a few minutes before; although she was not feeling well, she reached out and touched my hand as I examined her. I assured her mother she was in the best possible place for her care.

Five minutes later, the code bell alarmed. Our team rushed into her room to the most horrific sight I have ever seen.

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Putting families back together after a disaster

Five thousand children were separated from their families in the wake of Hurricane Katrina. With the REUNITE system, Sarita Chung wants to bring families back together more quickly following a disaster. (infrogmation/Flickr)

Once we’ve checked in at the disaster aid center, a social worker leads my wife and me into a room and warmly introduces us to a pair of technicians seated at computers. After asking us each some questions, the techs enter some commands on their keyboards and pictures of children start appearing on the screens before us, nine at a time. Our job: to find and be reunited with our boys.

Luckily, this is only a drill. But in the wake of a disaster like last month’s tornadoes in Western Massachusetts, reunifying separated children and parents is a real and urgent concern.

“Five thousand children were separated from their families after Hurricane Katrina, some by hundreds of miles once the evacuations started,” says Sarita Chung of the Division of Emergency Medicine at Children’s Hospital Boston. “And the 2010 Haiti earthquake put more than a million children at risk.” Children who cannot speak for themselves because they are too young or have developmental delays, or who are injured and have to be rushed to emergency rooms, are at particular risk of being separated from their families in the chaos following a hurricane, earthquake or other disaster.

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