December 2001 • Volume 7 • Number 12
Family practice residency meets challenge of bioterrorism scare
In a matter of hours on Oct. 26, family practice residents in Harpers Ferry, W. Va., were shaken from their usual Friday routine to respond to a public health threat raised by an anthrax scare.
When an anthrax scare threatened local postal workers, Rosemarie Cannarella, M.D., M.P.H., standing at left, associate program director for the West Virginia University Rural Family Medicine Residency Program, and Konrad Nau, M.D., standing at right, residency director, organized their residents and staff to screen nearly 400 workers. The events were set in motion when Rosemarie Cannarella, M.D., M.P.H., associate program director for the West Virginia University Rural Family Medicine Residency Program in Harpers Ferry, received a call for help. Workers at a nearby mail-sorting facility had just learned that most of their mail had passed through the anthrax-contaminated Brentwood mail facility in Washington, D.C. Fortunately for the postal workers, the family practice residents had taken grand rounds on bioterrorism via teleconference the week before.
"These events shine a bright light on the ability of small rural communities to respond to the public health demands of a true bioterrorist event," said residency director Konrad Nau, M.D., who quickly assembled 10 residents and four faculty members to answer the call for help. Nurses from nearby Jefferson Memorial Hospital also joined the effort.
And although the CDC and the state health department recommended that employees with potential mail contact be prophylactically treated with antibiotics, the Harpers Ferry physicians learned that they would not have access to government stores of ciprofloxacin. Calls made by Cannarella to local pharmacies revealed that there were only 1,200 doses of the drug in the county. But the pharmacies had 4,000 doses of doxycycline -- so doxycycline it was.
The residency's nurses drew on their experience conducting group immunization clinics and school physicals to organize the effort, said Nau. They set up distribution and examination areas at a nearby fire hall and individually bagged and labeled the pills into three-day supplies.
A West Virginia state trooper later drove through the fall's first snow to bring another 6,800 doses of doxycycline, procured from the state health department. The group cheered, said Nau, and then set to work packaging enough individual dose packs to complete the needed 10-day course.
And then the patients began coming. By midnight, the staff had screened 180 mail facility employees. Dozens more streamed in over the next two days. Ninety-two of the patients had symptoms that warranted blood cultures, chest X-rays and further examination by a doctor, said Nau. Within four days, 353 employees were put on prophylactic antibiotics, and 121 employees were examined by physicians.
And although none of the patients tested positive for anthrax, Nau said he was most heartened by seeing his residents spring to action in a time of crisis.
"There was no handbook to follow here," he said. "Everyone contributed what they could in a spirit of cooperation."
Cannarella concurred. "The ability to gather so much talent so quickly, and to know that all of the resident and faculty doctors were updated in this disease and able to provide consistent exams and recommendations, was a wondrous thing to see," she said.
Senate bill could halt big cut in Medicare payment rate
At press time, the AAFP was pushing key congressional members to support a Senate bill that could prevent a 5.4 percent cut in Medicare reimbursement rates scheduled to take effect Jan. 1.
S. 1660, introduced last month by Sens. James Jeffords, I-Vt., and John Breaux, D-La., calls for a 0.9 percent decrease in Medicare payments to physicians and requires the Medicare Payment Advisory Commission to report by March 1 on replacing the formula used to calculate reimbursement rates.
Academy leaders applaud the effort. "We're encouraged that members of Congress are willing to look at the issue despite their many other pressing concerns," says Board Chair Richard Roberts, M.D., J.D., of Madison, Wis.
The Centers for Medicare and Medicaid Services announced the 5.4 percent rate cut Nov. 1. On Nov. 6, the Academy urged key legislators to freeze the 2001 payment rate, a move that would have given lawmakers a year to analyze and revise the "flawed formula" used to calculate rates.
The annual update formula is linked to the nation's gross domestic product. When the economy falters, payments decline, even though there is no correlation between GDP and patients' need for health care.
Lawmakers are beginning to understand that the formula is flawed, says Jerome Connolly, government relations representative in the Government Relations Division. Moreover, Connolly says, because of the increased pressures and practice obligations FPs face, now is not the time to hit them with a 5.4 percent cut in payments.
"We have some sympathy in Congress, which we now have to translate into genuine support for overriding this regulation. And if we're going to get a resolution to this problem, it has to happen now," Connolly says. That's because Congress is working frantically to complete legislation on bioterrorism, appropriations and homeland security before adjourning for the year.
In mid-November, the Academy urged members to send their legislators messages in support of S. 1660 through Speak Out: AAFP Legislative Action Center, at http://capitol.aafp.org/.
Help AAFP stay in touch with you
In the aftermath of the Sept. 11 terrorist attacks, it has become painfully clear that the Academy needs to be able to pass accurate information along to members quickly. To achieve that goal, the AAFP is asking all members to provide fax and e-mail information to the Academy staff.
Watch for a mailing from AAFP this month targeting members for whom the AAFP does not have this contact information.
Help the AAFP help you better serve your patients by responding to this request quickly. By maintaining e-mail and preferred fax number lists, the AAFP can provide you with the latest clinical information instantaneously.
In addition, the AAFP is posting updated information online, with links, for example, to the CDC's interim guidelines for managing exposure to anthrax.
Go to the AAFP Web site at http://www.aafp.org/btresponse/ for the latest bioterrorism response information.
7,400 send letters
Members act to prevent primary care status for chiropractorsThousands of AAFP members joined forces with AAFP leaders and brought an end to legislative language that would have given primary care provider status to chiropractors in Veterans Affairs health care facilities.
When the House Veterans Affairs Committee approved H.R. 2792 -- the Disabled Veterans Service Dog and Health Care Improvement Act of 2001 -- on Oct. 10, the Academy quickly alerted family physicians, as well as legislators, to the bill's objectionable language. The bill would have required VA hospitals to let veterans designate chiropractors as primary care providers.
AAFP members acted immediately, as evidenced by the more than 7,400 letters and e-mails they sent to Congress from the Speak Out: AAFP Legislative Action Center at http://capitol.aafp.org/. The letters and e-mails strongly objected to the bill.
"We saw a danger to patients," said President Warren Jones, M.D., of Ridgeland, Miss. "And we took action. It's our role -- as the AAFP and family physicians -- to advocate patient-centered issues. Our impact was tremendous."
Some Senate leaders since have said publicly they will not pass the legislation with language giving primary care provider status to chiropractors. A mid-November proposal from Senate Majority Leader Thomas Daschle, D-S.D., omits such language. However, the proposal does call for a four-year pilot program involving chiropractors at 80 VA facilities in 25 states.
The major problem in granting chiropractors primary care provider status, Jones said, is that chiropractors are not qualified in primary care. Their training does not include the breadth or depth of medical education required of a primary care physician as defined by major medical organizations such as the Institute of Medicine.
"I knew early on that it would take a broad coalition to fight this issue," Jones said. The Academy became a "coalition manager" and recruited other medical organizations and veterans' groups to fight the language about chiropractors in primary care.
On Oct. 17, the coalition sent a letter strongly opposing the chiropractor designation in H.R. 2792 to House Speaker Dennis Hastert, R-Ill. Joining the Academy in signing the letter were the AMA and four osteopathic medical organizations.
On Nov. 8, another coalition letter stating opposition to H.R. 2792 was sent to Daschle. It was signed by the AAFP, AMA, the Vietnam Veterans of America and 14 other medical organizations.
At press time, Congress was expected to complete its work soon on the legislation, a version stripped of the provision about chiropractors as primary care providers.
"The issue here was very clear, and the message from members was equally as powerful," said Kevin Burke, director of the AAFP Government Relations Division. "We wanted to prevent a change in the VA system. Our efforts accomplished exactly what we intended.
"It happened because of the strength of our response. This is a complete success!"
Humanitarian aid arrives in Moldova
The phrase "mission accomplished" best summarizes phase one of the Physicians With Heart airlift to Moldova in October. Despite postponement of the delegation's travel until February, 20 tons of medical/humanitarian products valued at more than $7.7 million (wholesale value) arrived safely and on schedule.
The AAFP, the AAFP Foundation and Heart to Heart International, a humanitarian aid organization based in Olathe, Kan., are founding partners of Physicians With Heart.
Miles Zinn, Heart to Heart project coordinator, was on-site in Moldova to oversee documentation and distribution of the donated medicine and supplies. He said leaders at Moldova's State Medical University in Chisinau "are eager for Physicians With Heart to follow up with a second phase that will bring the delegation to Moldova for medical symposia on family practice."
Vaccine woes
To the editor:
I am writing regarding the recent decision by Wyeth Lederle to discontinue sales of tetanus-related vaccines. This abrupt announcement was described as a "business decision" but represents serious corporate irresponsibility.
I am assuming the $5 per dose in a multidose vial of diphtheria/tetanus toxoid just isn't worth the bother in comparison with the $100 vaccines and high-priced new medications. Clearly Wyeth Lederle does not consider very seriously the potential effect of their decision on the health of the population. I am particularly concerned about this issue given the large Amish population that I care for -- a high-risk group.
I am concerned by the lack of response from the medical community. If each of us communicated our displeasure to the drug company representatives in the field, perhaps the consequences of such actions would be given more attention in the future. I am asking the local detail person not to return to my office.
James De Line, M.D.
La Farge, Wis.To the editor:
I'm responding to a flu vaccine article in the October FP Report.
I have had two out-of-town suppliers offer flu vaccine at $125/5cc vial. This happened last year! I am disgusted with these scalpers. It is time for the CDC to take over.
Sports medicine
To the editor:
I was delighted to see the special section on sports medicine in the October FP Report. As one of the new breed of family doctors, I had the good fortune of helping establish the sports medicine division at the University of Florida in the 1960s while also serving as a member of the athletic medicine committee of the American College Health Association. That committee was instrumental in convincing the National Collegiate Athletic Association rules committee to make mouth pieces mandatory for participating college and university football teams and reassessing the importance of properly designed helmets and rules changes to reduce the risk of head injuries. It also recognized the contributions of Dr. Bob Cade at the University of Florida College of Medicine regarding the value of fluid replacement in sports programs. Yep, that's where Gatorade® got its start!
It is encouraging to see that family physicians are continuing in positions of leadership in the field of sports medicine. I wholeheartedly endorse the concept of having family physicians become knowledgeable about this discipline as a component of community-centered family medicine. Building it into their active practices provides many rewards not always associated with the practice of medicine in these times of drastic changes in our profession.
Stop collaborating with nurses, others
To the editor:
I just learned that the AAFP has been working with the American Nurses Association to help nurses become legally qualified to pronounce death.
First, in New York State, most of our counties have protocols that allow emergency medical technicians and paramedics to pronounce death based on established criteria. It is required, however, that a physician certify the death, indicating the cause.
Secondly, I think our Academy should stop collaborating with nurses, physician assistants and nurse practitioners. As these groups gain increased autonomy, which they have consistently demonstrated is their goal, they have uniformly used their autonomy to attempt to usurp physicians in general, and FPs in particular.
Over 10 years ago, as a member of the New York State Academy board, I helped advocate for changes to our state nurse practice law, which ultimately allowed nurse practitioners to move closer to becoming fully qualified primary care providers.
Please, let's not continue these mistakes. I think our Academy is too concerned with supporting and collaborating with others, and not concerned enough with protecting its own members' ability to practice medicine.
How about some effort in helping FPs gain colonoscopy privileges, or in helping us keep our OB-Gyn privileges?
Mental health position paper offers 'tool' for Fps
Even though treating mental illness is an integral part of primary care, reimbursement practices discriminate against FPs, says an AAFP position paper on the subject.
"The Provision of Mental Health Services by Family Physicians" was written in response to alarms sounded by family physicians, says Sharon Sweede, M.D., of Asheville, N.C. Those concerns were not just over reimbursement, but also about the public lack of perception of family physicians' ability to provide mental health care, says Sweede, a member of the AAFP Commission on Public Health.
Managed care companies often "carve out" mental health services from primary care and may deny coverage for mental health treatment by patients' personal physicians. In order to improve mental health care, primary care physicians need to be able to treat patients and be reimbursed for that care, says Sweede.
"This information will not come as a surprise to family physicians," says Sweede. "It's important more as a tool for us to present to insurance carriers, legislators and other agencies."
That "tool" is now available from the AAFP order department. It can be ordered by calling (800) 944-0000 and asking for product #714.
Check out deadlines for awards, proposals
Some 2002 deadlines are looming for award nominations and proposals.
For more information or applications, send an e-mail to the address provided below or call (800) 274-2237 and the extension noted below.
- You might have creative ideas for beginning a research project. Submit your proposal by Feb. 22 for a new Practice-Based Research Network Stimulation Grant for Family Practice Research. Contact: smorantz@aafp.org or Ext. 4470.
- AAFP's Public Health Award honors members who have made extraordinary contributions to public health. Submit your nomination by March 1. Contact: ncrossfi@aafp.org or Ext. 3142.
- The AAFP Awards for Graduate Education in Family Practice (formerly called the Mead Johnson Awards for Graduate Education in Family Practice) have an application deadline of March 1. The awards recognize second-year residents demonstrating leadership, community involvement and exemplary patient care. Contact: mgiocond@aafp.org or Ext. 6810.
- March 15 is the deadline for proposals for workshops, seminars, lectures, papers, poster displays and special interest discussions at the 2002 Conference on Patient Education Nov. 21 24 in Fort Lauderdale, Fla. Contact: mgoller@aafp.org or Ext. 3134.
- Encourage your chapter to submit nominations for the Thomas W. Johnson Award -- recognizing contributions in family medicine teaching at undergraduate, graduate and continuing education levels -- or the Exemplary Teaching Awards -- for excellence in teaching, implementing outstanding programs and/or creating innovative teaching models. Nomination deadline: April 15. Contact: ssinglet@aafp.org or Ext. 6705.
- Chapters need to apply by April 15 for Matching Grants for Constituent Chapter Research Activities. Contact: bschoof@aafp.org or Ext. 3160.
AAFP in 2001
"Keep the faith -- good things are coming for family physicians," says (then) President Richard Roberts, M.D., J.D., as he pledges to call a member a day -- his way of staying in touch and keeping abreast of the issues FPs are facing. By the end of his presidency, Roberts calls 382 members.
- The new childhood immunization schedule includes an added vaccine, the heptavalent pneumococcal conjugate vaccine, administered at ages 2, 4 and 6 months and from 12 to 15 months. The schedule is a joint effort of the AAFP, American Academy of Pediatrics and CDC.
- At a Washington news conference, Academy leaders take to the nation AAFP's draft plan for health care coverage for all. The media ask the public to comment on the plan. Some 1,200 responses later, mostly from FPs, the AAFP Board revises the proposal (see October).
- The Board of Directors gives the nod for creating a Commission on Resident and Student Issues, in part to help combat decreasing student interest in the specialty.
FP Marguerite Duane, M.D., left, talks about family practice with a Vietnamese medical student at Ho Chi Minh Medical University
- AAFP's public awareness campaign kicks off with ads in the nation's most-read newspapers, including USA Today and The Washington Post, and through on-air sponsorship of National Public Radio's highest-rated news programs. "Today's family physicians -- specializing in all of you," proclaim the ads.
- For the first time, Physicians With Heart travels to Vietnam, delivering goodwill, family practice education and medical supplies valued at $4.25 million.
- One hundred thirteen people gather in Colorado Springs, Colo., for the first convocation of the AAFP's National Network for Family Practice and Primary Care Research. The network's goal is to get 10 percent of AAFP active members (about 5,000 practicing FPs) involved in research.
- Match numbers for the specialty's residencies drop for the fourth consecutive year as the Academy works to both understand the trend and stem the tide of students' disenchantment with the specialty.
Title VII funding "is crucial to training the physicians that America needs most," (then) AAFP Director James Martin, M.D., tells a congressional panel. The Bush administration's call for zero funds for training FPs prompts lobbying by more than 450 family physicians from spring to fall. The campaign to save the federal support works. At press time, Congress is expected to approve a level of funding at least as high as last year's funding.
- AAFP joins other organizations in developing new antibiotic use guidelines on evaluating and treating adults with acute respiratory tract infections. The guidelines aim to curb fallout from overuse and inappropriate use of antibiotics.
These family physicians and about 45 others gather at AAFP's first convocation on practice-based research (see March).
- Results of an e-Health survey show that 69 percent of AAFP members already use the Internet in their practices, reports (then) Board Chair Bruce Bagley, M.D. The AAFP wants all FPs using the Internet in their offices by 2003 and using electronic medical record systems by 2005.
- "Some physicians are afraid of using high-powered drugs, but those drugs may be what our patients need," says AAFP Director Karla Birkholz, M.D., at a news conference in Washington. She helps launch the National Initiative on Prescription Drug Misuse and Abuse, sponsored by the National Institute on Drug Abuse, the Academy and six other groups.
- About 50 family physicians "hit the hill," lobbying U.S. senators and representatives on issues such as Medicare prescription drug coverage and funding for family practice training, the National Health Service Corps and the Agency for Healthcare Research and Quality.
- News reports this spring indicate about 120 people died from misusing the painkiller OxyContin, and Drug Enforcement Administration officials suggest the drug should be prescribed only by pain specialists. "Don't restrict OxyContin prescribing rights," AAFP officers, staff and members advise the FDA and DEA. The Academy takes quick action to educate members about OxyContin abuse. In November, past President Bruce Bagley, M.D., tells state attorneys general about family physicians' expertise in pain control.
- Executive Vice President Douglas Henley, M.D., vows that the Academy will continue working through government channels to ensure that Health Insurance Portability and Accountability Act regulations are fair and doable for FPs. "The Academy will also make resources available to FPs to ease the process of complying with HIPAA," says Henley.
"As doctors, we are fighting hard for our patients," FP Darlene Lawrence, M.D., says at a Capitol Hill rally for the Bipartisan Patient Protection Act. She tells Congress, "We need you to fight hard for patients, too -- this legislation will do just that." Nearly 400 FPs send e-mails and letters to the Senate, which passes the bill. But the House adopts a narrower bill the administration supports, and no compromise is expected in 2001 or even 2002.
Families rally on Capitol Hill for a patients rights bill. The Academy championed the bill at the June event.
- After tracking the issue for years and providing feedback to the Centers for Medicare and Medicaid Services, the AAFP is pleased to report HHS Secretary Tommy Thompson's statement that HHS is taking a new approach to the development of its controversial evaluation and management documentation guidelines.
- The Accreditation Council for Continuing Medical Education awards AAFP's CME accreditation program full accreditation with commendation for a six-year period, the longest period available.
- Marshall Kubota, M.D., a member of the AAFP Commission on Public Health, represents the AAFP at a Senate forum on the impact of sexually explicit entertainment on children.
FP Marshall Kubota, M.D., discusses the impact of sexually explicit entertainment on children during testimony at a July 26 Senate forum.
- Results of the 2001 Member Attitude Survey show that a whopping 85 percent of AAFP members are satisfied with the Academy when it's compared with other medical organizations.
- Two FPs -- Paul Ambrose, M.D., left, and Frederick Rimmele, M.D., right -- die in the Sept. 11 terrorist attacks. The AAFP responds quickly to the national emergency by setting up a special hotline and e-mail address to help members volunteer for relief efforts. The AAFP also posts a list of online resources for post-traumatic stress disorder.
- The Congress of Delegates, meeting in Atlanta, takes these actions:
- -- adopts "Assuring Health Care Coverage for All," a plan for all in this country, even undocumented aliens, to gain basic health care services and caps on costs for catastrophic illnesses;
- -- grants seats in the Congress to international medical graduates;
- -- approves a position on the AAFP Board for a representative of new physicians, those in practice for up to seven years;
- -- asks the AAFP to protest unjustifiable price increases for flu vaccine and recommend ways to prevent shortages of flu, tetanus and other vaccines; and
- -- chooses (then) Director James Martin, M.D., as president-elect.
- Despite travel uncertainties after the Sept. 11 terrorist attacks, 3,794 physicians attend the Scientific Assembly in Atlanta.
- The Future of Family Medicine project is the subject of a standing-room-only meeting during the Scientific Assembly. Pondering new directions for the specialty, members crowd the microphones to discuss both practice frustrations and the rewards of the doctor-patient relationship.
- The Agency for Healthcare Research and Quality awards $750,000 in two research grants to the Academy.
- To ensure adherence to ethical guidelines, the Academy and a bevy of pharmaceutical companies sign onto a joint statement in which all parties pledge to honor guidelines on gifts to physicians from industry.
- After hearing from some 7,400 fired-up family physicians, Congress stops short of allowing veterans to identify chiropractors as their primary care physicians in Veterans Affairs facilities (see story, page 1).
- Mac Cahal, J.D., 94, the Academy's visionary first chief executive, dies after a brief illness. He served as executive director from 1948 to 1971. He received Honorary Membership in 1970.
- AAFP members receive a letter about emergency preparedness from President Warren Jones, M.D. "As sentinel family physicians," he says, "we will be able to recognize terrorist threats and events without overreacting, help patients recognize these threats without overreacting, treat our patients when appropriate, and know what, when and where to report." Jones encourages members to access resources at www.aafp.org/btresponse/.
Wound care 101: Take pains with your patients
FP James Tiemann, M.D., of Lee's Summit, Mo., one of 391 attendees at AAFP's first course on emergency and urgent care, examines Erma Fauerbach of Lee's Summit in the emergency department at Lee's Summit Hospital. Tiemann works full time in the hospital's ED, where Fauerbach was brought Nov. 3 with lower-extremity edema and shortness of breath. Sure, you've patched up your share of bumps, scrapes, cuts and other assorted "boo-boos." You've been confronted with Screaming Child, Hysterical Mom and Stoic Dad. (Or maybe it's Stoic Mom and Hysterical Dad -- take your pick; Screaming Child is the constant here.)
What may not be a constant is your approach to wound care. Indeed, different wounds in different patients require different strategies. But there are some general recommendations that can lessen patients' pain and trepidation, said Robert Dachs, M.D., during AAFP's new Emergency and Urgent Care course, held here Oct. 29 Nov. 1.
Dachs, chair of the emergency medicine department at Westerly Hospital in Westerly, R.I., presented a literature-based review of wound care dos and don'ts. Topping the list were tips on injecting local anesthetics.
Buffer it. That looming needle is bad enough, said Dachs. Take some of the sting out by buffering that lidocaine with sodium bicarbonate. A 9:1 ratio works well, he said.
Warm it. An ice cube down the back is rather jarring, don't you think? Same principle applies here. Assuming that neonatal warmer sitting in the corner is unoccupied, consider using it or another method to warm the solution before injection.
Use a small-gauge needle. Choose a 27- or 30-gauge needle, and you're already halfway to the next item ...
Emergency physician Robert Dachs, M.D., demonstrates hair tying as an alternative to scalp suturing. The technique is especially useful in young patients, Dachs said at AAFP's recent emergency care course in Scottsdale, Ariz. Inject slowly. "You just can't push as much through a 30-gauge needle," said Dachs.
Inject inside the wound. It's already open. You don't need to poke through the skin.
With intact skin (e.g., biopsy), pinch it. Using your thumb and forefinger, pinch repeatedly just behind the injection area.
Augmenting the anesthetic with epinephrine extends the numbing effect, said Dachs. Caution is justified with extensive injection of this combination into a digit when circulation may be compromised. However, he said, anecdotal reports of ischemic necrosis resulting from injection of combined solution into digit stems have created unnecessary concern.
"With a young, healthy person, if you happen to pull out the lidocaine with epi, don't worry about it," Dachs said. "You don't have to call up your malpractice attorney and say, 'Oh god, I just lopped somebody's fingers off!'"
Alternatives to lidocaine for infiltration anesthesia are plentiful. Some, such as bupivacaine, offer a longer duration of action with no loss in rapidity of effect onset.
Topical anesthetics may be just the thing for some of your youngest patients. A solution of lidocaine-epinephrine-tetracaine, or LET (also called lidocaine-adrenaline-tetracaine, or LAT), and eutetic mixture of local anesthetics cream, or EMLA, are viable options for certain uncomplicated wounds.
When it comes to closing wounds, suturing's not the only game in town. Dachs described three other options.
Hair tying. This technique works particularly well in youngsters with scalp wounds that aren't under a lot of tension, said Dachs. The benefits of using the child's own hair in place of suture materials include less pain and lower costs, and there's no need for a return visit.
Staples. "I just love doing this," said Dachs. "I think it's the neatest thing since sliced bread." He described a case where the patient had "basically scalped himself" running under a trailer. "If I'd been using sutures on this patient, it would've taken all day to stitch him up," he said.
Tissue adhesives. Basically Super Glue® for the skin, it's quick, easy and does a great job, Dachs said.
There's only one caveat, he added: "Get your fingers out of the way!"
When a child dies
Dealing with survivors of sudden, unexpected deathIn a calm, quiet voice, George Higgins III, M.D., opened his discussion, "Dealing With Survivors of Sudden, Unexpected Death," by telling of his own near-death experience at age 5.
He touched on themes you've probably heard about: leaving his body, seeing a tremendous luminescence, feeling an overwhelming peacefulness -- and being called back.
Higgins, chief of emergency services for Maine Medical Center, Portland, and an associate professor at the University of Vermont College of Medicine, Burlington, spoke during an Oct. 29 workshop at the AAFP Emergency and Urgent Care CME course.
"Not knowing it at the time, at that moment I ceased to be afraid of death," he said of his childhood experience.
Perhaps it was that realization that allowed him to relate another story -- this one with a tragic ending.
Encircled by colleagues bending close to hear each word, Higgins described how he held his 11-year-old son -- a victim of a car accident -- as the ventilator maintaining his son's breathing was turned off.
"I want you to wear two kinds of hats as we go through this," Higgins said, urging participants to consider the sudden death of a child from the perspective of both the physician and the parent.
A SHARED PERSPECTIVE
"Imagine yourself as the physician working to resuscitate that child," said Higgins. "You're trying and trying and trying, but it doesn't work, and you finally have to make the call. Just then the nurse walks in and tells you the child's parents are here. What do you do?"
Now, turn that viewpoint around, Higgins said, and envision yourself in the parents' place.
"If you're the parent, and it's your child, what are you thinking right now? You know I'm in there with your child, and I haven't told you anything yet. What do you expect?" he asked. "You expect a miracle. Every parent believes their child is blessed."
It's a shield parents use to try to ward off the reality of a child's death, he said. Physicians, too, shield their emotions during resuscitation efforts by immersing themselves in the process. But it's a tendency physicians should guard against when delivering that most unwelcome message to parents, he said.
BREAKING THE NEWS
"When you come into the room, you may see the parents sitting together, or they may be apart," said Higgins. "It doesn't matter; it's what works for them."
Higgins said he typically approaches the mother, sits down at her level, and leans forward to touch her hand. "I have tragic news for you" are the words he uses to make that first verbal contact.
"You've read all these books that say use the D-word as soon as possible. 'Dead.' Well, the people who wrote those books don't work where I work. I can't get that word out of my mouth," said Higgins. "The parents will tell you what word works for them."
The steps Higgins next recommended are designed to ease the impact of the news on parents without unduly shielding them from the reality of their child's death:
- Clean the child carefully, removing all tubes, IV lines and other equipment. Don't, however, discard clothing that may have been removed or cut away during resuscitation efforts, regardless of its condition. Often, parents desperately want these reminders of their child's life.
- Invite the parents to spend time with their child in a private, quiet area. Ensure that all staff treat them with respect and compassion.
- Offer them the option of meeting with a spiritual counselor.
- And difficult as it may be, you need to broach the subject of organ and tissue donation.
"Unfortunately," Higgins added, "another part of this is that we often have to treat the death as child abuse. You're looking for a murderer here." Listen for discrepancies in the explanations given by different family members.
Above all, don't delegate the responsibility of breaking the news, Higgins advised. "I encourage you to look on this as not only a duty, but also a profound challenge and privilege that will make you better people and more compassionate physicians."
Pediatric procedural sedation: Don't shortchange kids in pain
As far as James Ducharme, M.D., is concerned, if a child feels pain during a clinical procedure, it's only because the physician lets it happen.
If you're having to pry kids down from the ceiling during clinical procedures, it's time to rethink your procedural sedation techniques, emergency physician James Ducharme, M.D., tells particpants at AAFP's emergency care course."You know how the pediatricians are always saying, 'Kids aren't little adults'? Well, that's true; they're not little adults. They're little patients. And there's no more reason for kids to suffer pain than there is for adults to," said Ducharme, professor of emergency medicine at Dalhousie University, Halifax, Nova Scotia. Ducharme spoke to FPs and ER physicians at AAFP's recent CME course on emergency and urgent care.
Too many physicians mistake fear for pain, Ducharme added. "We all tend to assume that a kid's crying because he's scared. No, it's because he's in pain. That tibia sticking out of his skin? He's not scared of it. It hurts."
A key component of adequate procedural sedation in children, said Ducharme, is realizing there's no single "magic bullet" for these patients. "I'd like to say I have the perfect drug for all pediatric procedures," he said, "but I can't -- much as I love ketamine. There are all kinds of scenarios, and there are different drugs for different durations."
When choosing medication and performing a procedure, follow these tips, said Ducharme:
- Avoid deep sedation and its attendant loss of protective reflexes.
- Use an area and equipment dedicated to procedural sedation, with supplies tailored to children as well as adults.
- Collaborate with a nurse skilled in dealing with these patients, or, as Ducharme put it, "one who can start an IV in a fat 2-year-old with no veins."
Several features of ketamine make it a solid choice in many pediatric situations, Ducharme said. This rapid-acting drug doesn't affect reflexes or vital signs. It is given as a single intramuscular or intravenous bolus, so there's no need for titration. It also has the advantage of providing anesthetic and amnesic effects.
Although there's a small risk of nausea and vomiting, said Ducharme, and the medical literature has raised the possibility of an emergence effect, ketamine is often the drug of choice both from an efficacy and a safety aspect.
For more articles on emergency/urgent care for the family physician, access http://www.aafp.org/fpr/20011200/ and click on stories listed under "Emergency and Urgent Care." For more information on AAFP's 2002 emergency and urgent care course, see "Quick Fax."
Nitrous oxide is another tried and true sedative in certain cases, said Ducharme. He cited the example of an 11-year-old mentally challenged patient who requires urinary catheterization. Because this patient receives daily phenothiazine therapy, certain sedating agents would be ineffective, rendering nitrous oxide a good choice.
Members of the fentanyl family likewise have their place in procedural sedation, Ducharme said, but these and other short-acting drugs should be used with caution. "The shorter acting they are, the greater their propensity is, and that propensity is to induce respiratory suppression," he said.
Above all, he advised, don't take risks with your patients; the operating room is always an option. Realize, too, that you need to treat the child's parents right along with the child.
"You have to tell them what you're going to do, how long it's going to take and what their child's going to be like after you do it," said Ducharme. "If you're going to reduce a fracture, you have to tell them what it's going to sound like. Otherwise, you have a pale, clammy person sliding down onto the floor."
Time running out to accrue, report 2001 CME activities
Are you due for re-election to AAFP membership this year? If so, Dec. 31 is the final date you can accrue the required CME hours. All credits earned should be reported to the AAFP as soon as possible. Members in the Active and Supporting (FP) categories must accrue at least 150 hours of AAFP Prescribed and Elective credit within each three-year re-election period.
Quiz card responses from American Family Physician and Family Practice Management are posted to the year in which they are postmarked. So cards received after Dec. 31, 2001 are applied to 2002 CME records.
All questions about CME opportunities and requirements should be directed to a CME representative at (800) 274-8043. CME hours may be submitted online at http://www.aafp.org/cme/; by fax to (913) 906-6087; or by mail to CME Records, AAFP, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672.
See "Quick Fax" at left for information on requesting a fax of the CME reporting form.
Order from AAFP at (800) 944-0000 unless otherwise noted.
Would you like to exchange ideas about nonclinical aspects of family practice with other FPs? The new Practice Management E-Mail Discussion List, available at http://www.aafp.org/members/lyris/, provides that opportunity. Share tips about negotiating contracts, staffing, improving productivity and more. Use your AAFP ID number to access the site.
For information on AAFP insurance products, visit http://www.aafpins.com/. On Dec 1, rates for term life insurance were reduced by as much as 30 percent. This is the third rate reduction within five years, so go online to check your current rate. Also, request a premium comparison for long-term-care insurance from as many as 17 carriers. Your AAFP membership means you -- and your extended family -- can get a discount of up to 10 percent off an identical LTC policy purchased elsewhere.
Proven value: Stay up-to-date on prevention, diagnosis and treatment of athletes through a CME course, Sports Medicine: Strategies for Treating Athletes, Feb. 6 10 in St. Louis. This program will also help prepare physicians sitting for the April 12 exam leading to a Certificate of Added Qualifications in Sports Medicine.
Proven value: Escape winter and earn high-quality CME in topic areas such as cardiology, endocrinology and rheumatic diseases at the Selected Internal Medicine Topics for Family Physicians CME course Feb. 11 15 in Freeport on Grand Bahama Island. Registration materials for this and the above course are online at http://www.aafp.org/meetings/ and are available by calling (800) 926-6890. For faxed materials, see "Quick Fax" at left.
A shipping fee may apply; Kansas residents pay a 7 percent tax.
Available on AAFP Express
Call the AAFP Express toll-free number -- (800) AAFP EXP [223-7397] -- and supply your AAFP ID number to have selected materials sent almost immediately to your fax machine for free. Some documents available:
Description of document Doc. no. 2001 Recommended Childhood Immunization Schedule 7001 CME reporting form 4006 Information on the 2002 conferences
- Advanced Life Support in Obstetrics Instructor Courses
- Jan. 26, Kiawah Island, S.C.
- July 23, Salt Lake City
2015
- Sports Medicine Review
- Feb. 6 - 10, 2002, St. Louis
2000
- Selected Internal Medicine Topics for Family Physicians
- Feb. 11-15, Freeport, Bahamas
2001
- National Network Convocation of Practices
- March 13 - 16, 2002, Kansas City, Mo.
7015
- Women's Health in Primary Care
- March 13 -16, Seattle
2008
- Colposcopy Update and Review
- March 16 - 17, Seattle
2007
- Family Practice Board Review
- April 7 - 13, Seattle
- April 28 - May 4, Kansas City, Mo.
- June 2 - 8, Greensbotro, N.C.
2005
- National Conference of Special Constituencies
- April 24 - 27, Kansas City, Mo.
8003
- Annual Leadership Forum
- April 25 - 27, Kansas City, Mo.
8003
- Skin Problems and Diseases
- June 12 - 16, Ft. Lauderdale, Fla.
2003
- Family-Centered Maternity Care
- July 24 - 28, Salt Lake City
2010
- Emergency and Urgent Care
- Sept. 19 - 22, Orlando, Fla.
2009
- Geriatric Medicine for the Family Physician
- Oct. 3 - 6, Destin, Fla.
2002
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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