Emergency Room Visits: When is the Right Time to come in?

It's been a crazy couple weeks. I'm on vacation now, so I'm hoping to get a few of these cranked out so that I don't miss any for a while. Apologies for not keeping up with my self-imposed schedule!

I'm on my Emergency rotation this month, and after having only worked a handful of shifts, I've learned a ton. I've also seen a wide variety of anxious and worried patients and parents. However, I've also seen families who are frustrated by a perceived lack of help.

I encourage all parents, if they think there is a problem, to first call their pediatrician. This is not idle advice... half the things I see in the Emergency Department can be seen in a pediatrician's office, not only faster, but generally cheaper for both the family and the insurance company. I also recognize that there is a trend among primary care physicians in general to refer their patients to the Emergency Department if anything is concerning to them, rather than working it up themselves. This isn't necessarily a bad thing--it can just be very frustrating for the parents.

Let's go through some cases to see who is best treated in the Emergency Department (henceforth referred to as ED), and what expectations for them are.

Patient 1: 3 week old infant comes in with a fever to 101. Otherwise looks healthy.

Should the patient come to the ED? Yes, Absolutely. Infants are not good at localizing infection because their immune system--what helps them fight off disease--is not developed yet. Virtually all their protection comes from mom--either from that protection crossing the placenta prior to delivery, or in the breastmilk afterward. So, these babies are at risk of getting serious infections, and sometimes the only outward sign of those serious infections is fever.

What should you expect in bringing this child in? Because we cannot easily identify the source of the infection, we check the major areas where infections can hide: the urine, the blood, and the spinal fluid. This means collecting urine, drawing blood, and doing a procedure called a lumbar puncture to get the fluid from around the spinal cord. The child will then have to be admitted to the hospital to await the results of those tests.

Patient 2: 3 1/2 year old girl with a few red spots on her back. Otherwise looks and feels healthy. No fever.

Should the patient come to the ED? This one can probably be treated best at the pediatrician's office. If the child has a fever and it's after hours, it's reasonable to bring her in, but without a fever, the spots are either bug bites, hives, or maybe a viral rash. In any case, there isn't a whole lot that the ED is going to do for you other than reassure you that these things are not serious, and that might be better conveyed by your local pediatrician.

What should you expect if you do bring the child into the ED? Long wait times. We have kids that are legitimately sick, so they get priority. I will not fault you for bringing your child in if you are worried, but again, you're probably going to be seen faster and have a better relationship with your pediatrician in the office.

Patient 3: 14 year old who nearly passes out on the toilet, and has gained weight and been overly tired for a year.

Should the patient come to the ED? This is a soft call. Passing out is something that raises red flags for us in the pediatric population, but in this case, there was no actual passing out. So either we're going to say he's sick with some virus, dehydrated, or something along those lines, or we're going to say that maybe he was straining a little too hard on the toilet and that's why he suddenly felt lightheaded.

What should you expect if you do bring this child in? A lot of reassurance. Maybe a few tests if something in the history raises a red flag for us. However, you should NOT expect us to magically cure your child or figure out what is wrong with him, nor should you expect us to be able to expedite your wait to get in to see a specialist. We can rule out any life-threatening causes of the passing out, but we are not going to solve the mystery as to why he has been tired so long, especially if you've already been seen recently by a pediatrician. That is not the purpose of the ED.

Patient 4: 8 year old who has had headaches on and off for months at various times of day. They go away with ibuprofen/Motrin/Advil, but usually come back.

Should this patient come to the ED? This patient was a little complex, but as he only had a minor headache when he came in, there really wasn't anything we could do for him. Since it was a chronic problem, and the headaches were going away, this is really a patient that should be seen in a general pediatrician's office.

What should you expect if you do bring this child in? Again, a lot of reassurance. While there is some diagnostic testing we can do, unless the child is getting worse, vomiting with the headaches, or they do not resolve with medication, the testing really isn't needed on an urgent basis, so we're probably going to refer him back to his primary pediatrician. If you don't have a primary pediatrician, we will gladly give you some numbers for some.


The bottom line? I won't fault you for bringing in your kid to the ED if you are worried something is wrong. But please, if the problem has been going on for a while, and your child doesn't appear to be getting worse, please call your primary pediatrician and have your child be seen there. You will probably get in and out faster anyway (since waiting times in the ED for non-urgent problems can be several hours, even after you are initially seen).

Contraceptives and Abortifacients

So, originally this week I was going to write about some of the developmental delays I've been seeing this past week in clinic. But after multiple Supreme Court rulings on the contraceptive mandate, I decided I really can't stay quiet about this.

For those of you who haven't heard of these rulings, allow me to summarize them for you.

First, we have Burwell vs. Hobby Lobby. Hobby Lobby is an arts and crafts store owned by the Green family, who are devout Christians. Their argument was that their corporation remains a family owned business, and they should be able to run that corporation in line with their religious beliefs. The particular argument was that the contraceptive mandate of the ACA (the section that required insurers to cover at no additional cost all 20 FDA approved contraceptives) violated their religious beliefs because 4 of the contraceptives covered (two forms of IUDs and two forms of 'emergency contraception') are abortifacients, that is, they have an action that may prevent implantation and thus result in 'abortion' of a fertilized egg.

A linked case, Conestoga vs. Burwell, had a similar argument. The Hahn family is the sole owner of the company and also believe that these four contraceptives are abortifacients.

In these cases, the Supreme Court voted 5-4 in favor of the companies. It should be noted that all three female justices voted against this decision.

Wheaton College vs. Burwell was not decided this week, but was allowed to abstain from the contraceptive mandate until they can gather arguments to go in front of the Supreme Court in the future.

I see multiple issues with these decisions, but for now am only going to focus on the medical aspect: Whether these contraceptives are abortifacients or not.

Before we get into how these contraceptives work, here's a crash course on what needs to happen for pregnancy.

First, there needs to be a viable egg. Each month, roughly, an egg is released from the ovary following a hormonal signal called the LH surge. This is referred to as ovulation. The egg then travels down the Fallopian tube towards the uterus (you can view of diagram of this here, if you're more of a visual person). Somewhere in this Fallopian tube, it is met by the sperm released after sex. The sperm fight to be the first inside the egg, and the now fertilized egg (soon to be an embryo) travels down to the uterus, where it implants in the rich lining and starts to form an actual baby. Progesterone, another hormone, is produced by the ovary following ovulation to promote the growth of the lining of the uterus until the placenta (the direct connection between baby and mama) forms and can produce this hormone on its own.

You'll note that I said the sperm meet the egg in the Fallopian tube. Sperm can live inside the female body for up to 5 days after sex. The egg can only survive without being fertilized for 24 hours or so after ovulation. So the most fertile time for women is actually having sex prior to ovulation so that the sperm can already be present when the egg is released.

When the embryo does not implant, there is obviously no development of a placenta, so after a period of time (usually 2 weeks), the ovary stops producing progesterone, and the uterine lining sheds, resulting in a period. Birth control pills work by supplying the body with a continuous dose of progesterone (and some estrogen, yet another hormone), so the body thinks its pregnant and doesn't release another egg. Thus, when you are on the placebo pill week, you have your period because you are not producing progesterone.

Onto the 'emergency contraceptives'. Plan B, Plan B One-Step, and Next Choice are levonorgestrel, a progesterone-like hormone. Thus, it acts like progesterone by preventing ovulation. As already described, progesterone is necessary to keep the uterine lining intact for the developing embryo. So, if this pill was taken after ovulation, the ovary would continue to produce progesterone, allowing the implantation of the embryo into the uterine lining. This is taken after sex, so it wouldn't prevent the sperm from getting into the Fallopian tube in the first place (as daily birth control pills might). The only way it would prevent pregnancy is if it prevents ovulation. So, not an abortifacient.

Now, an aside, taking the pill after ovulation doesn't mean you'll get pregnant. Everything else has to go right for that to happen. Successful implantation is estimated to occur in 15-30% of natural cycles. Many miscarriages are not realized because the body simply rejects the embryo before the woman knows she's pregnant. Most of the time, this is because there is some major genetic issue--an extra set of chromosomes, or something of that nature. Trust me, after studying genetics and embryology, I was amazed that this process worked at all.

There are some studies showing that there may be some changes in the uterine lining following administration of loveonorgestrel, but as far as I can tell, these studies were all done in the 80s, and much more recent studies have shown that there is little to no effect on the lining. Medications have also changed a great deal in that time.

Ella, ulipristal acetate, is another pill form of emergency contraception. It acts as a mixed progesterone receptor agonist and antagonist, which means it sometimes acts like progesterone and sometimes blocks the action of progesterone. Its effect is determined by the timing of the cycle. It can prevent the LH surge if given early enough, but can also block the effect of the LH surge (ovulation) if given after this hormonal signal. Essentially, it directly delays ovulation, ideally long enough so that the sperm are no longer viable. If given after ovulation, though, it diminishes the ability for the ovary to produce progresterone, thus affecting the uterine lining. Because of this action, I can see its potential for 'abortion', by preventing implantation. Ella is a relatively new contraceptive medication, so there are relatively few studies out there--it was difficult for me to pin down its exact mechanism of action.

Intrauterine Devices (IUDs) are implants placed by an OB/GYN or another clinician trained in the insertion that are used for long-term contraception. Historically, they were thought to have effects primarily in the post-fertilization phase of pregnancy, but other evidence now suggests otherwise.

There are two types available on the market today. First is the copper IUD. This one has been around forever. There is no hormonal effect to this contraceptive, and it is cited as an effective emergency contraception. It seems the effect is primarily toxic to the sperm as they move through the uterus, but it also produces an inflammatory response in the uterus which may affect implantation. So, potentially disrupts implantation.

The second type of IUD is the hormonal IUD, such as Mirena or Skylar. It is a small plastic device that contains progesterone, which acts in much the same way that the progesterone pills function. They are effective for about 3-5 years after insertion and prevent 99% of pregnancies. In theory, these can cause a foreign body reaction in the uterus that prevents implantation, but women can still get pregnant using this device, and it's not very effective as an emergency contraception, so it doesn't seem that this is an active issue. Therefore, I say it's not an abortifacient.

Conclusions: Hobby Lobby may have had a case. As I mentioned, I disagree with the decision on multiple fronts, and this was only the start of it. At minimum, they should not be permitted to object to Plan B and hormonal IUDs on the basis of them being abortifacients, because the science indicates that they are not, and thus it is a flawed argument. Ella and other similar oral emergency contraceptives need to be studied more before we determine for certain whether they result in decreased implantation of a viable embryo. Copper IUDs likely produce an environment that is hostile to life in general in the uterus, and thus potentially disrupt implantation.

There is some disagreement about the term 'abortifacient' as well, since by definition an abortion is the termination of a pregnancy, and a pregnancy can only occur if there is implantation of the embryo, but I chose not to get into this discussion for now.

Thoughts? Questions? Concerns? Feel free to comment or use the contact me form located at the top of the blog. See you next week!

E-cigarettes? Viable alternative to smoking?

Let me start by saying smoking is bad. You shouldn't do it. Period. I wouldn't be doing my due diligence as a physician if I didn't say that out front. Now that we've established that, let's talk about e-cigarettes.

Why does this matter for pediatrics? Simple. Second-hand smoke is a serious problem with kids, to the point where it can severely damage their overall health, especially if they have diseases like asthma. So, at every single well-check, we ask about smoke exposure. Most people I've dealt with seem to have gotten smart and are at least limiting smoking to outside and not in the car. This is a huge reason why there has been such an effort at eliminating smoking in the workplace.

Enter e-cigarettes. They were developed in the early 2000's as an alternative to smoking. Essentially, there's a liquid cartridge with nicotine and other staff that is heated by a coil and inhaled by the smoker.

Lots of concern about e-cigarettes has hit the news recently. So much that one blog post probably won't do it justice, but at least I can attempt to hit the high points. So, let's play a game of myth or fact?


1. E-cigarettes reduce smoking.
Myth.

One study done in September demonstrates a very small percentage of people were more likely to quit using e-cigarettes vs nicotine patches. The effect was very small, with only 1.5% more e-cigarette users quitting after 6 months. What's more, the confidence intervals (CI) crosses 0, which means the difference wasn't really a difference.

Another study in JAMA Internal Medicine shows a similar result: no difference in quitting between users of e-cigarettes and users of conventional cigarettes.

However, a study done in JAMA Pediatrics that hit the press earlier this month shows that e-cigarette use has doubled in teens in the past few years, and about half of current e-cigarette users also smoked conventional cigarettes. In fact, those who smoked conventional cigarettes were more likely to have tried e-cigarettes in the past. This goes against the claim that e-cigarettes are good for quitting smoking.

The increased usage might have something to do with the fact that while ads for cigarettes have been banned for 40 years, there is no ban in place for e-cigarettes, so an ad for such a device actually ran during the Super Bowl this year. It doesn't help that only about half states have bans against minors buying e-cigarettes, and there is relatively little attention to buying them online.


2. Second hand exposure from e-cigarettes is better than regular cigarettes.
True.

A review looking at several studies examined this question from the perspective of occupational health. That is, if an industrial worker was exposed to the same chemicals in the vapor of an e-cigarette, would this worker be at a higher risk of disease. They did negate the nicotine, since it is legal and the smoker is already voluntarily consuming more than the recommended exposure limit by using the device. It was the secondary exposures that they specifically wanted to look at.

The primary chemicals exposed to with e-cigarettes are propylene glycol and glycerin, which do not have known exposure thresholds, and volatile organic compounds. Polycyclic Aromatic Hydrocarbons are most of the cancer-causing chemicals in cigarettes; these were not found in most vapors.

I don't think anyone doubts that e-cigarettes produce fewer chemicals than regular cigarettes, thus reducing second-hand exposure. What seems to be the big debate right now, and the subject of e-cigarette bans in places like Los Angeles, is whether there is ANY risk for e-cigarette exposure, and the public health implications of encouraging e-cigarette smoking in public.


3. E-cigarettes are safer.
Generally true, as alluded to above, with a few exceptions.

Nicotine in cigarette form is relatively difficult to ingest. Smoking is the best way to do this. However, as I mentioned earlier, the nicotine for e-cigarettes is in liquid form. That makes it much easier to either drink or absorb through the skin, which could cause serious harm, especially to children. The number of calls to poison control centers related to the nicotine liquid went up 300% in 2013.

Why is it so dangerous? Well, nicotine is similar to a chemical naturally used by the body at the point where either two nerves meet or a nerve meets a muscle. That means it can cause any amount of damage to the brain, the spinal cord, and to muscles. Commonly, it affects the GI tract first, and the person gets vomiting, but if it is not caught early, it can result in seizures or other problems with the brain. In a small child, it doesn't take a lot of nicotine to have this effect.


Bottom line is that while e-cigarettes are safer than conventional cigarettes, we don't know the long-term effects of e-cigarettes because they are so new, and they do have unique safety concerns. It took a good 20-30 years before we saw lung cancer deaths spike from the cigarette usage in the 1960s, and it's very possible we'll see a similar rise 20-30 years down the line from e-cigarettes. But maybe not. As I'm pretty sure e-cigarettes are cheaper and generally less toxic, I'd encourage people who are smoking to switch to them, but that doesn't mean I'd encourage their blanket marketing.

Until then, I'll hold to my general recommendations: Don't smoke around kids. Don't smoke indoors or in the car. And when you do smoke, wear a jacket that can be removed when you are done, so you don't bring those chemicals inside with you.

Having Kids Young: A Saga of Teen Pregnancy

Teen pregnancy. It was a fairly commonplace occurrence back in the 'old days', when 12 and 13 year olds were married off and made to have children. Now, it's something that will get you, in many ways, ostracized from normal society. Because there are many issues surrounding this topic, I will focus on them one at a time. There are also a number of charged political issues surrounding this topic, most notably the idea that teenagers can make their own medical decisions with regard to reproductive health, as well as the availability and use of contraception and abortion, particularly in the teenage population. I will do my best to limit my bias in those topics, but discussing them at all presents a bias on its own, so I can't make every piece completely unbiased.

For today, we'll examine the trends in teenage births (in the US).

The data that contains the most time is that of the National Vital Statistics Reports, covering the time period from 1940 to 2000. During this time period, we reached a peak of teen births in 1957, with a rate of 96.3 per 1,000 births. That means for every 1,000 babies more in 1957, roughly 96 of them were born to girls aged 15-19. Up until 1965 or so, we were still in the baby boom--the same population that has now grown up and is currently entering or in retirement. The fact that 1957 was the peak indicates that the desire to have children was present even in the teenagers of the era, who were too young to participate in the war itself.

A few more statistics that might be relevant: in 1950, the marriage rate in the US was 11.1%; in 1960, it was down to 8.5%. I don't have the numbers for the individual years, but the peak of births may very well have corresponded with a drop in marriage rates (fewer people getting married --> fewer people having children in future). Of course, that data does not break it down into teens vs. older women, so it may not be relevant at all. In addition, it should be noted that a 'soft peak' in the overall birth rate was seen in 1957 as well (see 1958 data, page 76), as 1958 began the decline of the overall birth rate as well.

After 1957, there was a steep decline in teen births, which was also associated with an increase in the percentage of these births to unmarried women. That is, prior to 1957, only 10% or so of births to women 15-19 were to unmarried women (so in 1957, 10 per 1000 babies was to an unwed teen). After 1957, as the birth rate decreased, the number of those to unmarried women increased. By the early 1980s, the teen birth rate was about 50 per 1,000 births, and half of them were to unmarried women (that is, roughly 25 per 1,000 babies born in the early 80s were to unwed teens).

In the late 1980s, we experienced an increase in the rate of teen births, which hit another peak in 1991 at 61.8 per 1000 births. Since 1991, though, teen birth rates have been declining, reaching an all-time low of 29.4 in 2012 (the most recent data available). Meanwhile, during that same period, overall births in the US have remained roughly the same, between 60 and 70 births per 1000 women since the mid-70s.

One more thing that is important to note; these statistics all refer to rates, not hard numbers. However, as the numbers from 2012 point out, we also experienced the lowest number of babies born to teen mothers in 2012 since the end of WWII. The year 1970 was the highest for the number of babies, at 644,708; for 2012, only 305,420 babies were born to girls aged 15-19.

However, note that all these statistics refer to live births by teenage mothers during the time period. It does not include abortions, miscarriages, or still-births. But those are a discussion for another blog.

So next time someone tells you that teen pregnancy is out of hand, it's worth it to refer to these statistics and point out that teen birth rates have been declining since 1991. The reason is likely multifactorial, and, once again, is a discussion for another blog.

Until next week!