Fran Lowry

ATLANTA — Early identification and intervention are crucial to a good long-term outcome in children with autism, experts agreed at the annual meeting of the American Academy of Pediatrics. The disorder can be tricky to diagnose, so, when in doubt, one should refer the child for further evaluation and intervention sooner rather than later, they said.

Red flags that a child may have autism include no pointing or babbling by 1 year; no single words by 16 months; no 2-word phrases by 24 months; no pretend play; intense tantrums; and strong resistance to a change in routine, said Dr. Marshalyn Yeargin-Allsopp of the Centers for Disease Control and Prevention, Atlanta.

“The autistic child has a marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, [as well as] flat affect, failure to develop peer relationships, [and] lack of spontaneous seeking to share enjoyment, interests, or achievements with other people, characterized by a lack of showing, bringing, or pointing at objects of interest. They may only eat one type of food, or use repetitive, restricted language if they talk at all,” she said.

Parents often do not recognize these as problems that may portend a diagnosis of autism, but most do worry that something is not quite right with their child. It is therefore essential for the doctor to pay close attention to the parents as well, Dr. Yeargin-Allsopp said.

Autistic children are affectionate but on their own, unique terms. For example, they may form a strong attachment to inanimate objects, such as keys or nails.

Unfortunately, autism is not rare. Autism spectrum disorders affect an estimated 1 in 166 children, according to the CDC. “You are very likely to see children with an autism spectrum disorder in your practice,” Dr. Yeargin-Allsopp told her audience.

Clinicians should screen for autism in all children at 9, 18, 24, and 30 months. They should refer the child to a specialist as soon as they discover anything that might indicate autism.

“The autistic label is frightening to parents and to professionals, so there is a tendency to wait and see, but waiting is not the best strategy. Early and intense intervention does make a difference,” said Dr. Yeargin-Allsopp.

School and learning problems develop in the older child with autism. Children with some form of autism, like Asperger's syndrome, also can suffer from comorbid conditions such as depression or anxiety, or both, said Catherine E. Rice, Ph.D., also of the CDC.

These older children with autism may start to be bullied by their peers, and often develop unusual hobbies. Suicidality and shutting down or withdrawing may increase, especially in children who are of higher than normal intelligence. Seizure disorder is another important comorbid diagnosis in the older autistic child, Dr. Rice said.

She said that telling parents that their child may have autism is difficult, but it is better to suggest further testing than to do nothing.

“Saying that you are 'a bit concerned about the way Johnny is communicating, so let's check it out' is preferable to having to say 'oops, sorry' some 10 years later,” she explained.

Clinicians also should be aware of the so-called cures for autism that are on the Internet. Included in the lists are things such as separation from the parents, a yeast-free diet, and chelation therapy are just a few of the treatments that are being proposed to well-intentioned but desperate parents.

“It is our belief that there is currently no cure for autism, but a lot of pressure is put on parents to use some of these treatments. However, a lot of progress can be made by helping a family [to] tailor interventions to their child's needs. Our role as clinicians is to give the family as much support as we can because a child with autism means a great deal of stress for the family,” she said.

A useful acronym to remember is ALARM, added Dr. Yeargin-Allsopp. This is the autism alarm, as published by the AAP: Autism is prevalent, Listen to the parents, A means to act early, R is for refer, and M is for monitor.

“If pediatricians remember the autism alarm, they'll be in good shape,” Dr. Yeargin-Allsopp advised.

ATLANTA — Early identification and intervention are crucial to a good long-term outcome in children with autism, experts agreed at the annual meeting of the American Academy of Pediatrics. The disorder can be tricky to diagnose, so, when in doubt, one should refer the child for further evaluation and intervention sooner rather than later, they said.

Red flags that a child may have autism include no pointing or babbling by 1 year; no single words by 16 months; no 2-word phrases by 24 months; no pretend play; intense tantrums; and strong resistance to a change in routine, said Dr. Marshalyn Yeargin-Allsopp of the Centers for Disease Control and Prevention, Atlanta.

“The autistic child has a marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, [as well as] flat affect, failure to develop peer relationships, [and] lack of spontaneous seeking to share enjoyment, interests, or achievements with other people, characterized by a lack of showing, bringing, or pointing at objects of interest. They may only eat one type of food, or use repetitive, restricted language if they talk at all,” she said.

Parents often do not recognize these as problems that may portend a diagnosis of autism, but most do worry that something is not quite right with their child. It is therefore essential for the doctor to pay close attention to the parents as well, Dr. Yeargin-Allsopp said.

Autistic children are affectionate but on their own, unique terms. For example, they may form a strong attachment to inanimate objects, such as keys or nails.

Unfortunately, autism is not rare. Autism spectrum disorders affect an estimated 1 in 166 children, according to the CDC. “You are very likely to see children with an autism spectrum disorder in your practice,” Dr. Yeargin-Allsopp told her audience.

Clinicians should screen for autism in all children at 9, 18, 24, and 30 months. They should refer the child to a specialist as soon as they discover anything that might indicate autism.

“The autistic label is frightening to parents and to professionals, so there is a tendency to wait and see, but waiting is not the best strategy. Early and intense intervention does make a difference,” said Dr. Yeargin-Allsopp.

School and learning problems develop in the older child with autism. Children with some form of autism, like Asperger's syndrome, also can suffer from comorbid conditions such as depression or anxiety, or both, said Catherine E. Rice, Ph.D., also of the CDC.

These older children with autism may start to be bullied by their peers, and often develop unusual hobbies. Suicidality and shutting down or withdrawing may increase, especially in children who are of higher than normal intelligence. Seizure disorder is another important comorbid diagnosis in the older autistic child, Dr. Rice said.

She said that telling parents that their child may have autism is difficult, but it is better to suggest further testing than to do nothing.

“Saying that you are 'a bit concerned about the way Johnny is communicating, so let's check it out' is preferable to having to say 'oops, sorry' some 10 years later,” she explained.

Clinicians also should be aware of the so-called cures for autism that are on the Internet. Included in the lists are things such as separation from the parents, a yeast-free diet, and chelation therapy are just a few of the treatments that are being proposed to well-intentioned but desperate parents.

“It is our belief that there is currently no cure for autism, but a lot of pressure is put on parents to use some of these treatments. However, a lot of progress can be made by helping a family [to] tailor interventions to their child's needs. Our role as clinicians is to give the family as much support as we can because a child with autism means a great deal of stress for the family,” she said.

A useful acronym to remember is ALARM, added Dr. Yeargin-Allsopp. This is the autism alarm, as published by the AAP: Autism is prevalent, Listen to the parents, A means to act early, R is for refer, and M is for monitor.

“If pediatricians remember the autism alarm, they'll be in good shape,” Dr. Yeargin-Allsopp advised.

ATLANTA — Early identification and intervention are crucial to a good long-term outcome in children with autism, experts agreed at the annual meeting of the American Academy of Pediatrics. The disorder can be tricky to diagnose, so, when in doubt, one should refer the child for further evaluation and intervention sooner rather than later, they said.

Red flags that a child may have autism include no pointing or babbling by 1 year; no single words by 16 months; no 2-word phrases by 24 months; no pretend play; intense tantrums; and strong resistance to a change in routine, said Dr. Marshalyn Yeargin-Allsopp of the Centers for Disease Control and Prevention, Atlanta.

“The autistic child has a marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, [as well as] flat affect, failure to develop peer relationships, [and] lack of spontaneous seeking to share enjoyment, interests, or achievements with other people, characterized by a lack of showing, bringing, or pointing at objects of interest. They may only eat one type of food, or use repetitive, restricted language if they talk at all,” she said.

Parents often do not recognize these as problems that may portend a diagnosis of autism, but most do worry that something is not quite right with their child. It is therefore essential for the doctor to pay close attention to the parents as well, Dr. Yeargin-Allsopp said.

Autistic children are affectionate but on their own, unique terms. For example, they may form a strong attachment to inanimate objects, such as keys or nails.

Unfortunately, autism is not rare. Autism spectrum disorders affect an estimated 1 in 166 children, according to the CDC. “You are very likely to see children with an autism spectrum disorder in your practice,” Dr. Yeargin-Allsopp told her audience.

Clinicians should screen for autism in all children at 9, 18, 24, and 30 months. They should refer the child to a specialist as soon as they discover anything that might indicate autism.

“The autistic label is frightening to parents and to professionals, so there is a tendency to wait and see, but waiting is not the best strategy. Early and intense intervention does make a difference,” said Dr. Yeargin-Allsopp.

School and learning problems develop in the older child with autism. Children with some form of autism, like Asperger's syndrome, also can suffer from comorbid conditions such as depression or anxiety, or both, said Catherine E. Rice, Ph.D., also of the CDC.

These older children with autism may start to be bullied by their peers, and often develop unusual hobbies. Suicidality and shutting down or withdrawing may increase, especially in children who are of higher than normal intelligence. Seizure disorder is another important comorbid diagnosis in the older autistic child, Dr. Rice said.

She said that telling parents that their child may have autism is difficult, but it is better to suggest further testing than to do nothing.

“Saying that you are 'a bit concerned about the way Johnny is communicating, so let's check it out' is preferable to having to say 'oops, sorry' some 10 years later,” she explained.

Clinicians also should be aware of the so-called cures for autism that are on the Internet. Included in the lists are things such as separation from the parents, a yeast-free diet, and chelation therapy are just a few of the treatments that are being proposed to well-intentioned but desperate parents.

“It is our belief that there is currently no cure for autism, but a lot of pressure is put on parents to use some of these treatments. However, a lot of progress can be made by helping a family [to] tailor interventions to their child's needs. Our role as clinicians is to give the family as much support as we can because a child with autism means a great deal of stress for the family,” she said.

A useful acronym to remember is ALARM, added Dr. Yeargin-Allsopp. This is the autism alarm, as published by the AAP: Autism is prevalent, Listen to the parents, A means to act early, R is for refer, and M is for monitor.

“If pediatricians remember the autism alarm, they'll be in good shape,” Dr. Yeargin-Allsopp advised.

ATLANTA — When it comes to choosing an effective method of contraception for adolescents, ease of use should probably top the list of requirements. Dr. Geri Hewitt said at the annual meeting of the American Academy of Pediatrics.

Adolescents, particularly younger teens, are less likely to use consistent contraception, and when they do, they are less likely to use effective methods. In fact, adolescents are reluctant to seek medical contraceptive advice, even though they may already be sexually active, said Dr. Hewitt of Ohio State University, Columbus.

Teens face numerous barriers to good contraception, said Dr. Hewitt. Teens are still covered by their parents' health insurance and so may be shy, or feel awkward, approaching their physician for contraception advice. They have inadequate knowledge about good contraception, they tend to be in denial about engaging in sexual activity, they have concerns about the side effects of “the pill,” and they also fear, mistakenly as it turns out, that they will have to have a pelvic examination in order to obtain a prescription for an oral contraceptive.

“Planning is not what they do…. They have to acknowledge that they are going to be sexually active, and many teenagers are not mature enough to do this,” Dr. Hewitt said.

One way she gets her teenage patients to open up about their sexual activity is by asking them if they have a boyfriend. “This approach often works better than directly asking them if they are sexually active, or even if they are thinking of having sex,” she said.

Dr. Hewitt highlighted these new options for adolescent contraception:

▸ The transdermal contraceptive patch (Ortho Evra). This patch is highly effective, with an easy, once-a-week dosing schedule. The active ingredients, norelgestromin 150 mcg/day and ethinyl estradiol 20 mcg/day, are released from the medicated layer of the patch and delivered into the systemic circulation, in a steady state, with no peaks and troughs. The patch is at its most effective in teens who are within 35% of their ideal body weight. But it may fall off with excessive heat, humidity, exercise, and swimming. “Mothers like it. They say 'if I have to go to war with my daughter about taking her contraception, at least I only have to do it once a week,'” Dr. Hewitt said.

▸ The combined contraceptive vaginal ring (NuvaRing). This flexible, transparent ring contains ethinyl estradiol and etonogestrel. The ring is inserted into the vagina for 3 weeks, and then removed for 1 week for a withdrawal bleed. “If it's in the vagina, it's in the right spot. It needs to be in contact with the vaginal mucosa for transvaginal absorption. If she can use a tampon, she can use the Nuvaring.” The Nuvaring uses the “absolute lowest” dose of estrogen, which is a “good selling point” for teens, she said.

▸ The subdermal contraceptive rod (Implanon). This single-rod, nonbiodegradable implantable contraceptive rod is 4 cm in length and 2 mm in diameter, and it contains progestin etonogestrel, an active metabolite of desogestrel. The rod provides contraception for up to 3 years. “The Implanon is much easier to insert and remove than the Norplant, and is very highly effective. But, you do need someone to insert and remove the rod, and you must allow the teen to [have it removed] if she wants,” Dr. Hewitt said.

One way to get teenagers to open up about their sexual activity is by asking them if they have a boyfriend. DR. HEWITT

ATLANTA — When it comes to choosing an effective method of contraception for adolescents, ease of use should probably top the list of requirements. Dr. Geri Hewitt said at the annual meeting of the American Academy of Pediatrics.

Adolescents, particularly younger teens, are less likely to use consistent contraception, and when they do, they are less likely to use effective methods. In fact, adolescents are reluctant to seek medical contraceptive advice, even though they may already be sexually active, said Dr. Hewitt of Ohio State University, Columbus.

Teens face numerous barriers to good contraception, said Dr. Hewitt. Teens are still covered by their parents' health insurance and so may be shy, or feel awkward, approaching their physician for contraception advice. They have inadequate knowledge about good contraception, they tend to be in denial about engaging in sexual activity, they have concerns about the side effects of “the pill,” and they also fear, mistakenly as it turns out, that they will have to have a pelvic examination in order to obtain a prescription for an oral contraceptive.

“Planning is not what they do…. They have to acknowledge that they are going to be sexually active, and many teenagers are not mature enough to do this,” Dr. Hewitt said.

One way she gets her teenage patients to open up about their sexual activity is by asking them if they have a boyfriend. “This approach often works better than directly asking them if they are sexually active, or even if they are thinking of having sex,” she said.

Dr. Hewitt highlighted these new options for adolescent contraception:

▸ The transdermal contraceptive patch (Ortho Evra). This patch is highly effective, with an easy, once-a-week dosing schedule. The active ingredients, norelgestromin 150 mcg/day and ethinyl estradiol 20 mcg/day, are released from the medicated layer of the patch and delivered into the systemic circulation, in a steady state, with no peaks and troughs. The patch is at its most effective in teens who are within 35% of their ideal body weight. But it may fall off with excessive heat, humidity, exercise, and swimming. “Mothers like it. They say 'if I have to go to war with my daughter about taking her contraception, at least I only have to do it once a week,'” Dr. Hewitt said.

▸ The combined contraceptive vaginal ring (NuvaRing). This flexible, transparent ring contains ethinyl estradiol and etonogestrel. The ring is inserted into the vagina for 3 weeks, and then removed for 1 week for a withdrawal bleed. “If it's in the vagina, it's in the right spot. It needs to be in contact with the vaginal mucosa for transvaginal absorption. If she can use a tampon, she can use the Nuvaring.” The Nuvaring uses the “absolute lowest” dose of estrogen, which is a “good selling point” for teens, she said.

▸ The subdermal contraceptive rod (Implanon). This single-rod, nonbiodegradable implantable contraceptive rod is 4 cm in length and 2 mm in diameter, and it contains progestin etonogestrel, an active metabolite of desogestrel. The rod provides contraception for up to 3 years. “The Implanon is much easier to insert and remove than the Norplant, and is very highly effective. But, you do need someone to insert and remove the rod, and you must allow the teen to [have it removed] if she wants,” Dr. Hewitt said.

One way to get teenagers to open up about their sexual activity is by asking them if they have a boyfriend. DR. HEWITT

ATLANTA — When it comes to choosing an effective method of contraception for adolescents, ease of use should probably top the list of requirements. Dr. Geri Hewitt said at the annual meeting of the American Academy of Pediatrics.

Adolescents, particularly younger teens, are less likely to use consistent contraception, and when they do, they are less likely to use effective methods. In fact, adolescents are reluctant to seek medical contraceptive advice, even though they may already be sexually active, said Dr. Hewitt of Ohio State University, Columbus.

Teens face numerous barriers to good contraception, said Dr. Hewitt. Teens are still covered by their parents' health insurance and so may be shy, or feel awkward, approaching their physician for contraception advice. They have inadequate knowledge about good contraception, they tend to be in denial about engaging in sexual activity, they have concerns about the side effects of “the pill,” and they also fear, mistakenly as it turns out, that they will have to have a pelvic examination in order to obtain a prescription for an oral contraceptive.

“Planning is not what they do…. They have to acknowledge that they are going to be sexually active, and many teenagers are not mature enough to do this,” Dr. Hewitt said.

One way she gets her teenage patients to open up about their sexual activity is by asking them if they have a boyfriend. “This approach often works better than directly asking them if they are sexually active, or even if they are thinking of having sex,” she said.

Dr. Hewitt highlighted these new options for adolescent contraception:

▸ The transdermal contraceptive patch (Ortho Evra). This patch is highly effective, with an easy, once-a-week dosing schedule. The active ingredients, norelgestromin 150 mcg/day and ethinyl estradiol 20 mcg/day, are released from the medicated layer of the patch and delivered into the systemic circulation, in a steady state, with no peaks and troughs. The patch is at its most effective in teens who are within 35% of their ideal body weight. But it may fall off with excessive heat, humidity, exercise, and swimming. “Mothers like it. They say 'if I have to go to war with my daughter about taking her contraception, at least I only have to do it once a week,'” Dr. Hewitt said.

▸ The combined contraceptive vaginal ring (NuvaRing). This flexible, transparent ring contains ethinyl estradiol and etonogestrel. The ring is inserted into the vagina for 3 weeks, and then removed for 1 week for a withdrawal bleed. “If it's in the vagina, it's in the right spot. It needs to be in contact with the vaginal mucosa for transvaginal absorption. If she can use a tampon, she can use the Nuvaring.” The Nuvaring uses the “absolute lowest” dose of estrogen, which is a “good selling point” for teens, she said.

▸ The subdermal contraceptive rod (Implanon). This single-rod, nonbiodegradable implantable contraceptive rod is 4 cm in length and 2 mm in diameter, and it contains progestin etonogestrel, an active metabolite of desogestrel. The rod provides contraception for up to 3 years. “The Implanon is much easier to insert and remove than the Norplant, and is very highly effective. But, you do need someone to insert and remove the rod, and you must allow the teen to [have it removed] if she wants,” Dr. Hewitt said.

One way to get teenagers to open up about their sexual activity is by asking them if they have a boyfriend. DR. HEWITT

ATLANTA — Being sued for medical malpractice is almost as inevitable as death and taxes. But taking the time to establish good communication with patients and their families may afford the best protection against a lawsuit, Dr. Robert A. Mendelson said at the annual meeting of the American Academy of Pediatrics.

“Try never to appear rushed, talk to your patients, answer all their questions, and explain to them the reasons for any poor results. If the family feels that you truly care about them and that you are sincerely interested in their child's well-being, the chances are good that they will forego a lawsuit, should something untoward happen,” he said. “These are some of the most powerful things we can do to make our practices less vulnerable to successful lawsuits.”

Dr. Mendelson, of a group practice in Portland, Ore., suggested informing patients about worst case scenarios before starting any therapy. “With any procedure or treatment, bad things can happen. If you explain this up- front to patients, and have written proof that you have done so, it can be very powerful in court.”

Effective risk management starts with recognition of the risk exposures in your practice, Dr. Mendelson said. Among the biggest offenders are illegible handwriting and incomplete or sloppy documentation. “If it's not written in the record, it didn't happen. Write everything that you do in the chart or in the electronic medical record.”

Failure to diagnose certain conditions—such as meningitis, neonatal problems, appendicitis, and congenital deafness and cataracts—is a leading cause of law suits. Medication errors also are common causes, he said.

Patients sue their doctors for many reasons, he continued. They include:

▸ Anger.

▸ Revenge, usually due to poor communication.

▸ True monetary needs, such as those that arise when a child is facing very expensive long-term care.

▸ Guilt or misplaced blame: “If I had just taken my child to the doctor earlier.”

▸ Comments from relatives and other professionals: “Your doctor did what?”

▸ Greed, in a minority of cases.

Many physicians are sued, but few actually go to court. Most neonatal intensive care unit physicians will be sued if they practice long enough; 30% of American Academy of Pediatrics members, 10% of pediatric residents, and 80% of American College of Obstetricians and Gynecologists members will be sued at some time in their career. However, 60%–70% of all lawsuits are dropped or settled before they get to court, Dr. Mendelson said.

The average cost for defending a case is $34,000, but the highest costs are often emotional, he added. “There [are] the long time frame, the time lost from work due to worry, assisting your defense, dealing with lawyers—these are all draining. Be available as a support to your unfortunate colleagues (if necessary), even though you cannot discuss the medical aspects of their case with them. It's an intensely stressful process to go through.”

Document to Minimize Your Legal Risk

▸ Every word on every chart should be legible. Typed is best.

▸ Consider using voice recognition software to speed up the process of documenting your actions.

▸ If you thought of a treatment strategy but did not use it, document why you made that decision.

▸ Never alter a medical record. If you do have to make a change, cross it out with a single line so that it is still legible; initial and date the change. Erasures can put the entire medical record in jeopardy.

▸ To change an electronic medical record (EMR), make an addendum on it.

▸ If there has been a bad outcome, dictate a detailed narrative as soon as possible. Date and time the dictation accurately, and consider notifying your insurance carrier if you feel vulnerable.

▸ Initial all lab and imaging studies and correspondence before placing them in the chart.

Source: Dr. Mendelson

ATLANTA — Being sued for medical malpractice is almost as inevitable as death and taxes. But taking the time to establish good communication with patients and their families may afford the best protection against a lawsuit, Dr. Robert A. Mendelson said at the annual meeting of the American Academy of Pediatrics.

“Try never to appear rushed, talk to your patients, answer all their questions, and explain to them the reasons for any poor results. If the family feels that you truly care about them and that you are sincerely interested in their child's well-being, the chances are good that they will forego a lawsuit, should something untoward happen,” he said. “These are some of the most powerful things we can do to make our practices less vulnerable to successful lawsuits.”

Dr. Mendelson, of a group practice in Portland, Ore., suggested informing patients about worst case scenarios before starting any therapy. “With any procedure or treatment, bad things can happen. If you explain this up- front to patients, and have written proof that you have done so, it can be very powerful in court.”

Effective risk management starts with recognition of the risk exposures in your practice, Dr. Mendelson said. Among the biggest offenders are illegible handwriting and incomplete or sloppy documentation. “If it's not written in the record, it didn't happen. Write everything that you do in the chart or in the electronic medical record.”

Failure to diagnose certain conditions—such as meningitis, neonatal problems, appendicitis, and congenital deafness and cataracts—is a leading cause of law suits. Medication errors also are common causes, he said.

Patients sue their doctors for many reasons, he continued. They include:

▸ Anger.

▸ Revenge, usually due to poor communication.

▸ True monetary needs, such as those that arise when a child is facing very expensive long-term care.

▸ Guilt or misplaced blame: “If I had just taken my child to the doctor earlier.”

▸ Comments from relatives and other professionals: “Your doctor did what?”

▸ Greed, in a minority of cases.

Many physicians are sued, but few actually go to court. Most neonatal intensive care unit physicians will be sued if they practice long enough; 30% of American Academy of Pediatrics members, 10% of pediatric residents, and 80% of American College of Obstetricians and Gynecologists members will be sued at some time in their career. However, 60%–70% of all lawsuits are dropped or settled before they get to court, Dr. Mendelson said.

The average cost for defending a case is $34,000, but the highest costs are often emotional, he added. “There [are] the long time frame, the time lost from work due to worry, assisting your defense, dealing with lawyers—these are all draining. Be available as a support to your unfortunate colleagues (if necessary), even though you cannot discuss the medical aspects of their case with them. It's an intensely stressful process to go through.”

Document to Minimize Your Legal Risk

▸ Every word on every chart should be legible. Typed is best.

▸ Consider using voice recognition software to speed up the process of documenting your actions.

▸ If you thought of a treatment strategy but did not use it, document why you made that decision.

▸ Never alter a medical record. If you do have to make a change, cross it out with a single line so that it is still legible; initial and date the change. Erasures can put the entire medical record in jeopardy.

▸ To change an electronic medical record (EMR), make an addendum on it.

▸ If there has been a bad outcome, dictate a detailed narrative as soon as possible. Date and time the dictation accurately, and consider notifying your insurance carrier if you feel vulnerable.

▸ Initial all lab and imaging studies and correspondence before placing them in the chart.

Source: Dr. Mendelson

ATLANTA — Being sued for medical malpractice is almost as inevitable as death and taxes. But taking the time to establish good communication with patients and their families may afford the best protection against a lawsuit, Dr. Robert A. Mendelson said at the annual meeting of the American Academy of Pediatrics.

“Try never to appear rushed, talk to your patients, answer all their questions, and explain to them the reasons for any poor results. If the family feels that you truly care about them and that you are sincerely interested in their child's well-being, the chances are good that they will forego a lawsuit, should something untoward happen,” he said. “These are some of the most powerful things we can do to make our practices less vulnerable to successful lawsuits.”

Dr. Mendelson, of a group practice in Portland, Ore., suggested informing patients about worst case scenarios before starting any therapy. “With any procedure or treatment, bad things can happen. If you explain this up- front to patients, and have written proof that you have done so, it can be very powerful in court.”

Effective risk management starts with recognition of the risk exposures in your practice, Dr. Mendelson said. Among the biggest offenders are illegible handwriting and incomplete or sloppy documentation. “If it's not written in the record, it didn't happen. Write everything that you do in the chart or in the electronic medical record.”

Failure to diagnose certain conditions—such as meningitis, neonatal problems, appendicitis, and congenital deafness and cataracts—is a leading cause of law suits. Medication errors also are common causes, he said.

Patients sue their doctors for many reasons, he continued. They include:

▸ Anger.

▸ Revenge, usually due to poor communication.

▸ True monetary needs, such as those that arise when a child is facing very expensive long-term care.

▸ Guilt or misplaced blame: “If I had just taken my child to the doctor earlier.”

▸ Comments from relatives and other professionals: “Your doctor did what?”

▸ Greed, in a minority of cases.

Many physicians are sued, but few actually go to court. Most neonatal intensive care unit physicians will be sued if they practice long enough; 30% of American Academy of Pediatrics members, 10% of pediatric residents, and 80% of American College of Obstetricians and Gynecologists members will be sued at some time in their career. However, 60%–70% of all lawsuits are dropped or settled before they get to court, Dr. Mendelson said.

The average cost for defending a case is $34,000, but the highest costs are often emotional, he added. “There [are] the long time frame, the time lost from work due to worry, assisting your defense, dealing with lawyers—these are all draining. Be available as a support to your unfortunate colleagues (if necessary), even though you cannot discuss the medical aspects of their case with them. It's an intensely stressful process to go through.”

Document to Minimize Your Legal Risk

▸ Every word on every chart should be legible. Typed is best.

▸ Consider using voice recognition software to speed up the process of documenting your actions.

▸ If you thought of a treatment strategy but did not use it, document why you made that decision.

▸ Never alter a medical record. If you do have to make a change, cross it out with a single line so that it is still legible; initial and date the change. Erasures can put the entire medical record in jeopardy.

▸ To change an electronic medical record (EMR), make an addendum on it.

▸ If there has been a bad outcome, dictate a detailed narrative as soon as possible. Date and time the dictation accurately, and consider notifying your insurance carrier if you feel vulnerable.

▸ Initial all lab and imaging studies and correspondence before placing them in the chart.

Source: Dr. Mendelson

ORLANDO – Pharmacists who dispense in the community tend to be skeptical about patients who require chronic medication with controlled substances, according to a survey of pharmacists practicing in both urban and rural areas of Alabama.

The survey revealed that many pharmacists have serious misconceptions about chronic pain patients and the way physicians prescribe medications to manage their pain, Karen F. Marlowe, Pharm.D., of the University of South Alabama Medical Center, Mobile, said at the annual clinical meeting of the American Academy of Pain Management.

Dr. Marlowe sent a 40-question survey to 150 pharmacists who dispensed in two counties between December 2005 and February 2006. Seventy-eight surveys were returned: slightly more than half of responders (53%) were female, and 25% worked in chain drugstores, 25% in independent pharmacies, 20% in hospitals, 16% in “big box” or superstores, and 14% in grocery stores.

For most of the respondents, pain medication, including NSAIDs represented 25% of their daily prescription volume.

The pharmacists' main concern was for their compliance with controlled substance regulations. Most considered their knowledge of pain management and controlled substances good or excellent.

None felt they had received inadequate education about pain medications in pharmacy school. That response was something of a surprise to Dr. Marlowe. “I have looked at what is included in pharmacy school [curricula] in various parts of the country. Pharmacy schools on the West Coast have better pain [curricula] than do pharmacy schools on the East Coast. I graduated from Auburn University in 1995, and I got just 1 day … out of 4 years to learn about choosing and monitoring pain therapy.”

Two of the survey's most interesting findings were that pharmacists perceive early refills of pain medication as a sign of addiction and that the majority of pharmacists felt uncomfortable dispensing opiates. “These are serious misunderstandings, and we need to target them as areas for further education,” she said.

The survey also found that female pharmacists were more likely to dispense emergency supplies of controlled substances than male pharmacists (70% vs. 40%, respectively), while male pharmacists were more likely to agree with the statement that physicians overprescribe (males, 48%, vs. females, 35%). Also, 50% of pharmacists in practice longer than 15 years were more likely to contact a physician regarding pain medications and seek an opinion on early refills.

Dr. Marlowe said that she plans to conduct her survey nationwide. “We need to determine which issues need to be addressed. … We'll be able to look at who specifically needs to be educated [and whether] misconceptions [are] regional. Are they due to length of time out of school? Are they more prevalent in rural versus urban areas? In chain versus hospital pharmacies? The results will be interesting to see.”

Surveyed pharmacists perceived early refills of pain medication as a sign of addiction. DR. MARLOWE

ORLANDO – Pharmacists who dispense in the community tend to be skeptical about patients who require chronic medication with controlled substances, according to a survey of pharmacists practicing in both urban and rural areas of Alabama.

The survey revealed that many pharmacists have serious misconceptions about chronic pain patients and the way physicians prescribe medications to manage their pain, Karen F. Marlowe, Pharm.D., of the University of South Alabama Medical Center, Mobile, said at the annual clinical meeting of the American Academy of Pain Management.

Dr. Marlowe sent a 40-question survey to 150 pharmacists who dispensed in two counties between December 2005 and February 2006. Seventy-eight surveys were returned: slightly more than half of responders (53%) were female, and 25% worked in chain drugstores, 25% in independent pharmacies, 20% in hospitals, 16% in “big box” or superstores, and 14% in grocery stores.

For most of the respondents, pain medication, including NSAIDs represented 25% of their daily prescription volume.

The pharmacists' main concern was for their compliance with controlled substance regulations. Most considered their knowledge of pain management and controlled substances good or excellent.

None felt they had received inadequate education about pain medications in pharmacy school. That response was something of a surprise to Dr. Marlowe. “I have looked at what is included in pharmacy school [curricula] in various parts of the country. Pharmacy schools on the West Coast have better pain [curricula] than do pharmacy schools on the East Coast. I graduated from Auburn University in 1995, and I got just 1 day … out of 4 years to learn about choosing and monitoring pain therapy.”

Two of the survey's most interesting findings were that pharmacists perceive early refills of pain medication as a sign of addiction and that the majority of pharmacists felt uncomfortable dispensing opiates. “These are serious misunderstandings, and we need to target them as areas for further education,” she said.

The survey also found that female pharmacists were more likely to dispense emergency supplies of controlled substances than male pharmacists (70% vs. 40%, respectively), while male pharmacists were more likely to agree with the statement that physicians overprescribe (males, 48%, vs. females, 35%). Also, 50% of pharmacists in practice longer than 15 years were more likely to contact a physician regarding pain medications and seek an opinion on early refills.

Dr. Marlowe said that she plans to conduct her survey nationwide. “We need to determine which issues need to be addressed. … We'll be able to look at who specifically needs to be educated [and whether] misconceptions [are] regional. Are they due to length of time out of school? Are they more prevalent in rural versus urban areas? In chain versus hospital pharmacies? The results will be interesting to see.”

Surveyed pharmacists perceived early refills of pain medication as a sign of addiction. DR. MARLOWE

ORLANDO – Pharmacists who dispense in the community tend to be skeptical about patients who require chronic medication with controlled substances, according to a survey of pharmacists practicing in both urban and rural areas of Alabama.

The survey revealed that many pharmacists have serious misconceptions about chronic pain patients and the way physicians prescribe medications to manage their pain, Karen F. Marlowe, Pharm.D., of the University of South Alabama Medical Center, Mobile, said at the annual clinical meeting of the American Academy of Pain Management.

Dr. Marlowe sent a 40-question survey to 150 pharmacists who dispensed in two counties between December 2005 and February 2006. Seventy-eight surveys were returned: slightly more than half of responders (53%) were female, and 25% worked in chain drugstores, 25% in independent pharmacies, 20% in hospitals, 16% in “big box” or superstores, and 14% in grocery stores.

For most of the respondents, pain medication, including NSAIDs represented 25% of their daily prescription volume.

The pharmacists' main concern was for their compliance with controlled substance regulations. Most considered their knowledge of pain management and controlled substances good or excellent.

None felt they had received inadequate education about pain medications in pharmacy school. That response was something of a surprise to Dr. Marlowe. “I have looked at what is included in pharmacy school [curricula] in various parts of the country. Pharmacy schools on the West Coast have better pain [curricula] than do pharmacy schools on the East Coast. I graduated from Auburn University in 1995, and I got just 1 day … out of 4 years to learn about choosing and monitoring pain therapy.”

Two of the survey's most interesting findings were that pharmacists perceive early refills of pain medication as a sign of addiction and that the majority of pharmacists felt uncomfortable dispensing opiates. “These are serious misunderstandings, and we need to target them as areas for further education,” she said.

The survey also found that female pharmacists were more likely to dispense emergency supplies of controlled substances than male pharmacists (70% vs. 40%, respectively), while male pharmacists were more likely to agree with the statement that physicians overprescribe (males, 48%, vs. females, 35%). Also, 50% of pharmacists in practice longer than 15 years were more likely to contact a physician regarding pain medications and seek an opinion on early refills.

Dr. Marlowe said that she plans to conduct her survey nationwide. “We need to determine which issues need to be addressed. … We'll be able to look at who specifically needs to be educated [and whether] misconceptions [are] regional. Are they due to length of time out of school? Are they more prevalent in rural versus urban areas? In chain versus hospital pharmacies? The results will be interesting to see.”

Surveyed pharmacists perceived early refills of pain medication as a sign of addiction. DR. MARLOWE

TORONTO – Harm-reduction programs that use clean needle exchanges and other measures to limit the spread of HIV infection among injection heroin users also can educate crack users about safer crack-smoking materials, according to a Canadian public health study presented at the 16th International AIDS Conference.

Although harm-reduction programs have been initiated in various countries for heroin addicts–with success in reducing the transmission of HIV–much less has been done for individuals who inject stimulants, said Lynne Leonard, Ph.D., of the University of Ottawa.

“We have to make sure that harm reduction applies to all injection drug users, not just heroin users,” she said at a press briefing.

Dr. Leonard presented the results of a harm-reduction program that was undertaken in Ottawa among 550 injection drug users who also used crack.

Their response to the program was “immediate, high, and sustained,” she reported, with 80% of the study population accessing the safe crack-smoking initiative after just 1 month of the program's operation; the participation rate was 87% after 12 months.

Ottawa has one of the highest rates of HIV and hepatitis B infection among injection drug users. In April, the city started an initiative that gave men and women access through the needle-exchange program to safer crack-smoking materials.

“Our initiative demonstrated a clear need. These resources were provided, and there was immediate and high use among the population we were aiming to reach,” she noted.

The controversial decision by the Ottawa Public Health Department to start such a program has significantly reduced a dangerous practice, Dr. Leonard added. “It was not an easy program to get approved, and it still doesn't sit well with the community.

“But needle-exchange programs should be maintained in our cities,” she said. “The evidence is very clear that this is what needs to happen.”

TORONTO – Harm-reduction programs that use clean needle exchanges and other measures to limit the spread of HIV infection among injection heroin users also can educate crack users about safer crack-smoking materials, according to a Canadian public health study presented at the 16th International AIDS Conference.

Although harm-reduction programs have been initiated in various countries for heroin addicts–with success in reducing the transmission of HIV–much less has been done for individuals who inject stimulants, said Lynne Leonard, Ph.D., of the University of Ottawa.

“We have to make sure that harm reduction applies to all injection drug users, not just heroin users,” she said at a press briefing.

Dr. Leonard presented the results of a harm-reduction program that was undertaken in Ottawa among 550 injection drug users who also used crack.

Their response to the program was “immediate, high, and sustained,” she reported, with 80% of the study population accessing the safe crack-smoking initiative after just 1 month of the program's operation; the participation rate was 87% after 12 months.

Ottawa has one of the highest rates of HIV and hepatitis B infection among injection drug users. In April, the city started an initiative that gave men and women access through the needle-exchange program to safer crack-smoking materials.

“Our initiative demonstrated a clear need. These resources were provided, and there was immediate and high use among the population we were aiming to reach,” she noted.

The controversial decision by the Ottawa Public Health Department to start such a program has significantly reduced a dangerous practice, Dr. Leonard added. “It was not an easy program to get approved, and it still doesn't sit well with the community.

“But needle-exchange programs should be maintained in our cities,” she said. “The evidence is very clear that this is what needs to happen.”

TORONTO – Harm-reduction programs that use clean needle exchanges and other measures to limit the spread of HIV infection among injection heroin users also can educate crack users about safer crack-smoking materials, according to a Canadian public health study presented at the 16th International AIDS Conference.

Although harm-reduction programs have been initiated in various countries for heroin addicts–with success in reducing the transmission of HIV–much less has been done for individuals who inject stimulants, said Lynne Leonard, Ph.D., of the University of Ottawa.

“We have to make sure that harm reduction applies to all injection drug users, not just heroin users,” she said at a press briefing.

Dr. Leonard presented the results of a harm-reduction program that was undertaken in Ottawa among 550 injection drug users who also used crack.

Their response to the program was “immediate, high, and sustained,” she reported, with 80% of the study population accessing the safe crack-smoking initiative after just 1 month of the program's operation; the participation rate was 87% after 12 months.

Ottawa has one of the highest rates of HIV and hepatitis B infection among injection drug users. In April, the city started an initiative that gave men and women access through the needle-exchange program to safer crack-smoking materials.

“Our initiative demonstrated a clear need. These resources were provided, and there was immediate and high use among the population we were aiming to reach,” she noted.

The controversial decision by the Ottawa Public Health Department to start such a program has significantly reduced a dangerous practice, Dr. Leonard added. “It was not an easy program to get approved, and it still doesn't sit well with the community.

“But needle-exchange programs should be maintained in our cities,” she said. “The evidence is very clear that this is what needs to happen.”

ATLANTA – Adolescents with attention-deficit hyperactivity disorder need to be listened to by their physicians and given a sense of being in control of their lives and their therapy, Dr. Howard Schubiner said at the annual meeting of the American Academy of Pediatrics.

This approach tends to improve compliance, increase motivation, and create an atmosphere for success for the adolescent, he said.

Teenagers must be made to feel that they are respected and that they are equal partners with their physicians in terms of deciding whether, or when, they will take ADHD medications, said Dr. Schubiner of Providence Hospital, Southfield, Mich.

“Teens want to be in control …. So I give them control, assuming that they are ready to make reasonable decisions for themselves. I ask them what their goals are, and they tend to respond well to this,” he said.

“The reality is that I do not have access to any different medications than you do. What makes me effective with teens is my relationship with them,” Dr. Schubiner told his audience.

ADHD can impair a teen's chances of success in life if it is not treated. It is true that adolescents can be difficult to reach, but if the physician makes an effort to “really listen to them, find out what they are good at and what they like to do, encourage them to pursue positive activities, and believe in them, they tend to do well,” said Dr. Schubiner, who specializes in treating children, adolescents, and adults with ADHD.

A plethora of studies has demonstrated that taking stimulants improves distractibility, fidgeting, parent-child interactions, and problem-solving activities with a child's peers.

The studies also have shown that academic progress often is dramatically improved, and that spelling, math, and reading skills are enhanced when children who have ADHD take the appropriate medications, said Dr. Schubiner, who disclosed that he is a member of the speakers' bureaus for McNeil and Shire pharmaceutical companies.

Dr. Schubiner stressed the importance of rolling with a teen's resistance and never pushing medication use.

He gave some tips on ways to talk to patients, giving examples of how he talks to his teen ADHD patients to allay their fears (and the fears of their parents) about taking medication and–most importantly–to establish a good rapport with them and encourage them to be motivated:

▸ First, explain what ADHD is. “I explain that ADHD has no relation to intelligence, that it is a mild disability. Take myself, for example, I wear glasses. If I didn't have them, I wouldn't have been able to go to medical school and become a doctor. So my glasses have allowed me to use my potential,” he said. He tells patients that “it is the same with you and medications for ADHD. You have potential, and you can realize your potential if you are successfully treated.”

▸ Ask the patients what they are good at. “That is the most important question. I don't care if it's video games. I found out that one of my patients was interested in NASCAR racing, so I asked who was his favorite driver, what was that driver doing, and so on. The critical thing is to find something that you can connect with these kids on, to get them to show you their strengths,” Dr. Schubiner said.

“I encourage them to recognize how they have been successful at learning new skills, such as video games, NASCAR, dance, art, or music, and show them that these same skills can help them in school or in any endeavor,” he said.

▸ Reassure them they can stop taking their medication any time they want. “I treat a lot of people with medication because it works. I tell them, 'I don't care if you take the medication or not. It doesn't matter to me. But I care that you achieve your goals. I use medications because they usually help teenagers achieve their goals. But if you don't want to take medications, that's fine. We can discuss how you plan on achieving your goals without it. If you ever want to stop your medication, just let me know.'”

▸ Put the patients in control. “I tell them, 'If you choose to try medications for ADHD, I will work with you very closely to ensure that there is benefit and there are no side effects, because I would not want to give you any medications if you're not being helped or you are having any side effects.'”

Dr. Schubiner said that he has zero tolerance for side effects, and emphasizes to his patients that side effects simply mean that they are not on the right dose, or not on the right medication.

Common stimulant side effects include headache, insomnia, decreased appetite, dry mouth, and feeling sweaty, jittery, or spaced out. Rare side effects include tics, psychosis, seizures, glaucoma, arrhythmia, and sudden cardiac death.

“Sudden cardiac death is extremely rare, and most are due to an underlying cardiac abnormality. The rate of sudden cardiac death in children taking ADHD medication is 0.4 per 100,000 person-years. But the rate of sudden cardiac death in the general population of children is 1.5–8.3 per 100,000 person-years. So it's actually higher in the general pediatric population,” Dr. Schubiner said.

Teens with a personal history of chest pain, shortness of breath, dizziness with exertion, syncope, hypertension, palpitations, or other potential cardiac problems should be evaluated further. In addition, physicians should inquire about a family history of sudden cardiac death, myocardial infarction prior to the age of 50 years, congenital heart disease, or rhythm problems.

'I ask [teens] what their goals are, and they tend to respond well to this.' DR. SCHUBINER

ATLANTA – Adolescents with attention-deficit hyperactivity disorder need to be listened to by their physicians and given a sense of being in control of their lives and their therapy, Dr. Howard Schubiner said at the annual meeting of the American Academy of Pediatrics.

This approach tends to improve compliance, increase motivation, and create an atmosphere for success for the adolescent, he said.

Teenagers must be made to feel that they are respected and that they are equal partners with their physicians in terms of deciding whether, or when, they will take ADHD medications, said Dr. Schubiner of Providence Hospital, Southfield, Mich.

“Teens want to be in control …. So I give them control, assuming that they are ready to make reasonable decisions for themselves. I ask them what their goals are, and they tend to respond well to this,” he said.

“The reality is that I do not have access to any different medications than you do. What makes me effective with teens is my relationship with them,” Dr. Schubiner told his audience.

ADHD can impair a teen's chances of success in life if it is not treated. It is true that adolescents can be difficult to reach, but if the physician makes an effort to “really listen to them, find out what they are good at and what they like to do, encourage them to pursue positive activities, and believe in them, they tend to do well,” said Dr. Schubiner, who specializes in treating children, adolescents, and adults with ADHD.

A plethora of studies has demonstrated that taking stimulants improves distractibility, fidgeting, parent-child interactions, and problem-solving activities with a child's peers.

The studies also have shown that academic progress often is dramatically improved, and that spelling, math, and reading skills are enhanced when children who have ADHD take the appropriate medications, said Dr. Schubiner, who disclosed that he is a member of the speakers' bureaus for McNeil and Shire pharmaceutical companies.

Dr. Schubiner stressed the importance of rolling with a teen's resistance and never pushing medication use.

He gave some tips on ways to talk to patients, giving examples of how he talks to his teen ADHD patients to allay their fears (and the fears of their parents) about taking medication and–most importantly–to establish a good rapport with them and encourage them to be motivated:

▸ First, explain what ADHD is. “I explain that ADHD has no relation to intelligence, that it is a mild disability. Take myself, for example, I wear glasses. If I didn't have them, I wouldn't have been able to go to medical school and become a doctor. So my glasses have allowed me to use my potential,” he said. He tells patients that “it is the same with you and medications for ADHD. You have potential, and you can realize your potential if you are successfully treated.”

▸ Ask the patients what they are good at. “That is the most important question. I don't care if it's video games. I found out that one of my patients was interested in NASCAR racing, so I asked who was his favorite driver, what was that driver doing, and so on. The critical thing is to find something that you can connect with these kids on, to get them to show you their strengths,” Dr. Schubiner said.

“I encourage them to recognize how they have been successful at learning new skills, such as video games, NASCAR, dance, art, or music, and show them that these same skills can help them in school or in any endeavor,” he said.

▸ Reassure them they can stop taking their medication any time they want. “I treat a lot of people with medication because it works. I tell them, 'I don't care if you take the medication or not. It doesn't matter to me. But I care that you achieve your goals. I use medications because they usually help teenagers achieve their goals. But if you don't want to take medications, that's fine. We can discuss how you plan on achieving your goals without it. If you ever want to stop your medication, just let me know.'”

▸ Put the patients in control. “I tell them, 'If you choose to try medications for ADHD, I will work with you very closely to ensure that there is benefit and there are no side effects, because I would not want to give you any medications if you're not being helped or you are having any side effects.'”

Dr. Schubiner said that he has zero tolerance for side effects, and emphasizes to his patients that side effects simply mean that they are not on the right dose, or not on the right medication.

Common stimulant side effects include headache, insomnia, decreased appetite, dry mouth, and feeling sweaty, jittery, or spaced out. Rare side effects include tics, psychosis, seizures, glaucoma, arrhythmia, and sudden cardiac death.

“Sudden cardiac death is extremely rare, and most are due to an underlying cardiac abnormality. The rate of sudden cardiac death in children taking ADHD medication is 0.4 per 100,000 person-years. But the rate of sudden cardiac death in the general population of children is 1.5–8.3 per 100,000 person-years. So it's actually higher in the general pediatric population,” Dr. Schubiner said.

Teens with a personal history of chest pain, shortness of breath, dizziness with exertion, syncope, hypertension, palpitations, or other potential cardiac problems should be evaluated further. In addition, physicians should inquire about a family history of sudden cardiac death, myocardial infarction prior to the age of 50 years, congenital heart disease, or rhythm problems.

'I ask [teens] what their goals are, and they tend to respond well to this.' DR. SCHUBINER

ATLANTA – Adolescents with attention-deficit hyperactivity disorder need to be listened to by their physicians and given a sense of being in control of their lives and their therapy, Dr. Howard Schubiner said at the annual meeting of the American Academy of Pediatrics.

This approach tends to improve compliance, increase motivation, and create an atmosphere for success for the adolescent, he said.

Teenagers must be made to feel that they are respected and that they are equal partners with their physicians in terms of deciding whether, or when, they will take ADHD medications, said Dr. Schubiner of Providence Hospital, Southfield, Mich.

“Teens want to be in control …. So I give them control, assuming that they are ready to make reasonable decisions for themselves. I ask them what their goals are, and they tend to respond well to this,” he said.

“The reality is that I do not have access to any different medications than you do. What makes me effective with teens is my relationship with them,” Dr. Schubiner told his audience.

ADHD can impair a teen's chances of success in life if it is not treated. It is true that adolescents can be difficult to reach, but if the physician makes an effort to “really listen to them, find out what they are good at and what they like to do, encourage them to pursue positive activities, and believe in them, they tend to do well,” said Dr. Schubiner, who specializes in treating children, adolescents, and adults with ADHD.

A plethora of studies has demonstrated that taking stimulants improves distractibility, fidgeting, parent-child interactions, and problem-solving activities with a child's peers.

The studies also have shown that academic progress often is dramatically improved, and that spelling, math, and reading skills are enhanced when children who have ADHD take the appropriate medications, said Dr. Schubiner, who disclosed that he is a member of the speakers' bureaus for McNeil and Shire pharmaceutical companies.

Dr. Schubiner stressed the importance of rolling with a teen's resistance and never pushing medication use.

He gave some tips on ways to talk to patients, giving examples of how he talks to his teen ADHD patients to allay their fears (and the fears of their parents) about taking medication and–most importantly–to establish a good rapport with them and encourage them to be motivated:

▸ First, explain what ADHD is. “I explain that ADHD has no relation to intelligence, that it is a mild disability. Take myself, for example, I wear glasses. If I didn't have them, I wouldn't have been able to go to medical school and become a doctor. So my glasses have allowed me to use my potential,” he said. He tells patients that “it is the same with you and medications for ADHD. You have potential, and you can realize your potential if you are successfully treated.”

▸ Ask the patients what they are good at. “That is the most important question. I don't care if it's video games. I found out that one of my patients was interested in NASCAR racing, so I asked who was his favorite driver, what was that driver doing, and so on. The critical thing is to find something that you can connect with these kids on, to get them to show you their strengths,” Dr. Schubiner said.

“I encourage them to recognize how they have been successful at learning new skills, such as video games, NASCAR, dance, art, or music, and show them that these same skills can help them in school or in any endeavor,” he said.

▸ Reassure them they can stop taking their medication any time they want. “I treat a lot of people with medication because it works. I tell them, 'I don't care if you take the medication or not. It doesn't matter to me. But I care that you achieve your goals. I use medications because they usually help teenagers achieve their goals. But if you don't want to take medications, that's fine. We can discuss how you plan on achieving your goals without it. If you ever want to stop your medication, just let me know.'”

▸ Put the patients in control. “I tell them, 'If you choose to try medications for ADHD, I will work with you very closely to ensure that there is benefit and there are no side effects, because I would not want to give you any medications if you're not being helped or you are having any side effects.'”

Dr. Schubiner said that he has zero tolerance for side effects, and emphasizes to his patients that side effects simply mean that they are not on the right dose, or not on the right medication.

Common stimulant side effects include headache, insomnia, decreased appetite, dry mouth, and feeling sweaty, jittery, or spaced out. Rare side effects include tics, psychosis, seizures, glaucoma, arrhythmia, and sudden cardiac death.

“Sudden cardiac death is extremely rare, and most are due to an underlying cardiac abnormality. The rate of sudden cardiac death in children taking ADHD medication is 0.4 per 100,000 person-years. But the rate of sudden cardiac death in the general population of children is 1.5–8.3 per 100,000 person-years. So it's actually higher in the general pediatric population,” Dr. Schubiner said.

Teens with a personal history of chest pain, shortness of breath, dizziness with exertion, syncope, hypertension, palpitations, or other potential cardiac problems should be evaluated further. In addition, physicians should inquire about a family history of sudden cardiac death, myocardial infarction prior to the age of 50 years, congenital heart disease, or rhythm problems.

'I ask [teens] what their goals are, and they tend to respond well to this.' DR. SCHUBINER

ATLANTA — Delivering optimal well-child care in the office depends on teamwork, teamwork, and more teamwork.

And the best way to determine how well your “medical home team” is working is to look at how you are doing with the help of an outside observer, Dr. Paula Duncan, professor of pediatrics at the University of Vermont, Burlington, said at the annual meeting of the American Academy of Pediatrics.

Dr. Duncan, cochairperson of the Bright Futures Pediatric Implementation Project, outlined some strategies that individual practices can use to improve the preventive and developmental services they offer their young patients and families.

First and foremost, each practice has to put itself under a microscope to see just how it actually functions, she said.

A well-trained outside facilitator can be extremely helpful, she added. Dr. Duncan described a practice that hired an observer to detail exactly how it operated.

“This practice was obviously interested in improvement. They were willing to look at how everyone in the practice—from the receptionist at the front desk, to the nurse-practitioner, to the physicians—interacted with each other and with patients. The observer noted how patients were moved through the office, how work was actually done in this office, and how patients were treated. The results highlighted where improvements could be made and also showed what they were doing that was absolutely right,” she said.

As part of this process of looking inward, the practice also had meetings once a week. In addition to the personnel of the practice and the facilitator, the meetings included a parent. “I love having a parent as part of the team. The partnership between parents and the medical home is very important,” Dr. Duncan said.

It is essential to be able to learn what is on the parent's mind. The logical way to assess this is via questionnaires, but the practice team must be alert to those parents who may have difficulty filling out these questionnaires for one reason or another.

“One way to make sure we are getting this information is to have the nurse, or physician, or both, ask: “What are you concerned about today? Once we learn the parents' concerns, we then have to make sure we address them,” she said. Other strategies include:

▸ Use of reminder systems.

▸ Development of a registry of patients who have special health care needs.

▸ Use of questionnaires at every visit to ask about parental and youths' concerns.

▸ Use of a confidentiality policy for teens.

▸ Use of a list to prompt essential preventive services.

▸ A referral follow-up system.

“The way to make improvements is to get the whole office involved, and to get everybody working together,” she said.

ATLANTA — Delivering optimal well-child care in the office depends on teamwork, teamwork, and more teamwork.

And the best way to determine how well your “medical home team” is working is to look at how you are doing with the help of an outside observer, Dr. Paula Duncan, professor of pediatrics at the University of Vermont, Burlington, said at the annual meeting of the American Academy of Pediatrics.

Dr. Duncan, cochairperson of the Bright Futures Pediatric Implementation Project, outlined some strategies that individual practices can use to improve the preventive and developmental services they offer their young patients and families.

First and foremost, each practice has to put itself under a microscope to see just how it actually functions, she said.

A well-trained outside facilitator can be extremely helpful, she added. Dr. Duncan described a practice that hired an observer to detail exactly how it operated.

“This practice was obviously interested in improvement. They were willing to look at how everyone in the practice—from the receptionist at the front desk, to the nurse-practitioner, to the physicians—interacted with each other and with patients. The observer noted how patients were moved through the office, how work was actually done in this office, and how patients were treated. The results highlighted where improvements could be made and also showed what they were doing that was absolutely right,” she said.

As part of this process of looking inward, the practice also had meetings once a week. In addition to the personnel of the practice and the facilitator, the meetings included a parent. “I love having a parent as part of the team. The partnership between parents and the medical home is very important,” Dr. Duncan said.

It is essential to be able to learn what is on the parent's mind. The logical way to assess this is via questionnaires, but the practice team must be alert to those parents who may have difficulty filling out these questionnaires for one reason or another.

“One way to make sure we are getting this information is to have the nurse, or physician, or both, ask: “What are you concerned about today? Once we learn the parents' concerns, we then have to make sure we address them,” she said. Other strategies include:

▸ Use of reminder systems.

▸ Development of a registry of patients who have special health care needs.

▸ Use of questionnaires at every visit to ask about parental and youths' concerns.

▸ Use of a confidentiality policy for teens.

▸ Use of a list to prompt essential preventive services.

▸ A referral follow-up system.

“The way to make improvements is to get the whole office involved, and to get everybody working together,” she said.

ATLANTA — Delivering optimal well-child care in the office depends on teamwork, teamwork, and more teamwork.

And the best way to determine how well your “medical home team” is working is to look at how you are doing with the help of an outside observer, Dr. Paula Duncan, professor of pediatrics at the University of Vermont, Burlington, said at the annual meeting of the American Academy of Pediatrics.

Dr. Duncan, cochairperson of the Bright Futures Pediatric Implementation Project, outlined some strategies that individual practices can use to improve the preventive and developmental services they offer their young patients and families.

First and foremost, each practice has to put itself under a microscope to see just how it actually functions, she said.

A well-trained outside facilitator can be extremely helpful, she added. Dr. Duncan described a practice that hired an observer to detail exactly how it operated.

“This practice was obviously interested in improvement. They were willing to look at how everyone in the practice—from the receptionist at the front desk, to the nurse-practitioner, to the physicians—interacted with each other and with patients. The observer noted how patients were moved through the office, how work was actually done in this office, and how patients were treated. The results highlighted where improvements could be made and also showed what they were doing that was absolutely right,” she said.

As part of this process of looking inward, the practice also had meetings once a week. In addition to the personnel of the practice and the facilitator, the meetings included a parent. “I love having a parent as part of the team. The partnership between parents and the medical home is very important,” Dr. Duncan said.

It is essential to be able to learn what is on the parent's mind. The logical way to assess this is via questionnaires, but the practice team must be alert to those parents who may have difficulty filling out these questionnaires for one reason or another.

“One way to make sure we are getting this information is to have the nurse, or physician, or both, ask: “What are you concerned about today? Once we learn the parents' concerns, we then have to make sure we address them,” she said. Other strategies include:

▸ Use of reminder systems.

▸ Development of a registry of patients who have special health care needs.

▸ Use of questionnaires at every visit to ask about parental and youths' concerns.

▸ Use of a confidentiality policy for teens.

▸ Use of a list to prompt essential preventive services.

▸ A referral follow-up system.

“The way to make improvements is to get the whole office involved, and to get everybody working together,” she said.

ATLANTA — Adolescents with attention-deficit hyperactivity disorder need to be listened to by their physicians and given a sense of being in control of their lives and their therapy, Dr. Howard Schubiner said at the annual meeting of the American Academy of Pediatrics.

This approach tends to improve compliance, increase motivation, and create an atmosphere for success for the adolescent. Teenagers must be made to feel that they are respected and that they are equal partners with their physicians in terms of deciding whether, or when, they will take ADHD medications, said Dr. Schubiner of Providence Hospital, Southfield, Mich.

ADHD can impair a teen's chances of success in life if it is not treated. It is true that adolescents can be difficult to reach, but if the physician makes an effort to “really listen to them, find out what they are good at and what they like to do, encourage them to pursue positive activities, and believe in them, they tend to do well,” said Dr. Schubiner, who specializes in treating children, adolescents, and adults with ADHD.

A plethora of studies has demonstrated that taking stimulants improves distractibility, fidgeting, parent-child interactions, and problem-solving activities with a child's peers. The studies also have shown that academic progress often is dramatically improved, and that spelling, math, and reading skills are enhanced when children with ADHD take appropriate medications, said Dr. Schubiner, who disclosed that he is a member of the speakers' bureau for McNeil and Shire pharmaceutical companies.

Dr. Schubiner stressed the importance of rolling with a teen's resistance and never pushing medication use. He gave the following tips on ways to manage patients:

▸ First, explain what ADHD is. “I explain that ADHD has no relation to intelligence, that it is a mild disability. Take myself, for example. I wear glasses. If I didn't have them, I wouldn't have been able to go to medical school and become a doctor. So my glasses have allowed me to use my potential. It is the same with you and medications for ADHD. You have potential, and you can realize your potential if you are successfully treated.”

▸ Ask the patients what they are good at. “That is the most important question. I don't care if it's video games. I found out that one of my patients was interested in NASCAR racing, so I asked who was his favorite driver, what was that driver doing, and so on. The critical thing is to find something that you can connect with these kids on, to get them to show you their strengths.” I encourage them to recognize how they have been successful at learning new skills, such as video games, NASCAR, dance, art, or music, and show them that these same skills can help them in school or in any endeavor.

▸ Reassure them they can stop taking their medication any time they want. I treat a lot of people with medication because it works. I tell them, “I don't care if you take the medication or not. It doesn't matter to me. But I care that you achieve your goals. I use medications because they usually help teenagers achieve their goals. But if you don't want to take medications, that's fine. We can discuss how you plan on achieving your goals without it. If you ever want to stop your medication, just let me know.”

▸ Put the patients in control. I tell them, “If you choose to try medications for ADHD, I will work with you very closely to ensure that there is benefit and there are no side effects, because I wouldn't want to give you any medications if you're not being helped or you are having any side effects.” Dr. Schubiner said that he has zero tolerance for side effects, and emphasizes to his patients that side effects simply mean that they are not on the right dose, or not on the right medication.

Common stimulant side effects include headache, insomnia, decreased appetite, dry mouth, and feeling sweaty, jittery, or spaced out. Rare side effects include tics, psychosis, seizures, glaucoma, arrhythmia, and sudden cardiac death. The rate of sudden cardiac death in children taking ADHD medication is 0.4 per 100,000 person-years. But the rate of sudden cardiac death in the general population of children is 1.5 to 8.3 per 100,000 person-years. So it's actually higher in the general pediatric population,” Dr. Schubiner said.

Find something to help you connect with the patient; ask what they are good at, and get them to show you their strengths. DR. SCHUBINER

ATLANTA — Adolescents with attention-deficit hyperactivity disorder need to be listened to by their physicians and given a sense of being in control of their lives and their therapy, Dr. Howard Schubiner said at the annual meeting of the American Academy of Pediatrics.

This approach tends to improve compliance, increase motivation, and create an atmosphere for success for the adolescent. Teenagers must be made to feel that they are respected and that they are equal partners with their physicians in terms of deciding whether, or when, they will take ADHD medications, said Dr. Schubiner of Providence Hospital, Southfield, Mich.

ADHD can impair a teen's chances of success in life if it is not treated. It is true that adolescents can be difficult to reach, but if the physician makes an effort to “really listen to them, find out what they are good at and what they like to do, encourage them to pursue positive activities, and believe in them, they tend to do well,” said Dr. Schubiner, who specializes in treating children, adolescents, and adults with ADHD.

A plethora of studies has demonstrated that taking stimulants improves distractibility, fidgeting, parent-child interactions, and problem-solving activities with a child's peers. The studies also have shown that academic progress often is dramatically improved, and that spelling, math, and reading skills are enhanced when children with ADHD take appropriate medications, said Dr. Schubiner, who disclosed that he is a member of the speakers' bureau for McNeil and Shire pharmaceutical companies.

Dr. Schubiner stressed the importance of rolling with a teen's resistance and never pushing medication use. He gave the following tips on ways to manage patients:

▸ First, explain what ADHD is. “I explain that ADHD has no relation to intelligence, that it is a mild disability. Take myself, for example. I wear glasses. If I didn't have them, I wouldn't have been able to go to medical school and become a doctor. So my glasses have allowed me to use my potential. It is the same with you and medications for ADHD. You have potential, and you can realize your potential if you are successfully treated.”

▸ Ask the patients what they are good at. “That is the most important question. I don't care if it's video games. I found out that one of my patients was interested in NASCAR racing, so I asked who was his favorite driver, what was that driver doing, and so on. The critical thing is to find something that you can connect with these kids on, to get them to show you their strengths.” I encourage them to recognize how they have been successful at learning new skills, such as video games, NASCAR, dance, art, or music, and show them that these same skills can help them in school or in any endeavor.

▸ Reassure them they can stop taking their medication any time they want. I treat a lot of people with medication because it works. I tell them, “I don't care if you take the medication or not. It doesn't matter to me. But I care that you achieve your goals. I use medications because they usually help teenagers achieve their goals. But if you don't want to take medications, that's fine. We can discuss how you plan on achieving your goals without it. If you ever want to stop your medication, just let me know.”

▸ Put the patients in control. I tell them, “If you choose to try medications for ADHD, I will work with you very closely to ensure that there is benefit and there are no side effects, because I wouldn't want to give you any medications if you're not being helped or you are having any side effects.” Dr. Schubiner said that he has zero tolerance for side effects, and emphasizes to his patients that side effects simply mean that they are not on the right dose, or not on the right medication.

Common stimulant side effects include headache, insomnia, decreased appetite, dry mouth, and feeling sweaty, jittery, or spaced out. Rare side effects include tics, psychosis, seizures, glaucoma, arrhythmia, and sudden cardiac death. The rate of sudden cardiac death in children taking ADHD medication is 0.4 per 100,000 person-years. But the rate of sudden cardiac death in the general population of children is 1.5 to 8.3 per 100,000 person-years. So it's actually higher in the general pediatric population,” Dr. Schubiner said.

Find something to help you connect with the patient; ask what they are good at, and get them to show you their strengths. DR. SCHUBINER

ATLANTA — Adolescents with attention-deficit hyperactivity disorder need to be listened to by their physicians and given a sense of being in control of their lives and their therapy, Dr. Howard Schubiner said at the annual meeting of the American Academy of Pediatrics.

This approach tends to improve compliance, increase motivation, and create an atmosphere for success for the adolescent. Teenagers must be made to feel that they are respected and that they are equal partners with their physicians in terms of deciding whether, or when, they will take ADHD medications, said Dr. Schubiner of Providence Hospital, Southfield, Mich.

ADHD can impair a teen's chances of success in life if it is not treated. It is true that adolescents can be difficult to reach, but if the physician makes an effort to “really listen to them, find out what they are good at and what they like to do, encourage them to pursue positive activities, and believe in them, they tend to do well,” said Dr. Schubiner, who specializes in treating children, adolescents, and adults with ADHD.

A plethora of studies has demonstrated that taking stimulants improves distractibility, fidgeting, parent-child interactions, and problem-solving activities with a child's peers. The studies also have shown that academic progress often is dramatically improved, and that spelling, math, and reading skills are enhanced when children with ADHD take appropriate medications, said Dr. Schubiner, who disclosed that he is a member of the speakers' bureau for McNeil and Shire pharmaceutical companies.

Dr. Schubiner stressed the importance of rolling with a teen's resistance and never pushing medication use. He gave the following tips on ways to manage patients:

▸ First, explain what ADHD is. “I explain that ADHD has no relation to intelligence, that it is a mild disability. Take myself, for example. I wear glasses. If I didn't have them, I wouldn't have been able to go to medical school and become a doctor. So my glasses have allowed me to use my potential. It is the same with you and medications for ADHD. You have potential, and you can realize your potential if you are successfully treated.”

▸ Ask the patients what they are good at. “That is the most important question. I don't care if it's video games. I found out that one of my patients was interested in NASCAR racing, so I asked who was his favorite driver, what was that driver doing, and so on. The critical thing is to find something that you can connect with these kids on, to get them to show you their strengths.” I encourage them to recognize how they have been successful at learning new skills, such as video games, NASCAR, dance, art, or music, and show them that these same skills can help them in school or in any endeavor.

▸ Reassure them they can stop taking their medication any time they want. I treat a lot of people with medication because it works. I tell them, “I don't care if you take the medication or not. It doesn't matter to me. But I care that you achieve your goals. I use medications because they usually help teenagers achieve their goals. But if you don't want to take medications, that's fine. We can discuss how you plan on achieving your goals without it. If you ever want to stop your medication, just let me know.”

▸ Put the patients in control. I tell them, “If you choose to try medications for ADHD, I will work with you very closely to ensure that there is benefit and there are no side effects, because I wouldn't want to give you any medications if you're not being helped or you are having any side effects.” Dr. Schubiner said that he has zero tolerance for side effects, and emphasizes to his patients that side effects simply mean that they are not on the right dose, or not on the right medication.

Common stimulant side effects include headache, insomnia, decreased appetite, dry mouth, and feeling sweaty, jittery, or spaced out. Rare side effects include tics, psychosis, seizures, glaucoma, arrhythmia, and sudden cardiac death. The rate of sudden cardiac death in children taking ADHD medication is 0.4 per 100,000 person-years. But the rate of sudden cardiac death in the general population of children is 1.5 to 8.3 per 100,000 person-years. So it's actually higher in the general pediatric population,” Dr. Schubiner said.

Find something to help you connect with the patient; ask what they are good at, and get them to show you their strengths. DR. SCHUBINER

NEW ORLEANS — Abusive head trauma is misdiagnosed in almost a third of children who are brought to the emergency department, Dr. Denis R. Pauzé said at the annual meeting of the American College of Emergency Physicians.

A missed diagnosis of abusive head trauma (AHT), also known as inflicted head trauma or shaken baby syndrome, can have tragic consequences, he said. Most infant homicides are caused by AHT, with the highest incidence occurring in babies less than 6 months old, said Dr. Pauzé of Inova Fairfax Hospital, Falls Church, Va.

“Failure to diagnose these infants and children leaves them at high risk for repeat abuse, which can lead to learning disabilities, permanent brain damage, or death. Just 5–20 seconds of shaking can kill,” Dr. Pauzé said. But making the diagnosis can be difficult. A child who has been shaken often presents with nonspecific symptoms, such as poor feeding, vomiting, diarrhea, irritability, and fever. “We therefore must have a high index of suspicion in order to diagnose inflicted head trauma,” he said.

An article published in the Journal of the American Medical Association (1999;281:621–6) is “must reading” for emergency department physicians, he said.

In a chart review, the researchers studied the characteristics of unrecognized AHT in children less than 3 years old. They found that nearly one-third of abused children who presented after AHT had their initial diagnosis missed. The average delay in diagnosis was 7 days.

The most common erroneous diagnoses made were gastroenteritis, influenza, accidental head injury, rule-out sepsis, increasing head size, otitis media, seizure disorder, reflux, and apnea. Misinterpretation of the CT scan or radiograph also caused a delay in diagnosis, which ranged from 1 to 174 days.

On the horizon to help emergency physicians make the right diagnosis in a timely manner are traumatic brain markers. Many organs, including the liver, pancreas, kidney, and heart, have serum biomarkers that act as guides to organ injury. The hope is that a biomarker for brain injury will become a bedside test for AHT in the future.

Until then, a complete and thorough history and physical exam are needed to diagnose AHT, Dr. Pauzé said.

Conflicting histories, delay in seeking medical care, or repetitive injuries should make physicians suspicious. Other red flags include injuries that are not consistent with the history given or with the developmental age of the infant or child.

A head-to-toe physical exam must be done, including checking for macrocephaly and inspecting for scalp, facial, or neck bruises. Examine the ribs and extremities for signs of tenderness or deformity and, if possible, perform a funduscopic exam for retinal hemorrhages.

'We … must have a high index of suspicion in order to diagnose inflicted head trauma.' DR. PAUZÉ

NEW ORLEANS — Abusive head trauma is misdiagnosed in almost a third of children who are brought to the emergency department, Dr. Denis R. Pauzé said at the annual meeting of the American College of Emergency Physicians.

A missed diagnosis of abusive head trauma (AHT), also known as inflicted head trauma or shaken baby syndrome, can have tragic consequences, he said. Most infant homicides are caused by AHT, with the highest incidence occurring in babies less than 6 months old, said Dr. Pauzé of Inova Fairfax Hospital, Falls Church, Va.

“Failure to diagnose these infants and children leaves them at high risk for repeat abuse, which can lead to learning disabilities, permanent brain damage, or death. Just 5–20 seconds of shaking can kill,” Dr. Pauzé said. But making the diagnosis can be difficult. A child who has been shaken often presents with nonspecific symptoms, such as poor feeding, vomiting, diarrhea, irritability, and fever. “We therefore must have a high index of suspicion in order to diagnose inflicted head trauma,” he said.

An article published in the Journal of the American Medical Association (1999;281:621–6) is “must reading” for emergency department physicians, he said.

In a chart review, the researchers studied the characteristics of unrecognized AHT in children less than 3 years old. They found that nearly one-third of abused children who presented after AHT had their initial diagnosis missed. The average delay in diagnosis was 7 days.

The most common erroneous diagnoses made were gastroenteritis, influenza, accidental head injury, rule-out sepsis, increasing head size, otitis media, seizure disorder, reflux, and apnea. Misinterpretation of the CT scan or radiograph also caused a delay in diagnosis, which ranged from 1 to 174 days.

On the horizon to help emergency physicians make the right diagnosis in a timely manner are traumatic brain markers. Many organs, including the liver, pancreas, kidney, and heart, have serum biomarkers that act as guides to organ injury. The hope is that a biomarker for brain injury will become a bedside test for AHT in the future.

Until then, a complete and thorough history and physical exam are needed to diagnose AHT, Dr. Pauzé said.

Conflicting histories, delay in seeking medical care, or repetitive injuries should make physicians suspicious. Other red flags include injuries that are not consistent with the history given or with the developmental age of the infant or child.

A head-to-toe physical exam must be done, including checking for macrocephaly and inspecting for scalp, facial, or neck bruises. Examine the ribs and extremities for signs of tenderness or deformity and, if possible, perform a funduscopic exam for retinal hemorrhages.

'We … must have a high index of suspicion in order to diagnose inflicted head trauma.' DR. PAUZÉ

NEW ORLEANS — Abusive head trauma is misdiagnosed in almost a third of children who are brought to the emergency department, Dr. Denis R. Pauzé said at the annual meeting of the American College of Emergency Physicians.

A missed diagnosis of abusive head trauma (AHT), also known as inflicted head trauma or shaken baby syndrome, can have tragic consequences, he said. Most infant homicides are caused by AHT, with the highest incidence occurring in babies less than 6 months old, said Dr. Pauzé of Inova Fairfax Hospital, Falls Church, Va.

“Failure to diagnose these infants and children leaves them at high risk for repeat abuse, which can lead to learning disabilities, permanent brain damage, or death. Just 5–20 seconds of shaking can kill,” Dr. Pauzé said. But making the diagnosis can be difficult. A child who has been shaken often presents with nonspecific symptoms, such as poor feeding, vomiting, diarrhea, irritability, and fever. “We therefore must have a high index of suspicion in order to diagnose inflicted head trauma,” he said.

An article published in the Journal of the American Medical Association (1999;281:621–6) is “must reading” for emergency department physicians, he said.

In a chart review, the researchers studied the characteristics of unrecognized AHT in children less than 3 years old. They found that nearly one-third of abused children who presented after AHT had their initial diagnosis missed. The average delay in diagnosis was 7 days.

The most common erroneous diagnoses made were gastroenteritis, influenza, accidental head injury, rule-out sepsis, increasing head size, otitis media, seizure disorder, reflux, and apnea. Misinterpretation of the CT scan or radiograph also caused a delay in diagnosis, which ranged from 1 to 174 days.

On the horizon to help emergency physicians make the right diagnosis in a timely manner are traumatic brain markers. Many organs, including the liver, pancreas, kidney, and heart, have serum biomarkers that act as guides to organ injury. The hope is that a biomarker for brain injury will become a bedside test for AHT in the future.

Until then, a complete and thorough history and physical exam are needed to diagnose AHT, Dr. Pauzé said.

Conflicting histories, delay in seeking medical care, or repetitive injuries should make physicians suspicious. Other red flags include injuries that are not consistent with the history given or with the developmental age of the infant or child.

A head-to-toe physical exam must be done, including checking for macrocephaly and inspecting for scalp, facial, or neck bruises. Examine the ribs and extremities for signs of tenderness or deformity and, if possible, perform a funduscopic exam for retinal hemorrhages.

'We … must have a high index of suspicion in order to diagnose inflicted head trauma.' DR. PAUZÉ

NEW ORLEANS — Implementation of an organized transfer protocol has yielded proof that moving high-risk ST-segment elevation myocardial infarction patients—even those who are in cardiogenic shock—from community hospitals for percutaneous coronary intervention is safe.

Primary percutaneous coronary intervention (PCI) is the treatment of choice for ST-elevation MI if done at experienced centers in a timely fashion. Unfortunately, in the United States, only 25% of hospitals have PCI capability, which makes transferring these patients for PCI essential most of the time, Dr. David M. Larson, of the Ridgeview Medical Center, Waconia, Minn., and the Minneapolis Heart Institute, said at the annual meeting of the American College of Emergency Physicians.

No deaths occurred during transfer of 746 consecutive ST-elevation MI (STEMI) patients for PCI using the Level 1 Heart Attack program, a standardized transfer protocol developed by a team of cardiologists and emergency physicians from the Minneapolis Heart Institute, Dr. Larson said.

The patients were transferred from the emergency departments of 28 rural and community hospitals, at distances ranging from 23 to 210 miles, to Abbott Northwestern Hospital in Minneapolis. Two-thirds of the patients were transferred by helicopter and the rest were moved by ground ambulance, with median transport times of 28 and 32 minutes, respectively.

The median door-to-balloon time was 97 minutes for the hospitals that were up to 70 miles away from Abbott Northwestern, and 117 minutes for the hospitals that were up to 210 miles away. The national door-to-balloon time average for patients receiving ad hoc transfer for PCI is 180 minutes, Dr. Larson said.

“Our times are excellent and show that transferring STEMI patients is definitely doable, as long as you have an organized approach.”

All patients were very high risk, with ST elevation or new left bundle branch block. Seventeen percent were aged 80 years or older, 14% had cardiogenic shock, 10% had a cardiac arrest before their transfer for PCI, and 46% had a Thrombolysis in Myocardial Infarction (TIMI) risk score of at least 4.

A pretransfer fibrinolytic was given to 252 patients (33.8%), and endotracheal intubation was performed pretransfer in 34 patients (4.6%) and during transfer in 5 (0.7%).

During transfer, 12 patients experienced cardiopulmonary arrest but all were resuscitated, with return of spontaneous circulation. However, two of these patients, who had severe cardiogenic shock, died during angiography, and one died from anoxic brain injury. The remaining nine patients were discharged neurologically intact, Dr. Larson said.

An organized, integrated system involving collaboration among cardiology, emergency medicine, nursing, and prehospital and other ancillary medical personnel is required to achieve the recommended door-to-balloon times for patients with STEMI who are transferred for primary PCI (see above article), Dr. Larson said.

This requires the development of a standardized protocol that empowers the emergency physician to make key decisions, he added.

“One of the key features of our program is that we allow the emergency department physicians to make the decision to activate the cath lab, so we don't have to wait until a cardiologist calls back and consults us. As soon as we make one phone call, the cath lab team will be waiting for the patient when he or she arrives. This really empowers the physician,” he said.

Additionally, each hospital should have prearranged transfer agreements in place with local ambulance and helicopter companies.

Also, patients should be taken immediately to the cath lab and not undergo reevaluation in the emergency department upon arrival at the PCI center, Dr. Larson said.

A patient being transferred under the Level 1 Heart Attack protocol is unloaded at Abbott Northwestern Hospital. The door-to-balloon time for patients transferred from up to 70 miles away from Abbot is 97 minutes, about half the national average. Barbara Unger

NEW ORLEANS — Implementation of an organized transfer protocol has yielded proof that moving high-risk ST-segment elevation myocardial infarction patients—even those who are in cardiogenic shock—from community hospitals for percutaneous coronary intervention is safe.

Primary percutaneous coronary intervention (PCI) is the treatment of choice for ST-elevation MI if done at experienced centers in a timely fashion. Unfortunately, in the United States, only 25% of hospitals have PCI capability, which makes transferring these patients for PCI essential most of the time, Dr. David M. Larson, of the Ridgeview Medical Center, Waconia, Minn., and the Minneapolis Heart Institute, said at the annual meeting of the American College of Emergency Physicians.

No deaths occurred during transfer of 746 consecutive ST-elevation MI (STEMI) patients for PCI using the Level 1 Heart Attack program, a standardized transfer protocol developed by a team of cardiologists and emergency physicians from the Minneapolis Heart Institute, Dr. Larson said.

The patients were transferred from the emergency departments of 28 rural and community hospitals, at distances ranging from 23 to 210 miles, to Abbott Northwestern Hospital in Minneapolis. Two-thirds of the patients were transferred by helicopter and the rest were moved by ground ambulance, with median transport times of 28 and 32 minutes, respectively.

The median door-to-balloon time was 97 minutes for the hospitals that were up to 70 miles away from Abbott Northwestern, and 117 minutes for the hospitals that were up to 210 miles away. The national door-to-balloon time average for patients receiving ad hoc transfer for PCI is 180 minutes, Dr. Larson said.

“Our times are excellent and show that transferring STEMI patients is definitely doable, as long as you have an organized approach.”

All patients were very high risk, with ST elevation or new left bundle branch block. Seventeen percent were aged 80 years or older, 14% had cardiogenic shock, 10% had a cardiac arrest before their transfer for PCI, and 46% had a Thrombolysis in Myocardial Infarction (TIMI) risk score of at least 4.

A pretransfer fibrinolytic was given to 252 patients (33.8%), and endotracheal intubation was performed pretransfer in 34 patients (4.6%) and during transfer in 5 (0.7%).

During transfer, 12 patients experienced cardiopulmonary arrest but all were resuscitated, with return of spontaneous circulation. However, two of these patients, who had severe cardiogenic shock, died during angiography, and one died from anoxic brain injury. The remaining nine patients were discharged neurologically intact, Dr. Larson said.

An organized, integrated system involving collaboration among cardiology, emergency medicine, nursing, and prehospital and other ancillary medical personnel is required to achieve the recommended door-to-balloon times for patients with STEMI who are transferred for primary PCI (see above article), Dr. Larson said.

This requires the development of a standardized protocol that empowers the emergency physician to make key decisions, he added.

“One of the key features of our program is that we allow the emergency department physicians to make the decision to activate the cath lab, so we don't have to wait until a cardiologist calls back and consults us. As soon as we make one phone call, the cath lab team will be waiting for the patient when he or she arrives. This really empowers the physician,” he said.

Additionally, each hospital should have prearranged transfer agreements in place with local ambulance and helicopter companies.

Also, patients should be taken immediately to the cath lab and not undergo reevaluation in the emergency department upon arrival at the PCI center, Dr. Larson said.

A patient being transferred under the Level 1 Heart Attack protocol is unloaded at Abbott Northwestern Hospital. The door-to-balloon time for patients transferred from up to 70 miles away from Abbot is 97 minutes, about half the national average. Barbara Unger

NEW ORLEANS — Implementation of an organized transfer protocol has yielded proof that moving high-risk ST-segment elevation myocardial infarction patients—even those who are in cardiogenic shock—from community hospitals for percutaneous coronary intervention is safe.

Primary percutaneous coronary intervention (PCI) is the treatment of choice for ST-elevation MI if done at experienced centers in a timely fashion. Unfortunately, in the United States, only 25% of hospitals have PCI capability, which makes transferring these patients for PCI essential most of the time, Dr. David M. Larson, of the Ridgeview Medical Center, Waconia, Minn., and the Minneapolis Heart Institute, said at the annual meeting of the American College of Emergency Physicians.

No deaths occurred during transfer of 746 consecutive ST-elevation MI (STEMI) patients for PCI using the Level 1 Heart Attack program, a standardized transfer protocol developed by a team of cardiologists and emergency physicians from the Minneapolis Heart Institute, Dr. Larson said.

The patients were transferred from the emergency departments of 28 rural and community hospitals, at distances ranging from 23 to 210 miles, to Abbott Northwestern Hospital in Minneapolis. Two-thirds of the patients were transferred by helicopter and the rest were moved by ground ambulance, with median transport times of 28 and 32 minutes, respectively.

The median door-to-balloon time was 97 minutes for the hospitals that were up to 70 miles away from Abbott Northwestern, and 117 minutes for the hospitals that were up to 210 miles away. The national door-to-balloon time average for patients receiving ad hoc transfer for PCI is 180 minutes, Dr. Larson said.

“Our times are excellent and show that transferring STEMI patients is definitely doable, as long as you have an organized approach.”

All patients were very high risk, with ST elevation or new left bundle branch block. Seventeen percent were aged 80 years or older, 14% had cardiogenic shock, 10% had a cardiac arrest before their transfer for PCI, and 46% had a Thrombolysis in Myocardial Infarction (TIMI) risk score of at least 4.

A pretransfer fibrinolytic was given to 252 patients (33.8%), and endotracheal intubation was performed pretransfer in 34 patients (4.6%) and during transfer in 5 (0.7%).

During transfer, 12 patients experienced cardiopulmonary arrest but all were resuscitated, with return of spontaneous circulation. However, two of these patients, who had severe cardiogenic shock, died during angiography, and one died from anoxic brain injury. The remaining nine patients were discharged neurologically intact, Dr. Larson said.

An organized, integrated system involving collaboration among cardiology, emergency medicine, nursing, and prehospital and other ancillary medical personnel is required to achieve the recommended door-to-balloon times for patients with STEMI who are transferred for primary PCI (see above article), Dr. Larson said.

This requires the development of a standardized protocol that empowers the emergency physician to make key decisions, he added.

“One of the key features of our program is that we allow the emergency department physicians to make the decision to activate the cath lab, so we don't have to wait until a cardiologist calls back and consults us. As soon as we make one phone call, the cath lab team will be waiting for the patient when he or she arrives. This really empowers the physician,” he said.

Additionally, each hospital should have prearranged transfer agreements in place with local ambulance and helicopter companies.

Also, patients should be taken immediately to the cath lab and not undergo reevaluation in the emergency department upon arrival at the PCI center, Dr. Larson said.

A patient being transferred under the Level 1 Heart Attack protocol is unloaded at Abbott Northwestern Hospital. The door-to-balloon time for patients transferred from up to 70 miles away from Abbot is 97 minutes, about half the national average. Barbara Unger