Tuesday, July 28, 2009

Is the Needle Length on Epinephrine Auto-Injectors Too Short?

A 0.3 mg EpiPen auto-injector.Image via Wikipedia

Epinephrine is the first-line medication for the immediate treatment of anaphylaxis (sometimes referred to as "killer allergy"). Intramuscular injection of epinephrine is superior to subcutaneous injection in terms of how fast peak plasma levels of the life-saving drug are achieved. Consequently, epinephrine auto-injectors are deigned to deliver the medication to the large muscle of the anterior thigh (called the vastus lateralis).

A recent study published in the July issue of the Journal of Pediatrics, however, suggests that intramuscular injection may not be achieved in a significant percentage of children with the current needle lengths of epinephrine auto-injectors (EpiPen and TwinJect). Ultrasound measurements of the thickness of subcutaneous tissue in children indicated that the needle lengths of the auto-injectors may be too short to penetrate into the muscle.

When the outcome that one is attempting to prevent is death, this is no small issue.

However, as the study authors themselves note, the method of measurement was not an exact approximation of the injection technique. Ultrasound generally uses light pressure, which may overestimate the depth of tissue that a needle needs to traverse to reach the muscle. Injection of epinephrine using an auto-injector, however, requires a firm hand. When I demonstrate the proper use of autoinjectable epinephrine, I generally end up with bruises on my thigh. Therefore, when used properly, the current needle lengths may be sufficient to deliver the mediation to its desired location after all.

That said, I often note that patients seem to be timid when it comes to auto-injected epinephrine- both in terms of using it in the first place, and also in terms of not being aggresive enough with the amount of pressure applied during administration. This is why adequate training for this medication is so vitally important. It is simply not enough to be given a prescription for an EpiPen- the patient, family and caregivers MUST be trained in the use of the injector with a demonstration device.

The study authors have recommended increasing the needle length for auto-injected epinephrine. More research likely needs to be done before the manufacturers of these devices will increase the needle lengths. Until that time, the only way you can ensure that your child will receive an intramuscular injection is to have excellent technique.

If you have an EpiPen for your child, please ask your physician for guidance and a demonstration of the proper way to administer this important medication. It just may be the most important training you ever have!

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Thursday, July 23, 2009

My Letter to the President After Listening to his Press Conference

Mr. President,

I am writing to you today as a physician, a patient, a mother, and as an American voter.

It is difficult for me to put into words how deeply hurtful your characterization of physicians during your most recent press conference was, both professionally and personally. Your portrayal of the American physician as self-serving was both inaccurate and counter-productive.

The vast majority of physicians in this nation hold themselves to the highest standards of ethical behavior- I believe I speak for my colleagues when I state that I care not only for the physical health of my patients, but also care deeply about how my medical recommendations impact their financial health. To imply that I, or any of my colleagues, would routinely consult a fee schedule before making a medical decision implies that we value our pocketbooks over our patients’ welfare.

I sincerely hope that this is not the opinion you want the American public to have of the individuals who have sacrificed their youth in the service of others, missed many a night with their own children in order to care for another’s, worked repeated 30 hour shifts with no breaks or sleep for what amounts to minimum wage, amassed hundreds of thousands of dollars in educational debt… all to have the privilege of becoming a physician. If Americans can’t have faith in their physicians, who will they turn to when they need care and counsel- their elected officials in Washington?

I still consider it an honor to be able to go to work every day with the confidence that my medical training and experience give me a unique set of skills that truly contribute to the greater good. I felt that way when I cared for your own daughter, and I feel the same way now as a Board-Certified Allergist and Immunologist, caring for adults and children with asthma, allergy, and immune deficiency. I know that my colleagues similarly value their respective opportunities to preserve and improve the health of the American people.

Your recent words have expressed to Americans your low opinion of those who have committed their lives to the health of the nation. Although this slight may have been intended as an example only, the end result was the mischaracterization of a noble profession. When the President stands in front of the nation and essentially claims that physicians are the ones who ail us rather than heal us, it is difficult to find hope for the future of healthcare in America.

Mr. President, I believe you owe the nation’s physicians an apology. I recognize that you do not need the votes of physicians to stay in office, or even to pass the current version of healthcare reform. That’s not what this is about.

To adapt a famous quote: “Mr. President, you have bigger problems than losing my vote. You just lost me as your physician.”

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Tuesday, July 21, 2009

Can Eating More Butter Prevent Allergies?

Here's some food for thought: Researchers in New Zealand are studying whether eating butter instead of margarine can help to reduce the risk of allergies and asthma. They are currently recruiting children to take part in a study examining the effects of butter and an enriched butter made from cows fed fish oil on eczema.

Read about the study here: http://www.nzherald.co.nz/health/news/article.cfm?c_id=204&objectid=10585257

Apparently, you don't need to eat a stick of the stuff to obtain benefit- 10grams (just a few pats) may do the trick!

Just wait until this gets out- my dad (who refuses to even touch anything that's not "real butter" because it "just doesn't taste right") and father-in-law (who forwards me emails about how margarine is "one molecule away from plastic") are going to be thrilled.

Wednesday, July 15, 2009

The Teeth Are In- And My Kid's Still Smiling!

Well, after a few weeks of procrastination and second opinions, I ultimately deferred to the dentist's sound judgment and scheduled the appointments for Son #1 to get his stainless steel crowns.

Turns out all my worries about "metal-mouth" were largely unwarranted. For the most part, you can't see the shiny new molars, unless my kiddo's laughing hysterically or screaming his brains out. (Which means that we do see them at least a few times each day... as life with a 4 year old is equal parts giggle-fit and hissy-fit.)

Although I'm glad it's done and that my child doesn't hate me, I'm still disappointed that I wasn't able to ward away the caries despite excellent dental hygeine. Brushing, flossing, fluoride rinsing... why did this still happen to my baby?

The dentist blames genetics. But I think that secretly, he blames me.

Or is it that, not-so-secretly, I still blame me? Such is the perpetual angst of motherhood.

Sometimes, our best may not be enough to change the inevitable. Difficult for any parent, to be sure. And as a physician, an especially tough pill to swallow...

Tuesday, July 7, 2009

Children's Memorial Hospital Food Allergy Study- Your Chance to Participate!

If you have a child or children with food allergies, consider participating in the Children's Memorial Hospital Food Allergy Study.

"The Children’s Memorial Food Allergy Study is a large, family-based food allergy study and holds great potential for scientific discovery and clinical translation. It is gaining momentum with the support of the National Institutes of Health (NIH), the Chicago Community Trust, Food Allergy Initiative, and generous donors."

Your participation will advance knowledge regarding the genetic basis of food allergy, environmental contributors to food allergy, the possibility of predicting and/or preventing food allergy, and the optimal treatments for this condition. Participation will not alter your child's current medical treatment.

This is an excellent opportunity to contribute to the knowledge about a condition that affects so many of our children.

For more information, visit http://www.childrensmrc.org/allergy/, call 1-888-573-1833 or email allergystudy@childrensmemorial.org.

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Wednesday, July 1, 2009

Ringleader of Allergy Scam Sentenced- Good Riddance!

On June 29, 2009, the ringleader of an allergy scam which fraudulently billed for allergy blood tests which were not properly stored, and then gave over 800 patients allergy injections which were prepared by unlicensed individuals in unsanitary conditions, was sentenced to 9 years in prison and a $2.6 million fine. The ringleader was a nurse, but some doctors (also included n the indictment) allowed this man's company to bill insurance under their names, even though they never examined the patients or supervised the selection or preparation of the allergen extracts.

Read the Department of Justice press release here: http://www.usdoj.gov/usao/iln/pr/chicago/2009/pr0629_01.pdf

For shame! This type of malpractice is unconscionable, unethical, and DANGEROUS! However, suboptimal allergy testing and treatments are offered by all manner of self-proclaimed "experts", many of whom aren't even M.D.'s or D.O's. It's easy to be swindled the the title "Dr." and a white coat.

This is all the more reason to ensure that you are evaluated, and your allergy treatment is being designed and supervised, by a Board-Certified Allergist and Immunologist. Find one here: Find an Allergist, Find Relief
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