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March 12, 2012, 2:56 pm, Things Adult Medicine Could Learn From
Pediatrics, By PERRI KLASS, M.D., Columnist

Twenty-eight years ago, I wrote about drawing blood for the first time, about the
pain of the patient and the self-doubt of the medical student. In my first clinical
experience, I was learning a strange new color code: red-top tube for blood chemistries,
purple top for hematology, green top, yellow top, and so on.

In pediatrics, I soon discovered, the colors were the same but the tubes themselves
were much smaller. And instead of those big needles I had learned to use on adults, we
used butterflies, tiny needles with plastic wings to keep them stable.

I thought: If you can get enough blood through a small butterfly needle filling a
small tube to do the necessary tests, why must we jab big needles into adults and fill
comparatively huge tubes to do the same assessments?

It wasn’t the last time I wondered why children were treated with more concern
than adults. And now it seems that attitudes long taken for granted in the care of children
might be working their way up the life span to become more standard for adults.

Take those big tubes. In a 2011 article in the journal Archives of Internal Medicine,
researchers showed that adults hospitalized with heart attacks who had more blood drawn
were more likely to develop anemia while in the hospital. Patients who develop such
anemia have a higher risk of death.

Dr. Mikhail Kosiborod, one of the authors of the study, a cardiologist at St. Luke’s
Mid America Heart Institute in Kansas City, Mo., told me that the result surprised some
physicians; the average volume of blood lost did not seem substantial enough to cause
anemia in healthy adults. Patients in the study who developed anemia lost 174 milliliters
of blood on average during hospitalization — just under six ounces — though some lost
much more. A healthy adult might not become anemic after such blood loss, but the sick
and debilitated may be at higher risk.

His own hospital, like many other institutions, is now using smaller tubes, he said —
not the tiniest tubes, which require special handling, but a smaller size that can still be
handled routinely by the lab.

So why had anyone ever used larger tubes if smaller would work? “It just hasn’t
been brought up in the adult world,” Dr. Kosiborod said. “It hasn’t been made a big
issue.”

Dr. Bradley Monash, an academic hospitalist at the University of California, San

Francisco, who works on both pediatric and adult wards, said: “There’s something about
the care of a child that touches people. There’s something about caring for children that
people address differently.”

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The pain and fear that children feel about having their blood drawn, for example,
probably influence the frequency with which doctors order tests.

“Fear is acceptable in pediatrics much more than it is in adults,” Dr. Monash said.
“There are a lot of things we could take from pediatrics and translate into medicine.”

When children get hospitalized, for instance, we understand that they’re scared. An
unfamiliar place, painful procedures, strangers with needles — all are piled atop the
underlying feeling of being sick or hurt. And we routinely expect parents to stay over in
their children’s hospital rooms, providing cots and chairs that unfold to lie flat.

When children need surgery, we promise company and comfort.

The children are told that “the parents are going to be going with them into the
operating room, and they’re going to stay with them till they fall asleep,” said Florencia
Catanzaro, who coordinates the pre-hospitalization child life program at Bellevue Hospital
in New York City.

Parents are routinely allowed into recovery, so that children can see them when they
wake up, or soon after. But really, are adults any less scared, uncertain or disoriented?

In adult surgery, it is not routine to promise that someone can be with you in the
operating room till you go to sleep, or to have family members a standard part of recovery
room care. Many hospitals will let a family member stay overnight with an adult patient,
but policies vary hospital by hospital, ward by ward.

“We accommodate family members much more in pediatrics,” Dr. Monash said.
“We don’t have visiting hours where everyone has to leave.”

Still, the trend in adult medicine is that new patient rooms are more likely to be
constructed, as pediatric rooms are, to accommodate family members.

It seems to me we should be able to promise any hospital patient that a relative, a

friend, can stay close at hand. We should be able to promise anyone going in for surgery
that when she wakes up, someone familiar will be there.

It won’t always be perfectly convenient for hospital routine, but the lesson from
pediatric care is that hospitals will adjust. This was all unthinkable in pediatrics, too, just
over a half century ago.

The adage “children are not just small adults” is so basic in pediatrics that you can
search medical journals and find it applied to treatments for facial fractures, liver failure

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and cardiac arrhythmias, for example. We have learned over time to fine-tune medical care
to the differently wired physiologies of children, and to their emotional development.

But when it comes to certain aspects of medical treatment, especially hospitalization,

perhaps it’s time to acknowledge that adults are really just big children. Illness, pain and
the shadows of disability and death — all hospital familiars — make all of us vulnerable,
at any age, and reassurance and comfort are welcome. Blood is a useful reminder: Every
patient needs to be treated in a way that conserves every drop of strength and resilience.

Books: Sleepless, Bored and in Pain, a Patient Watched

By ABIGAIL ZUGER, M.D.
Published: March 12, 2012

Just when it seems long past time for the age of memoir to be over — just when it
seems impossible that any ailing person with literary inclinations could find anything new
to say about illness, and the list of not-to-be-missed “patients are people too” books should
be closed and locked — yet another book comes along.
And despite all the above, no one with even a passing interest in the experience of
illness should miss Robert C. Samuels’s “Blue Water, White Water,” a memoir drafted
about 30 years ago and published without fanfare a few months ago; it stands head and
shoulders above the crowd.

The details are slightly obsolete, to be sure: Mr. Samuels endured his many months
of dire illness tethered to a respirator back in the 1980s, the Stone Age of modern
intensive-care treatment. Nonetheless, his story from the wrong end of the tubes is
timeless; the technology may evolve briskly, but the experience changes glacially, if at all.

A former beat reporter for The New York World-Telegram & Sun, Mr. Samuels
covers his own story like a pro. He was healthy, 44, just returned from a trip around the
world in December 1981, when he got out of bed one morning with a weak left leg. He
wandered into the local emergency room half convinced he was imagining things.

By the next day he was completely paralyzed with a respirator breathing for him:
Guillain-Barré syndrome, an autoimmune disease, was rapidly and efficiently stripping
his motor nerves of their myelin sheathing, short-circuiting them all. Only his eyes still
moved a little, from left to right. Nothing was wrong with his brain.

It would be many months before any part of him but his eyes moved again. He
spent all that time in intensive care, first in his local hospital and then in one of New York
City’s premier teaching institutions, a particularly grubby and uninspiring place. His
mantra throughout, and the encouraging phrase on everyone’s lips: Guillain-Barré
patients always get better.

That cheerful thought calmed his fear a little but did nothing for his constant
discomfort. Completely immobile, incommunicado save for eye signals, sleepless and

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bored out of his mind, Mr. Samuels endured more pain than anyone might imagine —
including, predictably enough, his own doctors and nurses.

His biggest enemy was gravity itself, as his flaccid muscles could no longer cushion
his tender bones from any pressure, including that of mattress and pillow. Holding any
position for more than half an hour meant misery. A tiny empty syringe left forgotten
under his shoulder spelled agony. His primitive system of communication (eyes to the left
for no, right for yes, back and forth for help) was seldom up to the challenge.

But others have covered the pain-and-helplessness story at greater length and
complexity than Mr. Samuels. What makes his version so compelling is its mural of the
medical personnel who wandered in and out of his shrunken world. With nothing to do
but watch and remember, Mr. Samuels assembled the sketchbook of a professional
observer, brisk, unsentimental, sardonic and altogether deadly.

His doctors were a well-meaning but erratic crowd, wise and foolish in equal
measure. Their enthusiasms often seemed to have little to do with anything, certainly not
the patient lying in front of them. One doctor guiding a fiber-optic tube through Mr.
Samuels’s congested lungs was dazzled by their geography: “Right upper lobe,” she called
out with passion. “Left lower lobe!” (No one in the room knew that Mr. Samuels was
silently making conversation with his own list: his friends Werner and Nedra and their
children, Susan, Janice and Chuck Loeb. Were the married daughters still Loebs? His mind
spun a welcome momentary distraction.)

But it is the nurses who get the brunt of his attention, only because they ruled his
days and nights. Seldom has anyone provided a better illustration of the simultaneous
power and powerlessness of that complicated profession. Mr. Samuels’s good nurses
struggled against the arbitrary constraints of their routines, while his bad ones drifted in a
haze of marginal competence. Candy, Ingrid, Doria, Vinnie and the altogether fearsome
Clare Ann — they are a terrifying, inspiring, nuanced and completely human bunch.

Mr. Samuels limits his own moralizing, but provides enough grist for any
philosopher mulling over the essential conundrums of health care. Whose fault is it when
a patient doesn’t get better? Some of his caretakers took every setback as a personal affront
— a foolish reaction, or one that is essential to the enterprise? Some blamed the patient
instead — misguided or brilliant psychology? There’s plenty to debate here, particularly
because Mr. Samuels flouts all predictions and, sadly enough, does not get completely
better, for all that he writes with the jaunty triumph of the survivor.

People with the terrible luck to get Guillain-Barré these days will be spared some of
his misery. Certainly techniques of sedation and pain control are more sophisticated now,
and accessories for the paralyzed body a little more streamlined and comfortable. But the
essentials of the experience remain, and health care personnel who live through it in this
book will appreciate the dreadful familiarity of the reflections from its author’s perfectly
placed mirror.