Smoke and Ear Effusions

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PEDIATRICS

Vol. 79 No. 2 February

1 987

309 Letters

to the Editor

Statements appearing here are those of the writers and do not represent the official position of the American Academy of Pediatrics, Inc, or its Committees. Comments on any topic, including the contents of PEDIATRICS, are invited from all members of the profession: those accepted for publication

will not be subject to major editorial revision but generally must be no more than 400 words in length. The editors reserve the right to publish replies and may solicit responses from authors and others.

Letters should be submitted

in duplicate

in double-spaced

typing

on plain white paper. Send them

to Jerold F. Lucey, MD, Editor, Pediatrics Editorial Office, Mary Fletcher Hospital, Colchester Aye, Burlington, VT 05401.

Pain-A

Subject

Ignored

To the

Editor.-The majority of hospitalized children with severe pain do not receive optimal analgesia for its relief. Our opinion

is based upon personal experience, communication with

colleagues, and published surveys.” Misuse of analgesics

includes subtherapeutic doses, “pm” orders,

inappro-pniately long intervals between doses, and use of placebos to prove that pain is not organic. This maltreatment

reaches cruel proportions in infants and neonates when

surgical procedures are sometimes performed without

anesthesia and postoperative analgesia.

Why pediatricians who are compassionate child

advo-cates have tolerated this insensitive and uncaring

behav-ior is puzzling. We suspect that the answer lies in lack of

education during residency training and lack of readily available information in the pediatric literature. Confirm-ing our suspicion, we found little if any useful information

on the management of pain in the ten most frequently

used textbooks of pediatrics. Our findings are

summa-rized in the Table (p 310).

Of the 15,472 pages in these textbooks, only three and

one-half pages are devoted to discussion of pain and

related topics. Although a majority of the textbooks

de-scribe dosages of analgesics in tables, guidelines for their use are conspicuously absent. The little information that

is there relates to mild to moderate pain and ignores

severe pain. Nelson Textbook of Pediatrics, in the section on sickle cell disease, recommends the following: “Anal-gesics such as codeine and phenothiazines usually suffice

for discomfort and pain. Regular administration of

nan-cotics should be avoided to prevent addiction.”

State-ments of this kind are incorrect and have contributed to

health professionals’ unjustified fear of iatrogenic addic-tion.3

Certainly, much research needs to be done on pain and

its management. Analgesics with fewer side effects are

needed and nonpharmacologic means of pain relief

de-serve further exploration. Until this can be accomplished,

opiates remain the mainstay of management of severe

pain. We must educate ourselves and teach our students and residents the established principles of analgesic ther-apy for children. Failure to relieve pain amounts to child abuse and must not be tolerated.

REFERENCES

S0HAIL R. RANA, MD

Howard

University

Hospital

Department of Pediatrics

2041 Georgia Aye, NW

Washington, DC 20060

1. Schechter NL, Allen DA, Hanson K: Status ofpediatric pain control: A comparison of hospital analgesic usage in children

and adults. Pediatrics 1986;77:11-15

2. Beyer JE, DeGood DE, Ashley LC, et al: Patterns of post-operative analgesic use with adults and children following cardiac surgery. Pain 1983;17:71-81

3. Jaffe JR, Martin WR: Opioid analgesics and antagonists, in Gilman AG, Goodman LS (eds): The Pharmacologkal Bass

of Therapeutics, ed 7. New York, Macmillin Publishing Co,

1985, p 491

Smoke

and

Ear Effusions

To the

Editor.-The Committee on Environmental Hazards of the American Academy of Pediatrics has reviewed the acute

and long-term health effects of involuntary smoking and

offered recommendations to reduce the exposure of

chil-dren to tobacco smoke.’

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LETTERS

TO

THE

EDITOR

311

Chronic middle ear effusions requiring tympanostomy

tube placement occur more often in the children of

par-ents who smoke than in the children of parents who do

not smoke.2’3 Although not mentioned in the Committee’s statement, this is another important adverse health effect

associated with involuntary smoking about which both parents and pediatricians should be informed.

RUTH A. ETzEL, MD, PHD

Center

for Environmental

Health

Centers for Disease Control Public Health Service

US Department of Health and Human

Services

Atlanta, GA 30333

REFERENCES

1. American Academy of Pediatrics, Committee on Environ-mental Hazards: Involuntary smoking-A hazard to chil-dren. Pediatrics 1986;77:755-757

2. Kraemer MJ, Richardson, MA, Weiss NS, et al: Risk factors for persistent middle-ear effusions. JAMA

1983;249:1022-1025

3. Black N: The aetiology of glue ear-A case-control study. Int J Pediatr Otorhinokiryngol 1985;9:121-133

Residents

on the Phone

To the

Editor.-Dr Wood

has

raised

a number

of valid

points

in her

article,

“Pediatric

Resident

Training

in Telephone

Man-agement:

A Survey

of Training

Programs

in the

United

States” (Pediatrics 1986;77:822-825). Residents do

man-age many

patient-initiated

telephone

calls

in clinics

and

emergency

rooms.

The

acquisition

of diagnostic

skills

and

efficiency

in “telephone

medicine”

during

residency

is important not only for practice as a resident but also

for the practicing pediatrician, in fee-for-service or pre-paid (HMO) group practice.

Some may argue that the resident’s telephone practice

is not typical of the telephone practice that he will have as a practitioner. The caller is rarely known to the

resi-dent; the caller’s implementation of the advice rendered cannot be assumed or verified; the sheer number of calls

received

in an acute

care

facility

makes

it unlikely that

the resident can “re-call” most of his callers to check on the patients’ progress. Furthermore, the number of calls

and on-site

patient

responsibilities

do not foster

adequate

documentation

of calls,

even

though

(as Dr Wood

has

pointed

out)

the

call

from

an

unknown

person

to an

emergency

room

is the

call that

should

be documented.

Residents are frequently reassured, “Don’t worry . . .calls

will be easier

to

handle

when

you

are

in practice. You

will know your callers and have fewer calls to manage.” This advice may be realistic for physicians in solo or limited two- to three-partner practices, but how realistic

is it for those physicians in HMOs?

We recently

conducted

a national

survey

of the

pedi-atric directors of HMOs about their telephone systems

and their satisfaction with them. Of 123 surveys, 67 (55%) were returned. Of these 67 directors, only 37 (55%) were

satisfied with their HMO’s telephone practices. There

were no differences between satisfied and dissatisfied

directors by HMO (1) length ofexistence (mean 11 years),

(2) total and pediatric enrollment (means 46,000 and

15,000, respectively), (3) number of staff pediatricians

and pediatric nurse practitioners (means 8.5 and 1.5,

respectively), (4) number of calls personally taken by a

pediatrician during the day, an on-call evening and night, and weekend (means 13, 9, and 29 per weekend day,

respectively), (5) provision of a “telephone hour” for

routine questions (present in only 10% to 15%), (6) policy

on which HMO personnel can independently dispense

advice by telephone, (7) provision of printed telephone triage guidelines to staff (80% did), and (8) provision of regular and structured in-service classes to staff on

tele-phone technique and practice (only 56% did). Dissatisfied

directors were more likely to be associated with HMOs

with regular evening hours, more satellite clinics, more

total incoming calls during the weekday and weekend,

and policies about the maximum number of rings before a telephone must be answered and the maximum length of time that someone can remain on hold. They rarely

reported positive features of their systems but most

fre-quently cited improved staff training and support,

pro-vision of more consistent advice, and decreased delays

for patients to get through as the changes that they most desired. Satisfied directors, on the other hand, were more

likely to be associated with HMOs in which permanent

records of calls were kept and patients’ charts were at

hand when calls were returned. They reported that the

best features of their systems were their excellent staffs

and their prompt telephone response to patient needs;

they reported desiring few changes in their systems.

The residents in Dr Wood’s survey handled an average

of 19 calls per day, mostly from unknown callers. The

physicians in the HMOs surveyed handled 22 to 29 calls

per on-call day; because there was an average of 15,000 pediatric patients per HMO, it is likely that the

physi-cians were unfamiliar with some of their callers. This

may be corroborated by the finding that dissatisfied directors were more likely to be associated with more

satellites and, hence, more unknown patients. Only 45%

of the programs surveyed by Dr Wood offered training in

telephone triage; only 44% of the HMOs surveyed by us

did the same. Finally, only 51% ofthe residency programs

documented calls; only 62% of the HMOs in our survey

did so.

The

American

public

has come

to believe

that

a

phy-sician is as close as the nearest telephone. As American medicine moves toward larger group practices and more

HMOs,

an increasing

proportion

of patients

will be

un-familiar to the physician who takes their calls, especially

on nights

and

weekends.

It is time

to quit fooling

our-selves: the telephone experience of residents in the 1980s may be close indeed to postgraduate practice in the 1990s.

We agree

with

Dr Wood;

it is imperative for those who

train residents to give them the foundation for their

future practices. Residents must learn the basics of

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1987;79;309

Pediatrics

RUTH A. ETZEL