Healthy Futures - Tufts Medical Center

Working together for
Healthy Futures
A MAGAZINE FOR REFERRING PHYSICIANs
SPRING 2013
Center for Youth Wellness
GOAL!
Empowering Adolescents
to Make Healthy Choices
see page 4
PLUS Comfort Corner 8
8
Digital Help for Bedwetting 10
Quality Initiatives 12
10
The principal pediatric teaching hospital for Tufts University School of Medicine
12
Research
A letter from John Schreiber, MD
Dear Physician,
One of the exciting parts of working at Floating Hospital for Children at Tufts Medical Center is our continued
growth. This summer we will be expanding our network of 24/7 hospitalists and ambulatory specialists
to Signature Healthcare Brockton Hospital. And as we help change how care is delivered to children in
Massachusetts, we are attracting outstanding new pediatric specialists who are excited to be part of Floating
Hospital for Children at Tufts Medical Center. We have several important new appointments I am delighted to
tell you about.
Pediatric Gastroenterology
Floating Hospital has a proud tradition in offering leading-edge pedi GI services; we are building on that legacy with a new team:
Chief of Pediatric Gastroenterology and Nutrition Jyoti Ramakrishna, MD is an outstanding clinician, researcher and
teacher who comes to us from Massachusetts General Hospital and Harvard Medical School, where she focused on inflammatory
bowel disease and food allergy and was co-director of the pediatric voice, airway and swallowing program at Massachusetts
Eye and Ear Infirmary and Massachusetts General Hospital for Children. In the 1990s she completed her fellowship in pediatric
gastroenterology and nutrition here at Floating Hospital, and we are so glad she has returned to lead this important department.
Dr. Ramakrishna is already seeing patients in Boston and at several of our ambulatory specialty centers.
Marcella Radano, MD completed her residency at Hasbro Children’s Hospital in Rhode Island and her fellowship in pediatric
gastroenterology and nutrition at Mass General Hospital for Children. She has already started seeing patients at Floating Hospital
and our specialty centers.
Khoa Tran, MD will join Drs. Ramakrishna and Radano as an attending pediatric GI physician in July 2013. He is a Tufts University
graduate, completed his pediatric residency at the University of Connecticut and is completing his GI fellowship at Massachusetts
General Hospital, specializing in adult and pediatric motility.
Pediatric Rheumatology
Chief of Pediatric Rheumatology Diana Milojevic, MD will join us in July from the University of California, San Francisco, where
she is Associate Clinical Professor of Pediatrics in the Division of Rheumatology and Immunology, and is Clinical Director of the
division. Dr. Milojevic trained in both Belgrade and Johannesburg as well as the Albert Einstein College of Medicine/Schneider
Children’s Hospital in New York. She is recognized as one the very best pediatric rheumatologists on the west coast, and we
look forward to offering our community hospitals and pediatric primary care partners state-of-the-art management of pediatric
rheumatologic problems.
Pediatric Intensive Care Unit
Carol Pineda, MD will join our excellent team in the PICU in July. Dr. Pineda is completing her fellowship in pediatric critical care
medicine at Mattel Children’s Hospital at UCLA.
Floating Hospital’s ability to attract outstanding physicians from across the country is one measure of our growing national stature.
But what’s most important to us is making sure that we always cater to the needs of our referring physician community here in the
greater Boston region. I always want to hear from you, so please don’t hesitate to reach out at [email protected].
Sincerely,
John Schreiber, MD, MPH
Pediatrician-in-Chief, Chief Administrative Officer
Floating Hospital for Children at Tufts Medical Center
Chairman, Department of Pediatrics
Tufts University School of Medicine
COVER: Angela Wong, a participant in Floating Hospital for Children’s
Center for Youth Wellness, celebrates after scoring a goal during a
program game at the Chinatown YMCA in Boston.
Pediatric Clinical Trials:
expanding the possibility
for breakthroughs
PERFORMING CLINICAL RESEARCH is a vital part of the
practice of many physicians at Floating Hospital for Children. But finding time to keep up with the administrative
work required by study sponsors isn’t easy for clinicians
with busy patient panels. Over the past year, Floating
Hospital has been able to expand the number of clinical
trials available to patients by making trial participation
easier on physicians.
Thanks to these changes, the number of trials open for
enrollment at Floating Hospital is expanding. Pediatricians should call the Pediatric Clinical Trials office at
617-636-0240 or email [email protected] if they have a patient who they feel would benefit
for enrollment in a trial to see if trials are available for a
particular child.
“We started a support structure for infectious disease that
worked so well we expanded it to the rest of our pediatric
clinical trials, and the result is that more clinicians are
able to offer more trials to their patients,” explains Chief
of the Division of Pediatric Infectious Diseases H. Cody
Meissner, MD.
Clinical Research Associate Karen Murray has played a
key role in expanding Floating Hospital’s clinical trials
portfolio. Murray manages the pediatric clinical research
staff of five full-time employees who are supported by the
industry- and government-backed clinical trials that enroll
pediatric patients.
“Our administrative work started with one trial, and now
we are up to 30 active at one time,” Murray says, “We want
to make it user-friendly to potential investigators and
facilitate physicians doing the research that they really
want to do.”
Murray and her team can look at a trial request from a
sponsor or respond to a potential Tufts MC investigator and help determine whether the trial is a good fit for
Floating Hospital’s patient population. Murray’s team
also handles facility tours required by sponsors, completes
regulatory documents, collects research data and submits
it to sponsors, and assists in the recruitment of potential
research subjects by talking to parents about the study.
They also shepherd the trials through the Institutional
Review Board process. The IRB reviews every clinical
research study to ensure the study is safe, ethical and
that the rights and well-being of participants in the study
are protected in accordance with federal and study
sponsor regulations.
“Research is much more successful with strong support,”
she says. “Often we are the only pediatric hospital in New
England that offers a particular study. Kids can get cuttingedge care here. ●
To learn more about pediatric clinical trials at
Floating Hospital for Children, call 617-636-0240
or email [email protected].
Healthy Futures
3
Center for Youth Wellness
GOAL!
Empowering Adolescents
to Make Healthy Choices
BEING A TEENAGER IS CHALLENGING. But being an obese
teenager can be an overwhelming struggle, especially if the
young person doesn’t know the first thing about healthy
nutrition or is embarrassed to be seen exercising.
Enter the Center for Youth Wellness at Floating Hospital
for Children at Tufts Medical Center. Two years ago, it launched
an innovative 10-week adolescent obesity group program
designed for young people from 11 to 18. Today, the program
is available in Boston, at Lowell General Hospital and at
MetroWest Medical Center in Framingham, with plans to
offer it at other Floating-affiliated community hospitals in
the near future.
Most importantly, it’s changing young lives for the better.
“Our program provides a safe, supportive environment
where teens can feel comfortable learning new techniques
and skills so they can implement healthier habits on their
own,” explains Clinical Director of the Center for Youth
Wellness Michael Leidig, RD, LDN.
4
Brian Pham (foreground)
and Samantha Melanson
(background) get some
exercise as part of their
weekly session with staff
from the Center for Youth
Wellness at Floating Hospital
for Children.
“The group approach has real benefits,” he continues.
“Social isolation is common among obese teens who often
are struggling with friendships, teasing and bullying. In the
group setting, it’s more fun and they see they’re not alone.
Yet we keep the groups small enough so each participant
gets individual attention.”
“This program
taught me that
it is possible
to eat and be
healthy without starving
myself...”
A patient’s perspective
Sixteen-year-old Malik Ferguson, a sophomore at Boston
Preparatory Charter Public
Teen Evaluation
School in Hyde Park, is one
participant who has seen the
program work. He says that losing weight is his number-one
priority because he realizes he needs to be healthy in order
to get good grades — and he wants to attend college to study
mechanical engineering. Ferguson attended the Boston
program in the fall of 2012, driven by his motivation to focus
on his schoolwork and to plan for his future.
A few weeks into the program, he said, “So far it’s really
helping a lot; I’ve already lost five pounds. This opportunity
is basically my life.”
The program is designed exclusively for adolescents with
a body mass index (BMI) at or above the 95th percentile, or
above the 85th percentile with a comorbid condition such
as hypertension or hyperlipidemia. It comprises two initial
assessment visits — which at least one parent or legal
guardian must also attend — and 10 weekly two-hour group
sessions that occur after school. There also are follow-up
visits at three and 12 months after program completion.
At the initial 90-minute assessment, the teen meets
with a physician, psychologist and dietitian to identify any
continued on next page
Healthy Futures
5
Center for Youth Wellness
Talking to Adolescent Patients —
and Their Parents — About Obesity
continued from previous page
underlying medical, psychological or nutritional conditions
that could affect weight loss. At the second visit, held two to
three weeks later, the physician shares the results gathered by
the team at the first visit, including lab results, and discusses
the teen’s interest in and eligibility for the 10-week group
program.
The first hour of the after-school program, taught by
dietitians and psychologists, focuses on nutrition, stress
reduction and how to successfully make dietary and behavioral changes. During the second hour, enrollees take part
in a variety of fun physical activities at YMCAs located in
Chinatown, Lowell and Framingham (all program participants
receive a 10-week membership to their local Y). Kids also
are taught how to modify activities so they can perform
exercises at home.
Impressive results
About three-quarters of the adolescents who’ve been assessed go on to start the group program. About 75 percent
complete it, a retention rate that compares favorably for this
type of program. Floating Hospital was involved in a national
focus group with 24 other children’s hospitals with pediatric
obesity programs, and most had a 50 percent dropout rate.
“Most teens have participated in other weight management
programs and often feel judged and deprived of the foods they
love, which sets them up for a negative relationship with food
and healthcare providers,” Leidig says. “We focus on teaching
the knowledge and skills they need to navigate the many
eating situations they find themselves in.”
“For example, they may not be eating breakfast at home,
they’re eating school lunches, and maybe hitting a fast-food
restaurant or convenience store after school,” he continues.
“We teach them healthy options to choose in all of these
situations. We’re not giving out a diet or putting them on a
strict calorie-, fat- or carbohydrate-controlled diet. We’re
empowering them to makes the changes they want to
make versus being told what to do.”
“We don’t eliminate treats, but encourage them to reduce
portion size and be mindful of what, when and why they’re
eating,” he says, noting that many kids engage in emotional
eating, turning to food without really being hungry.
“We don’t expect teens to lose a ton of weight during our
10-week program,” he adds. “But it’s 10 weeks of helping them
build healthy living skills and empowering them to make some
important long-term changes. As a result, we start to see
participants consuming more fruits and vegetables, and
reducing consumption of sugar-sweetened beverages in
particular.”
It’s an approach that’s resonating with the youth who take
part in the program.
“This program taught me that it is possible to eat and be
healthy without starving myself,” one teen wrote in an evaluation of the program. “It gave me the tools to lead a healthy life
and with patience and determination changes can be made.
It was also very supportive. I made amazing friends and had
great discussions. Through this program I learned how to lead
a healthy lifestyle, and that I am not in it alone.”
Leidig says that at times it can be difficult for busy pediatricians
to engage patients and parents in discussing weight issues. To
jumpstart the process, however, he and his team have developed
a simple 10-question survey about teens’ eating and activity patterns (see graphic).
“Pediatricians can have patients complete the questionnaire
in the waiting room prior to a well visit,” he says. “Then it can
be used as a conversation starter during the visit. It’s a way of
engaging the patient in a spirit of inquiry and concern, using his
or her own responses, versus providing unsolicited advice. And
it’s not perceived as judgmental since you’re letting the patient
decide if he or she is concerned about any specific behaviors.”
And, Leidig notes, it’s a great opener for introducing his
team’s group program, for which referrals are welcomed.
“The first two assessment visits require trips to Boston, but
if you can make the case to patients and parents north and west
of the city that it’s worth it, then the 10-week program is right in
their own community,” he adds.
Another wrote, “This program was a great success. I was
able to learn something that actually worked. I noticed that I
was losing pounds. I was able to meet people with the same
problem as me and we were able to help one another out.
I’m glad I joined the program. I truly recommend it.”
“It’s unusual to get positive comments from an adolescent
going through a weight management program,” Leidig says,
“but during our program, a light bulb goes off and teens realize
‘I can do it.’ They decide to make the changes versus being told
to do so by a parent or healthcare provider. And they’re so
much more likely to succeed when the idea to make a healthy
change is their idea.”
The 10-week after-school teen program is currently
available at the MetroWest YMCA on Tuesdays, the Greater
Lowell Family YMCA on Wednesdays and the Wang YMCA of
Chinatown on Fridays. Currently, the only out-of-pocket cost
to families is a $50 administrative fee and whatever insurance
copayments apply for the first two assessment visits and the
three- and 12-month follow-up visits. ▲
(Above Right to Left) Pediatric psychologist Susan Meagher,
PhD and dietician Emily Biever, MS, RD, LDN talk with Brian Pham,
Samantha Melanson and Angela Wong (back to camera) about
healthy eating.
(Above Left to Right) Biever, Meagher and Michael Leidig, MS, RD,
LDN, CPT have designed the Center for Youth Wellness programs to
empower adolescents who are obese to take control of their habits
and improve their health.
6 Floating Hospital for Children at Tufts Medical Center
To learn more or refer a patient, please call
617-636-3381 or visit www.floatinghospital.org/cyw.
Healthy Futures
7
Comfort Corner
Pediatric sedation
service gets a
calm new location
Pediatric Intensive Care
AWASH IN MUTED BUT CHEERFUL GREENS AND YELLOWS, Floating Hospital’s
new pediatric sedation unit — aptly nicknamed the Comfort Corner — will soon
offer children and their families a supportive atmosphere as they are sedated for
imaging or minor procedures.
The new unit ­— the first of its kind in Boston for children — was built entirely
with donations, including a major gift from the Ronald McDonald House Charities of Eastern New England. For a number of years, Floating Hospital has had a
dedicated pediatric sedation team based in the Pediatric Intensive Care Unit, but
the service has outgrown its original home. With more space, the new unit will
provide the sedation team with the ability to see more patients in less time, which
should cut down considerably on waits for non-emergent imaging, such as MRIs.
“It’s great to have a child-friendly place where children can have their procedures done with minimal discomfort and appropriate sedation in a safe and
controlled manner,” says Chief of Pediatric Critcal Care Rashed Durgham, MD.
“We look forward to providing a very child-friendly experience, to limit the stress
on patients and their families.”
Clinical Nursing Director for the Sedation Service Laura O’Garro, RN will
oversee the new facility with Durgham. “We have a very experienced and caring
team of nurses in pediatric sedation, and we will be adding to that team as we
move to this new unit,” she says. “Some children, particularly those
being treated for various types of cancer, need frequent sedations
for procedures and imaging. We’re really pleased that they and their
families will now have an environment that’s as comforting to them
as our staff is.”
Pediatric sedation nurses Carole McCarthy, RN (top left) and Alice
Rose, RN (bottom left) are known for their dedication to the patients
in their care — a commitment that has included coming to work on
their days off when one of their patients needed to have sedation
that day. In 2012 the two were jointly honored with a “True Blue”
award, Floating Hospital and Tufts Medical Center’s highest award
for employees who demonstrate remarkable dedication.
8 Floating Hospital for Children at Tufts Medical Center
Vital for kids with frequent procedures
McCarthy said she is particularly pleased that
some of the children she sees on an ongoing
basis, such as leukemia patients who face a
three-year course of treatment, will have a
more comfortable location in which to receive
some of their vital care. Sedation for patients
who face repeat procedures is particularly
important to avoid traumatizing kids or creating intensely negative memories of receiving
medical care. “Children with leukemia, for
example, go through many stressful and painful treatments, and it’s life-changing for the
family and the child. And if you’re asking a
child to have a lumbar puncture every week
for a period of time and then every month for
a time thereafter, they may have a horrible
memory of the pain without sedation,” she
says. “We have
children who
come to us and
they skip into the
room, wondering
what ‘prize’ we’re
going to reward
them with that
day. We sedate
them, the procedure is performed,
they recover and
then skip out. It
Chief of Pediatric Critical Care Rashed
Durgham, MD, with Clinical Nursing
becomes a posiDirector Laura O’Garro, RN (pictured left). tive experience,
not a negative one.”
Floating Hospital’s Child Life experts,
who spend time with children while they are
prepared for sedation, are also an integral
part of the pediatric sedation team. Often
during the half-hour wait for numbing cream
to take effect before an IV is placed, a child
life specialist will take a youngster and his or
her family to Floating Hospital’s Ace’s Place
playroom, where kids and families can play
and relax a bit before the procedure. That short
trip is often helpful for calming jittery children
and families and it makes sedation easier, too,
says McCarthy: “They’re calm, they’re relaxed,
their extremities are warmed up, their veins
are easier to find, and the whole experience
is more comfortable.” ■
“It’s great to have
a child-friendly
place where
children can have
their procedures
done with minimal
discomfort.”
Healthy Futures
9
Pediatric Urology
Biofeedback
for Bedwetting
For children aged six and older who struggle with
nighttime or daytime wetting, Floating Hospital
offers a non-invasive and drug-free solution with
a well-established track record.
“IT BASICALLY INVOLVES physical therapy via
biofeedback for the pelvic floor,” explains
Director of Pediatric Neuro-Urology
Jeremy Wiygul, MD. “For treating persistent voiding problems in preadolescent
kids — before adolescence and after toilet
training — this is the recommended
first-line approach versus medication
like Ditropan (oxybutynin).”
And it delivers results.
“This program can definitely help with
wetting problems and overcome the
social issues that come along with it,”
Wiygul says, noting that about 70 percent
of his patients report an improvement, a
response rate consistent with several
broad-based outcomes analyses. “It also
places the child in control which, in my
experience, is the single most important
factor in overcoming the problem.”
are asked to fill out a log to document the
child’s voiding habits and diet between
biofeedback sessions.
In fact, Wiygul has developed an Apple®platform smartphone and tablet app
called “HapPee Time” to help support
and encourage compliance. The app
enables parents and kids to track what
children eat and drink to get a clear
picture of what may be affecting their
ability to avoid wetting.
“Parents — or children — can track these
behaviors in the app and, at the end of
therapy, email results to me or the treating
physician,” he explains.
Wiygul points out that there is a large
percentage of patients whose bedwetting
issues resolve simply by treating them for
constipation.
“It’s very common for constipation to be
the main issue, and I don’t think that’s
widely known,” he says. “But it’s really the
biggest contributing factor in wetting. So
my advice to referring pediatricians is to
first evaluate the child for constipation.
It’s amazing how often patients can avoid
additional testing and doctors’ visits simply
by having their constipation treated.”
“If a child doesn’t have constipation or doesn’t
respond to treatment, then refer him or her
for a biofeedback consultation,” he adds.
Wiygul offers initial consultations at Floating
Hospital in downtown Boston as well as at
MetroWest Medical Center in Framingham.
Because the biofeedback equipment is
currently only available at Floating Hospital,
the treatment occurs there.
“The first thing I tell patients and parents after
taking a history is that ‘this will resolve,’” he
says. “I always try to emphasize that wetting
is much more common than they realize, and
we know this from epidemiological studies as
well as from clinical experience.”
“I don’t recommend biofeedback unless I think
it’ll really help, and I administer it myself,”
he adds, noting that the Floating Hospital
program is one of only two in Boston and it
is the only one lead by a physician.“Here at
Floating, it’s highly personalized, used
judiciously and it definitely can help.” ◆
(above) pediatric
urologist Jeremy
Wiygul, MD has
developed HapPee Time,
an app for smartphones that uses a
game-based rewards
system to encourage
kids to engage in
behavior that will
help improve urinary
continence.
To learn more or refer a patient to
Dr. Wiygul, call 617-636-5360.
How does it work?
In biofeedback sessions, sensors are
placed on the child’s sphincter muscles.
The child is then instructed to contract
the muscles, and a figure on the computer
screen moves in response.
“It graphically represents to the child how
to become more aware of the sphincter
muscles, and we can show parents how
the child is improving over time,” he says.
Parents are present during the biofeedback sessions to provide encouragement,
and kids are given ‘homework’ in the form
of Kegel exercises. Parents also
10 Floating Hospital for Children at Tufts Medical Center
Left: These screen shots show the biofeedback game
used by Wiygul to help young patients with enuresis
learn sphincter control. After Wiygul attaches
the sensors (above) on the skin over a youngster’s
sphincter muscles, the child moves the character on
the screen by tightening and loosening the muscles.
As youngster’s gain finer control, the game gets
more difficult.
Healthy Futures
11
Quality Standards
Better All the Time
Quality Initiatives at Floating Hospital
National benchmarking
Compared to adults, children respond
differently, and often uniquely, to
illnesses and treatments, and require
different approaches to care at different
ages, sizes and phases of development.
So quality benchmarks for inpatient
pediatric care have been trickier to
develop than standards for adults. But
that’s changing rapidly, and Floating
Hospital is at the forefront, having recently joined a groundbreaking network
of children’s hospitals working together
to improve pediatric patient safety.
Floating Hospital’s Executive Director for Perinatal and Pediatric Services
Mary Beth Williams, RN, MN explains
that Floating Hospital recently joined
a Center for Medicare and Medicaid
Services-supported network of Children’s Hospitals established by Ohio
Children’s Hospitals Solutions for
Patient Safety. “We’re now one of 70
children’s hospitals across the nation
in the network,” she continues. “It’s
not just submission of our quality data
but a commitment by our clinicians to
probe into our practices. We’re excited,
focused and committed as we engage
with this `all teach, all learn’ approach
to improving care.
Floating Hospital is also participating in national field testing of what’s
being referred to as the new ‘pediatric
HCAHPS,’ the Hospital Consumer Assessment of Healthcare Providers and
Systems. The hospital is a pilot site for
a new Press Ganey tool through which
families can provide feedback on their
perception of care.
Central line infections:
the quest for zero
Floating Hospital’s Neonatal Intensive Care Unit has joined a national
prevention collaborative involving 75
NICUs in eight states, to further our
quest to eliminate central line infections.
“We’ve worked with the group to
develop bundles of ways to manage
central lines,” Williams says. “With
incredible effort on part of the NICU
team, we were proud to complete close
to one year without an infection.”
Safer hand-offs
Chief of the Pediatric Hospitalist
Program Elisabeth Schainker, MD
describes another initiative to improve
sign-out communication between
hospitalists working at Floating Hospital affiliates Lowell General Hospital, Lawrence General Hospital and
MetroWest Medical Center:
“Good communication during the
hand-off between shifts significantly
reduces the risk of harm to patients,”
she says. “We’re developing a standardized template that helps physicians be more complete in their handoff communications. A pilot study
demonstrated that this template not
only improves clinical decision-making and reduces errors and duplication
of effort, but it also strengthens rapport
among clinicians and families.”
12 Floating Hospital for Children at Tufts Medical Center
Giving referring physicians
the info they need
Similarly, with support from the New
England Quality Care Alliance (NEQCA), Floating Hospital is working on
ways to improve discharge communications with referring providers.
“We recognize that different doctors
have different preferences on what information they want to receive and in
what format, so we’re working with our
information technology department to
develop a system that supports an individual approach to communications,”
Schainker says. For example, with
computerized medical records, there’s
an opportunity to send information
directly to the patient’s record instead
of faxing a hard copy.
“We’ll be sending out a survey to all
referring physicians in our network
and to NEQCA to make sure we have
the correct contact information and
are meeting expectations,” she adds.
“Quality improvement is very much
a part of our culture here,” Schainker
adds. “Our goal is to be continually
self-reflective because it’s critical to
identify when we’re not meeting our
quality goals. That way we can all work
together to figure out ways to do better.
And we appreciate feedback from the
primary care community to help us
learn and improve.” ●
WORKING
TOGETHER
Real experiences from our referring physicians and their staff
HAVE A STORY TO TELL US?
At Floating Hospital for Children,
we value our referring physician
partners and are committed to
doing all we can to make it easy
for you to refer your patients
here. It is our mission to ensure
that they, and you, have a positive experience during the entire
referral process. If you have a
story to tell about your experience with Floating Hospital, please contact us at
[email protected]. We would
love to include it in a future
Working Together column.
To refer inpatients
to Floating Hospital
for Children at
Tufts Medical Center,
call 877-KIDS-FHC
(877-543-7342)
For the Pediatric
Specialty Center
closest to you,
call 617-636-8100.
Beth Freire, MD
Beth Anne Freire, MD is a pediatrician at Pediatric Associates of Woburn and North Andover, working primarily
in the North Andover practice, which sees about 7,000
patients who live in the area from Andover into southern
New Hampshire. An alumna of Floating Hospital’s
residency program, Freire frequently refers patients to
Floating specialists and also works closely with Floating
Hospital hospitalists at Lawrence General Hospital.
Freire says that the hospitalist service at Lawrence General
has been helpful in enabling more patients to stay close to home — making life easier
on them and their parents.
“The hospitalists give excellent pediatric care to our patients — they can provide a
Boston level of care at a community hospital,” she says. “It’s also very cost efficient,
because we can call them and say `we have an asthmatic patient who needs to be
hospitalized,’ and that patient can bypass the emergency department and be directly
admitted.”
“The hospitalists’ communication has been excellent. We’re called on a daily basis
when our patients are there, we’re called at the time of discharge — it’s been great
for us with patients we don’t want to send to Boston,” she says.
When her patients need to see a subspecialist or they need tertiary-level inpatient
care, Freire says that Floating Hospital is her first choice. She knows many subspecialists personally and has particularly productive relationships with the hematology/
oncology, cardiology, infectious disease, pediatric gynecology and rheumatology
services.
She says the communication she receives when her patients receive inpatient treatment at Floating Hospital is particularly important to allow her to maximize their care
when they return home.
“Communication is critical, because they’re our patients, they come back to us, and
a lot of times they have questions about the hospitalization they didn’t think to ask
while they were hospitalized,” she says. “Floating Hospital is able to provide top-notch
specialty and tertiary care for my patients and they communicate extremely well with
us, and that’s why I keep sending my patients there.” ▲
Healthy Futures 13
Health Sheet
Concussions in young athletes
Pediatric NEUROLOGY Q&A
with Douglas Hyder, MD
Director, Ambulatory Pediatric Neurology
Which sports lead to the most concussions for young athletes?
Douglas Hyder, MD
Director, Ambulatory
Pediatric Neurology
Medical School
University of Chicago Pritzker
School of Medicine
Postgraduate Training
University of Chicago;
Children’s Hospital of
Philadelphia
Board Certification
Neurology (with Special
Qualification in Child
Neurology)
Clinical Specialties
General pediatric neurology,
neuro-oncology, headaches
To refer a patient to Dr. Hyder,
call 617-636-8100.
In high school sports, football has the highest rate of concussion, followed by girls’
soccer, boys’ lacrosse, boys’ soccer and girls’ basketball. According to one widelyreported statistic, about 17 percent of football players aged 12 to 17 have had at least
one concussion; another study, conducted in 2004, suggests that up to half of all
football players do not report their concussion symptoms.
Are girls who play sports more likely to sustain concussions
than boys?
In terms of the data we have for similar sports, girls report more concussion
symptoms than boys. However, that may not be related to the actual incidence of
concussion, as it appears that girls may be more forthright than boys in reporting
their symptoms. Obviously girl and boy athletes are both competing as hard as they
can, and it’s not the level of competition that seems to change the rate of reporting.
There just seems to be greater reluctance among boys to report, so parents
and coaches should be aware of that.
If some athletes avoid reporting or actively work to hide concussion
symptoms, how can parents and coaches recognize the warning
signs?
All coaches should be familiar with the symptoms that typically immediately follow
a concussion. These symptoms include a dazed or stunned appearance, confusion
over an assignment or position, unfamiliarity with where he or she is in the game,
what the score is or who the opponent is. Also, a brief loss of consciousness or an
inability to recall events immediately prior to, or after a hit or fall are telltale signs of
a concussion. It’s also become quite standard to do pre-season cognitive testing to
get an idea of an athlete’s baseline cognitive functioning. This is helpful because it
can generate results that we can use to compare to an athlete’s functioning after a
hit or fall, or after multiple hits through a portion of a season. We do need to emphasize to our athletes the importance of answering honestly on the baseline tests. One
of the biggest issues we see is ‘sandbagging’, or purposely answering incorrectly,
so that the baseline test doesn’t show their full mental capacity at the beginning of
the season. The misguided hope of the athletes who engage in this practice is that
if they do get concussions during the season, the damage will be less obvious when
later tests are compared to the baseline.
14 Floating Hospital for Children at Tufts Medical Center
A quick resource guide for your patients: clip and copy or download at
www.floatinghospital.org/concussions
What should coaches be doing to help their athletes
avoid or minimize the risk of concussions?
What should parents and coaches do when
an athlete experiences multiple concussions?
I think many coaches already are making changes to reduce
the risk of concussions, especially during practices. The oldfashioned view of football practice, for example, is that you’d
want to do as many practices in full pads as possible so that
you could condition your body to receive blows. I think a more
modern view of coaching is that by doing full-pad, full-contact
practices, you’re probably just increasing injuries. Many of the
high schools and even some college and pro teams are increasing the amount of time spent in drills where they practice
everything except the impact. This places the emphasis on
preventing injuries and strengthening the muscular-skeletal
system, so that when players do go into a game, they’re more
protected against injury.
Many leagues have concussion policies, and obviously those
should be followed. But whenever a young athlete has sustained multiple injuries in a particular sport, it would be wise
for the athlete and his or her parents to assess whether it
makes sense to continue participating in that particular
sport. Most people’s bodies were not designed to be in the
World Premiere Soccer League or even to play Division I college sports, and while many kids do fine playing high-contact
sports, others are at greater risk. At a certain point, a young
athlete may need to switch to sports that can still be exciting
and competitive, but that involve less contact. This isn’t an
easy message to deliver as a doctor or a parent. I had a knee
injury in high school and my doctor told me I had to quit the
sport I was playing. Now, decades later, I can still do a lot of
things I might not have been able to do had I not seen that
particular doctor and quit when I did. I can appreciate the hard
feelings and the mourning that takes place for an athlete who
reaches that point. I always try to articulate a clear goal —
protecting their health and safety — while emphasizing that
there are plenty of other things they can do that will better fit
with their bodies’ physiology. ◆
How much time does it take to recover from
a concussion?
The younger the athlete, the greater the likelihood that the
recovery will take longer — young brains are doing a great deal
of developing and it can take them more time to heal. Studies
show that 90 percent of concussions in college athletes and
75 percent of concussions in high school athletes resolve in
10 to 14 days. So for the average athlete who has a typical
concussion, chances are they’re going to be better in a couple
of weeks. The problem we run into as pediatric neurologists
is the 10 to 25 percent who have a delayed recovery. One
contributing factor is often a personal history of head injury;
there is likely a cumulative effect, which means it’s going to
take longer and longer to recover after each head injury. Another factor is the athlete’s pre-injury state. If the athlete was
struggling with school and family issues or had anxiety or depression problems, all of those problems would be amplified
with the injury. That’s why establishing a pre-injury baseline
is so important.
RESOURCES
For more information:
http://www.cdc.gov/concussion/sports/recognize.html
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Update in Pediatrics — On the Move 2013
Join us for one of the region’s finest educational
opportunities for pediatricians. This year, our free
CME conference will be on the move, with sessions
held at our community hospital affiliates.
Go to our website to register or check the dates
and locations for 2013:
www.floatinghospital.org/updateinpediatrics
Working Together for Healthy Futures is published
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Department of Public Affairs and Communications.
Please contact us at 617-636-0200 or
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Floating Hospital for Children at Tufts Medical Center
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