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Canadian siblings born four months early set record as the world’s most premature twins | CNN

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CNN
—

For expectant parents Shakina Rajendram and Kevin Nadarajah, the doctor’s words were both definitive and devastating: Their twins were not “viable.”

“Even in that moment, as I was hearing those words come out of the doctor’s mouth, I could still feel the babies very much alive within me. And so for me, I just wasn’t able to comprehend how babies who felt very much alive within me could not be viable,” Rajendram recalled.

Still, she knew that there was no way she would be able to carry to term. She had begun bleeding, and the doctor said she would give birth soon. The parents-to-be were told that they would be able to hold their babies but that they would not be resuscitated, as they were too premature.

Rajendram, 35, and Nadarajah, 37, had married and settled in Ajax, Ontario, about 35 miles east of Toronto, to start a family. They had conceived once before, but the pregnancy was ectopic – outside the uterus – and ended after a few months.

As crushing as the doctor’s news was, Nadarajah said, they both refused to believe their babies would not make it. And so they scoured the Internet, finding information that both alarmed and encouraged them. The babies were at just 21 weeks and five days gestation; to have a chance, they would need to stay in the womb a day and a half longer, and Rajendram would have to go to a specialized hospital that could treat “micropreemies.”

The earlier a baby is born, the higher the risk of death or serious disability, the US Centers for Disease Control and Prevention says. Babies born preterm, before 37 weeks gestation, can have breathing issues, digestive problems and brain bleeds. Development challenges and delays can also last a lifetime.

The problems can be especially severe for micropreemies, those born before 26 weeks gestation who weigh less than 26 ounces.

Research has found that infants born at 22 weeks who get active medical treatment have survival rates of 25% to 50%, according to a 2019 study.

Adrial was born weighing less than 15 ounces.

Rajendram and Nadarajah requested a transfer to Mount Sinai Hospital in Toronto, one of a limited number of medical centers in North America that provides resuscitation and active care at 22 weeks gestation.

Then, they say, they “prayed hard,” with Rajendram determined to keep the babies inside her just a few hours longer.

Just one hour after midnight on March 4, 2022, at 22 weeks gestation, Adiah Laelynn Nadarajah was born weighing under 12 ounces. Her brother, Adrial Luka Nadarajah, joined her 23 minutes later, weighing not quite 15 ounces.

According to Guinness World Records, the pair are both the most premature and lightest twins ever born. The previous record holders for premature twins were the Ewoldt twins, born in Iowa at the gestational age of 22 weeks, 1 day.

It is a record these parents say they want broken as soon as possible so more babies are given the opportunity to survive.

“They were perfect in every sense to us,” Rajendram said. “They were born smaller than the palm of our hands. People still don’t believe us when we tell them.”

The babies were born at just the right time to be eligible to receive proactive care, resuscitation, nutrition and vital organ support, according to Mount Sinai Hospital. Even an hour earlier, the care team may not have been able to intervene medically.

“We just didn’t really understand why that strict cut off at 22, but we know that the hospital had their reasons. They were in uncharted territory, and I know that they had to possibly create some parameters around what they could do,” Rajendram said.

“They’re definitely miracles,” Nadarajah said as he described seeing the twins in the neonatal intensive care unit for the first time and trying to come to terms with what they would go through in their fight to survive.

“I had challenging feelings, conflicting feelings, seeing how tiny they were on one hand, feeling the joy of seeing two babies on the second hand. I was thinking, ‘how much pain they are in?’ It was so conflicting. They were so tiny,” he said.

These risks and setbacks are common in the lives of micropreemies.

Dr. Prakesh Shah, the pediatrician-in-chief at Mount Sinai Hospital, said he was straightforward with the couple about the challenges ahead for their twins.

He warned of a struggle just to keep Adiah and Adrial breathing, let alone feed them.

The babies weighed little more than a can of soda, with their organs visible through translucent skin. The needle used to give them nutrition was less than 2 millimeters in diameter, about the size of a thin knitting needle.

“At some stage, many of us would have felt that, ‘is this the right thing to do for these babies?’ These babies were in significant pain, distress, and their skin was peeling off. Even removing surgical tape would mean that their skin would peel off,” Shah told CNN.

But what their parents saw gave them hope.

“We could see through their skin. We could see their hearts beating,” Rajendram said.

They had to weigh all the risks of going forward and agreeing to more and more medical intervention. There could be months or even years of painful, difficult treatment ahead, along with the long-term risks of things like muscle development problems, cerebral palsy, language delays, cognitive delays, blindness and deafness.

Rajendram and Nadarajah did not dare hope for another miracle, but they say they knew their babies were fighters, and they resolved to give them a chance at life.

“The strength that Kevin and I had as parents, we had to believe that our babies had that same strength, that they have that same resilience. And so yes, they would have to go through pain, and they’re going to continue going through difficult moments, even through their adult life, not only as premature babies. But we believed that they would have a stronger resolve, a resilience that would enable them to get through those painful moments in the NICU,” Rajendram said.

There were painful setbacks over nearly half a year of treatment in the hospital, especially in the first few weeks.

“There were several instances in the early days where we were asked about withdrawing care, that’s just a fact, and so those were the moments where we just rallied in prayer, and we saw a turnaround,” Nadarajah said.

Adiah spent 161 days in the hospital and went home on August 11, six days before her brother, Adrial, joined her there.

Adrial’s road has been a bit more difficult. He has been hospitalized three more times with various infections, sometimes spending weeks in the hospital.

Both siblings continue with specialist checkups and various types of therapy several times a month.

But the new parents are finally more at ease, celebrating their babies’ homecoming and learning all they can about their personalities.

The twins are now meeting many of the milestones of babies for their “corrected age,” where they would be if they were born at full-term.

“The one thing that really surprised me, when both of them were ready to go home, both of them went home without oxygen, no feeding tube, nothing, they just went home. They were feeding on their own and maintaining their oxygen,” Shah said.

Adiah is now very social and has long conversations with everyone she meets. Their parents describe Adrial as wise for his years, curious and intelligent, with a love of music.

“We feel it’s very important to highlight that contrary to what was expected of them, our babies are happy, healthy, active babies who are breathing and feeding on their own, rolling over, babbling all the time, growing well, playing, and enjoying life as babies,” Rajendram said.

These parents hope their story will inspire other families and health professionals to reassess the issue of viability before 22 weeks gestation, even when confronted with sobering survival rates and risks of long-term disability.

“Even five years ago, we would not have gone for it, if it was not for the better help we can now provide,” Shah said, adding that medical teams are using life-sustaining technology in a better way than in previous years. “It’s allowing us to sustain these babies, helping keep oxygen in their bodies, the role of carbon dioxide, without causing lung injury.”

Adiah and Adrial’s parents say they’re not expecting perfect children with perfect health but are striving to provide the best possible life for them.

“This journey has empowered us to advocate for the lives of other preterm infants like Adiah and Adrial, who would not be alive today if the boundaries of viability had not been challenged by their health care team,” Rajendram said.

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A shortage of albuterol is about to get worse, especially in hospitals | CNN

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CNN
—

An ongoing shortage of a medicine commonly used to treat people with breathing problems is expected to get worse after a major supplier to US hospitals shut down last week.

Liquid albuterol has been in short supply since last summer, according to the American Society of Health-System Pharmacists. It has been on the US Food and Drug Administration’s shortages list since October. The news of the plant shutdown worries some doctors who work with patients with breathing problems such as asthma.

“This is definitely concerning, especially as we are coming out of the respiratory season where we had a big demand with RSV, Covid-19 and flu, and are now heading into spring allergy season when a lot of kids and adults experience asthma symptoms,” said Dr. Juanita Mora, a national volunteer medical spokesperson for the American Lung Association and an allergist/immunologist based in Chicago. “This is a life-saving drug and being able to breathe is vital for everyone.”

The manufacturer that recently shut down, Akorn Operating Company LLC, had filed for Chapter 11 bankruptcy in May 2020.

It was the only company to make certain albuterol products used for continuous nebulizer treatment. It’s a staple in children’s hospitals, but had been out of stock since last fall. Without that particular form of the product, hospitals have had to scramble to find alternatives.

“Members are either forced to compound it themselves to make the product or go to an outside third party source who is compounding the product,” said Paula Gurz, senior director of pharmacy contracting with Premier Inc., a major group purchasing company for hospitals.

With the Akorn shutdown, Gurz said products from the one remaining major domestic source of liquid albuterol, Nephron Pharmacuticals, have been on back order. Nephron just started shipping albuterol last Friday, Gurz said, but to get back on track, “it’s going to be an uphill climb.”

Hospitals around the country said they’re watching the supply chain – and their current stock – closely. There’s concern they might have to delay discharging patients because they don’t have enough medicine, or that they may see more ER visits for people with breathing problems who don’t have access to medicine.

Dr. Eryn Piper, a clinical pharmacist at Children’s Hospital of New Orleans, said her hospital has been largely unaffected so far, but for months she has heard about retail pharmacies and other health systems that have had issues with albuterol shortages.

“The big problem we’ve been hearing about is inhalation solutions, not really the inhalers, it’s more like the solutions that go into the nebulizer machines for inhalation that the patients breath in,” said Piper.

Without the larger Akorn product, staff at Lurie Children’s Hospital in Chicago had to squeeze out the albuterol contents from smaller packages.

It’s “time-consuming and labor-intensive as it takes opening 40 containers to equal 20 mL (each patient on continuous albuterol requires 3-5 syringes per day),” said hospital spokesperson Julianne Bardele in an email.

When Nephron was unable to meet demand due to manufacturing issues, Bardele said Lurie had to make another temporary switch to a different concentration and use an alternative liquid bronchodilator, levalbuterol.

Most hospital pharmacies are aware of supply issues for many medicines, particularly pediatric medicines, said T.J. Grimm, the director of retail and ambulatory services at University Hospitals Cleveland Medical Center, and they try to keep a higher stock – especially of the less expensive medicines like albuterol.

“Just so we can cover situations like this,” Grimm said.

Grimm said his system has albuterol supply for a couple of months still, but he’s frustrated and concerned about the supply chain.

“When you have supply chains that are just-in-time, it can create some issues with when something goes off,” Grimm added. “There’s the short-term crisis we all have to get through and then there’s a longer term. We need to think about these things a little more strategically, especially with our kids.”

Jerrod Milton, the chief clinical officer at Children’s Hospital Colorado, said they’ve been paying close attention to the albuterol shortages for many months. The hospital has experienced shortages in the past, and has continued to implement protocols to conserve doses.

“Challenges are what we deal with when it comes to pediatric medicine. We consider most of the kids that we take care of as somewhat therapeutic orphans,” Milton said. “It’s just another one of the myriad of shortages that we have to deal with, I guess.”

Jessica Daley, the group vice president of strategic sourcing for Premier, said that she doesn’t anticipate that the albuterol shortage will be an ongoing problem for years, but when the market has only a handful of suppliers, “it makes for a very tight market, a very concerning market right now.”

Daley said there are things hospitals can do to help, such as protocol changes, making products on site and finding different suppliers.

The Children’s Hospital Association stepped in to help when it heard from members having difficulty finding enough supply. The association worked with STAQ Pharma, a facility that provides compounded pediatric medication, to start production on batches of albuterol for children’s hospitals in the sizes they needed.

“We’ve been creative and trying to work proactively. So when we think there’s going to be a problem, we’re trying to plan ahead,” said Terri Lyle Wilson, director of supply chain services for the Children’s Hospital Association.

STAQ should be at full production by May, so hospitals will have a steady, stable supply ahead of the next season in which respiratory viruses are in wide circulation, the association says.

Daley at Premier said that in an ideal world, there would be more suppliers of these products, particularly with generic drugs, so that when there is a problem with one, the market could handle it. When there is a concentration of manufacturing with a small number of suppliers, it is very hard to recover, she said.

“We really advocate for diversity and supply to prevent types these types of issues,” Daley said. “Meaning at least three globally, geographically diverse suppliers that are supplying the market with sufficient products.”

For patients, Piper at Children’s Hospital of New Orleans said they are encouraging patients with breathing problems to take precautions and avoid asthma triggers if possible. She said if a patient’s usual pharmacy runs out, it’s also good to check with a doctor to see if there is another medication that’s available.

Inhalers don’t seem to be impacted by the shortage so far, but Daley said if people panic about the lack of albuterol for hospitals, that could change.

“Albuterol is one of those things that if there’s a patient who needs it, you want to have it all the time. So there’s always that potential for the market to respond and react in a way that that will then create downstream shortages of other sizes or presentations of a product,” Daley said.

To avoid that problem, Milton at Children’s Hospital Colorado said it’s simple: “Talk to a provider and see if there are alternatives,” Milton said. “And please don’t hoard.”

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Ohio, Pennsylvania offer health services following train derailment, but some residents feel skeptical | CNN

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Darlington Township, Pennsylvania
CNN
—

The municipal building in tiny Darlington Township, Pennsylvania, was buzzing with activity on Wednesday afternoon as a stream of locals arrived seeking information on health screenings, chemical exposures and well testing.

Darlington, home to about 1,800 people, sits just over the border from East Palestine, Ohio, the site of a catastrophic train derailment and controlled burn of toxic chemicals that sent black smoke billowing over the area for days in early February. Residents here say the wind blew acrid smoke into their homes and coated their cars with a fine ash. State and federal officials gave East Palestine residents the all-clear to return to their homes days later.

But residents in both places are now wondering whether their water is safe to drink and their air safe to breathe. The characteristic floral, fruity odor of butyl acrylate still permeates some homes and wafts up from some of the impacted streams that run through the town. Some say they’re experiencing symptoms – cough, headaches, rashes, watering eyes and dripping noses – that might be related to a chemical exposure.

Government-run community resource centers and health clinics have opened in East Palestine and Darlington to answer residents’ questions and connect them to any care they might need. More than 140 people have come to the clinic in East Palestine since it first opened on February 21, according to the Ohio Department of Health. The Darlington center opened February 28, and more than 200 people visited in its first two days, according to the Pennsylvania Department of Health.

Still, some residents are skeptical of the clinics, and the response overall. While many residents who live near the derailment site are following the testing for chemicals in the air and water, what they really want to know is whether they’ve had chemicals from the accident in their bodies, and whether those chemicals have impacted their health.

They’re swapping information online, and seeking out blood tests they hope will identify potential problems. Some are seeking out medical care so there’s a record of their symptoms.

On the advice of a lawyer, Ron Book and his wife came to the East Palestine Health Assessment Clinic on Wednesday afternoon to have their illnesses documented. Book says since the derailment, his nose has been running constantly. He has a sore throat, and he feels stuffy.

“It’s like I have a cold, but I don’t have a cold,” he said.

Book said he saw a doctor who took his vitals and advised him to keep up with the regular blood work that he needs for his ongoing treatment for prostate cancer. He was inside for about 45 minutes, and said the experience was helpful, and about what he expected.

“They can’t heal you,” Book says, “because nobody knows about this chemical.”

At the Darlington center, tables were staffed with experts to answer questions about the chemicals involved in the train derailment, free well and air testing for residents, and potential impacts to area farms.

There were pamphlets on how to manage stress following a disaster and mental health counselors, as well as Zuko, a 3-year-old Great Dane therapy dog.

Residents are also invited to take a nine-page questionnaire to contribute data to a newly launched Assessment of Chemical Exposure, or ACE, study, which is being conducted by the federal Agency for Toxic Substances and Disease Registry. Health investigators can use their data to inform a study into the health effects associated with the chemical exposures after the derailment.

People could see a doctor, or get referrals for a primary care physician.

“I think approximately 40% of people sought some sort of clinical evaluation,” said Nate Wardle, who is the special response project manager for the Pennsylvania Department of Health.

Wardle said when they opened the clinic, they weren’t sure what to expect – whether residents would be angry that it took more than three weeks to get them these services. So far, he said, people have been grateful and eager to get the help.

Jim Denes, who is 71, came to the health clinic in Darlington Township on Wednesday. He said he lives less than 2 miles from the accident site. On Friday of last week, Denes said he felt awful.

“I was just miserable. I was trying to cough up stuff, I couldn’t,” Denes said. “My eyes were all runny and watery.”

He said he took a Covid-19 test, but it was negative.

Denes said he’s extremely tired and had to drag himself to the clinic, but he’s glad he did. The doctor he saw diagnosed him with bronchitis and prescribed an antibiotic. The clinic was a lot closer than his regular doctor in Ellwood City, and he was able to walk in and be seen without a wait.

Denes said the doctor told him he couldn’t say whether it was related to the chemicals that were spilled or not.

Some residents said they have no interest in going to government-run health clinics.

“I honestly, at this point, don’t know who’s working with who and I really just don’t trust anything that has to do with the government right now,” said Giovanni Irizarry, whose family lives within a mile of the train derailment site.

In the evening hours of February 3, his wife Ashley Irizarry was driving to work when she noticed she could see thick black smoke hanging in the air, even though it was dark. Eventually, she saw the raging fire along the railroad tracks.

That night, Ashley had a red rash on her cheeks, her eyes were burning and red and a metallic chemical smell had burned her nose and throat. On Saturday, Giovanni said, his lips burned like he’d had scalding hot soup. Giovanni’s mother, who was living with them, developed a cough so severe she couldn’t catch her breath. The Irizarrys evacuated on Sunday to Boardman, Ohio, about 15 miles away.

They returned home on Saturday, February 11, in anticipation of school restarting on Monday.

As soon as they got close to town, Giovanni said, “I immediately felt my lips like start that burning sensation.”

He and his mom started coughing. His wife and kids developed debilitating and unrelenting headaches. After the kids came home from school on Monday, both started vomiting.

Ashley says she has taken the family to their primary care doctor, an urgent care and the hospital.

“It was not getting better,” she said.

Medical records reviewed by CNN show Ashley was prescribed a steroid and given a chest X-ray due to “toxic effects of gas exposure.” Her son was also diagnosed with chemical exposure.

When the doctors looked into her nose and throat they told her ” ‘Your mucous membranes are all pale. Like they were burned,’ but they didn’t know what to do at this time,” Ashley said in an interview with CNN on Wednesday.

On public Facebook groups, residents are sharing names of providers who will order blood testing for chemical exposures, which isn’t something either of the government-run clinics is doing currently. Some have even tried to do their own research to try to identify the medical codes needed to order tests for specific chemicals in the blood from large labs.

Instead of going to the government health clinic, on Wednesday, Ashley went to see their chiropractor, Richard Tsai, who has been ordering certain blood tests for existing patients who think they have having health problems connected to chemical exposures from the derailment.

Tsai’s practice, Blackhawk Chiropractic, is right next door to the Darlington Township community resource center and clinic that was opened by the Pennsylvania Department of Health and other state agencies this week.

The tests Tsai orders are general and standard in medical care – a test called a complete blood count, which measures levels of red cells, white cells, and clotting factors in the blood; and a test called a basic metabolic panel, which measures blood sugar, electrolytes, and kidney function. If his patients ask for it, he also orders a more specialized test that measure exposure to the chemical benzene. In the past two days, he estimates about 15 patients have asked him for blood testing.

Tsai, who lives in East Palestine, says he’s been frustrated by the government’s response.

“We shouldn’t be having to do this,” Tsai said, in an interview with CNN on Wednesday.

“Why are people having to figure this out on Facebook? These people need to know where to go and what’s available.”

Dr. Bruce Vanderhoff, director of the Ohio Department of Health, pushed back against the idea that the government wasn’t giving people enough information. He said that during the course of the medical assessment at the health clinic, the clinic physician might make recommendations for further testing, but that would be done by the person’s regular doctor.

If people don’t have a doctor that they see regularly, Vanderhoff said they are trying to help residents find one.

Vanderhoff said it would be important for the primary care providers to continue to monitor changes in a patient’s overall health.

“Because when we look at the chemicals involved, especially the primary chemical vinyl chloride, there is simply not a blood test that we can do or a urine test that we can do that would say ‘Aha! You had an exposure,’ ” Vanderhoff said. “That would be great, but that’s just not the case.”

Tsai, who lives in East Palestine, said that he’s legally able to order medical tests, so he does, within limits. “Why wouldn’t you do that?” he said.

Dr. Erin Haynes, the chairperson of the department of epidemiology and environmental health at the University of Kentucky, says she thinks it’s sound for residents to seek out common blood tests.

In an email to CNN, Haynes said in addition to a complete blood count and basic metabolic panel she would add a liver function test, since vinyl chloride, one chemical that was on the train, can damage the liver.

But Haynes says trying to test for specific chemicals may be a step too far.

“Testing for chemical exposure at this point is a difficult,” says Haynes, who has helped impacted communities investigate environmental exposures. “The high levels are now gone, and we aren’t exactly sure what to measure in blood or urine since we don’t know what chemicals formed during the fire. There are suspects, but not clear answers yet.”

Haynes said it would be ideal to collect blood and urine samples now, but store them for later testing, but this would be difficult for a local clinic to do.

Overall, Haynes says the government’s response to chemical spills like this one leaves something to be desired.

“The community is in dire need of an organized and coordinated health monitoring study that includes exposure assessment,” said Haynes, who hopes to bring such a study to the area soon.

Down the road, she says, there’s still a lot to learn about the health impacts of environmental exposures to toxins.

“We also need more research on what these chemicals do and methods for rapid testing,” Haynes said. “Communities with railroad must know what is moving through their community, when and how much. They also must receive training on how to safely respond when a disaster occurs.”

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Beware the budget butt lift, regulators warn amid social media-inspired boom | CNN

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In hindsight, Nikki Ruston said, she should have recognized the red flags.

The office in Miami where she scheduled what’s known as a Brazilian butt lift had closed and transferred her records to a different facility, she said. The price she was quoted – and paid upfront – increased the day of the procedure, and she said she did not meet her surgeon until she was about to be placed under general anesthesia.

“I was ready to walk out,” said Ruston, 44, of Lake Alfred in Central Florida. “But I had paid everything.”

A few days after the July procedure, Ruston was hospitalized due to infection, blood loss, and nausea, her medical records show.

“I went cheap. That’s what I did,” Ruston recalled recently. “I looked for the lowest price, and I found him on Instagram.”

People like Ruston are commonly lured to office-based surgery centers in South Florida through social media marketing that makes Brazilian butt lifts and other cosmetic surgery look deceptively painless, safe, and affordable, say researchers, patient advocates, and surgeon groups.

Unlike ambulatory surgery centers and hospitals, where a patient might stay overnight for observation after treatment, office-based surgery centers offer procedures that don’t typically require an inpatient stay and are regulated as an extension of a doctor’s private practice.

But such surgical offices are often owned by corporations that can offer discount prices by contracting with surgeons who are incentivized to work on as many patients per day as possible, in as little time as possible, according to state regulators and physicians critical of the facilities.

Ruston said she now lives with constant pain, but for other patients a Brazilian butt lift cost them their lives. After a rash of deaths, and in the absence of national standards, Florida regulators were the first in the nation to enact rules in 2019 meant to make the procedures safer. More than three years later, data shows deaths still occur.

Patient advocates and some surgeons – including those who perform the procedure themselves – anticipate the problem will only get worse. Emergency restrictions imposed by the state’s medical board in June expired in September, and the corporate business model popularized in Miami is spreading to other cities.

“We’re seeing entities that have a strong footprint in low-cost, high-volume cosmetic surgery, based in South Florida, manifesting in other parts of the country,” said Dr. Bob Basu, a vice president of the American Society of Plastic Surgeons and a practicing physician in Houston.

During a Brazilian butt lift, fat is taken via liposuction from other areas of the body – such as the torso, back, or thighs – and injected into the buttocks. More than 61,000 buttock augmentation procedures, both butt lifts and implants, were performed nationwide in 2021, a 37% increase from the previous year, according to data from the Aesthetic Society, a trade group of plastic surgeons.

As with all surgery, complications can occur. Miami-Dade County’s medical examiner has documented nearly three dozen cosmetic surgery patient deaths since 2009, of which 26 resulted from a Brazilian butt lift. In each case, the person died from a pulmonary fat embolism, when fat entered the bloodstream through veins in the gluteal muscles and stopped blood from flowing to the lungs.

No national reporting system nor insurance code tracks outcomes and patient demographics for a Brazilian butt lift. About 3% of surgeons worldwide had a patient die as a result of the procedure, according to a 2017 report from an Aesthetic Surgery Education and Research Foundation task force.

Medical experts said the problem is driven, in part, by having medical professionals like physician assistants and nurse practitioners perform key parts of the butt lift instead of doctors. It’s also driven by a business model that is motivated by profit, not safety, and incentivizes surgeons to exceed the number of surgeries outlined in their contracts.

In May, after a fifth patient in as many months died of complications in Miami-Dade County, Dr. Kevin Cairns proposed the state’s emergency rule to limit the number of butt lifts a surgeon could perform each day.

“I was getting sick of reading about women dying and seeing cases come before the board,” said Cairns, a physician and former member of the Florida Board of Medicine.

Some doctors performed as many as seven, according to disciplinary cases against surgeons prosecuted by the Florida Department of Health. The emergency rule limited them to no more than three, and required the use of an ultrasound to help surgeons lower the risk of a pulmonary fat clot.

But a group of physicians who perform Brazilian butt lifts in South Florida clapped back and formed Surgeons for Safety. They argued the new requirements would make the situation worse. Qualified doctors would have to do fewer procedures, they said, thus driving patients to dangerous medical professionals who don’t follow rules.

The group has since donated more than $350,000 to the state’s Republican Party, Republican candidates, and Republican political action committees, according to campaign contribution data from the Florida Department of State.

Surgeons for Safety declined KHN’s repeated interview requests. Although the group’s president, Dr. Constantino Mendieta, wrote in an August editorial that he agreed not all surgeons have followed the standard of care, he called the limits put on surgeons “arbitrary.” The rule sets “a historic precedent of controlling surgeons,” he said during a meeting with Florida’s medical board.

In January, Florida state Sen. Ileana Garcia, a Republican, filed a draft bill with the state legislature that proposes no limit on the number of Brazilian butt lifts a surgeon can perform in a day. Instead, it requires office surgery centers where the procedures are performed to staff one physician per patient and prohibits surgeons from working on more than one person at a time.

The bill would also allow surgeons to delegate some parts of the procedure to other clinicians under their direct supervision, and the surgeon must use an ultrasound.

Florida’s legislature convenes on March 7.

Consumers considering cosmetic procedures are urged to be cautious. Like Ruston, many people base their expectations on before-and-after photos and marketing videos posted on social media platforms such as Facebook, Snapchat, and Instagram.

“That’s very dangerous,” said Basu, of the American Society of Plastic Surgeons. “They’re excited about a low price and they forget about doing their homework,” he said.

The average price of a buttocks augmentation in 2021 was $4,000, according to data from the Aesthetic Society. But that’s only for the physician’s fee and does not cover anesthesia, operating room fees, prescriptions, or other expenses. A “safe” Brazilian butt lift, performed in an accredited facility and with proper aftercare, costs between $12,000 and $18,000, according to a recent article on the American Society of Plastic Surgeons’ website.

Although Florida requires a physician’s license to perform liposuction on patients who are under general anesthesia, it’s common in the medical field for midlevel medical practitioners, such as physician assistants and nurse practitioners, to do the procedure in office settings, according to Dr. Mark Mofid, who co-authored the 2017 Aesthetic Surgery Education and Research Foundation task force study.

By relying on staffers who don’t have the same specialty training and get paid less, office-based surgeons can complete more butt lifts per day and charge a lower price.

“They’re doing all of them simultaneously in three or four different rooms, and it’s being staffed by one surgeon,” said Mofid, a plastic surgeon in San Diego, who added that he does not perform more than one Brazilian butt lift in a day. “The surgeon isn’t doing the actual case. It’s assistants.”

Basu said patients should ask whether their doctor holds privileges to perform the same procedure at a hospital or ambulatory surgery center, which have stricter rules than office surgery centers in terms of who can perform butt lifts and how they should be done.

People in search of bargains are reminded that cosmetic surgery can have other serious risks beyond the deadly fat clots, such as infection and organ puncture, plus problems with the kidneys, heart, and lungs.

Ruston’s surgery was performed by a board-certified plastic surgeon she said she found on Instagram. She was originally quoted $4,995, which she said she paid in full before surgery. But when she arrived in Miami, she said, the clinic tacked on fees for liposuction and for post-surgical garments and devices.

“I ended up having to pay, like, $8,000,” Ruston said. A few days after Ruston returned home to Lake Alfred, she said, she started to feel dizzy and weak and called 911.

Paramedics took her to an emergency room, where doctors diagnosed her with anemia due to blood loss, and blood and abdominal infections, her medical records show.

“If I could go back in time,” she said, “I wouldn’t have had it done.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Almost half of children who go to ER with mental health crisis don’t get the follow-up care they need, study finds | CNN

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Editor’s Note: If you or someone you know is struggling with suicidal thoughts or mental health matters, please call the 988 Suicide and Crisis Lifeline, or visit the hotline’s website.

CNN
—

Every night that Dr. Jennifer Hoffmann works as an attending physician in the pediatric ER, she says, at least one child comes in with a mental or behavioral health emergency. Over the span of her career, she’s seen the number of young people needing help grow enormously.

“The most common problems that I see are children with suicidal thoughts or children with severe behavior problems, where they may be a risk of harm to themselves or others,” said Hoffmann, who works at Ann & Robert H. Lurie Children’s Hospital of Chicago. “We’re also seeing younger children, especially since the pandemic started. Children as young as 8, 9 or 10 years old are coming to the emergency department with mental health concerns.

“It’s just mind-blowing.”

The surge of children turning up in emergency departments with mental health issues was a challenge even before 2020, but rates soared during the Covid-19 pandemic, studies show.

ER staffers may be able to stabilize a child in a mental health care crisis, but research has shown that timely follow-up with a provider is key to their success long-term. Unfortunately, there just doesn’t seem to be enough of it, according to a new study co-authored by Hoffmann. Without the proper follow-up, these children too often wound up back in the ER.

For their study, published Monday in the journal Pediatrics, Hoffmann and her co-authors looked at records for more than 28,000 children ages 6 to 17 who were enrolled in Medicaid and had at least one trip to the emergency department between January 2018 and June 2019. They found that less than a third of the children had the benefit of an outpatient mental health visit within seven days of being discharged from the ER. A little more than 55% had a follow-up within 30 days.

Research has shown that follow-up with a mental health care provider lowers a person’s suicide risk, raises the chances that they will take their prescription medicine and decreases the chances that they will make repeated trips to the ER.

The new study found that without a follow-up, more than a quarter of the children had to go back to the ER for additional mental health care within six months of their initial visit.

“The emergency department is a safety net. It’s always open, but there’s limited extent to the types of mental health services we can provide in that setting,” Hoffmann said. “This really speaks to inadequate access to services that these kids need.”

This dynamic can be “devastating” for parents and emergency department staff alike, she said.

“We know what a child needs, but we’re just not able to schedule follow-up due to shortages among the mental health profession. They’re widespread across the US,” she said.

A lack of professional help is a problem for many children. Before the Covid-19 pandemic, the US Centers for Disease Control and Prevention found that 1 in 5 children had a mental health disorder, but only about 20% got care from a mental health provider.

Children’s mental health has become such a concern in the US that the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association declared a national emergency in 2021.

Hoffmann’s study found that Black children fared worse than their peers. They were 10% less likely to have timely follow-up than White children – “which is very concerning, given that there are many disparities in access to care in our mental health system,” Hoffmann said.

The study can’t pinpoint why there is this racial disparity, but Hoffmann thinks there may be a few factors at play.

Black children are more likely to live in neighborhoods that have shortages of mental health professionals. There is also limited diversity among the mental health work force. Studies show that nearly 84% of psychologists are White, as are nearly 65% of counselors and more than 60% of social workers. And Black children more often rely on school-based mental health services, studies show.

Although the number of school counselors has been increasing over the years, few schools meet the National Association of School Psychologists’ recommended ratio of one school psychologist to 500 students. The national ratio for the 2021-22 school year was 1,127 to 1, the association found.

The new study found that the children who did not have mental health help before their ER visits had the most difficulty finding timely care afterward.

Dr. Toni Gross, chief of the Emergency Department at Children’s Hospital New Orleans, said she wasn’t entirely surprised by the study findings. Her hospital’s beds for with mental health concerns are “always busy,” she said.

“I’m well aware of the fact that we need more providers for these services. We deal with it every day,” said Gross, who was not involved in the new research.

The lack of providers who can do follow-up is a real source of concern. It’s not ideal to hand a phone number to a parent and hope they can arrange care, she said. It often takes weeks or even months to get a first appointment with a child and adolescent psychiatrist.

“It leaves a lot of us feeling like we wish we could do more,” Gross said. “When you always leave asking yourself at the end of the day, ‘did I really do what I set out to do, and that is to help people,’ it’s one of our biggest frustrations, and it may be one of the biggest reasons people in my group of physicians feel burnout.”

Like many children’s hospitals, hers has an active partnership with local school health programs that can provide some mental health care.

Hoffmann said that the amount of support varies by emergency department. Lurie has 24/7 coverage by mental health workers who can do an evaluation and provide recommendations for appropriate care, but not all areas do. For example, many rural emergency rooms don’t have pediatric mental health providers and may have few resources in the community, if any.

Several US counties have no practicing child and adolescent psychiatrists. Primary care physicians can help, but some patients would benefit from more specialized care, Hoffmann said.

President Joe Biden’s administration announced in August that plans to make it easier for millions of children to get access to mental health services by allowing schools to use Medicaid dollars to hire additional school counselors and social workers. He even mentioned the issue in his State of the Union address Tuesday.

But even more will need to be done. Hoffmann hopes her study will prompt policy-makers to invest more so children can access care no matter where they live. Investing in telehealth could also bridge the gap, she said, as would increasing Medicaid reimbursement rates for mental health services and more funding to pay for people to train to work with children as a mental health professional.

In a commentary published alongside the new study, the authors say their research shows that the US “is not meeting the behavioral health needs of our young people.”

“EDs are the last stop when all else has failed, and they, too, lack the resources to support, or even discharge, these patients,” the commentary says.

It points out that research has found this lack of access as far back as 2005.

“This new analysis adds to the overwhelming evidence that there is an urgent need for a dramatic change in our pediatric mental health care system,” the commentary says. “We believe it is time for a ‘child mental health moonshot,’ and call on the field and its funders to come together to launch the next wave of bold mental health research, for the benefit of these children and their families who so desperately need our support.”

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The virus threat is easing, but US hospitals are still as full as ever | CNN

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CNN
—

At Massachusetts General Hospital in downtown Boston, the hallways of the emergency department are lined with dozens of patients waiting to get a room upstairs.

“Imagine spending days and nights in the hallway under fluorescent lights in the ER next to a trauma bay while [patients] have heart failure, kidney failure or pneumonia,” said Dr. Melissa Mattison, a physician and chief of hospital medicine at Mass General, which is a founding member of Mass General Brigham.

“Everybody’s doing their best, but where do they go to the bathroom? How do they take a shower if they want to clean up? How do they eat? There’s no privacy. It’s just, it’s awful. It’s absolutely awful.”

As of Friday, about 87% of all available hospital beds in the state are in use, and capacity strains have eased little despite a dramatic decrease in the number of people being treated for respiratory illness.

“Every day, our emergency room has a backlog of anywhere between 25 and 100 patients waiting for a bed upstairs. So if today, that number was 25, and two weeks ago, it was 100 – yes, that’s better, but there’s still a long line,” Mattison said. “Maybe the patients aren’t piled like sardines in the ER as much when you only have 35 patients waiting compared to 75. But it’s still not great.”

The winter triple threat of flu, Covid-19 and RSV is easing across the United States, and as in Massachusetts, most states are now reporting low or minimal levels of respiratory illness activity overall.

Nationwide, emergency department visits for the respiratory viruses are a third of what they were a month ago, federal data shows. Flu hospitalizations are nearly as low as they’ve been all season, since October. Hospitalizations for Covid-19 – the last of the three viruses to trend down – have been falling for the past few weeks, and just 4% of hospital beds nationwide are being used by Covid-19 patients.

That’s a dramatic shift from January 2022, when Covid-19 patients were filling most hospital beds amid the early Omicron surge. But hospitals are still about as full as they’ve ever been during the pandemic – at least three-quarters of available beds across the country were in use for all of 2022 – and that doesn’t seem likely to change any time soon.

Hospitals were facing capacity and resource challenges long before the pandemic hit, experts say, in large part because the people who are being admitted are sicker than they were before.

“It’s been a continuing trend over the last decade or so that there’s been this greater acuity of patients inside the hospitals,” said Nancy Foster, vice president for quality and patient safety with the American Hospital Association. “So what you see is this incredibly sick group of people inside of hospitals. If you’re a doctor or nurse or respiratory therapist or pharmacist or any other health professional working inside the hospital, that means it’s always a difficult puzzle you’re trying to solve to help that patient out.”

At Mass General, an emergency department boarder program – which outlines plans for how to cover patients who were waiting for a bed – was well-established years before the pandemic hit, Mattison said.

Hospitals started to report capacity data to the federal government in 2020 under a pandemic requirement, so there’s no federal data to compare to pre-pandemic years.

But Mattison was quick to say her hospital is 99% full now, like it was in 2019 and years before the pandemic. Still, she says, “how long is that waiting list, and who’s on that waiting list? That’s something that’s not reflected in that metric.”

By and large, the mix of patients in hospitals is similar to what it was pre-pandemic, said Aaron Wesolowski, vice president of policy research, analytics and strategy at the American Hospital Association.

As the share of Covid-19 patients drops, it’s perhaps “a breath less stressful” for health care providers who felt frustrated by the lack of tools available to help people as they so desperately wanted to in the early days of the pandemic, Foster said.

In fact, for most categories of care – with infectious disease as a noticeable exception – the number of people seen in inpatient and emergency department settings in 2022 was lower than it was in 2019, Wesolowski said, citing data from Strata, a health care data analytics firm.

A mix of complicating factors were exacerbated during the pandemic, experts say, straining resources more than ever.

“Length of stay is longer because people are needing more acute care. Because of work force pressures, there are not as many people who can be treated in an inpatient setting all at once,” Wesolowski said. “So both things, I think, can be true.”

Samuel Scarpino, director of AI and life sciences at Northeastern University, says it’s a “perfect storm” of issues: Covid-19 and the ongoing infection control measures that hospitals have to keep in place, a backlog of other patients with a delayed need for acute care, and work force burnout three years into a pandemic.

The biggest risk factor in the equation is still Covid-19, he says, not because a new variant will necessarily cause more hospitalizations but because the unpredictability is forcing hospitals to leave more beds open as a buffer just in case.

“The biggest risk is almost certainly the uncertainty associated with what’s coming,” said Scarpino, who was previously vice president at the Rockefeller Foundation’s Pandemic Prevention Institute.

Foster, of the American Hospital Association, says the pandemic emergency declaration has granted a number of flexibilities – such as telehealth – that have helped more patients have options for care that are outside of hospitals.

The federal government has continuously renewed the emergency declaration since January 2020, but it is likely to come to an end in May.

Without it, Foster says, hospitals would probably be even more full than they already are – particularly as alternative options for care outside of the hospital may become more limited again.

“Part of the reason we have the kind of inpatient hospital capacity that we have right now is that we do have a number of flexibilities that were granted to hospitals by [the Centers for Medicare and Medicaid Services] and other federal agencies and the states during Covid that are being used for a wide variety of patients,” she said. “If those were to disappear overnight, we would be struggling to care for the current level of patients.”

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Pediatricians are giving out free gun locks to approach the gun violence epidemic as a public health crisis | CNN

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CNN
—

In a triage waiting room of St. Louis Children’s Hospital in Missouri, a clear basket filled with gun locks sits near the walkway, just noticeable enough to those passing by.

The hospital staff calls it the “No Questions Asked” basket, to encourage gun safety without having to confront gun owners about what can be a sensitive and divisive topic. It holds an assortment of cable gun locks free of charge, available to those who need them, alongside pamphlets explaining how to properly and safely store firearms.

The initiative, aimed at reducing the stigma of addressing gun safety, is part of a growing effort by medical professionals who are treating the country’s gun violence epidemic as a public health crisis.

“It takes standing at the bedside of one child who has been shot to realize that we all have to do more and as the leading cause of death for children in this country, pediatricians need to be front and center of the solution, of all the solutions,” said Dr. Annie Andrews, a professor of pediatrics at the Medical University of South Carolina and an expert on gun violence prevention.

Over the course of two years, thousands of gun locks have been taken from the basket, according to Dr. Lindsay Clukies, a pediatric emergency medicine physician at the hospital.

In the coming weeks, baskets filled with free gun locks will be available at more than 17 locations operated by BJC HealthCare, an organization serving metro St. Louis, mid-Missouri and Southern Illinois, Clukies said. It’s a low-cost and effective way to easily distribute firearm safety devices.

“We’ve had employees as well as patients take our locks, also their families and even a grandmother who took one for her grandson. It’s for anyone who needs them,” Clukies told CNN. In recent years, a rising number of pediatricians across the country have been engaging with the topic of gun safety in medical settings by focusing on safety and prevention, already a natural aspect of their work.

During patient visits, it’s increasingly common for pediatricians to ask the patient’s parents if there are guns at home, and if so, how they are stored. Some hospitals then offer free gun locks, often sourced from donations or police departments and paired with safe storage education.

Some pediatricians, who bear witness to the effects of gun violence on children in their workplace every day, told CNN they see it as their obligation as medical professionals to be part of the solution to the epidemic.

In 2022, 1,672 children and teenagers under 17 were killed by gun violence and 4,476 were injured, according to the Gun Violence Archive, a nonprofit organization tracking injuries and deaths by gunfire since 2014.

“We have just as an important voice in this conversation as anyone else because we’re the ones who have invested our entire careers to protecting children and ensuring that children can grow up to be the safest healthiest version of themselves,” said Andrews.

“It is only natural that we see these things that we understand that they’re preventable, and we want to get involved in finding the solutions,” she added.

So far in 2023, high-profile incidents of children accessing firearms have heeded calls for stronger, more consistent laws nationwide, requiring adults to safely secure their guns out of the reach of children and others unauthorized to use them. They have also highlighted a lack of public education on the responsibility of gun owners to store their guns unloaded, locked and away from ammunition, CNN previously reported.

In early January, a 6-year-old boy was taken into police custody after he took a gun purchased by his mother from his home, brought it to school and shot his teacher at Richneck Elementary School in Newport News, Virginia, police said. Just over a week later, a man was arrested in Beech Grove, Indiana, after video was shown on live TV of a toddler, reportedly the man’s son, waving and pulling the trigger of a handgun, CNN previously reported.

Hundreds of children in the US every year gain access to firearms and unintentionally shoot themselves or someone else, according to research by Everytown for Gun Safety, a leading non-profit organization focusing on gun violence prevention. In 2022, there were 301 unintentional shootings by children, resulting in 133 deaths and 180 injuries nationally, Everytown data showed.

Firearm injuries are now the leading cause of death among people younger than 24 in the United States, according to the Centers for Disease Control and Prevention. The American Academy of Pediatrics released an updated policy statement in October 2022, stating firearms are now the leading cause of death in children under the age of 24 in the US.

The Academy’s statement urged a “multipronged approach with layers of protection focused on harm reduction, which has been successful in decreasing motor vehicle-related injuries, is essential to decrease firearm injuries and deaths in children and youth.”

The Academy has free educational modules for pediatricians to guide them on how to have what can be challenging or uncomfortable conversations about firearms with families, according to Dr. Lois Kaye Lee, a pediatrician and the chair of the Academy’s Council on Injury, Violence and Poison Prevention.

“This shouldn’t be considered as something extra; it should be considered as part of the work that we do every day around injury prevention, be it around firearms, child passenger safety and suicide prevention,” Lee said.

Dr. Georges Benjamin, executive director of the American Public Health Association, told CNN the public health approach to addressing gun violence removes the politics from the issue and “puts it into a scientific evidence-based framework.”

“Physicians have a unique opportunity to engage their patients, the parents of kids or the parents themselves as individuals to make their homes safer,” Benjamin said. “We already do this for toxins under our kitchen cabinets, razor blades and outlets in the wall.”

In the emergency department at St. Louis Children’s Hospital, all patients are screened for access to firearms and offered free gun locks, as well as safe storage education, Clukies said. Gun locks can also be mailed to families, free of cost, through the hospital’s website.

“Every patient that comes into our emergency department, whether it’s for a fever or a cold or a broken arm, is asked about access to firearms,” said Clukies, adding 5,000 locks have been given out since the initiatives were started in 2021.

In a collaborative effort between trauma nurses, physicians, social workers, violence intervention experts and family partners, the hospital created a “nonjudgmental” script for doctors to follow as they ask patients about access to firearms, Clukies said.

During the screening process, pediatricians will ask parents or caretakers questions such as: Do you have access to a firearm where your child lives or plays? How is it stored? Is it stored unloaded or loaded?

“When I first started doing this, I would say, ‘Are there any guns in the home? Yes, or no?’ But I have found and learned from other experts that if you just say, ‘If there are any guns in the home, do you mind telling me how they’re secured?’ it takes away the judgment,” said Andrews, a pediatrician whose hospital, the Medical University of South Carolina, also offers free gun locks to patients.

An assortment of cable gun locks offered free of charge by the Medical University of South Carolina.

Families are asked about firearms in the “social history” phase of a patient visit, during which pediatricians will ask who lives in the home, what grade the child is in, what activities they engage in and where the child goes to school, according to Andrews. When parents indicate their firearms are not safely stored, like on the top of a shelf or in a nightstand drawer, Andrews said those are important opportunities for intervention and education about storage devices such as keypad lockboxes, fingerprint biometric safes and other types of lock systems.

It’s also important for pediatricians to understand the parents’ or caretakers’ motivation for owning a firearm to “inform the conversation about where they’re willing to meet you as far as storage goes,” she added.

Andrews and Clukies said they were pleasantly surprised by the willingness of families to discuss firearm safety, most of whom recognize it is an effort to protect their children.

“I expected more pushback than we received, which is attributed to us really focusing on how we properly word these questions,” Clukies said. “I think it’s because we turn it into a neutral conversation, and we focus on safety and prevention.”

Andrews added it is uncommon for medical schools or residencies to discuss gun violence prevention, which she says is due to the “politics around the issue.”

“Thankfully, that has evolved, and more and more pediatricians are realizing that we have to be an integral part of the solution to this problem,” Andrews said.

At the St. Louis Children’s Hospital, pediatricians followed up with patients who received a free gun lock in a research study roughly two months after they launched the initiative in the fall of 2021 to see if their storage practices changed.

The study found two-thirds of families reported using the gun lock provided to them by the hospital and there was a “statistically significant decrease” in those who didn’t store their firearms safely, as well as an increase in those who stored their firearms unloaded, according to Clukies.

But there is still much more work to be done in the medical community to fight the gun violence epidemic and scientific research on the issue is “woefully underfunded,” Andrews contended.

According to the American Public Health Association’s Benjamin, a multidisciplinary approach by policymakers, law enforcement and the medical community is essential to fostering a safer environment for children.

“Injury prevention is a core part of every physician’s job,” Benjamin said. “It’s clearly in our lane.”

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Flu, Covid-19 and RSV are all trending down for the first time in months | CNN

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CNN
—

A rough respiratory virus season in the US appears to be easing, as three major respiratory viruses that have battered the country for the past few months are finally all trending down at the same time.

A new dataset from the US Centers for Disease Control and Prevention shows that the number of emergency department visits for the three viruses combined – flu, Covid-19 and RSV – have dropped to the lowest they’ve been in three months. The decline is apparent across all age groups.

Measuring virus transmission levels can be challenging; health officials agree that Covid-19 cases are vastly undercounted, and surveillance systems used for flu and RSV capture a substantial, but incomplete picture.

But experts say that tracking emergency department visits can be a good indicator of how widespread – and severe – the respiratory virus season is.

“There’s the chief complaint. When you show up to the emergency room, you complain about something,” said Janet Hamilton, executive director at Council of State and Territorial Epidemiologists. “Being able to look at the proportion of individuals that seek care at an emergency department for these respiratory illness concerns is a really good measure of the respiratory disease season.”

In the week following Thanksgiving, emergency department visits for respiratory viruses topped 235,000 – matching rates from last January, according to the CDC data.

While the surge in emergency department visits early in the year was due almost entirely to Omicron, the most recent spike was much more varied. In the week ending December 3, about two-thirds of visits were for flu, about a quarter were for Covid-19 and about 10% were for RSV.

Grouping the impact of all respiratory viruses together in this way offers an important perspective.

“There’s a strong interest in thinking about respiratory diseases in a more holistic way,” Hamilton said. “Transmission is the same. And there are certain types of measures that are good protection against all respiratory diseases. So that could really help people understand that when we are in high circulation for respiratory diseases, there are steps that you can take – just in general.”

Now, Covid-19 again accounts for most emergency department visits but flu and RSV are still the reason behind about a third of visits – and they’re all trending down for the first time since the respiratory virus season started picking up in September.

More new data from the CDC shows that overall respiratory virus activity continues to decline across the country. Only four states, along with New York City and Washington, DC, had “high” levels of influenza-like illness. Nearly all states were in this category less than a month ago.

Whether that pattern will hold is still up in the air, as vaccination rates for flu and Covid-19 are lagging and respiratory viruses can be quite fickle. Also, while the level of respiratory virus activity is lower than it’s been, it’s still above baseline in most places and hospitals nationwide are still about 80% full.

RSV activity started to pick up in September, reaching a peak in mid-November when 5 out of every 100,000 people – and 13 times as many children younger than five – were hospitalized in a single week.

RSV particularly affects children, and sales for over-the-counter children’s pain- and fever-reducing medication were 65% higher in November than they were a year before, according to the Consumer Healthcare Products Association. While “the worst may be over,” demand is still elevated, CHPA spokesperson Logan Ramsey Tucker told CNN in an email – sales were up 30% year-over-year in December.

But this RSV season has been significantly more severe than recent years, according to CDC data. The weekly RSV hospitalization rate has dropped to about a fifth of what it was two months ago, but it is still higher than it’s been in previous seasons.

Flu activity ramped up earlier than typical, but seems to have already reached a peak. Flu hospitalizations – about 6,000 new admissions last week – have dropped to a quarter of what they were at their peak a month and a half ago, and CDC estimates for total illnesses, hospitalizations and deaths from flu so far this season have stayed within the bounds of what can be expected. It appears the US has avoided the post-holiday spike that some experts cautioned against, but the flu is notoriously unpredictable and it’s not uncommon to see a second bump later in season.

The Covid-19 spike has not been as pronounced as flu, but hospitalizations did surpass levels from the summer. However, the rise in hospitalizations that started in November has started to tick down in recent weeks and CDC data shows that the share of the population living in a county with a “high” Covid-19 community level has dropped from 22% to about 6% over the past two weeks.

Still, the XBB.1.5 variant – which has key mutations that experts believe may be helping it to be more infectious – continues to gain ground in the US, causing about half of all infections last week. Vaccination rates continue to lag, with just 15% of the eligible population getting their updated booster and nearly one in five people remain completely unvaccinated.

Ensemble forecasts published by the CDC are hazy, predicting a “stable or uncertain trend” in Covid-19 hospitalizations and deaths over the next month.

And three years after the first Covid-19 case was confirmed in the US, the virus has not settled into a predictable pattern, according to Dr. Maria Van Kerkhove, the World Health Organization’s technical lead for the Covid-19 response.

“We didn’t need to have this level of death and devastation, but we’re dealing with it, and we are doing our best to minimize the impact going forward,” Van Kerkhove told the Conversations on Healthcare podcast this week.

Van Kerkhove says she does believe 2023 could be the year in which Covid-19 would no longer be deemed a public health emergency in the US and across the world, but more work needs to be done in order to make that happen and transitioning to longer-term respiratory disease management of the outbreak will take more time.

“We’re just not utilizing [vaccines] most effectively around the world. I mean 30% of the world still has not received a single vaccine,” she said. “In every country in the world, including in the US, we’re missing key demographics.”

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ER on the field: An inside look at how NFL medical teams prepare for a game day emergency | CNN

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CNN
—

When Buffalo Bills safety Damar Hamlin dropped to the ground from a cardiac arrest earlier this month, help was by his side in under 10 seconds to administer CPR.

It wasn’t coincidence or luck. Rather, it’s the result of careful planning and practice – the execution of detailed choreography performed by the medical personnel present at every National Football League game.

Saving Hamlin’s life was the ultimate test.

“What we want is that the players are getting the same care here that they would if they were in a hospital or health care facility and that’s what the system has been set up to do,” NFL Chief Medical Officer Dr. Allen Sills told CNN Chief Medical Correspondent Dr. Sanjay Gupta on Saturday.

About 30 medical personnel are at every game, including orthopedic and trauma specialists, athletic trainers, paramedics and dentists. Sills gave CNN a rare behind-the-scenes look at the league’s medical personnel during Saturday’s playoff game between the Jacksonville Jaguars and the Los Angeles Chargers. The goal, Sills said, is to deliver hospital-quality care on the gridiron.

When Hamlin collapsed on January 2, speed was of the essence. Studies find that for every minute someone who experiences cardiac arrest and doesn’t receive CPR, their chances of survival decrease 7 to 10%.

Hamlin’s heart was restarted on the field. The 24-year-old spent more than a week in the hospital in Cincinnati, then transferred to a hospital in Buffalo before he was released home last week.

Sills said that being on the field was likely a factor for Hamlin: Survival is more likely for someone who experiences cardiac arrest in the hospital. One study found that 10 to 12% those who have cardiac arrest outside of the hospital survive to discharge, but that survival rate more than doubled for those who experienced cardiac arrest in the hospital.

“I think he was being resuscitated as he would have been in an emergency room at that moment,” Sills said.

Hear audio of medical personnel treating Damar Hamlin after he collapsed

The NFL requires all teams to have an emergency action plan, or EAP, for all player facilities, including practice fields.

The plans are filed by the teams every year and are approved by the League as well as the NFL Players Association, the players’ union, Sills said. They run drills on the plan, so when an event like Hamlin’s cardiac arrest occurs, the medical team’s choreography is close to automatic.

“The EAP was followed to a letter that night,” Sills said. “In that moment everyone knew what they needed to do, how they needed to do it and had the equipment to do it and felt comfortable.”

These plans include details about where ambulances are located, the quickest route to the hospital, where medical equipment is stored, and even what radio and hand signals will be used in case of a medical event.

While the teams are all connected by radio, the sound from the game and the crowd can be overwhelming.

“It gets loud and so having those nonverbal signs is a way for us to communicate,” explained Dr. Kevin Kaplan, Jacksonville Jaguars’ head physician. For example, using two hands as if driving a steering wheel indicates needing the medical cart, while crossing arms to make an “X” is an all-call for medical personnel.

The home team sends the plan to the visiting team a week before the game. Then, an hour before kickoff, medical teams from both teams gather to review and confirm the details in what’s known as a “60-minute meeting.”

Medical teams from the Los Angeles Chargers and Jacksonville Jaguars gathered for the 60-minute meeting ahead of kickoff on Saturday.

It’s like the NFL’s version of what happens in a hospital: Before doctors perform a procedure, the medical team gathers for a “timeout” to review who is responsible for what.

Before the football game, they identify the team physicians, athletic trainers and key trauma personnel, including an airway specialist who can place a breathing tube in moments, if needed.

In the excitement of game day, there needs to be a simple, clear way to identify who can help in case of an emergency. At any NFL game, you’ll see it: a red hat.

Dr. Justin Deaton, NFL airway management physician, wears a red hat on the sideline of the Jacksonville Jaguars-Los Angeles Chargers game on Saturday.

“That signifies me as the emergency physician, the airway physician, so that even the other team knows when I come out what my role is,” Dr. Justin Deaton told Gupta. “Once I come out onto the field, I kind of take over, I identify if the patient is either unconscious or has an airway obstruction.”

At every game, Deaton stands along the 30 yard line, just like his counterparts at other games.

“We standardize the location so that everybody knows where our airway physician is going to be located,” said Sills.

If the player isn’t breathing, it’s up to Deaton to identify who will administer CPR. If the player’s breathing is blocked and he can’t breathe on his own, Deaton may have to intubate the player on the field. In order to do so, he carries a videoscope to look down someone’s throat and an ultrasound machine.

In the event Deaton can’t get the patient to breathe through their mouth, he’s prepared to essentially do surgery on the field.

“If someone has an obstruction or significant trauma to the face and we can’t secure an airway by the mouth, we’re able to make an incision and insert that way,” he told Gupta. “I really have all the resources available here that I would have in an emergency room.”

The challenge is that they’re surrounded by chaos – not the more controlled environment of the emergency department or operation room.

“When you have a larger-than-average-sized person that’s laying flat on the ground and not able to be elevated to a certain level with extra equipment, plus cameras and other people around, those are really the confounders and things that make it more difficult to manage,” Deaton said.

In football, it’s not just about executing in the moment – it’s about anticipating. The same is true for medical personnel.

The NFL includes certified athletic trainers on its medical team to serve as spotters. They’re positioned throughout the stadium, including a booth that oversees the entire stadium, to watch the game in real time and again in replay – sometimes over and over – to immediately catch any injuries or assess those that might have been overlooked. They have around 30 different angles of the field at their fingertips.

“We watch every play probably minimally four times and then we’ll go back and watch it again,” said Sue Stanley-Green, one of the athletic trainer spotters assigned to Saturday’s game. “We just want to make sure we don’t miss anything.”

Spotters around the field at every game have different views of plays -- and potential injuries.

The spotters who sit in a stadium booth above the field are able to communicate directly with the medical team on the sidelines and direct them to concerning plays and possible injuries. They also have a unique line of communication to the referees, and the ability to stop the game for a medical timeout.

Sills acknowledges that there is always room for improvement and need to evolve.

In September, Miami Dolphins quarterback Tua Tagovailoa experienced an apparent head injury while playing against the Bills. He stumbled after being hit, but was allowed to return to the game. The incident put new scrutiny of the NFL and its policies.

Afterward, the league changed its concussion policy. Now, Sills says, “if we see something that looks like ataxia on video, (players) are done.”

Sills said he believes the NFL’s network of practices is working to keep players safe, and the league is currently reviewing the moments around Hamlin’s cardiac arrest. One aspect of emergencies that Sills wants to see more work on is privacy.

In the moments after Hamlin fell, his teammates formed “kind of a shield,” Sills said, which limited the view of Hamlin.

“I think there’s some things there that we may look at,” Sill said. “Obviously any of us would want some privacy in a moment like that.”

But when facing a test like saving a life on the field, “everything went really as well as you could have asked to have gone in the moment,” Sills said. “It’s always about the right people, the right plan and the right equipment.”

Bob Costas: Hamlin collapsing is not an indictment of NFL safety

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Damar Hamlin could be released from a Buffalo hospital in the next day or two | CNN

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CNN
—

A week after suffering a cardiac arrest while playing the Cincinnati Bengals, doctors are hoping Buffalo Bills safety Damar Hamlin is healthy enough to be released from a Buffalo hospital within 24 to 48 hours, Michael Hughes, senior vice president and chief administrative officer at Kaleida Health, told CNN on Tuesday.

Doctors are finishing tests and are identifying possible causes of the event, including whether there were any pre-existing conditions that played a role in Hamlin’s January 2 cardiac arrest.

“Hamlin is going through a series of testing and evaluation today,” Kaleida Health said in a statement Tuesday. The Buffalo General Medical Center team will also “potentially treat any pathology that may be found, as well as plan for his recovery, discharge and rehabilitation.”

Hamlin himself updated his fans Tuesday afternoon.

“Not home quite just yet,” Hamlin tweeted. “Still doing & passing a bunch of test. Special thank-you to Buffalo General it’s been nothing but love since arrival! Keep me in y’all prayers please!”

Hamlin was transferred from a Cincinnati hospital to the Buffalo hospital on Monday after doctors determined his critical condition had improved to good or fair – surpassing expectations.

“We felt that it was safe and proper to help get him back to the greater Buffalo area,” Dr. Timothy Pritts, chief of surgery at the University of Cincinnati Medical Center, said Monday.

Hamlin’s parents flew from Cincinnati back home to Pittsburgh but then flew to Buffalo. They were en route Tuesday from the Buffalo Bills’ practice facility and were expected to arrive at the hospital to see Hamlin soon.

Hamlin, a second-year NFL player, has been regaining strength over the past several days after his sudden collapse after a tackle against the Bengals in Cincinnati.

“He’s certainly on what we consider a very normal to even accelerated trajectory from the life-threatening event that he underwent,” Pritts said, “but he’s making great progress.”

Normal recovery from a cardiac arrest can be measured in weeks to months, Pritts explained. But Hamlin has been beating that timeline at each stage and is neurologically intact.

Still, Pritts said it’s too early to say when Hamlin could get back to normal life or what caused his heart to stop, saying more testing is needed.

Hamlin was sedated and on a ventilator for days after his cardiac arrest. On Friday morning, the breathing tube was removed, and Hamlin began walking with some help by that afternoon, his doctors said Monday.

The safety’s condition was upgraded Monday because his organ systems were stable and he no longer needed intensive nursing or respiratory therapy, doctors said.

“He walks normally,” said Dr. William Knight, a neurovascular critical care expert who treated Hamlin at UC Health. “He is admittedly a little weak. I don’t think that’s of any real surprise after what he went through, just regaining his strength. And that’s part of his recovery process.”

Hamlin’s release Monday meant he could return to Buffalo, which prompted even more encouragement and eagerness for some of his teammates to see him again.

“Super excited that he’s back in Buffalo and what a job that the team of docs and the medical team did out in Cincinnati, and now he’s in great care here in Buffalo. We’re happy to have him back,” Buffalo Bills head coach Sean McDermott told reporters Monday.

After seeing him Monday, McDermott said Hamlin was “tired” but seemed happy. “Happy to be back in Buffalo and around a familiar area to him. I know he’s taking it just one step at a time.”

The coach also said his team has grown since Hamlin was injured, saying such experiences nurture growth.

“We will all have grown as people, and as men in this case,” McDermott said, noting there’s a plan in place for the players and staff to visit Hamlin “at the proper time.”

“Having him nearby will give us more comfort” and inspire the team as it prepares for the postseason, McDermott said.

Although Hamlin was not with the team when they played Sunday against the New England Patriots, his support was definitely felt.

When his team scored a touchdown, Hamlin set off alarms in the ICU, Pritts said.

“When the opening kickoff was run back, he jumped up and down and got out of his chair and set – I think – every alarm off in the ICU in the process, but he was fine, it was just an appropriate reaction to a very exciting play. He very much enjoyed it,” Pritts said.

Hamlin was “beyond excited” Sunday and felt “very supported by the outpouring of love from across the league, especially from the Buffalo area. We’ve learned this week that the Bills mafia is a very real thing,” Pritts added.

The immediate medical response to Hamlin’s collapse helped save his life, and the Buffalo Bills are now encouraging people to learn how to administer CPR.

Assistant athletic trainer Denny Kellington is credited with performing CPR when Hamlin lost his pulse on the field and needed to be revived through resuscitation and defibrillation.

The medical response was part of an emergency action plan that “involves team, independent medical and athletic training staff, equipment and security personnel, and is reviewed prior to every game,” a Monday statement from the Bills read.

The team pledged support for resources including CPR certifications, automated external defibrillator units and guidance developing cardiac emergency response plans within the Buffalo community, according to the statement.

“We encourage all our fans to continue showing your support and take the next step by obtaining CPR certification,” the Bills said.

Clarification: This story has been updated to clarify Hughes’ remarks about Hamlin’s injury and recovery.

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