Paging Dr. AI? What ChatGPT and artificial intelligence could mean for the future of medicine | CNN



CNN
 — 

Without cracking a single textbook, without spending a day in medical school, the co-author of a preprint study correctly answered enough practice questions that it would have passed the real US Medical Licensing Examination.

But the test-taker wasn’t a member of Mensa or a medical savant; it was the artificial intelligence ChatGPT.

The tool, which was created to answer user questions in a conversational manner, has generated so much buzz that doctors and scientists are trying to determine what its limitations are – and what it could do for health and medicine.

ChatGPT, or Chat Generative Pre-trained Transformer, is a natural language-processing tool driven by artificial intelligence.

The technology, created by San Francisco-based OpenAI and launched in November, is not like a well-spoken search engine. It isn’t even connected to the internet. Rather, a human programmer feeds it a vast amount of online data that’s kept on a server.

It can answer questions even if it has never seen a particular sequence of words before, because ChatGPT’s algorithm is trained to predict what word will come up in a sentence based on the context of what comes before it. It draws on knowledge stored on its server to generate its response.

ChatGPT can also answer followup questions, admit mistakes and reject inappropriate questions, the company says. It’s free to try while its makers are testing it.

Artificial intelligence programs have been around for a while, but this one generated so much interest that medical practices, professional associations and medical journals have created task forces to see how it might be useful and to understand what limitations and ethical concerns it may bring.

Dr. Victor Tseng’s practice, Ansible Health, has set up a task force on the issue. The pulmonologist is a medical director of the California-based group and a co-author of the study in which ChatGPT demonstrated that it could probably pass the medical licensing exam.

Tseng said his colleagues started playing around with ChatGPT last year and were intrigued when it accurately diagnosed pretend patients in hypothetical scenarios.

“We were just so impressed and truly flabbergasted by the eloquence and sort of fluidity of its response that we decided that we should actually bring this into our formal evaluation process and start testing it against the benchmark for medical knowledge,” he said.

That benchmark was the three-part test that US med school graduates have to pass to be licensed to practice medicine. It’s generally considered one of the toughest of any profession because it doesn’t ask straightforward questions with answers that can easily found on the internet.

The exam tests basic science and medical knowledge and case management, but it also assesses clinical reasoning, ethics, critical thinking and problem-solving skills.

The study team used 305 publicly available test questions from the June 2022 sample exam. None of the answers or related context was indexed on Google before January 1, 2022, so they would not be a part of the information on which ChatGPT trained. The study authors removed sample questions that had visuals and graphs, and they started a new chat session for each question they asked.

Students often spend hundreds of hours preparing, and medical schools typically give them time away from class just for that purpose. ChatGPT had to do none of that prep work.

The AI performed at or near passing for all the parts of the exam without any specialized training, showing “a high level of concordance and insight in its explanations,” the study says.

Tseng was impressed.

“There’s a lot of red herrings,” he said. “Googling or trying to even intuitively figure out with an open-book approach is very difficult. It might take hours to answer one question that way. But ChatGPT was able to give an accurate answer about 60% of the time with cogent explanations within five seconds.”

Dr. Alex Mechaber, vice president of the US Medical Licensing Examination at the National Board of Medical Examiners, said ChatGPT’s passing results didn’t surprise him.

“The input material is really largely representative of medical knowledge and the type of multiple-choice questions which AI is most likely to be successful with,” he said.

Mechaber said the board is also testing ChatGPT with the exam. The members are especially interested in the answers the technology got wrong, and they want to understand why.

“I think this technology is really exciting,” he said. “We were also pretty aware and vigilant about the risks that large language models bring in terms of the potential for misinformation, and also potentially having harmful stereotypes and bias.”

He believes that there is potential with the technology.

“I think it’s going to get better and better, and we are excited and want to figure out how do we embrace it and use it in the right ways,” he said.

Already, ChatGPT has entered the discussion around research and publishing.

The results of the medical licensing exam study were even written up with the help of ChatGPT. The technology was originally listed as a co-author of the draft, but Tseng says that when the study is published, ChatGPT will not be listed as an author because it would be a distraction.

Last month, the journal Nature created guidelines that said no such program could be credited as an author because “any attribution of authorship carries with it accountability for the work, and AI tools cannot take such responsibility.”

But an article published Thursday in the journal Radiology was written almost entirely by ChatGPT. It was asked whether it could replace a human medical writer, and the program listed many of its possible uses, including writing study reports, creating documents that patients will read and translating medical information into a variety of languages.

Still, it does have some limitations.

“I think it definitely is going to help, but everything in AI needs guardrails,” said Dr. Linda Moy, the editor of Radiology and a professor of radiology at the NYU Grossman School of Medicine.

She said ChatGPT’s article was pretty accurate, but it made up some references.

One of Moy’s other concerns is that the AI could fabricate data. It’s only as good as the information it’s fed, and with so much inaccurate information available online about things like Covid-19 vaccines, it could use that to generate inaccurate results.

Moy’s colleague Artie Shen, a graduating Ph.D. candidate at NYU’s Center for Data Science, is exploring ChatGPT’s potential as a kind of translator for other AI programs for medical imaging analysis. For years, scientists have studied AI programs from startups and larger operations, like Google, that can recognize complex patterns in imaging data. The hope is that these could provide quantitative assessments that could potentially uncover diseases, possibly more effectively than the human eye.

“AI can give you a very accurate diagnosis, but they will never tell you how they reach this diagnosis,” Shen said. He believes that ChatGPT could work with the other programs to capture its rationale and observations.

“If they can talk, it has the potential to enable those systems to convey their knowledge in the same way as an experienced radiologist,” he said.

Tseng said he ultimately thinks ChatGPT can enhance medical practice in much the same way online medical information has both empowered patients and forced doctors to become better communicators, because they now have to provide insight around what patients read online.

ChatGPT won’t replace doctors. Tseng’s group will continue to test it to learn why it creates certain errors and what other ethical parameters need to be put in place before using it for real. But Tseng thinks it could make the medical profession more accessible. For example, a doctor could ask ChatGPT to simplify complicated medical jargon into language that someone with a seventh-grade education could understand.

“AI is here. The doors are open,” Tseng said. “My fundamental hope is, it will actually make me and make us as physicians and providers better.”

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Children’s mental health tops list of parent worries, survey finds | CNN



CNN
 — 

Forty percent of US parents are “extremely” or “very” worried that their children will struggle with anxiety or depression at some point, a new survey finds.

The Pew Research Center report said mental health was the greatest concern among parents, followed by bullying, which worries 35% of parents. These concerns trumped fears of kidnapping, dangers of drugs and alcohol, teen pregnancy and getting into trouble with the police.

Concerns varied by race, ethnicity and income level, with roughly 4 in 10 Latino and low-income parents and 3 in 10 Black parents saying they are extremely or very worried that their children could be shot, compared with about 1 in 10 high-income or White parents.

Nearly two-thirds of the respondents said that being a parent has been at least somewhat harder than they expected, about 41% say that being a parent is tiring, and 29% say it is stressful all or most of the time.

The report captured the perceptions of a nationally representative sample of 3,757 US parents whose children were younger than 18 in 2022.

Experts say mental health issues among children and adolescents have skyrocketed in recent years.

“I would say over the last 10 years, since I’ve been practicing as a general pediatrician, I have seen a shift both in the amount of patients and of all ages dealing with anxiety and depression. And their parents being concerned about this is a key issue,” said Dr. Katherine Williamson, a pediatrician and spokesperson for the American Academy of Pediatrics. “Even before the pandemic, we were seeing skyrocketing numbers of kids and adolescents dealing with mental health issues, and that has increased exponentially since the pandemic.”

Suicide became the second leading cause of death among children 10 to 14 during the Covid-19 pandemic, according to the US Centers for Disease Control and Prevention. Mental health-related emergency room visits among adolescents 5 to 11 and 12 to 17 also jumped 24% and 31%, respectively.

Many parents feel helpless when their children have mental health issues because they don’t feel equipped to offer support in this area.

“They are unable to relieve [mental health issues] and address that as they could if they were struggling with their grades or other things that seem more traditional to for kids to struggle with,” said Allen Sabey, a family therapist at the Family Institute at Northwestern University.

Parents trying to “work out and look at and connect with their own feelings will give them important information about what feels off or OK for their kid,” he said.

When it comes to anxiety and depression in children, pediatricians say, parents can watch for signs like decreased interest or pleasure in things they previously enjoyed, poor self-esteem and changes in mood, appetite or sleep.

Experts also say parents should consider the amount and content of social media their child consumes, as research has found that it can have negative effects on their mental health.

But, they say, having more parents recognize the importance of mental health in children is a step in the right direction.

“I have always felt there’s been so much resistance to seeking care for mental health among the population that I serve. And I am actually happy that since the Covid pandemic, at least people now are recognizing this as a very key and important health need,” said Dr. Maggi Smeal, a pediatrician at Stanford Medicine Children’s Health.

Smeal hopes that “all people that are interacting with children can be aware of these issues and feel empowered to identify and advocate for these children, to tell them to go to their primary care provider and have an assessment just like you do if your kid has a cough or a fever or ear infection.”

The number of parents concerned about gun violence reflects the fact that guns are the leading cause of death among children in the US, research has showed. From 2019 to 2020, the rate of firearm-related deaths increased 29.5% – more than twice the increase as in the general population.

“Gun violence is a real risk to our kids today. And that is both being killed by somebody else as well as suicide in the face of the mental health issues that we’re seeing today,” Williamson said.

The survey found that Black, Hispanic and lower-income parents were most likely to be concerned about gun violence, a finding that’s consistent with the communities most affected. Research has shown that from 2018 to 2021, the rate of firearm-related deaths doubled among Black youth and increased 50% among Hispanic youth. Another study found that children living in low-income areas are at higher risk of firearm-related death.

Direct and indirect exposure to gun violence can contribute to mental health problems.

“Even if they hear gunshots in their community, they hear adults talking, there’s all different ways that children are traumatized and victimized by gun violence. And what we see is all the symptoms of anxiety in even the youngest of children. We see children with somatic complaints – stomachaches, headaches. They have post-traumatic stress disorder,” Smeal said.

Most of the parents in the survey said parenting is harder than they expected, and that they feel judgment from various sources.

“The findings of this of this report were, as a pediatrician and a parent, just exactly what you would expect. Parenting is the hardest thing you’ll ever do, and there are very high levels of stress and fatigue, especially in the parents of young children,” Smeal said.

One of the best things parents can do is lean on fellow parents, experts say.

“The main challenge for parents is our siloed independent nature sometimes, and so we want to find people who we trust and kind of work towards being more vulnerable and open with,” Sabey said. “To where it’s like not just you and your kid, but it’s a kind of a group of people caring and working together.”

Pediatricians emphasize that no parent is perfect and that the most important thing you can do is to just be there for your child.

“We know that the best chance for a child to be successful and happy is for them to have at least one person in their life who believes in them and advocates for them. So I think it’s important for parents to know that there’s no such thing as a perfect parent, because we are all human, and humans are imperfect by nature, but that is OK,” Williamson said.

A parent’s job is to “really make sure that they know how important they are and they have a voice in this world,” she said. “Every child will have their own unique struggles, whether it is academically, emotionally, physically. Our job is to help them with the areas [where] they struggle, but even more, help them recognize their strengths.”

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Recently identified inflammatory disease VEXAS syndrome may be more common than thought, study suggests | CNN



CNN
 — 

David Adams spent half a decade fighting an illness he couldn’t name. He was in and out of the hospital several times per year. His inflamed joints made his hands feel like they had been squeezed into gloves – and he could no longer play his beloved classical and jazz guitars.

He had constant fevers and fatigue. He even developed pain and swelling in his genitalia, which was his first sign that something was really wrong.

“At the turn of the year 2016, I started with some really painful effects in the male anatomy,” said Adams, now 70. “After that, again, a lot of fatigue – my primary care physician at that point had blood tests done, and my white blood cell count was very, very low.”

Next, Adams, who lives in Alexandria, Virginia, saw a hematologist, a pulmonologist, a urologist, a rheumatologist and then a dermatologist. Some of them thought he might have cancer.

Adams’ symptoms continued, with even more fatigue, pneumonia and a large rash below his waist. He tried at least a dozen medications, saw about two dozen doctors, and nothing helped.

In 2019, worsening symptoms forced him to retire early from his decades-long career in clinical data systems. But he remained in the dark about what was causing the problems.

Finally, in 2020, scientists at the National Institutes of Health discovered and named a rare genetic disorder: VEXAS syndrome, which wreaks havoc on the body through inflammation and blood problems.

Adams had an appointment with his rheumatologist at the time, and when he walked into the office, he saw that his physician “was giddy like a little kid.”

In his doctor’s hands was a copy of a paper in the New England Journal of Medicine detailing the discovery of VEXAS syndrome.

Adams had his answer.

“For the first time, there was a one-to-one correlation of symptoms,” he said. “It was quite a shock.”

An estimated 1 in about 13,500 people in the United States may have VEXAS syndrome, a new study suggests, which means the mysterious and sometimes deadly inflammatory disorder may be more common than previously thought.

In comparison, the genetic disorder spinal muscular atrophy affects about 1 in 10,000 people and Huntington’s disease occurs in about 1 in every 10,000 to 20,000 people.

Since its discovery, occasional VEXAS cases have been reported in medical research, but the study reveals new estimates of its prevalence.

The research, published Tuesday in the journal JAMA, suggests that about 1 in 13,591 people in the US have mutations in the UBA1 gene, which develop later in life and cause VEXAS syndrome.

“This study is demonstrating that there’s likely tens of thousands of patients in the US that have this disease, and the vast majority of them are probably not being recognized because physicians aren’t really considering this as a diagnosis more broadly,” said Dr. David Beck, an assistant professor in the Department of Medicine at NYU Langone Health and a lead author of the study.

VEXAS syndrome is not inherited, so people who have it don’t pass the disease to their children. But the UBA1 gene is on the X chromosome, so the syndrome is an X-linked disease. It predominantly affects men, who carry only one X chromosome. Women have two X chromosomes, so if they have a mutation in a gene on one X chromosome but not the other, they are generally unaffected.

“It’s present in 1 in 4,000 men over the age of 50. So we think it’s a disease that should be thought about in terms of testing for individuals that have the symptoms,” said Beck, who also led the federal research team that identified the shared UBA1 mutation among VEXAS patients in 2020.

“The benefit of VEXAS syndrome is that we have a test. We have a genetic test that can help directly provide the diagnosis,” he said. “It’s just a question of patients who meet the criteria – who are older individuals with systemic inflammation, low blood counts, who really aren’t responding to anything but steroids – then advocating to their doctors to get genetic testing to get a diagnosis.”

Adams, who became a patient of Beck’s, said that finally getting a diagnosis – and understanding the cause of his symptoms – was life-changing.

“It really was incredibly freeing to have the diagnosis,” he said.

“You can’t fight your enemy unless your enemy has a name,” he added. “We finally had something where we could point to and say, ‘OK, we understand what’s going on. This is VEXAS.’ “

For the new study, Beck and his colleagues at the NIH, New York University, Geisinger Research and other institutions analyzed data on 163,096 patients in a health system in central and northeastern Pennsylvania, from January 1996 to January 2022, including electronic health records and blood samples.

Eleven of the patients had a disease-causing UBA1 variant, and a 12th person had a “highly suspicious” variant.

Only three of the 12 are still alive. A five-year survival rate of 63% has been previously reported with VEXAS.

Among the 11 patients in the new study who had pathogenic variants in UBA1, only two were women. Seven had arthritis as a symptom, and four had been diagnosed with rheumatologic diseases, such as psoriasis of the skin or sarcoidosis, which causes swollen lumps in the body. All had anemia or low blood cell counts.

“None had been previously clinically diagnosed with VEXAS syndrome,” Beck said.

The finding “is emphasizing how it’s important to be able to pick these patients out, give them the diagnosis and start the aggressive therapies or aggressive treatments to keep their inflammation in check,” he said.

VEXAS – an acronym for five clinical characteristics of the disease – has no standardized treatment or cure, but Beck said symptoms can be managed with medications like the steroid prednisone or other immunosuppressants.

“But the toxicities of prednisone over years is challenging. There are other anti-inflammatory medications that we use, but they’re only partially effective at the moment,” he said. “One treatment for individuals that we’ve seen that’s very effective is bone marrow transplantation. That comes with its own risks, but that’s just underscoring the severe nature of the disease.”

Although the new study helps provide estimates of the prevalence and symptoms of VEXAS syndrome, the data is not representative of the entire United States, and Beck said that more research needs to be done on a larger, more diverse group of people.

Some men might be hesitant to seek medical care for VEXAS symptoms, but Adams said that doing so could save their life.

“Eventually, it’s going to get so bad that you’ll end up like my first hospitalization, where you’re on death’s door,” Adams said. “You don’t want to be in that situation.”

Adams has been taking prednisone to ease his symptoms, and it’s helped. But because steroid use can have side effects such as cataracts and weight gain, he has been working with his doctors to find other therapies so he can reduce his intake of the medication.

Beck and his colleagues are studying targeted therapies for VEXAS syndrome, as well as conducting stem cell bone marrow transplant trials at the NIH.

“There are many different facets of the disease,” Dr. Bhavisha Patel, a hematologist and researcher in the National Heart, Lung and Blood Institute’s Hematopoiesis and Bone Marrow Failure Laboratory, said in an NIH news release last month.

“I believe that is what is challenging when we think about treatment, because it’s so heterogeneous,” said Patel, who was not involved in the new study.

“Both at NIH and worldwide, the groups that have dedicated themselves to VEXAS are looking for medical therapies to offer to other patients who don’t qualify for a bone marrow transplant,” she said. “We continue to collaborate on many projects in order to categorize this disease further and ultimately come up with the best treatment options.”

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



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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Millions have the same ‘bendy body’ disease as my daughter. Why isn’t the medical profession paying more attention? | CNN



CNN
 — 

One day in July 2021, my then 15-year-old daughter Poppy stumbled and fell while walking down some stairs, grazing her knee. It wasn’t a serious wound, but over the weeks it didn’t heal.

Around the same time, her wrists and knees became sore; her ankles started rolling when she walked; her hands began shaking; her headaches and stomach aches became more frequent and intensely painful. She was always exhausted.

Before her health declined, Poppy had enjoyed horse riding and gymnastics, she’d competed in cross country races and been a fearless goalkeeper for the school hockey team.

But within a couple of months, as walking became increasingly difficult, she asked me for a walking stick. We found one that folds up and fits neatly in her school bag.

I took Poppy to doctors who conducted tests, but they couldn’t find out what was wrong with her. Then, in October, a breakthrough.

A podiatrist who was measuring Poppy for insoles to support her aching feet asked if Poppy could bend her thumb to reach her forearm. She could. Could she pull her little finger back to form a 90-degree angle with the back of her hand? She could do that, too.

“Have you heard of Ehlers-Danlos syndrome?” the podiatrist asked me. I hadn’t – so as soon as I got home, I went looking on the internet.

There are 13 types of Ehlers-Danlos syndrome (EDS), according to research and advocacy organization The Ehlers-Danlos Society. Most types are very rare, and can be diagnosed using genetic tests. However, the genes that cause hypermobile EDS (hEDS) – the most common form, accounting for about 90% of cases – are unknown, so diagnosis is based on a checklist of symptoms. The list includes a hypermobility rating, known as the Beighton Score.

Poppy had enough symptoms to qualify for hEDS, and the diagnosis was confirmed by a doctor one year ago, on Christmas Eve. He told us that although we can do our best to alleviate some symptoms, there is no cure.

Poppy reacted to the news better than I did. She had known for some time that something was fundamentally wrong. The diagnosis was upsetting but identifying her illness also gave her a sense of relief. I felt shocked and overwhelmed, and I cried for weeks.

Reading about EDS was like a dreadful slow reveal.

I learned that it’s a genetic disorder that causes the body to make faulty connective tissue, and connective tissue is everywhere – in the tendons, ligaments, skin, heart, digestive system, eyes and gums.

Weak connective tissue leads to hypermobility, which may sound like a good thing, but some people with bendy bodies suffer a mind-boggling array of symptoms, including joint dislocations and subluxations (like a mini dislocation, when the joint partially slips out of place), soft stretchy skin, abnormal scarring, poor wound healing, gastrointestinal disorders, chronic pain and fatigue.

The severity of symptoms varies wildly. Patients with milder cases can lead relatively normal lives, while others become housebound, and some can’t digest food and must be fed through tubes.

What’s more, people with hEDS are prone to other conditions, including POTS (postural orthostatic tachycardia syndrome, which makes you dizzy when you stand up) and MCAS (mast cell activation syndrome, which gives you allergy-type symptoms).

I learned a lot of new acronyms and they all spelled bad news.

I initially thought hEDS was rare, because all forms of EDS are commonly referred to as rare. But within a few weeks, I felt like I was seeing references to hEDS everywhere. Actor, writer and director Lena Dunham; actor and presenter Jameela Jamil; and drag queen Yvie Oddly live with it. I deep dived into EDS Twitter and EDS Instagram, while Poppy found it comforting to watch TikTok videos made by teenagers with the condition.

I discovered multiple patient groups on Facebook, each with tens of thousands of members, which turned out to be great sources of support. I asked questions (what kind of shoes are best for weak ankles? Which knee braces are easiest to pull on and off?) and kind strangers sent helpful advice. At the same time, scrolling through countless personal stories of pain, despair and shattered dreams made me feel terrified about what might lie ahead.

I noticed common themes. Many EDS patients had spent years seeking the correct diagnosis; others felt they’d been neglected and gaslit by doctors.

There was also a lot of talk of zebras.

Linda Bluestein, a Colorado-based physician who specializes in EDS and other hypermobility conditions, and has hEDS herself, explains why.

“I was told in medical school, ‘when you hear hoofbeats think horses, not zebras,’” she says. Many trainee doctors receive the same advice – when a patient presents with symptoms, “look for the common thing.” That’s why EDS patients commonly refer to themselves as zebras – and also use the fabulous collective noun “dazzle.” The name represents rarity and evokes the stripy stretch marks that are a common feature on EDS skin.

But if people with hEDS are medical zebras, why am I encountering so many of them?

Bluestein says that for many years it was thought that one in 5,000 people had Ehlers-Danlos syndrome. But she says the limited research that’s been carried out into the prevalence of hEDS suggests the true number of cases is “much, much higher” than that.

Dr. Linda Bluestein has treated hEDS patients  who have been searching for a diagnosis for decades.

Bluestein points me to a 2019 study carried out in Wales – a country of 3.1 million people. An examination of primary care and hospital records from 1990 to 2017 found that one in 500 people there has either hEDS or joint hypermobility syndrome (a similar condition with a slightly different set of symptoms). She says it’s “a good study” but believes it’s still an underestimate. The Ehlers-Danlos Society says more population studies need to be done to give a more accurate view of its incidence elsewhere.

But despite this possible prevalence, and how debilitating hypermobility disorders can be, the average time to diagnosis from the onset of symptoms is 10 to 12 years, according to The Ehlers-Danlos Society.

Bluestein has firsthand experience of this. Growing up, she wanted to become a ballet dancer and trained six days a week. When puberty hit, she started experiencing joint pain and migraines, and at 16 had her first orthopedic surgery. She realized she wouldn’t succeed in the ballet world and instead pursued her “back-up plan,” to become a doctor. But despite her career choice, Bluestein only received her hEDS diagnosis when she was 47 – more than 30 years later.

“I told my doctor on numerous occasions, ‘there is something wrong with me, I don’t heal well, I get injured more easily than other people’,” she says. “And he just never, never listened.”

Why, for so many patients, does it take so long to get diagnosed?

In 2014 a leading EDS expert, Professor Rodney Grahame, remarked at a conference that “no other disease in the history of modern medicine has been neglected in such a way as Ehlers-Danlos syndrome.”

Far more women than men are diagnosed with EDS, which could help to explain the neglect, because the medical profession has a long history of overlooking health complaints made by women.

A 2009 study, conducted by the European Organisation for Rare Diseases, surveyed 414 families of EDS patients from five countries and found that the average delay to an EDS diagnosis was four years for men – but 16 years for women.

The report states that women with EDS tend to be “diagnosed later because their pain and hypotonia (poor muscle tone) aren’t considered as physical symptoms but rather as psychological symptoms or common complaints.”

“We tend to get dismissed a lot more easily,” says Bluestein. “People jump to the conclusion that we’re histrionic females.”

Anxiety is very common in patients with hypermobility issues, says Bluestein, which can cloud the picture. “When people with anxiety present to a physician, it can suck all the air out of the room, so that the physician almost can’t see anything else.”

This can ramp up the patient’s anxiety further “because people aren’t validating our symptoms, and then we start to doubt ourselves,” she says.

What’s more, medicine is divided into silos which creates the “worst possible model” for EDS patients, says Bluestein.

VIDEO THUMBNAIL Ehlers-Danlos Syndrome 1

‘We’re born with this and will never be free:’ Hear stories from people with Ehlers-Danlos syndrome

She explains that undiagnosed patients might consult a neurologist for their migraines, a rheumatologist for joint pain, a cardiologist for palpitations, a gastroenterologist for digestive issues and a urologist for bladder symptoms. Each doctor focuses on the symptoms that fall within their specialty but doesn’t consider the other ailments. “Nowhere along the way does somebody realize that there are certain conditions that could tie all of these things together and explain everything,” says Bluestein.

The 2009 rare diseases study found that during the quest for a diagnosis, 58% of EDS patients consulted more than five doctors, and 20% consulted more than 20.

The consequences of not getting diagnosed for years can be devastating.

Melissa Dickinson, a psychotherapist in Atlanta, Georgia, says she experienced symptoms of a “mystery illness” since childhood. Then in 2013, she “went on honeymoon to Mexico, relatively healthy, and came back disabled and with a dislocated neck.”

While on vacation, Dickinson says she got food poisoning and was prescribed ciprofloxacin, an antibiotic that can pose a serious risk of aortic aneurysm to people with EDS. Instead, she says it triggered significant nerve damage, digestive issues that almost made her go blind because her body wasn’t absorbing nutrients, and put her in a wheelchair.

Dickinson, who finally received her hEDS diagnosis in 2014, says taking the wrong medication “wrecked me from head to toe.” Now that she’s receiving treatment, “I can walk with mobility aids, but most of my body has to have constant support to function.”

Lara Bloom, president and CEO of The Ehlers-Danlos Society, who herself has hEDS, says many patients have “medicalized PTSD.”

“They have had to stop their careers, they’ve had to drop out of school, their relationships have broken down.” The delay inevitably results in worsening symptoms and a declining quality of life, she says. In worst-case scenarios, patients “are dying by suicide, they’re self-harming.”

Sometimes, the failure to diagnose EDS has led to children being taken away from their parents.

In 2010, Americans Rana Tyson and her husband Chad were falsely accused of harming their 4-week-old twin daughters, who had unexplained fractures in their legs.

Along with their older sister, the baby girls were taken by state authorities in Texas and sent to live with relatives. “It was the worst day of my life,” Tyson tells me in a phone call.

Five months later, a geneticist identified the twins as having a connective tissue disorder, and they were subsequently diagnosed with EDS and a vitamin D deficiency. The family was reunited but “12 years later, it still hurts,” says Tyson.

Bloom says some other parents of children with EDS have been wrongly accused of “fabricated or induced illness (FII)” – a rare form of abuse, formerly known as Munchausen’s syndrome by proxy, in which a parent or care giver deliberately causes symptoms or tries to convince doctors that a healthy child is ill.

Ellie Pattison, who has hEDS, has been repeatedly misdiagnosed as having an eating disorder.

Ellie Pattison, a 19-year-old student who lives in County Durham, England, suffers from severe digestive issues linked to hEDS.

Throughout her childhood, Ellie was repeatedly misdiagnosed as having an eating disorder, she says, while her mother Caroline was accused of FII on three separate occasions. Caroline successfully fought to keep her daughter at home, says Ellie, but the ordeal has left the whole family with “an unimaginable amount of trauma.” Ellie says she suffered from PTSD and endured years of horrific nightmares, triggered by living with the fear from a young age that she could be forcibly separated from her family.

This underlines why prompt diagnosis is so important, says Bloom. “Our hope and dream is for people to get diagnosed when their symptoms begin.”

In the case of hEDS, a crucial first step is to find out what causes it.

Cortney Gensemer, a biomedical scientist in the Norris Lab at the Medical University of South Carolina’s department of Regenerative Medicine and Cell Biology, is trying to solve this mystery. She and research mentor Russell Norris, head of the lab, have been studying a gene mutation they believe causes hEDS (the results of the study are currently under peer review).

Like Poppy, Gensemer was diagnosed with hEDS as a teenager. She says the disease affects every aspect of her work. Looking down a microscope is particularly painful at times – her neck is unstable because of her hEDS, and she’s had metal screws put into some of her neck vertebrae to fuse them.

Cortney Gensemer working in the Norris Lab and recovering from neck surgery earlier this year.

Norris kitted the lab out with special equipment, including motion sensor doors (standard lab doors are very heavy), adjustable chairs and ergonomic pipettes that are gentle on the hands. “If I didn’t have all that stuff, I don’t think I’d be able to do it,” says Gensemer.

To find a hEDS-causing gene, Gensemer says she and Norris sampled DNA from a large family with cases spanning four generations and looked for a mutation that appears only in relatives who have the disease. They identified a “strong candidate gene” and inserted it into mice using gene editing tools.

Gensemer and Norris found that the hEDS mice had significantly more lax tissues, and floppier tails than regular rodents. “You can tie a loose knot into the mutant mouse tail. With a normal mouse tail, you can (only) bend it into a circle,” Gensemer says.

The gene that Gensemer and Norris found won’t account for all hEDS cases, she says. They believe that eventually multiple genes will be identified, and hEDS may be split into different subtypes. This would help to explain why different patients have different symptoms. Crucially, if genetic information sheds light on how the connective tissue is “messed up,” it could lead to effective treatments, says Gensemer.

The Ehlers-Danlos Society is also looking for genes as well as blood markers, working with a team of experts to sequence and analyze the DNA of 1,000 hEDS patients from around the world. And at the UK’s University of Warwick, Ph.D. candidate Sabeeha Malek, another scientist with hEDS, has proposed that EDS might be caused by a fault in the way that collagen binds to cell membranes in connective tissue. If she’s right, she hopes her work will lead to a skin biopsy test that could identify all forms of the disease.

Sabeeha Malek is working to identify biomarkers that could make EDS diagnosis easier.

Progress is being made but on a very small scale. “If you look at any major academic institution, there are multiple labs studying cancer, multiple labs studying heart disease. When you look at a disease that affects one in 500 people, and probably more than that, there should be a lab studying it at every single academic institution,” says Gensemer.

Gensemer hopes that as more discoveries are made and data is accumulated it will “change the way the medical community looks at the disease” – and that it will be taken more seriously.

A year has passed since Poppy’s diagnosis. The initial shock has subsided, and while I’m still grieving the loss of her health, we’ve both learned to accept our new reality and have adjusted to living with EDS.

I’ve assembled a team of supportive doctors and therapists and acquired an arsenal of paraphernalia to fight pain and manage symptoms, including braces and kinesiology tape to hold her joints in place; ice packs, heat pads, tiger balm and arnica gel for sore muscles; and a cupboard full of medications and supplements.

With Poppy often stuck at home, I also got her a giant kitten that she calls Bagel, and he provides the best therapy.

Poppy with Bagel.

Writing this article has taught me a lot more about EDS: It’s been upsetting to report on the terrible experiences some have suffered, but I’ve been awestruck by the dedication of people, many with the condition themselves, who are working to find solutions.

I don’t know what the future holds for Poppy. Some patients’ symptoms improve with age; others experience an increase in pain and a loss of mobility. I’ve learned there’s a limit to what we can control but there’s a lot we can do, to tackle symptoms and make life easier. And I believe that change is coming.

With a better understanding of the condition and diagnostic tools on the horizon, my biggest hope is that there will be a cure one day – and that it will come in time for Poppy.

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Decreasing rates of childhood immunization are a major concern. Our medical analyst explains why | CNN



CNN
 — 

Vaccine rates for measles, polio, diphtheria and other diseases are decreasing among US children, according to a new study from the US Centers for Disease Control and Prevention.

The rate of immunizations for required vaccines among kindergarten students declined from 95% to approximately 94% during the 2020-21 school year. It dropped further — to 93% — in the 2021-22 school year.

That’s still a high number, so why is this drop in immunization significant? What accounts for the decline? What might be the consequences if these numbers drop further? If parents are unsure about vaccinating their kids, what should they do? And what can be done on a policy level to increase immunization numbers?

To help us with these questions, I spoke with CNN Medical Analyst Dr. Leana Wen, an emergency physician, public health expert and professor of health policy and management at the George Washington University Milken Institute School of Public Health. She is also author of “Lifelines: A Doctor’s Journey in the Fight for Public Health.”

CNN: Why is it a problem that childhood immunization rates are declining?

Dr. Leana Wen: The reduction of vaccine-preventable diseases is one of the greatest public health success stories in the last 100 years.

The polio vaccine was introduced in the United States in 1955, for example. In the four years prior, there were an average of over 16,000 cases of paralytic polio and nearly 2,000 deaths from polio each year across the US. Widespread use of the polio vaccine had led to the eradication of polio in the country by 1979, according to the CDC, sparing thousands of deaths and lifelong disability among children each year.

The measles vaccine was licensed in the US in 1963. In the four years before that, there were an average of over 500,000 cases and over 430 measles-associated deaths each year. By 1998, there were just 89 cases recorded — and no measles-associated deaths.

These vaccines are very safe and extremely effective. The polio vaccine, for example, is over 99% effective at preventing paralytic polio. The measles vaccine is 97% effective at preventing infection.

We can do this same analysis for other diseases for which there are routine childhood immunizations.

It’s very concerning that rates of immunization are declining for vaccines that have long been used to prevent disease and reduce death. That means more children are at risk for severe illness — illness that could be averted if they were immunized. Moreover, if the proportion of unvaccinated individuals increases in a community, this also puts others at risk. That includes babies too young to be vaccinated or people for whom the vaccines don’t protect as well — for example, patients on chemotherapy for cancer.

CNN: What accounts for the decline in vaccination numbers?

Wen: There are probably many factors. First, there has been substantial disruption to the US health care system during the Covid-19 pandemic. Many children missed routine visits to the pediatrician during which they would have received vaccines due to pandemic restrictions. In addition, some community health services offered also became disrupted as local health departments focused on Covid-19 services.

Second, disruption to schooling has also played a role. Vaccination requirements are often checked prior to the start of the school year. When schools stopped in-person instruction, that led to some families falling behind on their immunizations.

Third, misinformation and disinformation around Covid-19 vaccines may have seeded doubt in other vaccines. Vaccine hesitancy and misinformation were already major public health concerns before the coronavirus emerged, but the pandemic has exacerbated the issues.

According to a December survey published by the Kaiser Family Foundation, more than one in three American parents said vaccinating children against measles, mumps, and rubella shouldn’t be a requirement for them to attend public schools, even if that may create health risks for others. This was a substantial increase from 2019, when a similar poll from the Pew Research Center found only 23% of parents opposed school vaccine requirements.

CNN: What are some consequences if immunization rates drop further?

Wen: If immunization rates drop further, we could see more widespread outbreaks. Diseases that were virtually eliminated in the US could reemerge, and more people can become severely ill and suffer lasting consequences or even die.

We are already seeing some consequences: Last summer, there was a confirmed case of paralytic polio in an unvaccinated adult in New York. It’s devastating that a disease like polio has been identified again in the US, since we have an extremely effective vaccine to prevent it.

There is an active measles outbreak in Ohio. As of January 17, 85 cases have been reported. Most of the cases involved unvaccinated children, and at least 34 have been hospitalized.

CNN: If parents are unsure of vaccinating their kids, what should they do?

Wen: As parents, we generally trust pediatricians with our children’s health. We consult pediatricians if our kids are diagnosed with asthma and diabetes, or if they have new worrisome symptoms of another illness. We should also consult our pediatricians about childhood immunizations; parents and caregivers with specific questions or concerns should address them.

The national association of pediatricians, the American Academy of Pediatrics, “strongly recommends on-time routine immunization of all children and adolescents according to the Recommended Immunization Schedules for Children and Adolescents.”

CNN: What can be done to increase immunization numbers?

Wen: There needs to be a concerted educational campaign to address why vaccination against measles, mumps, rubella, chickenpox, polio and so forth is so crucial. One of the reasons for vaccine hesitancy, in my experience, is that these diseases have been rarely seen in recent years. Many people who are parents now didn’t experience the devastation of these diseases growing up, so may not realize how terrible it would be for them to return.

Specific interventions should be targeted at the community level. In some places, low immunization levels may be due to access. Vaccination drives at schools, parks, shopping centers, and other places where families gather can help increase numbers. In other places, the low uptake may be because of vaccine hesitancy and misinformation. There will need to be different strategies implemented in that situation.

Overall, increasing immunization rates for vaccine-preventable childhood diseases needs to be a national imperative. I can’t underscore how tragic it would be for kids to suffer the harms of diseases that could be entirely prevented with safe, effective and readily available vaccines that have been routinely given for decades.

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



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 Damar Hamlin split for video

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

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