Starting With Curious

When I was in training, people would talk about “brutane” being their preferred agent for keep a child still during a procedure: hold them down by brute force. We didn’t have a lot of great options for sedation for relatively short procedures, so the choice might be knocking the child out for hours, or just getting it over with. We often went with the latter.

In hindsight, it sounds primitive and inhumane. (You are probably wondering if I studied with Hippocrates, and carried leeches around in my kit. No, and no.) But in the last 25 years, newer short-acting analgesic and sedative agents have been developed and approved. During that same time, there has been an increased understanding of the long-term effects of inadequately treated neonatal and early childhood pain, including changes in the brain’s structure and responsiveness and the immune response. Among pediatric specialists and subspecialists, use of analgesics and sedation for even minor procedures is now exceptionally common, and is in many cases an important quality differentiator.

OK, the sound you hear is that of the pendulum swinging back and getting ready to hit you in the head. In the past 5 years, there has been a growing body of literature demonstrating that the anesthetic and sedative agents we use to treat and prevent procedural pain in infants and children may themselves cause adverse effects in the developing brain. Most of the evidence comes from effects in baby animals, though there is some (albeit still incomplete) data on effects in humans as well. Some professional organizations and the FDA have begun to raise a red flag and suggest that at least some elective procedures should be deferred until after age 3.

There is evidence that pain is bad, and that preventing pain is bad. Now what? Do we go back to brutane? And more importantly, how can we help parents make sense of the options and make the best possible choice for their child.

First, this is a great illustration of the principle that children are not just small adults. Providers with the extra expertise that comes with subspecialty training are in the best position to understand the data and interpret it for families. The evidence for some agents being harmful is stronger than for others, and some have not been linked to these side effects. Pediatric subspecialists are also more likely to be familiar with and have access to the full range of alternatives. For example, sucrose solution (i.e., sugar water) has been shown to provide adequate analgesia and sedation for many minor procedures in infants, but is unlikely to have the kind of adverse effects seen with other agents. My anecdotal experience is that non-pediatric physicians are not as familiar with this option. Non-pharmacologic measures, including swaddling, or distraction and other techniques provided by child life specialists, may also be effective for babies and young children.

While the experts try to sort out the data, I may think twice before automatically giving a strong sedative. I’ll think carefully about the alternatives. And I’ll certainly try to keep up on the literature and emerging guidelines.   But I don’t want to go back to the brutane era. I still have images of children struggling mightily to break free of the 2 or 3 large adults holding them down while I tried to put stitches in or remove a bead from the ear; I have to imagine those kids have even worse memories of it than I do. They deserve better than that. They deserve the best.

I don’t know exactly what a prayer is.

I do know how to pay attention, how to fall down

into the grass, how to kneel down in the grass,

How to be idle and blessed, how to stroll through the fields,

which is what I have been doing all day.

Tell me, what else should I have done?

Doesn’t everything die at last, and too soon?

Tell me, what is it you plan to do

With your one wild and precious life?

-Mary Oliver, “The Summer Day”

It’s virtually impossible to go a day without asking someone how they are doing, and receiving the reply, “Busy.” It’s often implied that this is both good and bad; while we complain about being overwhelmed, we say it with a certain pride, busy-ness indicating success. This mixed message comes not only at the individual level but as a society. Commentators who lament the frenetic pace of the world also imply that this is unique in human history, an unintended consequence of the immense progress in our era. With the explosion of knowledge and technology, we have more options than ever before – how could we not be overwhelmed. More specifically, it arises from the globalization and connectedness begat by the Web. We are advanced, therefore we are busy.

Except this anxiety over lack of time goes back a long way. Back in 1910, Arnold Bennett wrote a small book called “How To Live On 24 Hours A Day.” He points out that people often try to live within a monetary budget, but that time is actually a more finite and therefore precious resource. “The supply of time, though gloriously regular, is cruelly restricted….We never shall have any more time. We have, and we have always had, all the time there is.” Time mis-management is a long-standing feature of our species.

The problem isn’t that we have too many choices now. It is that we are challenged to prioritize among them. This is true whether there are 12 TV channels or 1200. One way of looking at our choices is to categorize in two dimensions: timeliness (urgent vs. non-urgent), and significance (important vs. unimportant). Urgency too often trumps importance.

Greg McKeown, in his book Essentialism: The Disciplined Pursuit of Less, stresses the need to focus on significance, and to identify those things that are truly the most important. Essential. This, of course, sounds far easier than it is. None of us lives in a vacuum, and we do not have complete control over what we need to do. When a Joint Commission surveyor shows up at our hospital, my opinion about whether they are “important” or not doesn’t really matter. I know what I’m going to be doing the next few days.

But we do have a certain amount of discretion, which we fail to fully utilize. And it isn’t just a matter of doing things more efficiently to get more done. Paradoxically, focusing on the essential requires a certain investment of time into doing, well, nothing. More specifically, thinking rather than doing. McKeown emphasizes that determining what is essential takes some discipline itself. It isn’t necessarily obvious, and may not already be known. Taking time to explore and ponder options, time for discernment, is a critical part of essentialism.

Our leadership team, which has been reading McKeown’s book together, is experimenting with some things to help us move ourselves, and the organization, toward an essentialist mindset. One thing we’ve done is commit to building “thinking time” into our schedules. Time for reflection, time for discerning what are those most important things we should spend the rest of our time on. It may not involve kneeling down in the grass, as Mary Oliver’s poem suggests, but it does involve paying attention. How else are we to know what to do with our one wild and precious life?

It sounds like a plot for a corporate thriller: an industry that poisons people and then profits from selling the antidote.  In a sense, though, this could describe health care.  As one of the most energy-intense industries – hospitals account for 8% of all US energy use – health care facilities are an important contributor to both air pollutants and greenhouse gas emissions.  Those pollutants are an important cause of respiratory illness, especially in children.  We could, unintentionally, be contributing to adverse health effects for the children in our community.  That undermines our values of purpose and health.

Many hospitals, including Children’s, are taking steps to address this.  Our hospital actually already compares favorably to others in its energy footprint.  This year we will be installing new facility operations software that will further reduce our energy consumption.  And the thermal plant on Watertown Plank Road, which provides Children’s and the other facilities on the Milwaukee Regional Medical Campus with steam and chilled water for heating and cooling, is being converted from coal to natural gas, which will decrease both carbon and particulate matter emissions.

The good news is that efforts like these will lead to improved public health.  A recent study from the New England Journal of Medicine showed that in southern California over a 13 year period, pollution reductions as a result of regulations under the Clean Air Act were associated with improvements in lung function in children.  This affirms findings in other studies showing a link between improvements in air quality and overall life expectancy across the US.  Clean air is good.

Other hospitals are going even further.  Gundersen Lutheran, in La Crosse, WI, became the first hospital to go carbon neutral, getting all of its energy from wind, geothermal, solar, and other renewable sources.  That’s a stretch.  But even the steps we are taking will help.  And as individuals we can help to reduce the energy intensity of the organization by turning off lights and computers, using stairs, and other small things that will add up to less waste and healthier kids in our community.