When You Need the Best
Top pediatric facilities bring a large, child-focused team to the table. "There are some spectacular community hospitals," says Ziegler of Children's Hospital, "but it's unlikely that most of them have a complete pediacentric support system--the anesthesiologist, the social worker, the play therapist, people who are expert at drawing blood from children, labs that can work with very small amounts of blood."
This argues that parents should seek a top hospital even for a child's overnight stay, says Peter Pronovost, medical director of the Center for Innovation in Quality Patient Care at Johns Hopkins University School of Medicine. "If a problem or procedure is big enough for a child to be admitted," he says, "it's big enough to look for the best possible hospital." That's a little extreme for Kosloske, the first pediatric surgeon in New Mexico, where following Pronovost's advice easily could mean driving hundreds of miles.
But it's not all that different from referral guidelines issued in 2002 by the American Academy of Pediatrics. They advise primary-care doctors to refer all children from birth to age 5 who need operations not to general surgeons but to pediatric surgeons, who have special training. All children, period, should go to surgeons with relevant pediatric expertise for a long list of specific conditions, such as removing the tonsils of a child with heart problems or correcting undescended testicles. There are fewer than 1,000 board-certified pediatric surgeons in the country, and they work mostly at large tertiary-care centers where their skills are constantly in demand. But having a local general surgeon take on a difficult condition and then recognize the need to refer the child to an advanced center "isn't in the child's best interests," says Kosloske, who directed the final polishing of the AAP recommendations. "It's better to get them where they need to go right away." The guidelines are publicly available (aappolicy.aappublications.org, click on "AAP Policy Statements") and can be inspiration for questions to ask a pediatrician.
A PATIENT IS HIGH RISK
The standard treatment for smokers in the late stages of emphysema, when most are too debilitated even to get around, is simply to ease their physical distress by giving them supplemental oxygen, inhalers, and other drugs. Many patients never hear about an option called lung volume reduction surgery that might actually restore some quality of life. Their primary-care doctor may not know about the treatment, which is done at only a handful of medical centers. And lung-care specialists might not bring it up. Says pulmonologist Philip Diaz, medical director of lung volume reduction surgery at the Ohio State University Medical Center in Columbus: "They may figure the person is untreatable--why put them through surgery?"
People with late-stage emphysema don't make good surgery candidates. Their damaged lungs have left them with little strength or stamina. Most have a higher-than-usual chance of a heart attack or arrhythmia during surgery because of high blood pressure or heart disease. Yet, when the disease is concentrated in the upper part of the lungs, removing those portions may bring enormous relief.
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