A dangerous new street drug; studying gun violence; hospitalized teens: Upstate Medical University's HealthLink on Air for Sunday, April 2, 2023
Toxicologist Ross Sullivan, MD, goes over the dangers of xylazine, a veterinary drug that is showing up in street drugs. Public health researcher Margaret Formica, PhD, discusses what studies have shown about gun violence and a possible new approach to dealing with it. Pediatricians Karen Teelin, MD, and Jennifer Myszewski, DO, talk about the unique needs of adolescents who are hospitalized.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a toxicologist explains the dangers of xylazine, which is showing up in street drugs in Central New York:
Ross Sullivan, MD: ... It causes a profound sleepiness. We say almost coma-like. It's an anesthetic, right? So you'd be sleeping. It lowers your heart rate quite a bit, too. ...
Host Amber Smith: A public health researcher addresses the shortage of gun violence research:
Margaret Formica, PhD: ... There are over 100 firearm-related deaths in this country every day, and there's an additional two to three times as many nonfatal firearm injuries. ...
Host Amber Smith: And two pediatricians discuss how the needs of adolescents differ from those of younger kids in the hospital:
Karen Teelin, MD: ... It's a challenging time in life when your autonomy is emerging. Your identity is emerging, and you're working toward being independent, and being hospitalized feels like a little bit of that is taken away. ...
Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.
On this week's show, an Upstate researcher shares her experience as part of a national task force on gun violence and public health.
Then, two pediatricians talk about new guidelines for hospitalized adolescents.
But first, what's important to know about street drugs that may be altered with xylazine, a tranquilizer used in veterinary medicine?
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Xylazine is a drug that can cause serious, life-threatening effects in people. And recently this substance has been found in street drugs in Central New York.
So I'm talking with Dr. Ross Sullivan to learn more about xylazine. He's an assistant professor of emergency medicine at Upstate and director of medical toxicology. Welcome back to "HealthLink on Air," Dr. Sullivan.
Ross Sullivan, MD: Hi, good morning. Nice to be here.
Host Amber Smith: Xylazine was in the news recently, and it may have been the first time many people heard of it. Is xylazine a new medication, or is it just new to the Central New York area?
Ross Sullivan, MD: Well, it's probably just newer to our area. In fact, those of us who kind of work in this field, we've really noticed it actually here probably over a year ago now, kind of creeping in, geographically, from other areas in the Northeast. However, the last few months to six months, particularly more recently though, we've noticed it to really start becoming a larger problem. So it is newer. We have kind of been monitoring it already, over maybe the past year, but it's certainly exploded recently.
Host Amber Smith: Xylazine - does it have other names?
Ross Sullivan, MD: You know, on the street they might call it something like "tranq," I guess short for like tranquil or something like this. We hear that name quite a bit, or "sleep dope," or something like this. But we mostly call it xylazine, but there's a lot of words for it on the street. We probably don't even really know all of them. Tranq probably is the most popular one.
Host Amber Smith: So, is there a therapeutic use for xylazine in humans?
Ross Sullivan, MD: No, not in humans. You know, it's used as a veterinary medicine, in these large animals, and it causes sedation, right? So as a sedative in the veterinary medicine. So unfortunately it has similar effects in people, too.
Host Amber Smith: And so the drug suppliers are somehow getting their hands on the veterinary medicine and mixing it with other drugs? I mean, nobody's out on the street looking for this to buy just this, right?
Ross Sullivan, MD: Right. To the best of our knowledge, we don't think people are purchasing drugs that have xylazine in it. And in fact, most people, they tell us they have no idea. So why it's in there, we really don't know. You know, sometimes it's a bulking agent. But we do know that it will make someone be sedate for a long period of time.
And we are not sure if that would be desirable. It probably really isn't. So it is put in there probably unknowingly to the people who use drugs, and which makes our drug supply, which is already unsafe, even more unsafe.
Host Amber Smith: Well, I wanted to ask you what it does in the body, and I imagine it depends on how it's ingested, right? So, so it can be inhaled or injected?
Ross Sullivan, MD: Yeah. I mean, these things probably can be inhaled or injected, almost like any drug. A lot of the effects we're seeing locally are from people injecting it. But the effects would probably be similar in the human body. And what it does is it causes a profound sleepiness. We say almost coma-like. It's an anesthetic, right? So you'd be sleeping. It lowers your heart rate quite a bit, too. It'd be very difficult to arouse.
So why it's dangerous is, if you have a very low heart rate, you are in a coma, maybe even slows your breathing. And when you add that to something with fentanyl, which is what this is almost always mixed with, fentanyl, of course, also causes maybe coma, so to speak, and decreased to no breathing, so when you mix these two things together, what we're having is a real deadly combination.
Host Amber Smith: And fentanyl's been a problem. We've talked with you about that in the past, as well. That's another illegal drug that's showing up in drugs. People don't expect it to be there, but it is.
Ross Sullivan, MD: Yeah. Exactly. We're to a point now where our heroin supply is probably 80% or greater fentanyl, right? So it's almost expected. It is expected. We know it's here. And it's also in a great degree in a lot of other drugs that people are using. We know that it's been found in a cocaine supply, maybe in some methamphetamine supply. So, it's to the point now where it should be expected in our community, and if someone's using an illicit drug that it has a potential or a probability of having fentanyl in it.
Host Amber Smith: So how fast does xylazine take action once it's ingested?
Ross Sullivan, MD: Well, we think the xylazine works pretty quickly. It's pretty potent, or powerful. And when it's, let's say, injected, it probably just takes several minutes, really, to start working. But it lasts much longer than fentanyl, so not only do you have a combined sedation or coma from fentanyl and the xylazine, but the xylazine also acts a lot longer. So when someone may be waking up or recovering from the fentanyl, now they're having a much, even longer, prolonged sedation. So the chance of somebody stopping breathing, the chances of someone having a a problem due to a really low breathing or low heart rate, is just really, not only is it combined, but it's also now prolonged.
And this is why people are still dying. I mean, people are still dying mostly from fentanyl, but now we're trying to understand better how is the xylazine also playing a role in this? Most of the deaths from opioids have fentanyl in it and still not xylazine, most of them. But we're seeing now xylazine be part of the equation now. So certainly fentanyl, in and of itself, is still very deadly on its own. But we have this other bad actor now, coming into our supply.
Host Amber Smith: How does xylazine affect the cocaine or the heroin? You know, if a person is purchasing cocaine to use, but it has xylazine in it, does that affect how the cocaine works?
Ross Sullivan, MD: No. I mean, the drugs themselves still work the same. I'm not too sure if we've seen xylazine in cocaine yet. It's possible that it could be in cocaine in the future. I don't think we've really seen too much of that. We've seen it really in the heroin and fentanyl, so the heroin and fentanyl or even the cocaine, theoretically, it would all still be working itself the same, but then you have this extra added drug in it, which is just causing a whole another host of problems. So you have the drug doing its own work, which can be deadly. And then you have another drug doing its work, which also can be deadly.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Ross Sullivan, an emergency physician and director of medical toxicology at Upstate.
Can naloxone, or Narcan, reverse an overdose with xylazine in it?
Ross Sullivan, MD: It does not reverse xylazine. At all. They're very different drugs. Xylazine is not an opioid. It works completely differently. But the big message we tell everyone is, though, to keep giving naloxone, or Narcan, because it's still in the fentanyl. You still have to reverse the fentanyl portion of an overdose.
Because remember, like I said a little bit before, fentanyl is still the deadly or deadliest illicit drug in our area. And since we know the xylazine is predominantly or only mixed with fentanyl, you still have to give it to take the fentanyl away. And you might give it, and someone might not look like they're waking up, but maybe they're breathing again. And so when people are saying things like, "Well, the naloxone's not working," it is most likely working, but you'll still be sleeping from the xylazine. So that's why we say, look at the breathing if you can. I know not everyone's trained to do this, but if someone's breathing again, their chest going up and down, that's what you need.
They might not wake up. They won't wake up if there's xylazine in it. But they'll probably start breathing again because you'll block the fentanyl with the Narcan. So it's still very important to still give.
Host Amber Smith: So if you can get them breathing again, or feel secure that they are breathing, then maybe that will be what helps save them?
Ross Sullivan, MD: Absolutely. That will be most likely what can and will save them. You know, obviously we want you to call 911 as well, so that's really important for people in the community: if you see this, if you happen to have naloxone with you, or Narcan, to spray the bottle in someone's nose, but still call 911. And they might not wake up because of xylazine.
Host Amber Smith: So call 911. Use Narcan if you've got it. Anything else that a person should do, if they come upon someone who's overdosed? There's no way to really know what they've overdosed on?
Ross Sullivan, MD: There's really no way. Those are the two most important things, really. I mean, you can advocate for rescue breathing, but that's if you're comfortable. And I understand not doing that. Rolling people on their side sometimes is important because we don't want people to maybe vomit and choke on their vomit, which is also a big problem. But the main thing is call 911, give them the naloxone, the Narcan, and let the 911 people who are trained to come and take it from there. Those two things are the most important things.
Host Amber Smith: Is there any way to tell ahead of time, if you purchased an illegal drug, can you tell whether it has xylazine or fentanyl in it?
Ross Sullivan, MD: Well, we're really not there yet in terms of xylazine. There are some point-of-care or, I should say, a test strip that's being developed or is in early use in some parts of the country. I'm not aware of us having necessarily that capability locally. Certainly we don't at Upstate University Hospital or the local addiction treatment centers, we don't have access to these xylazine test strips.
What we do have access to in our community, though, are fentanyl test strips. And those are really important because, again, there's a whole host of people that are using drugs that are not heroin, so people using methamphetamines and cocaine, that don't want to be using fentanyl. And test trips are very important for those patients. They can get them from certain programs for the county. The Upstate Bridge Clinic has them, Helio Health has them. I'm sure others do as well. But that's a real important tool that we have locally as well.
Host Amber Smith: Can you talk about the longer term complications from xylazine? I've heard about skin ulcers and abscesses.
Ross Sullivan, MD: Yeah. You know, the real long term we probably don't even know yet, but absolutely, one of the things we're seeing are these skin wounds, or I should say, tissue wounds.
It goes through the skin, right? It actually can go down into the tissue and sometimes down to the bone. It's not just necessarily even an infection. We use the word necrosis, which just really means tissue breakdown, right? And it's not necessarily even due to an infection. Infection might be part of it. But there's something about this drug, maybe, or whatever it's in, that's causing damage locally, right to the tissue where the people are injecting. And over some time they develop a very aggressive wound that's difficult to treat. It's difficult to treat wounds. I mean, think of maybe a little cut sometimes that you say, "oh man, it's taking a long time to heal." You know, these can be this large, the size of a baseball or palm of someone's hand, or larger, on someone's arm, on their legs or anywhere, really.
It's terrible, right? And the people who are using, they don't want these, right? Of course they don't. These wounds cause terrible complications and infections and a lot of other problems. Again, we don't know exactly why, but it's causing damage locally. And it's pretty terrible for the patient.
Host Amber Smith: Well, Dr. Sullivan, thank you so much for making time for this interview.
Ross Sullivan, MD: Yeah, it's been my pleasure, as always.
Host Amber Smith: My guest has been emergency physician Dr. Ross Sullivan. He's director of medical toxicology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
A look at public health research into gun violence -- next on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
One step toward reducing gun violence is to deal with it effectively in public health and medical school programs, according to an Upstate researcher. My guest today is Margaret Formica. She's an associate professor of public health and preventive medicine at Upstate and one of 13 faculty on a national task force that drafted a report on gun violence and public health.
Welcome back to "HealthLink on Air," Dr. Formica.
Margaret Formica, PhD: Thank you. It's great to be back.
Host Amber Smith: I'm curious about what we know and what we still need to know. Can you give us a short overview of the kinds of research that public health researchers have already done on gun violence?
Margaret Formica, PhD: Sure. Over the past decade, we've really seen an increase in gun violence research from public health (experts), and that's really continuing to grow. There's been research that's describing the problem, so who is affected by gun violence, where is gun violence occurring, how is it changing over time?
We've also seen research regarding the different types of gun violence, so if it's gun violence related to suicide or possibly homicide, mass shootings, accidental shootings, intimate partner violence.
There's also been some research on factors and policies that may prevent gun violence, so things like safe storage, community-based programs or hospital-based violence intervention programs.
And there's also been quite a bit of work around state gun laws and the impact that those laws have on gun violence.
Host Amber Smith: It sounds like we're reading and hearing about mass shootings every day in America. Is it true that there's a huge increase in the number?
Margaret Formica, PhD: Actually, that is one of the areas that I've been working in for quite a while now, for the last several years. But it's interesting because only about 1% to 2% of firearm-related deaths are due to mass shootings.
So it's really a very tiny proportion of the gun violence that occurs in this country, but it does get a lot of attention. But there has been an increase in mass shootings, and there's also been a 35% increase in gun violence in general, which is very alarming. We've definitely seen this across the board in a lot of the work that has been done recently around gun violence.
Host Amber Smith: So if the mass shootings that we hear so much about only account for a very small number of the gun violence in America, what is the rest of it?
Margaret Formica, PhD: So the majority of the gun violence that occurs is actually suicide, so more than half of deaths related to gun violence are suicide. We then see a very high proportion of assault-related gun violence or homicides due to gun violence.
And then there's also the accidental shootings, too, but those tend to be a pretty small proportion, also.
Host Amber Smith: What do we still need to learn about gun violence?
Margaret Formica, PhD: There's just so much that we really still do not know about gun violence. You know, we don't have a good sense of, for example, how guns move through the country.
We don't know which laws and policies are the most effective at preventing gun violence. We're really just beginning to learn about the long-term effects of children, or among children, of hearing and seeing gun violence. Things like, "How do we best communicate gun safety to the public?" Those are things that we don't know either.
We also know very little about the long-term outcomes for all of the people who are injured, but not killed, by gun violence. So there's really so much more that we need to learn.
Host Amber Smith: Do we have a good idea of what factors lead to gun violence?
Margaret Formica, PhD: I would say no. We really don't have a good sense of all the factors that lead to gun violence at this point.
There are a couple of factors that have been shown time and time again to be associated with gun violence.
Probably the factor with the most evidence is poverty. Now, does poverty actually cause gun violence? No, not in the traditional sense, but poverty is certainly associated with gun violence. So any efforts to address disparities in poverty levels will also likely have a positive impact on gun violence prevention as well.
Another factor that we do know is related to gun violence is previous exposure to gun violence, so either being a victim of gun violence or witnessing it, those are factors that we know lead to additional gun violence. It's really a vicious cycle. But that's why we really need to boost the research that's being done in this area, because there's definitely more that we don't know than what we do know at this point.
Host Amber Smith: Are you aware of any revolutionary research that's underway or that has wrapped up recently dealing with gun violence?
Margaret Formica, PhD: I've been fortunate in the last few years to have the opportunity to serve as a grant reviewer for gun violence research for the CDC (Centers for Disease Control and Prevention), so I've been able to see the direction that gun violence research is headed in.
And there's been significant work being done related to building the surveillance systems that we need in place to study gun violence and also gain a better understanding of how multiple factors work together that lead to gun violence.
But with respect to recent revolutionary findings, I really do think the most striking is simply that significant increase in firearm violence that we've seen since the beginning of the pandemic.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Margaret Formica. She's an associate professor of public health and preventive medicine at Upstate, and she was part of a national task force that drafted a report on gun violence and public health.
Dr. Formica, the Association of Schools and Programs of Public Health published the report that you and your colleagues did, called "Gun Violence Prevention: an Academic Public Health Framework."
Can you tell us about the task force plan for academic public health to promote research, education and advocacy on this issue?
Margaret Formica, PhD: So the Association of Schools and Programs of Public Health, or ASPPH, is an organization that serves as really the voice of academic public health, and ending gun violence has long been a priority for ASPPH, but the mass shootings that occurred in Uvalde (Texas) and in Buffalo really renewed the organization's commitment to the issue, which then led to the formation of the task force on gun violence prevention that I served on.
We were asked to develop a framework that could be used not only by schools and programs of public health, which was the primary intended audience, but really at any institution or organization interested in engaging in gun violence prevention efforts.
So we reviewed the (research) literature, we identified areas of need and gaps in resources, and then we developed the recommended strategies that formed the basis of the framework. And so what each institution can do might differ, depending on their mission, on their resources, but some examples would be adding gun violence prevention to curricula in their educational programs or advocating for donor support of gun violence prevention efforts, developing and supporting strong community relationships and partnerships.
These are all strategies that academic institutions can engage in.
Host Amber Smith: What makes gun violence a public health issue?
Margaret Formica, PhD: Gun violence is a national public health crisis.
There are over 100 firearm-related deaths in this country every day, and there's an additional two to three times as many nonfatal firearm injuries. And so I think that's one of the statistics that people maybe aren't frequently aware of is the number of injuries related to firearm violence that occur.
It's also the leading cause of death among children and youth in the United States, that surpassed deaths related to motor vehicle accidents back in 2017. So gun violence is a public health issue because it's affecting the health of the public. It's also estimated to cost $280 billion a year, and not only does it impact the people who are injured and killed by gun violence, but it impacts their families, it impacts their loved ones, the community.
There's growing evidence of a long list of negative behavioral and health effects of exposure to gun violence, so those who aren't directly impacted, but they see and they hear gun violence regularly in their communities. There's also the fear and anxiety around frequent mass shootings that we face in this country, and I think "in this country" is a key point because we don't see this level of gun violence occurring in other countries. The United States has 26 times the number of deaths due to gun violence compared to other high-income countries.
Host Amber Smith: How does -- or does? -- gun violence impact someone who's not involved in any shooting?
Because a lot of people live in a community and are never a victim or witness. They're not involved in the shootings, but are they still affected by the fact that they're taking place?
Margaret Formica, PhD: That's an area that's really growing in terms of research right now, because we're just beginning to really understand that there are negative consequences to just living in an area where you hear the gun violence routinely, or you see the gun violence, you witness it.
We do know that being exposed to gun violence leads to more gun violence. But there's also other negative impacts, as well. So things like educational attainment is lower among children who live in neighborhoods where there's high levels of gun violence. We know that there's a lot of behavioral problems in teens and young adults in neighborhoods where they're exposed to gun violence. We know that there can definitely be negative health effects, even biological health effects, related to constant exposure to this gun violence, but we're really just beginning to understand that and learn more about that.
Host Amber Smith: Well, you mentioned that some of these gun violence numbers increased from before the pandemic until now. What role did the pandemic play in gun violence -- or did it?
Margaret Formica, PhD: We're trying to figure that out now, too. One of the areas that's really being pursued in research related to that increase is the fact that we saw a spike in gun sales at the very beginning of the pandemic, also.
So there's certainly a possibility that that's leading to some of the increase that we're seeing. We also in the past few years have seen a loosening of many state gun laws in other parts of the country, not necessarily New York -- we actually see the opposite in New York. But in some other states we've seen loosening of gun laws, and so there's definitely the potential that that is contributing to this increase that we're seeing.
But again, we're just really beginning to research that and have a better understanding of what happened.
Host Amber Smith: What has prevented research and education and advocacy about gun violence prevention from being implemented so far?
Margaret Formica, PhD: The public health approach that's been so effective at reducing other public health problems has really been hampered when it comes to gun violence.
So, to just give you a little background on the public health approach, the first thing is to define and monitor the problem.
Then we identify risk and protective factors.
Then we develop and evaluate prevention strategies.
And then we assure the widespread adoption of those strategies.
And the problem that we face with gun violence is that the infrastructure needed to monitor the problem, which is that very first step in the public health approach, just isn't there. We don't have the surveillance in place that we do for other public health problems, and that really hampers the remaining steps of the public health approach.
So, for example, much of the gun violence research to date has focused on firearm deaths because we know the data on deaths is accurate. But we're missing a huge piece of the puzzle because we aren't including those nonfatal firearm injuries. Currently we just don't have a mechanism to capture that data in an accurate and a timely way at the national level.
And part of the problem is there's been decades of restrictions in federal dollars being spent on gun violence research that really severely limited our understanding of the factors that lead to gun violence and what can be done to prevent it.
Host Amber Smith: The report on gun violence prevention indicates more than a hundred lives a day are lost to gun violence.
Half of those are to suicide. Four out of 10 are homicide, and one in a hundred are due to unintentional injuries or accidents.
How might the prevention strategies differ for suicide versus homicide versus accidents?
Margaret Formica, PhD: That's another great question because prevention strategies will be very different depending on the type of gun violence that we're dealing with.
For example, one of the newer policies that has a growing body of evidence supporting it as a prevention strategy for both suicide and intimate-partner gun violence are extreme risk protection orders. They're also known as red-flag laws. There's only a handful of states, including New York, that have these types of laws in place, but these laws essentially allow someone to petition the court to prevent a person from buying or possessing a firearm if they're at high risk of harming themselves or someone else. This is just a temporary order, so once the person is no longer considered a threat, the order is then lifted. But what we've seen is that states that have implemented these laws seem to have seen a reduction in firearm violence compared to the states that did not implement those laws.
On the other hand, if you were to look, let's say, at accidental shootings, the prevention strategies for that look quite different. So preventing the accidental shootings and deaths, or accidental injuries and deaths, the evidence really supports safe gun storage practices, firearm safety training.
So an example of that might be ensuring that firearms and ammunition are stored separately in locked cabinets so that children can't access them. So there are definitely differences depending on the intent and the circumstances around those types of gun violence.
Host Amber Smith: How would you go about setting up a study that would help determine a way to prevent gun violence?
Margaret Formica, PhD: I'm really personally quite interested in the community or the neighborhood level factors that influence gun violence. So we know that poverty is one of the leading factors associated with urban gun violence, but we also see that there are some neighborhoods that have very high levels of poverty that don't necessarily see those same high levels of gun violence.
That's definitely true here in the city of Syracuse, but it's true in other cities as well. So, with proper funding, what I would really like to be able to do is to take a deep dive into those neighborhoods to see what is it about those neighborhoods that actually protects them from the gun violence.
What's different about those highly impoverished neighborhoods that have low levels of gun violence compared to the highly impoverished neighborhoods that have high levels of gun violence? And so, really focusing in, again, on those root causes of poverty and those community level factors that could be playing a role, what can we do to prevent them?
And so studying those types of things is what's really my area of interest in gun violence research.
Host Amber Smith: In some of your research, you've already looked at injury epidemiology (injury's causes). What have you found regarding injury epidemiology?
Margaret Formica, PhD: Much of my research on injuries, including gun violence injuries, has focused on describing the problem, so again, the who, the what, the where, the when, so who is gun violence affecting, where is it occurring, how is it changing over time?
In the last few years, I've really looked quite a bit at the impact of the pandemic on injuries. So one of the projects I've been involved in is an international project that is actually combining injury hospitalization data from 40 pediatric hospitals.
And we're still analyzing that data, but preliminarily, we've seen some pretty interesting changes in the frequencies of different types of injuries from before the pandemic to during the pandemic, and that included an increase in firearm-related injuries. There's definitely more to come from that research.
We're really in those early stages, but I think there will be some really interesting findings from that.
I've also recently worked with a national data set on adult hospitalizations, and we found a spike in firearm-related hospitalizations in the first six to nine months of the pandemic, so very much in line with what other research has shown, related to firearm-related deaths.
And then just last month, a colleague at Syracuse University and I, Dr. Bryce Hruska, submitted a grant to look at the relationship of gun violence and neighborhood characteristics here in Syracuse. So, fingers crossed if the funding comes through, then we'll hopefully be able to gain a better understanding of those community factors that lead to firearm injuries here locally.
Host Amber Smith: Dr. Formica, thank you so much for making time for this interview.
Margaret Formica, PhD: Thank you. I really appreciate the opportunity to talk about this issue, so thank you for having me.
Host Amber Smith: My guest has been Dr. Margaret Formica, an associate professor of public health and preventive medicine at Upstate.
I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air" -- what a hospital stay is like for teens.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." The American Academy of Pediatrics made a policy statement recently that hospitalized adolescents have unique and essential needs that differ from those of younger pediatric patients. We'll learn more about this from two physicians from the Upstate Golisano Children's Hospital. Dr. Karen Teelin is the director of adolescent medicine at Upstate, and Dr. Jennifer Myszewski is a pediatric hospitalist at Upstate Golisano Children's Hospital. Welcome, both of you, to "HealthLink on Air."
Jennifer Myszewski, DO: Thank you for having us.
Host Amber Smith: At the Upstate Golisano Children's Hospital, what percent of patients are adolescents between the ages of 11 and 20?
Jennifer Myszewski, DO: It's a little over a third of our patients are adolescent medicine at this point. It depends on the service line. Surgery it's a little bit higher, but for inpatient medicine in general, it's over a third.
Host Amber Smith: What are the main reasons for hospitalizations in this age group?
Jennifer Myszewski, DO: By far it is mental health. It is suicidal ideation (thinking and planning). It is aggression. It is just struggling with home life and stressors at school. Eating disorders are a part of that, but it is hugely outnumbering any other diagnosis that they would come to the hospital with.
Host Amber Smith: And how long do adolescents typically stay in the hospital?
Jennifer Myszewski, DO: It depends on the diagnosis. If it's for a classically medical diagnosis -- they've had surgery, they had an infection, something like that -- the average length of stay is between two and three days. If it's for a mental health reason, it could be for much longer than that.
Host Amber Smith: Can you compare what a hospital stay is like for an adolescent compared with a younger child or toddler?
Jennifer Myszewski, DO: A lot of it is going to depend on the reasons that they're here. All patients are encouraged to have their social support there, to personalize the room, to bring in things from home that are going to make them most comfortable.
With adolescents, a lot of times that's their friends, their social network. Sometimes it's their siblings. Because of the pandemic and because of the visitor restrictions that we've had to place in the hospital, a lot of times the very people that they're closest with aren't allowed to visit in person. So we do encourage them to use their phones, use their tablets to communicate. The caveat is if they're there for a mental health reason, sometimes those are the very things that could trigger them. And so we don't allow access unless it's supervised under specific conditions to outside communication, to the internet, because we don't want them to be triggered by outside influences. We want them to be able to focus on what it's going to take for them to get better.
Host Amber Smith: I'm curious about the rooms. Are they different sizes for the little kids versus the older kids? And do they have the same food options, for instance?
Jennifer Myszewski, DO: The rooms are the exact same. We just allow them to bring in things from home that will make them more comfortable. As far as food options, there are graduated menus based on age, so they can select options from home depending on the reason that they're there. They could always bring in food from home or have food delivered, which is very popular.
Host Amber Smith: Are the child life specialists involved with the teens? I know they're very popular with the younger kids. Do you also have them devoted to teenagers?
Jennifer Myszewski, DO: Absolutely. They have activities for patients of all ages. They have activities that are specific to adolescents and teens. On the hematology/oncology (cancer and blood-related conditions) floor, there's a child life room where the activities are mostly designed around adolescent patients, depending on the reason that they're admitted to the hospital. Kind of right now, with the pandemic and with isolation precautions, access to those rooms are a little bit challenging, but we do kind of encourage them to participate in all kinds of different child life.
Host Amber Smith: So it sounds like there are features in the children's hospital that were designed specifically with hospitalized teenagers or adolescents in mind.
Jennifer Myszewski, DO: Absolutely.
Host Amber Smith: Dr. Teelin, I wonder if you can speak a little bit about the stresses of hospitalized teens and how that might differ from the stresses of hospitalized children or hospitalized adults. Do they have unique stressors?
Karen Teelin, MD: Well, being hospitalized can be so stressful regardless of the age of the child, or the adolescent, or the adult. It can be particularly stressful for adolescents because it's a challenging time in life when your autonomy is emerging. Your identity is emerging, and you're working toward being independent, and being hospitalized feels like a little bit of that is taken away. It's so hard for hospitalized adolescents.
There's some adolescents who have chronic illnesses who have been in the hospital frequently, and it feels frustrating to them to have to answer the same questions over and over. We have a teaching hospital. We have wonderful medical students, wonderful residents, but some of these patients with chronic illness have answered these questions so many times. And it gets hard for them and for their parents because they truly, they know their illness very well, and their parents know their illness very, very well too.
For patients who are just there once, for whether a mental health reason or an infection, an injury, it's a terrifying time. It's a life changing time. It's an extremely stressful time. And the adolescents just don't have as much experience advocating for themselves and speaking up. They're learning to do that, and they need to be given that respect and that autonomy. And we really try to work with them to give them the space to express what they need and to communicate with us so that we can take the best possible care of them. And that's always what we aim to do.
We're in a mental health crisis right now for adolescents. That's not just locally. That's nationally and internationally. And it's been an incredible change in all children's hospitals in the proportion of adolescents admitted for mental health concerns, really from almost none 10 or 15 years ago to, on a consistent level, I would say at least 10 at a time are in our hospital, if not more, with people waiting, waiting in the emergency room. And part of that is access to outpatient care. There aren't enough trained professionals, really, out there to take care of these kids outpatient. And then also, it's the severity of their illness that, that many of them need that respite in the hospital.
Host Amber Smith: What is done to help adolescents, who have to be hospitalized, particularly maybe those with a chronic illness, so that they can maintain their regular education and recreation while they're hospitalized?
Karen Teelin, MD: Well, it's a great point you bring up because it's so disruptive to their education. You know, you miss a few days of high school, and you can really be quite far behind. And a lot of these kids, that's pretty upsetting to them, and they're worried about that, worried about school, worried about their family, and worried about their friends. So we're lucky we have a full-time educator in the hospital.
Our children's hospital was designed to meet the needs of children. And each patient has their own room. The rooms are fairly large. We have the child life specialists. We have a teenage game room. We have the family resource center, and we have child life, and we have the educator. So we certainly do everything we can to help them maintain some sense of normality and not to have them fall behind. You know, their health comes first, but education's extremely important, of course, and we want to do everything we can to support that.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Upstate's director of adolescent medicine, Dr. Karen Teelin, along with Upstate pediatric hospital medicine specialist, Dr. Jennifer Myszewski.
The policy statement from the American Academy of Pediatrics says that confidentiality is important, but I know that laws vary by state. I'm curious about what the laws are like in New York state regarding medical confidentiality of teens. Dr. Myszewski?
Jennifer Myszewski, DO: So there are a number of things that families and patients should be aware of. Above the age of 12, parents do not have full access to their child's medical record. The notes are protected so that we can talk about topics like STDs (sexually transmitted diseases), sexual activity, drug use, marijuana use in a very protected environment where information doesn't necessarily get revealed to the parents without the patient's consent.
You'll often have conversations, and the patients won't want to be honest, and that can actually be dangerous if we don't know what they're doing. So as long as we are able to say, "You know, this stays between us unless we have a concern that you're at risk of hurting yourself or hurting somebody else." And a lot of times they will then open up and be very honest and very revealing about what's going on in their life.
We also want to make sure that we know what their home environment is, what their school environment is, so that if they are being bullied or threatened or hurt in any way, that we can offer them resources and offer them protection. And so we want to have that open line of communication. A lot of times when issues do come up, the patient has been very open with their family in the past, or maybe wants us to be the person who kind of like bridges that conversation and gets that conversation going, and is that safe space where both sides can kind of react and have the initial emotional response, and then kind of settle down and say, "OK, now that we all know and we're all on the same page, this is how we're going to move forward."
Host Amber Smith: Is it a 12-year-old who gives consent for medical procedures, or do parents do that?
Jennifer Myszewski, DO: Parents still give consent for procedures. And you have to make sure that they understand all of the risks and benefits. You also explain those to the patients themselves, and they give something called "assent," where they agree that what the plan is, is something that they're willing to go through.
If there's ever a conflict where it is in the best interest of the child, and the family agrees that the patient doesn't want that procedure or doesn't want that treatment, then you have additional discussion. It's rarely the other way around, where the family doesn't want it and the patient does. That's also a discussion that we are happy to mediate and help everybody kind of come to a reasonable, acceptable conclusion and agreement.
Host Amber Smith: So does a teenager have the legal right to refuse care?
Karen Teelin, MD: I mean, the parents are the ones who legally provide the consent for care up until 18. So we will always -- you know, as Dr. Myszewski points out so well -- that assent is also important. So consent and assent are both very important. We have emerging adults with emerging autonomy, and we want to include them, and we have to include them. And they have a right to be included. As she was saying, if an adolescent declines, but their parents want the care, and it's considered in their best interest medically, that's an very unusual situation. That would be very rare. But we would mediate that. We would work with them. If we are stuck, we have, we're lucky we have an ethics team, and we have legal team access right in our hospital that are really there for us 24 hours a day, if needed. But we always work with the parents to include them.
So adolescents have a right to privacy, and it has been shown to improve their health if they're able to talk to their care providers privately. But our goal is always to include the parents and to work with the youth to include their parents. So if they're telling us something and then we ask them, "Are your parents aware?" And if they're not -- often they are; they are already aware -- but if they're not, then we say, "You know, can we help you tell them? How can we help you? How would you like to let them know?" If it's a situation where they'd truly be in danger if their parents knew, then of course we do what we can to take excellent care of them and protect them. In New York state, they do have a right to privacy for sexual and reproductive health care and, in some cases, for mental health and substance use care.
Host Amber Smith: Another thing that's mentioned in the policy statement is the suggestion that physicians and other caregivers undergo implicit bias training. What is that?
Karen Teelin, MD: Implicit bias is just bias that we all, or nearly all, of us have that we don't necessarily realize. It may be subconscious, but it does affect actions and behaviors and outcomes. And there's been a lot of attention to it recently and a lot of research, and it's very common to have implicit bias training. The goal is to make things better, not to make things worse, of course, but to make all of us aware of what our biases are, so that we can mitigate that because we want, obviously, the best possible care for everyone regardless of their gender, their race, their sexual orientation, their socioeconomic status, their nationality, etc.
Host Amber Smith: So is that something that the Golisano Children's Hospital already does?
Karen Teelin, MD: Yes. Anyone who works here has to do some training every year. We have modules (readings and tests) that we do. Our hospital has a diversity, education and inclusion committee. And we're very, very active, and we do workshops where we talk through issues that have happened and ways to handle and mitigate these types of events.
Host Amber Smith: Well, before we wrap up, let's talk about how you go about transitioning an adolescent from pediatric care to adult medical care. This is something the authors of the policy statement talk about with regard to hospitalized patients, but it's also something that inevitably comes up with the healthy teens who age out of the pediatrician's office. So how do you handle this?
Jennifer Myszewski, DO: We're lucky at Golisano that we are a hospital within a hospital, so, on the pediatric floors, we tend to see patients up until the 20th birthday, sometimes a little bit longer if they have chronic medical illnesses that are typically taken care of by pediatric providers. But we have a number of providers who are trained in both pediatrics and adult medicine, and they can help link and bridge those transitions.
We also, when the patients who are in their later teens -- almost turning 18 through 20 year old -- if we need to consult a subspecialist, we'll make sure that it's an adult provider so that they have that support system and they can transition while they're still in the hospital. We also, as they're going back to their primary care provider, make sure that they have somebody who's able to transition them. There's also a couple of providers in the outpatient clinic that's associated with the hospital that specialize in transitioning patients, and Dr. Teelin, being in adolescent medicine, is one of those specialists.
Host Amber Smith: Is there a concern that people in their 20s will fall out of the habit of preventive care because they no longer are in the habit of going to a pediatrician regularly?
Jennifer Myszewski, DO: Absolutely. Being guilty of it myself, we tend to think that college aged patients or in the late 20s use urgent care in the emergency room as their primary care provider. And so there's a lot of education and support about the need for preventative care, for keeping up on just the annual health physicals, the vaccines, the blood work, the -- if there's anything that runs in your family, making sure that you're being screened for that and followed for that as well.
So, I think it starts with the pediatrician, and it continues while in the hospital, and it continues through adolescent medicine and family practice and internal medicine, just trying to keep that continuum in their minds and in keeping their health literacy also in their minds.
Host Amber Smith: Well, Dr. Teelin, Dr. Myszewski, I really appreciate you making time for this interview.
Jennifer Myszewski, DO: Thank you so much.
Karen Teelin, MD: Thank you.
Jennifer Myszewski, DO: My guests, from the Upstate Golisano Children's Hospital, have been Dr. Karen Teelin -- she's the director of adolescent medicine at Upstate -- and Dr. Jennifer Myszewski. She's a pediatric hospital medicine specialist; she also directs the new pediatric hospital medicine fellowship program. I'm Amber Smith for Upstate's "HealthLink on Air."
Host Amber Smith: And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: COVID continues to be a focal point for many writers. We received excellent poems from physicians describing some of their experiences with it. The first poem I'd like to read is by fourth-year medical student Ellen Zhang. She is a student at Harvard, and her poem "To Open Doors," won our Sean Hodge Prize for Poetry in Medicine this year.
"To Open Doors"
Your arrival reminds me of what it means to care
in the moment. It was not the way you weighed
merely two pounds, the way you necessitated
emergency surgery, or the way you gripped
onto life even though it caught you off guard.
It was the way your mother broke rumbling
of the monitors, wrapped in mask and goggles,
wearing gloves to cradle you. Asking for you to be
loved for the first time by grandparents, uncles,
aunts, cousins. To be loved for a long, long time.
In hospitals, so many bodies share the
same air. In times of pandemic, supplies are
lacking, regulations proliferative. Your ribs
barely rise to fall. Reminders that oxygen is
a scarce resource. But, love, love is plentiful.
Dr. Sarath Reddy is a gastroenterologist practicing in Brookline, Massachusetts. His poem "Unfinished Conversation" recalls the impact some patients can have on us.
The virus left his lungs moth eaten,
parched leaves crumbling to touch
unable to bear the work of breathing,
until machine, not man, was driving life.
Desk shrouded in silence, a friend taken
for granted like scenery, I sketch him
back in, give him back his Greek accent,
staccato on the computer.
As he bounces between topics, musings
on chili pepper and menu of India Delight
spicy samosas and vindaloo,
brought him back
long enough to say I'm sorry --
that I could give him only prayers
and not potions, had reluctantly lent
his obituary a pen,
that we never spoke about God or Plato
never got beyond headlines, whimsical weather,
just like trees regret never asking autumn
leaves the questions that really matter.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," a look at Onondaga County's most pressing public health issues.
If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.
Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel. This is your host, amber Smith, thanking you for listening.