- Email: [email protected]
The Pediatrician as Advocate
Symposium on Injuries and Injury Prevention
The Pediatrician as Advocate Sylvia H. Micik, M.D.* and Joel J. Alpert, M. D.t
Pediatricians have a special position that enables us to make an impact on preventing injuries to children. We are, perhaps, the most potent professional force available in the implementation of injury prevention strategies at all levels. This is true because: The pediatrician is an expert in child development and can appreciate the relationship of injuries to growing and developing children. The pediatrician may be the most credible and influential individual in changing parents' knowledge about injuries and preventive behaviors.l The pediatrician should have consistent, frequent contact with parents and children in the high-risk period of early childhood. The pediatrician has experience in anticipatory guidance for the prevention of other diseases and can have knowledge about the occurrence of stressful events in the family that have the potential for leading to an injury. The pediatrician treats injuries and is in an excellent position to ascertain how they occur and to understand that minor injuries may be another indication of family stress and a prelude to major injury. The pediatrician appreciates the need for systematic approaches to prevention because of experience with organized preventive visits and immunization schedules. The pediatrician is respected by governmental agencies, legislative bodies, and the public as a leader in the field of injury prevention. Pediatricians have an extensive and varied role in injury prevention. This article will discuss that role, focusing on the pediatrician as a child advocate in patient care, education, community organization, professional education, emergency medical service system development, and legislation and regulation. Although we will consistently make reference in this article to the pediatrician as an advocate for children, any health professionals, especially family physicians, can make a similar contribution. What is needed is career commitment and willingness to invest in injury prevention to *Associate Professor of Clinical Pediatrics and Community Medicine, University of California, San Diego, School of Medicine, La Jolla, California tProfessor and Chairman, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
Pediatric Clinics of North America-Vol. 31, No.2, February 1985
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MICIK AND JOEL J. ALPERT
children. This is not a new challenge. Wheatley20 in 1948, and Shaffer18 in 1954, proposed injury prevention agendas that included advocacy. PATIENT CARE AND EDUCATION One of the pp,diatrician's major responsibilities in the care of children is preventive health maintenance. Incorporating injury prevention counseling into this responsibility is not only feasible but now is an accepted standard of pediatric care. 2 The American Academy of Pediatrics policy statement on this area reads: All children should grow up in a safe environment. Anticipatory guidance for injury prevention should be an integral part of the medical care provided for all infants and children. All physicians caring for children should advise parents to acquire for their child's safety: 1. Currently approved child car restraints; 2. Smoke detectors in homes to protect children's sleeping areas; 3. Safe hot tap water temperatures; 4. Window and stairway guards/gates to prevent falls; 5. One ounce bottles of syrup of ipecac. In addition, physicians caring for children should counsel parents in age-appropriate, season-appropriate, locality-appropriate prevention strategies, which reduce common, serious injuries. Medical records should reflect this counseling.
The relationship of a child's growth and development to injury risk is well appreciated by pediatricians. The pediatrician can transmit this awareness to parents during standard preventive health visits in early childhood, and to children themselves as they grow older. Pediatricians are in an ideal position to accomplish this, because we have repeated access to parents during this time, and can reinforce specific preventive messages and behaviors. Studies have shown clearly that to obtain a behavioral change in individuals, the expected change must not only be simple, but also must be reinforced again and again. Making preventive behavior a daily habit requires knowledge, motivation, and practice. No one is in a better position to provide this knowledge and motivation to parents and to foster injury prevention practice than the pediatrician. Extensive review of the effectiveness of pediatrician activity on accident prevention has produced conclusions of limited effectiveness, but also exhortations to continue the activity. We not only support the exhortation but also choose to interpret the available information differently. Beginning with Bass' report in 19644 that patients he counseled were more likely to wear seat belts, there has been repeated evidence that pediatrician's actions, including counseling and education, can make a difference in preventing injuries. 1, 5, 9,11,12,13,14,19 Specifically, Dershowitz9 reported increased likelihood of use of electric outlet covers, Kravitz 13 reported that pediatric counseling could prevent injuries due to falls, and Alpert and Levine 1 reported that families were more likely to have ipecac syrup in their homes when they had a regular pediatrician. Berger reported that low income families increased their use of car safety seats from 9 per cent to 38 per cent after a program that included education and counseling. 7
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There are studies, of course, that report disappointing results if not failures. 6, 8, 16 Even those we judge as successful generally succeeded with only a portion of the target population. Rather than choose to let negative results deter us, we have chosen to focus on the positive aspects, with the limiting factor being the time a pediatrician is willing to spend on activities including counseling and education about injury prevention. In a national effort to address the injury problem, the American Academy of Pediatrics (AAP) has developed The Injury Prevention Program (TIPP)3 for practicing pediatricians. This program incorporates the basic principles of primary and secondary prevention, utilizing both a passive and active approach. It targets the most common and serious injuries at each developmental stage in children from birth to five years of age. TIPP also targets specific preventive messages that require a one-time or simple action, and reinforces these messages at specific preventive health visits. A schedule of recommended minimal safety counseling to be performed at specific visits, with introduction of new messages and reinforcement of the old, has been presented in the article by Zuckerman and Duby. Its similarity to the schedules of preventive health visits and immunizations is purposeful. To assist in carrying out this program, age-specific single-sheet handouts have been produced by the AAP for use by the pediatrician during the counseling process, and then by the parent for reinforcement. The pediatrician also plays an essential role in secondary injury prevention, providing appropriate treatment for injuries to prevent further damage and disability. The pediatrician accomplishes this in three ways. First, by teaching patients the basic first aid steps to be taken when· an injury occurs. Second, by treating children with injuries, providing the surgeons, intensivists, emergency physicians, and others with special expertise needed by children (resuscitation, fluid and electrolyte management, etc.). Finally, by assisting in the rehabilitation phase of injury, by providing a total family perspective on the rehabilitation process, and by considering the growth and development of the child, the pediatrician provides essential follow-up of the child over many years.
COMMUNITY ORGANIZATION As an advocate for child safety, the pediatrician can use professional credibility and influence to mobilize community efforts in injury prevention. The pediatrician may take a leadership role and initiate a program, or may provide support to established groups in reaching common goals. The following are a few examples of success when pediatricians took a leadership role in the community. (1) establishment of child passenger safety organizations resulting in the passage of legislation in over 49 states;18 (2) the "Children Can't Fly" campaign in New York, which virtually eliminated deaths due to falls from windows by regulating use of window guards; (3) collaboration with the Red Cross car seat loaner program; (4) establishment of Regional Poison Control Centers; (5) distribution of ipecac
246
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syrup as part of programs in Poison Prevention; (6) calling attention to teenage automobile safety. Because pediatricians have access to medical, business, and governmental agencies, we are in a good position to organize those agencies into a specific prevention activity. We can use the media to reinforce prevention messages to parents, to raise public concern about specific hazards, and to mobilize support for legislation. Pediatricians are one of the most powerful forces in a community's ability to rally around an injury prevention effort.
PROFESSIONAL EDUCATION As a teacher of future physicians and health care providers, the pediatrician can have a significant influence on students' knowledge, understanding, and appreciation of injuries as a major health problem of children. We can provide them with the basis for appreciating injury prevention as an essential function of pediatricians, one that has far-reaching implications in the ultimate health of our nation's children. The study of injuries provides students with experience in epidemiology, growth and development, behavior modification, and systematic analysis. It should be an integral part of the pediatric curriculum, both at the student and housestaff level. The real challenge for pediatricians is to have medical schools incorporate the management and prevention of childhood injuries into the medical school and postgraduate curricula in a multidisciplinary format, and to obtain faculty who are interested in studying injuries. The academic world needs to reorganize injury as a disease and its prevention as a major institutional responsibility. It is our hope that the recent competition by major medical centers for designation as pediatric trauma centers, and the regionalization of care for this special patient activity will result in a new interest in the injury problem and injury prevention. The pediatric trauma center should be a regional focal point for the education not only of medical students and housestaff, but also of practicing physicians in the community. In addition, major attention and investment by academic centers in organ transplantation provides the opportunity for discussion of such issues as where the organs came from, the ethics of organ banking, and the importance of supporting programs that can save thousands of children. No one engaged in organ transplantation could lament the inability to perform such procedures if there were no accident victims to provide those organs. Grand Rounds, continuing medical education programs, and mortality and morbidity reviews on injured patients can all be used to accomplish this training.
EMERGENCY MEDICAL SERVICE SYSTEM (EMSS) DEVELOPMENT Regional EMS systems are being implemented across this nation for the poison, trauma, burn, spinal cord injury, and cardiac patient. These
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systems provide for the orderly linkage of prehospital, hospital, and critical care for each emergency patient in a region. They define what care is to be given, to whom, where, and under what medical supervision. Unfortunately, because of the complexity of the medical and political processes by which these systems are established, and the need to implement them as rapidly as possible, less attention has been given to the needs of children within these systems. It is up to pediatricians and an informed public to correct these deficiencies and actively participate in EMS system planning and development. Pediatricians must define the special needs of children, establish criteria to identify critically ill or injured patients, and the means to transport them to designated centers with the resources and the organizational structure for optimal treatment. We must develop the treatment protocols for the care of the pediatric emergency patient by rescue and ambulance personnel and emergency department staff. If trauma centers have not yet been designated in a region, pediatricians should take an active role in the trauma system planning and determine whether a pediatric trauma center is needed and feasible. Pediatric leadership should be vital to the designation process. If pediatric trauma patients are taken to centers that treat both adults and children, it is the pediatrician's role to work with the trauma surgeons to establish protocols to meet the special needs of children. In a well-planned trauma system, the trauma center becomes a focal point for injury prevention activities. It is unlikely, however, that injury prevention will be given a high priority unless pediatricians assume a leadership role and work with the trauma center staff to develop a program. Individual trauma cases can have a great impact on the public and its political leaders, and pediatricians working with trauma centers can be very effective in making prevention happen. Although some argue that pediatricians should be more concerned about economic issues, the fact that we have not has provided the opportunity to succeed in other pressing areas.
LEGISLATION AND REGULATION Perhaps the most powerful advocacy role for the pediatrician is in developing and supporting legislation and regulatory intervention in injury control. The effectiveness of the legislative approach is well documented in the dramatic reduction of injuries following safety legislation. After the Poison Prevention Packaging Act of 1970, aspirin deaths decreased by 65 per cent. The Flammable Fabrics Act, and, recently, child passenger safety legislation are two more examples. IS Pediatricians can initiate injury prevention legislation individually or collectively, through the AAP. We can request introduction to the legislature of a specific bill by the administration or by a special legislator. 6 Legislators are strongly influenced by credible and dedicated physicians, particularly when the intent of the requested legislation benefits the public. It has been our experience that, among physicians, pediatricians are seen by legislators as the most credible, because the issue for us historically has been the welfare of children. A pediatrician, well prepared
248
SYLVIA
H.
MICIK AND JOEL
J.
ALPERT
with the facts, a rational solution to an injury problem, and a willingness to be available for testimony, can be successful in getting legislation enacted. When these efforts are coupled with an organizational effort via the AAP, success is even more likely. The Academy provides national visibility, the resources to have influence at the national and state level, and prominent visibility through the Accident Prevention Committee. However, this effort has been considerably aided and in some cases preceded by intense personal lobbying. There is no substitute for the pediatrician, who by chance of residence, provision of pediatric care, or personal contacts, has a personal and close relationship with a powerful national, state, or local legislator. Because pediatricians can be such a powerful force in the legislative process, those that undertake this mission must understand the process, the political environment, and how to testify before legislative committees. 6 There are key steps a pediatrician should take when testifying or presenting a program. 1. Be well prepared. 2. Present the program in 15 minutes or less, but leave a written summary of two to three pages with the legislator or committee members. 3. Keep medical terminology at a minimum. 4. Speak to legislators without arrogance. 5. Maintain ongoing communications with the staff of the bill's author. They will provide assistance in the logistics and strategies of testifying, and coordinate testimony with supporting colleagues and organizations. 6. Be prepared to deal with other experts and organizations who will disagree with you. Pediatricians generally have access to regulatory agencies in government. They can bring attention to hazardous products on the market and inadequate packaging of hazardous substances, and relate these to their own experience and the collective experience in their region. Thus, they can help bring about regulatory change better than most other concerned groups. In addition, pediatricians can report noncompliance with existing safety regulations to regulatory agencies, e. g., sale of prescription drugs in non-child-resistant containers, and in that way force compliance. Another effective activity for pediatricians is testifying before regulatory committees in favor of safety regulations (e.g., Consumer Product Safety Commission, the Federal Aviation Authority or Food and Drug Agency), thereby providing the necessary justification to issue the regulation. These activities take time, which is why most organizations who can, employ a professional lobbyist. The fact that there are pediatricians who have found the time to pursue an injury prevention cause without economic reward is a tribute to them and to our profession. CONCLUSION If pediatricians are to be true and effective advocates of children, they should assume, individually and collectively, the many roles discussed in this article. The extent to which childhood injuries are prevented in the
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future may depend on the degree to which pediatricians succeed in these roles. We have a responsibility to be informed and to inform. We have the opportunity to practice injury prevention and to influence those who make the products and pass the laws. The end result can be fewer injuries to children.
REFERENCES 1. Alpert, J. J., Levin, M. D., and Kosa, J.: Public knowledge ofIpecac syrup in the management of accidental poisonings. J. Pediatr., 71:89~94, 1967. 2. The American Academy of Pediatrics, 1801 Hinman Avenue, Evanston, Illinois 60204. 3. "TIPP"-The Injury Prevention Program, The American Academy of Pediatrics, 1801 Hinman Avenue, Evanston, Illinois 60204. 4. Bass, L. W., and Willson, T. R: The pediatrician's influence in private practice measured by a controlled seat belt study. Pediatrics, 3:700-704, 1964. 5. Bass, J. L., and Mehta, K. A.: Developmentally oriented safety surveys: Reported parental and adolescent practices. Clin. Pediatr., 19:350-356, 1980. 6. Berger, L. R: The pediatrician's role in child advocacy advances. Pediatrics, 29:273-291, 1982. 7. Berger, L. R, Saunders, S., Armitage, K., et al.: Promoting the use of car safety devices for infants: An intensive health education approach. Pediatrics, 74:16--19, 1984. 8. Bergman, A. B.: Use of education in preventing injuries. Pediatr. Clin. North Am., 29:331-338, 1982. 9. Dershewitz, R A.: Will mothers use free household safety devices? Am. J. Dis. Child., 133:61-64, 1979. 10. Feldman, K. W., Schaller, R T., Feldman, J. A., et al.: Tap water scald burns in children. Pediatrics, 62:1-7, 1978. 11. Feldman, K. W.: Prevention of childhood accidents: Recent progress. Pediatr. Rev., 2:75-82, 1980. 12. Gallagher, S. S., Guyer, B., Kotelchuck, M., et al.: A strategy for the reduction of childhood injuries in Massachusetts: SCIPP. N. Engl. J. Med., 307:1015-1019, 1982. 13. Kravitz, H., and Grove, M.: Prevention of accidental falls in infancy by counseling mothers. I. M. J., December 1973, 570-573. 14. Miller, R E., Reisinger, K. S., Blatter, M. M.: Pediatric counseling and subsequent use of smoke detectors. Am. J. Public Health, 72:392-393, 1982. 15. Results of Household Survey on 1200 families with children under 14 years performed by the San Diego Injury Prevention Project under a grant funded by Department of Health and Human Services, Division of Maternal and Child Health, Rockville, MD, 1979:1982. # 005001-03-2. 16. Reisenger, K., William, A. F., Wells, J., et al.: Effect of pediatrician counseling on infant restraint use. Pediatrics, 67:201, 1981. 17. Rosenblatt, S. F., Bass, J. L., and Mehta, K. A.: Childhood injury prevention in primary care settings. Physician Patient Education Newsletter, 4:25-26, 1981. 18. Shaffer, T. E.: Accident prevention. Pediatr. Clin. North Am., 1:421-432, 1954. 19. Spiegel, C. N., and Lindman, F. C.: Children Can't Fly.: A program to prevent childhood morbidity and mortality from window falls. Am. J. Pub. Health, 67:1143, 1977. 20. Wheatley, G. M.: Child accident reduction: A challenge to the pediatrician. Pediatrics, 2:367-368, 1948. 21. Williams, A. F., and Wells, K. A.: The Tennessee Child Restraint Law in its third year. Am. J. Public Health, 71:163-165, 1981. Scripps Medical Arts Center 9844 Genesee Avenue Suite 303 La Jolla, California 92037
The Pediatrician as Advocate Sylvia H. Micik, M.D.* and Joel J. Alpert, M. D.t
Pediatricians have a special position that enables us to make an impact on preventing injuries to children. We are, perhaps, the most potent professional force available in the implementation of injury prevention strategies at all levels. This is true because: The pediatrician is an expert in child development and can appreciate the relationship of injuries to growing and developing children. The pediatrician may be the most credible and influential individual in changing parents' knowledge about injuries and preventive behaviors.l The pediatrician should have consistent, frequent contact with parents and children in the high-risk period of early childhood. The pediatrician has experience in anticipatory guidance for the prevention of other diseases and can have knowledge about the occurrence of stressful events in the family that have the potential for leading to an injury. The pediatrician treats injuries and is in an excellent position to ascertain how they occur and to understand that minor injuries may be another indication of family stress and a prelude to major injury. The pediatrician appreciates the need for systematic approaches to prevention because of experience with organized preventive visits and immunization schedules. The pediatrician is respected by governmental agencies, legislative bodies, and the public as a leader in the field of injury prevention. Pediatricians have an extensive and varied role in injury prevention. This article will discuss that role, focusing on the pediatrician as a child advocate in patient care, education, community organization, professional education, emergency medical service system development, and legislation and regulation. Although we will consistently make reference in this article to the pediatrician as an advocate for children, any health professionals, especially family physicians, can make a similar contribution. What is needed is career commitment and willingness to invest in injury prevention to *Associate Professor of Clinical Pediatrics and Community Medicine, University of California, San Diego, School of Medicine, La Jolla, California tProfessor and Chairman, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
Pediatric Clinics of North America-Vol. 31, No.2, February 1985
243
244
SYLVIA
H.
MICIK AND JOEL J. ALPERT
children. This is not a new challenge. Wheatley20 in 1948, and Shaffer18 in 1954, proposed injury prevention agendas that included advocacy. PATIENT CARE AND EDUCATION One of the pp,diatrician's major responsibilities in the care of children is preventive health maintenance. Incorporating injury prevention counseling into this responsibility is not only feasible but now is an accepted standard of pediatric care. 2 The American Academy of Pediatrics policy statement on this area reads: All children should grow up in a safe environment. Anticipatory guidance for injury prevention should be an integral part of the medical care provided for all infants and children. All physicians caring for children should advise parents to acquire for their child's safety: 1. Currently approved child car restraints; 2. Smoke detectors in homes to protect children's sleeping areas; 3. Safe hot tap water temperatures; 4. Window and stairway guards/gates to prevent falls; 5. One ounce bottles of syrup of ipecac. In addition, physicians caring for children should counsel parents in age-appropriate, season-appropriate, locality-appropriate prevention strategies, which reduce common, serious injuries. Medical records should reflect this counseling.
The relationship of a child's growth and development to injury risk is well appreciated by pediatricians. The pediatrician can transmit this awareness to parents during standard preventive health visits in early childhood, and to children themselves as they grow older. Pediatricians are in an ideal position to accomplish this, because we have repeated access to parents during this time, and can reinforce specific preventive messages and behaviors. Studies have shown clearly that to obtain a behavioral change in individuals, the expected change must not only be simple, but also must be reinforced again and again. Making preventive behavior a daily habit requires knowledge, motivation, and practice. No one is in a better position to provide this knowledge and motivation to parents and to foster injury prevention practice than the pediatrician. Extensive review of the effectiveness of pediatrician activity on accident prevention has produced conclusions of limited effectiveness, but also exhortations to continue the activity. We not only support the exhortation but also choose to interpret the available information differently. Beginning with Bass' report in 19644 that patients he counseled were more likely to wear seat belts, there has been repeated evidence that pediatrician's actions, including counseling and education, can make a difference in preventing injuries. 1, 5, 9,11,12,13,14,19 Specifically, Dershowitz9 reported increased likelihood of use of electric outlet covers, Kravitz 13 reported that pediatric counseling could prevent injuries due to falls, and Alpert and Levine 1 reported that families were more likely to have ipecac syrup in their homes when they had a regular pediatrician. Berger reported that low income families increased their use of car safety seats from 9 per cent to 38 per cent after a program that included education and counseling. 7
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There are studies, of course, that report disappointing results if not failures. 6, 8, 16 Even those we judge as successful generally succeeded with only a portion of the target population. Rather than choose to let negative results deter us, we have chosen to focus on the positive aspects, with the limiting factor being the time a pediatrician is willing to spend on activities including counseling and education about injury prevention. In a national effort to address the injury problem, the American Academy of Pediatrics (AAP) has developed The Injury Prevention Program (TIPP)3 for practicing pediatricians. This program incorporates the basic principles of primary and secondary prevention, utilizing both a passive and active approach. It targets the most common and serious injuries at each developmental stage in children from birth to five years of age. TIPP also targets specific preventive messages that require a one-time or simple action, and reinforces these messages at specific preventive health visits. A schedule of recommended minimal safety counseling to be performed at specific visits, with introduction of new messages and reinforcement of the old, has been presented in the article by Zuckerman and Duby. Its similarity to the schedules of preventive health visits and immunizations is purposeful. To assist in carrying out this program, age-specific single-sheet handouts have been produced by the AAP for use by the pediatrician during the counseling process, and then by the parent for reinforcement. The pediatrician also plays an essential role in secondary injury prevention, providing appropriate treatment for injuries to prevent further damage and disability. The pediatrician accomplishes this in three ways. First, by teaching patients the basic first aid steps to be taken when· an injury occurs. Second, by treating children with injuries, providing the surgeons, intensivists, emergency physicians, and others with special expertise needed by children (resuscitation, fluid and electrolyte management, etc.). Finally, by assisting in the rehabilitation phase of injury, by providing a total family perspective on the rehabilitation process, and by considering the growth and development of the child, the pediatrician provides essential follow-up of the child over many years.
COMMUNITY ORGANIZATION As an advocate for child safety, the pediatrician can use professional credibility and influence to mobilize community efforts in injury prevention. The pediatrician may take a leadership role and initiate a program, or may provide support to established groups in reaching common goals. The following are a few examples of success when pediatricians took a leadership role in the community. (1) establishment of child passenger safety organizations resulting in the passage of legislation in over 49 states;18 (2) the "Children Can't Fly" campaign in New York, which virtually eliminated deaths due to falls from windows by regulating use of window guards; (3) collaboration with the Red Cross car seat loaner program; (4) establishment of Regional Poison Control Centers; (5) distribution of ipecac
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syrup as part of programs in Poison Prevention; (6) calling attention to teenage automobile safety. Because pediatricians have access to medical, business, and governmental agencies, we are in a good position to organize those agencies into a specific prevention activity. We can use the media to reinforce prevention messages to parents, to raise public concern about specific hazards, and to mobilize support for legislation. Pediatricians are one of the most powerful forces in a community's ability to rally around an injury prevention effort.
PROFESSIONAL EDUCATION As a teacher of future physicians and health care providers, the pediatrician can have a significant influence on students' knowledge, understanding, and appreciation of injuries as a major health problem of children. We can provide them with the basis for appreciating injury prevention as an essential function of pediatricians, one that has far-reaching implications in the ultimate health of our nation's children. The study of injuries provides students with experience in epidemiology, growth and development, behavior modification, and systematic analysis. It should be an integral part of the pediatric curriculum, both at the student and housestaff level. The real challenge for pediatricians is to have medical schools incorporate the management and prevention of childhood injuries into the medical school and postgraduate curricula in a multidisciplinary format, and to obtain faculty who are interested in studying injuries. The academic world needs to reorganize injury as a disease and its prevention as a major institutional responsibility. It is our hope that the recent competition by major medical centers for designation as pediatric trauma centers, and the regionalization of care for this special patient activity will result in a new interest in the injury problem and injury prevention. The pediatric trauma center should be a regional focal point for the education not only of medical students and housestaff, but also of practicing physicians in the community. In addition, major attention and investment by academic centers in organ transplantation provides the opportunity for discussion of such issues as where the organs came from, the ethics of organ banking, and the importance of supporting programs that can save thousands of children. No one engaged in organ transplantation could lament the inability to perform such procedures if there were no accident victims to provide those organs. Grand Rounds, continuing medical education programs, and mortality and morbidity reviews on injured patients can all be used to accomplish this training.
EMERGENCY MEDICAL SERVICE SYSTEM (EMSS) DEVELOPMENT Regional EMS systems are being implemented across this nation for the poison, trauma, burn, spinal cord injury, and cardiac patient. These
THE PEDIATRICIAN AS ADVOCATE
247
systems provide for the orderly linkage of prehospital, hospital, and critical care for each emergency patient in a region. They define what care is to be given, to whom, where, and under what medical supervision. Unfortunately, because of the complexity of the medical and political processes by which these systems are established, and the need to implement them as rapidly as possible, less attention has been given to the needs of children within these systems. It is up to pediatricians and an informed public to correct these deficiencies and actively participate in EMS system planning and development. Pediatricians must define the special needs of children, establish criteria to identify critically ill or injured patients, and the means to transport them to designated centers with the resources and the organizational structure for optimal treatment. We must develop the treatment protocols for the care of the pediatric emergency patient by rescue and ambulance personnel and emergency department staff. If trauma centers have not yet been designated in a region, pediatricians should take an active role in the trauma system planning and determine whether a pediatric trauma center is needed and feasible. Pediatric leadership should be vital to the designation process. If pediatric trauma patients are taken to centers that treat both adults and children, it is the pediatrician's role to work with the trauma surgeons to establish protocols to meet the special needs of children. In a well-planned trauma system, the trauma center becomes a focal point for injury prevention activities. It is unlikely, however, that injury prevention will be given a high priority unless pediatricians assume a leadership role and work with the trauma center staff to develop a program. Individual trauma cases can have a great impact on the public and its political leaders, and pediatricians working with trauma centers can be very effective in making prevention happen. Although some argue that pediatricians should be more concerned about economic issues, the fact that we have not has provided the opportunity to succeed in other pressing areas.
LEGISLATION AND REGULATION Perhaps the most powerful advocacy role for the pediatrician is in developing and supporting legislation and regulatory intervention in injury control. The effectiveness of the legislative approach is well documented in the dramatic reduction of injuries following safety legislation. After the Poison Prevention Packaging Act of 1970, aspirin deaths decreased by 65 per cent. The Flammable Fabrics Act, and, recently, child passenger safety legislation are two more examples. IS Pediatricians can initiate injury prevention legislation individually or collectively, through the AAP. We can request introduction to the legislature of a specific bill by the administration or by a special legislator. 6 Legislators are strongly influenced by credible and dedicated physicians, particularly when the intent of the requested legislation benefits the public. It has been our experience that, among physicians, pediatricians are seen by legislators as the most credible, because the issue for us historically has been the welfare of children. A pediatrician, well prepared
248
SYLVIA
H.
MICIK AND JOEL
J.
ALPERT
with the facts, a rational solution to an injury problem, and a willingness to be available for testimony, can be successful in getting legislation enacted. When these efforts are coupled with an organizational effort via the AAP, success is even more likely. The Academy provides national visibility, the resources to have influence at the national and state level, and prominent visibility through the Accident Prevention Committee. However, this effort has been considerably aided and in some cases preceded by intense personal lobbying. There is no substitute for the pediatrician, who by chance of residence, provision of pediatric care, or personal contacts, has a personal and close relationship with a powerful national, state, or local legislator. Because pediatricians can be such a powerful force in the legislative process, those that undertake this mission must understand the process, the political environment, and how to testify before legislative committees. 6 There are key steps a pediatrician should take when testifying or presenting a program. 1. Be well prepared. 2. Present the program in 15 minutes or less, but leave a written summary of two to three pages with the legislator or committee members. 3. Keep medical terminology at a minimum. 4. Speak to legislators without arrogance. 5. Maintain ongoing communications with the staff of the bill's author. They will provide assistance in the logistics and strategies of testifying, and coordinate testimony with supporting colleagues and organizations. 6. Be prepared to deal with other experts and organizations who will disagree with you. Pediatricians generally have access to regulatory agencies in government. They can bring attention to hazardous products on the market and inadequate packaging of hazardous substances, and relate these to their own experience and the collective experience in their region. Thus, they can help bring about regulatory change better than most other concerned groups. In addition, pediatricians can report noncompliance with existing safety regulations to regulatory agencies, e. g., sale of prescription drugs in non-child-resistant containers, and in that way force compliance. Another effective activity for pediatricians is testifying before regulatory committees in favor of safety regulations (e.g., Consumer Product Safety Commission, the Federal Aviation Authority or Food and Drug Agency), thereby providing the necessary justification to issue the regulation. These activities take time, which is why most organizations who can, employ a professional lobbyist. The fact that there are pediatricians who have found the time to pursue an injury prevention cause without economic reward is a tribute to them and to our profession. CONCLUSION If pediatricians are to be true and effective advocates of children, they should assume, individually and collectively, the many roles discussed in this article. The extent to which childhood injuries are prevented in the
THE PEDIATRICIAN AS ADVOCATE
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future may depend on the degree to which pediatricians succeed in these roles. We have a responsibility to be informed and to inform. We have the opportunity to practice injury prevention and to influence those who make the products and pass the laws. The end result can be fewer injuries to children.
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