The New York Times, May 15, 2013, by Perri Klass MD — Twenty-eight years ago, I wrote about drawing blood for the first time, about the pain of the patient and the self-doubt of the medical student. In my first clinical experience, I was learning a strange new color code: red-top tube for blood chemistries, purple top for hematology, green top, yellow top, and so on.
In pediatrics, I soon discovered, the colors were the same but the tubes themselves were much smaller. And instead of those big needles I had learned to use on adults, we used butterflies, tiny needles with plastic wings to keep them stable.
I thought: If you can get enough blood through a small butterfly needle filling a small tube to do the necessary tests, why must we jab big needles into adults and fill comparatively huge tubes to do the same assessments?
It wasn’t the last time I wondered why children were treated with more concern than adults. And now it seems that attitudes long taken for granted in the care of children might be working their way up the life span to become more standard for adults.
Take those big tubes. In a 2011 article in the journal Archives of Internal Medicine, researchers showed that adults hospitalized with heart attacks who had more blood drawn were more likely to develop anemia while in the hospital. Patients who develop such anemia have a higher risk of death.
Dr. Mikhail Kosiborod, one of the authors of the study, a cardiologist at St. Luke’s Mid America Heart Institute in Kansas City, Mo., told me that the result surprised some physicians; the average volume of blood lost did not seem substantial enough to cause anemia in healthy adults. Patients in the study who developed anemia lost 174 milliliters of blood on average during hospitalization — just under six ounces — though some lost much more. A healthy adult might not become anemic after such blood loss, but the sick and debilitated may be at higher risk.
His own hospital, like many other institutions, is now using smaller tubes, he said — not the tiniest tubes, which require special handling, but a smaller size that can still be handled routinely by the lab.
So why had anyone ever used larger tubes if smaller would work? “It just hasn’t been brought up in the adult world,” Dr. Kosiborod said. “It hasn’t been made a big issue.”
Dr. Bradley Monash, an academic hospitalist at the University of California, San Francisco, who works on both pediatric and adult wards, said: “There’s something about the care of a child that touches people. There’s something about caring for children that people address differently.”
The pain and fear that children feel about having their blood drawn, for example, probably influence the frequency with which doctors order tests.
“Fear is acceptable in pediatrics much more than it is in adults,” Dr. Monash said. “There are a lot of things we could take from pediatrics and translate into medicine.”
When children get hospitalized, for instance, we understand that they’re scared. An unfamiliar place, painful procedures, strangers with needles — all are piled atop the underlying feeling of being sick or hurt. And we routinely expect parents to stay over in their children’s hospital rooms, providing cots and chairs that unfold to lie flat.
When children need surgery, we promise company and comfort.
The children are told that “the parents are going to be going with them into the operating room, and they’re going to stay with them till they fall asleep,” said Florencia Catanzaro, who coordinates the pre-hospitalization child life program at Bellevue Hospital in New York City.
Parents are routinely allowed into recovery, so that children can see them when they wake up, or soon after. But really, are adults any less scared, uncertain or disoriented?
In adult surgery, it is not routine to promise that someone can be with you in the operating room till you go to sleep, or to have family members a standard part of recovery room care. Many hospitals will let a family member stay overnight with an adult patient, but policies vary hospital by hospital, ward by ward.
“We accommodate family members much more in pediatrics,” Dr. Monash said. “We don’t have visiting hours where everyone has to leave.”
Still, the trend in adult medicine is that new patient rooms are more likely to be constructed, as pediatric rooms are, to accommodate family members.
It seems to me we should be able to promise any hospital patient that a relative, a friend, can stay close at hand. We should be able to promise anyone going in for surgery that when she wakes up, someone familiar will be there.
It won’t always be perfectly convenient for hospital routine, but the lesson from pediatric care is that hospitals will adjust. This was all unthinkable in pediatrics, too, just over a half century ago.
The adage “children are not just small adults” is so basic in pediatrics that you can search medical journals and find it applied to treatments for facial fractures, liver failure and cardiac arrhythmias, for example. We have learned over time to fine-tune medical care to the differently wired physiologies of children, and to their emotional development.
But when it comes to certain aspects of medical treatment, especially hospitalization, perhaps it’s time to acknowledge that adults are really just big children. Illness, pain and the shadows of disability and death — all hospital familiars — make all of us vulnerable, at any age, and reassurance and comfort are welcome. Blood is a useful reminder: Every patient needs to be treated in a way that conserves every drop of strength and resilience.
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The New York Times, May 15, 2013, by Gretchen Reynolds — Most of us grew up hearing that we should warm up with a stretch. Strike and hold a pose, such as touching your toes, for 30 seconds or more, we were told, and you’ll be looser, stronger and injury-proof.
But anyone who follows fitness science knows that in recent years a variety of experiments have undermined that idea. Instead, researchers have discovered, this so-called static stretching can lessen jumpers’ heights and sprinters’ speeds, without substantially reducing people’s chances of hurting themselves.
Now, two new studies are giving us additional reasons not to stretch.
One, a study being published this month in The Journal of Strength and Conditioning Research, concluded that if you stretch before you lift weights, you may find yourself feeling weaker and wobblier than you expect during your workout. Those findings join those of another new study, a bogglingly comprehensive re-analysis of data from earlier experiments that was published in The Scandinavian Journal of Medicine and Science in Sports. Together, the studies augment a growing scientific consensus that pre-exercise stretching is generally unnecessary and likely counterproductive.
Many issues related to exercise and stretching have remained unresolved. In particular, it is unclear to what extent, precisely, subsequent workouts are changed when you stretch beforehand, as well as whether all types of physical activity are similarly affected.
For the more wide-ranging of the new studies, and to partially fill that knowledge gap, researchers at the University of Zagreb began combing through hundreds of earlier experiments in which volunteers stretched and then jumped, dunked, sprinted, lifted or otherwise had their muscular strength and power tested. For their purposes, the Croatian researchers wanted studies that used only static stretching as an exclusive warm-up; they excluded past experiments in which people stretched but also jogged or otherwise actively warmed up before their exercise session.
The scientists wound up with 104 past studies that met their criteria. Then they amalgamated those studies’ results and, using sophisticated statistical calculations, determined just how much stretching impeded subsequent performance.
The numbers, especially for competitive athletes, are sobering. According to their calculations, static stretching reduces strength in the stretched muscles by almost 5.5 percent, with the impact increasing in people who hold individual stretches for 90 seconds or more. While the effect is reduced somewhat when people’s stretches last less than 45 seconds, stretched muscles are, in general, substantially less strong.
They also are less powerful, with power being a measure of the muscle’s ability to produce force during contractions, according to Goran Markovic, a professor of kinesiology at the University of Zagreb and the study’s senior author. In Dr. Markovic and his colleagues’ re-analysis of past data, they determined that muscle power generally falls by about 2 percent after stretching.
And as a result, they found, explosive muscular performance also drops off significantly, by as much as 2.8 percent. That means that someone trying to burst from the starting blocks, blast out a ballistic first tennis serve, clean and jerk a laden barbell, block a basketball shot, or even tick off a fleet opening mile in a marathon will be ill served by stretching first. Their performance after warming up with stretching is likely to be worse than if they hadn’t warmed up at all.
A similar conclusion was reached by the authors of the other new study, in which young, fit men performed standard squats with barbells after either first stretching or not. The volunteers could manage 8.3 percent less weight after the static stretching. But even more interesting, they also reported that they felt less stable and more unbalanced after the stretching than when they didn’t stretch.
Just why stretching hampers performance is not fully understood, although the authors of both of the new studies write that they suspect the problem is in part that stretching does exactly what we expect it to do. It loosens muscles and their accompanying tendons. But in the process, it makes them less able to store energy and spring into action, like lax elastic waistbands in old shorts, which I’m certain have added significantly to the pokiness of some of my past race times by requiring me manually to hold up the garment.
Of course, the new studies’ findings primarily apply to people participating in events that require strength and explosive power, more so than endurance. But “some research speaks in favor” of static stretching impairing performance in distance running and cycling, Dr. Markovic said.
More fundamentally, the results underscore the importance of not prepping for exercise by stretching, he said. “We can now say for sure that static stretching alone is not recommended as an appropriate form of warm-up,” he said. “A warm-up should improve performance,” he pointed out, not worsen it.
A better choice, he continued, is to warm-up dynamically, by moving the muscles that will be called upon in your workout. Jumping jacks and toy-soldier-like high leg kicks, for instance, prepare muscles for additional exercise better than stretching. As an unscientific side benefit, they can also be fun.