Crash Cart: The EpiPen price surge, missed diagnoses, and stroller injuries

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This week: Mylan increases EpiPen prices over 400%. Plus, can you diagnose what’s wrong with this child that’s had a fever every night for a month? Join in as our editors discuss the week’s headlines.

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EpiPen prices rise 400%

The pharmaceutical company behind the allergy medication sees the high demand an an opportune market as patients struggle to afford the lifesaving drug. Original Article by Forbes // Accompanying Article by USA Today

E. Paul DeKoning, MD, MS: Reminds me of how the delivery device for Dermabond seems to change every few years, as if there was a problem with the old one. Good to know there’s a much cheaper alternative to the EpiPen I need to look in to. If it is stocked locally, I can give my patients a choice. But, this isn’t just about money. You know I love quotes: “The ‘what-if’ fears of parents are a rich vein to tap, one that clearly has proved immensely valuable to Mylan.” Don’t get me started on this paternalistic/fatalistic approach the medical community takes with parents and frankly all patients. Pharma is not alone here–we doctors do it, too. We simply know better, right?? At the risk of offending some of my colleagues, we call it anticipatory guidance or prognostication. Fear is a great motivator. And usually an unfair one.

William Sullivan, DO, JD: Mylan’s pricing increase is reprehensible, but after all, the situation is a result of ensuring patient safety, right? Recall that the article stated Mylan’s only competitor (Auvi-Q) recalled its products due to dosing irregularities, giving EpiPens a virtual monopoly. By the way, Auvi-Q wasn’t exactly cheap, either. Now with the EpiPen price hikes and the expert recommendation that everyone purchase two EpiPens in case one fails (by the way, where is the regulation over EpiPen failures?) EpiPens are being kept out of the hands of many patients who need the medication the most. Is this a good thing? One interesting epilogue to the Shrekli case mentioned in the article (a venture capitalist who purchased a company producing a toxoplasmosis medication and then jacked up the price 5000%) – another company began marketing the same medication at $1 per dose rather than Shkreli’s $750/dose. Not sure why price-gouging laws shouldn’t apply in these cases (one example here) – except that there isn’t any “declared” disaster. I suppose people dying from anaphylaxis should be considered a routine event. Hopefully epinephrine ampules, syringes, and nasal atomizers will take the place of EpiPens and put Mylan out of business. Oooh, and now Mylan is offering “generic” EpiPens at only $300 per pack. How compassionate of them. Now most working families only have to forego two weeks’ food costs to purchase one.

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Fever every night, could you diagnose this case?

A child presents with rare symptoms to the ed; cancer is ruled out and so is tuberculosis, so what can it be?. Original Article by The New York Times.

E. Paul DeKoning, MD, MS: I’m not really sure of the point of this article but I’ve got a sneaking suspicion that it’s meant to impugn us dumb doctors who couldn’t figure out a simple fever in a kid. “The E.R. doctors, like all the doctors they’d seen, were kind and gentle with her son. But they had no answers.” I take issue with this statement. I suspect the ED docs did have an answer — that when the child presented in the ED, it didn’t represent an immediately life-threatening condition. This isn’t a common ED diagnosis, especially if contracted in another part of the country, or better yet another country. But impending airway collapse from mediastinal compression is more up our alley and I know who I’d want managing that. I would have missed this one, no question. Kudos to the one who figured it out, the pediatric infectious disease guru. Good thing those dumb ED docs without answers were at least kind and gentle…

William Sullivan, DO, JD: I like articles like this that test my knowledge and differential diagnosis skills. I was betting on lymphoma. However, the theme that kept running through this patient’s (and his parents’) ordeal was that we don’t respect the “cognitive” specialties nearly as much as we should. There are pressures to get more patients in and out of the office, emergency department, and hospital to the point that we really don’t sit down and think things through. It’s much easier and quicker to write a prescription for a Z-pack and send a patient on their way than it is to take a full history, do a thorough physical exam, and think about what could be causing a patient’s symptoms. Easier to order shotgun testing and refer to someone else when there’s no obvious answer. I find myself falling into this same trap at times. Unfortunate for our patients. Don’t know that I would have caught this diagnosis any earlier, but as Paul mentioned, emergency physicians can’t replace a cadre of specialists. No matter how much that “mission creep” is forced down our throats, emergency medical care is episodic and not a subsitute for primary care. Fortunate that this child finally got to the right diagnosis after at least 10 different doctor visits.

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Stroller injuries are more likely to occur in male children

Almost half of the children studied in the 20-year span were diagnosed with soft-tissue injuries in the ED. Original Article by Scientific American.

E. Paul DeKoning, MD, MS: So, how exactly do you diagnose concussion in a 1 year old?? Never mind, don’t answer that. Fifty children a day in the whole United States? I’m sorry, call me heartless but I’m just not that concerned–and I have 2 almost 3 small children. How many kids per hour are bitten by the neighbor’s dog? How many kids fall down the stairs every minute. (While we’re on the topic, how many ADULTS fall down the stairs and end up in the ED with injuries that only Dilaudid will treat?) How many wobbly toddlers per microsecond smack their heads on the coffee table? We should definitely outlaw stairs. And coffee tables. And the neighbor’s dog. “If parents can take a few extra steps to avoid injuries and falls, then parents can hopefully use these products more safely and reduce the likelihood that their children will be injured.” That’s pure genius. I gotta remember that.

William Sullivan, DO, JD: OK, so I think that this entire article is a little misleading. First, the inclusion criteria – “injuries serious enough to require trips to the emergency department” – is highly subjective. How often did the kids have no injury at all, but were brought “just to be checked out”? I’ve seen at least half a dozen patients come to the ED for evaluation of bug bites in the past week. That fact doesn’t make bug bites the next national health threat to be published in Scientific American. Second, there’s no comparison of emergency department visits by children who were injured because they didn’t use strollers or carriers. It could very well be that the percentage of injuries from non-stroller/carrier users is much higher, making strollers and carriers a safer method of transportation. The advice noted in the article about actually using the buckles and avoiding things that may topple the stroller is good, but common sense. Then again, with 17,000 injuries per year, I suppose I shouldn’t assume things.

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