A pediatrician’s heart and an engineer’s brain

It’s a rare pediatrician who also has a doctoral degree in biomechanical engineering – but it’s a perfect, synergistic combination for Prof. Flaura Koplin Winston, director of the Center for Child Injury Prevention Studies (CChIPS) at The Children’s Hospital of Philadelphia (CHOP) and of the US National Science Foundation Center for Child Injury Prevention Studies.

It was she who, putting two and two together, was the first to realize in the mid- Nineties that airbags can kill young children who sit the front seat, even when the car seat is facing backwards. Some 150 children around the US are estimated to have been killed by the technology, which was meant to save lives. Since then, vehicle airbags have been changed to be less dangerous to vulnerable infants and toddlers, but even now it is advised that young children sit in car seats in the back seat for greater protection.

Winston, who was born to a Jewish family in Baltimore, was recently invited on her fifth visit to Israel by Beterem – the Israel National Center for Child Safety and Health, whose aim is to prevent child injury and death from accidents of all kinds. She attended a multi-disciplinary conference on child accident trauma that Beterem initiated at Haifa’s Rambam Medical Center.

Beterem director-general Orly Silbinger said the conference was aimed at exposing child accident prevention experts to new, evidence-based findings and promoting the integration of research and know-how. The American pediatrician also lectured during her visit at a researchers’ conference of Or Yarok, a non-profit organization dedicated to reducing road accidents.

Winston, who reads and speaks some Hebrew after attending Hebrew school and then spending a summer at Rehovot’s Weizmann Institute of Science, said in an interview with The Jerusalem Post that she always wanted to be a doctor.

“My father, a pharmacist, had a heart attack when I was in high school, so I initially thought I could become a cardiologist. But I have also loved children as long as I can remember. When I studied medicine, I realized I was ready to stay up all night with a sick child.”

She has been very loyal to the University of Pennsylvania, where she spent 11 years completing a joint MD-PhD program. That led to her devotion to the subject of traffic safety. She is also extremely proud of the childen’s hospital and its high level of comprehensive care.

“I am a board-certified pediatrician, a doctorally trained biomechanical engineer and a public health researcher who conducts research at the interface of child and adolescent health, injury, engineering and behavioral science. My focus is on addressing the leading cause of death and acquired disability in children and adolescents – traffic crashes,” she said. “My work spans prevention of teen driver crashes, child passenger safety and secondary prevention of post-traumatic stress disorder after injury.”

WINSTON RECALLS the day in 1995 that she realized airbags might not always be safe.

“A 20-day-old baby arrived at the emergency room. She had been in a rear-facing car seat and died in the hospital, but her mother survived. I realized that newborn must have been hit by the airbag. A few months later, another baby who had been in a car seat was brought in dead, followed soon after by an infant who had been seriously injured. I had just started my career, and no one had come across such a thing before.”

Airbags “add energy to the system that surpasses the child’s ability to handle it. Airbags are now better designed, and most Americans know not to sit young children in the front seat. Child airbag injuries are rare today; there are many more when adults leave young children in hot cars, which also happens in Israel.”

Too many drivers lose sight of the fact that “children are very precious cargo,” she said. “Drivers are too busy. We don’t think of themselves as being a threat.”

A large insurance company heard of her discovery and asked her about “whiplash” injuries, but she said airbags and children interested her.

“We set up the largest surveillance system for airbags, conducted crash investigations. We had 750,000 kids in our database. A total of 1.5 million American children vehicle passengers are injured in road accidents every year. It’s horrendous. Three or four percent suffer serious injuries. But if the child is sitting in a proper child restriant, they have less than a 1% risk of injury,” Winston said.

US states vary in the minimum driver’s age. Rural states, she said, allow children as young as 14 and a half to get a driver’s license because they live so far from schools that their only way of getting there and back is to drive their own cars.

“But,” she pointed out, “that is an exception,” adding that most states allow adults with licenses to teach minors how to drive and then taking a qualifying test.

“I’ve been impressed how Israelis have to have 40 hours of driving lessons with a professional teacher. Practicing driving is vital, as experience is very important. But one can safely learn driving from your father or mother if the parent is loving, patient and calm,” said Winston, whose husband is an expert in building design and computers and whose two sons – one who just graduated from college and the other from high school – are not interested in medicine.

“Indeed, there are not many pediatricians who are also engineers. But I use engineering all the time. I’m a composition who links this exact science with behavior, public health, pediatrics and epidemiology and can translate from one to the other. I can talk to engineers about airbag injuries and and to pediatricians about car seats. My brain works like an engineer’s because I think in terms of flow charts, but my interaction with people is more like than of a pediatrician’s. I love being with people, and I care the most about behavioral change so that they adopt a safety culture.”

She is concerned about the growing number of distractions in vehicles that affect drivers’ judgment and performance. Cellphones are “yet another thing that’s distracting people,” she said, “but many new ones are being built into vehicles.”

Laws banning texting or handheld phones are “not the panacea,” she said, “as drivers will find something else to distract them.”

MOST PARENTS know little about the dangers of concussions, which are traumatic brain injuries that can be serious (involving blood hemorrhage or other harm to the brain tissue). They should always be checked, said Winston. The word concussion comes from the Latin for “shake violently.” It can result from the head hitting an object or a moving object hitting the head.

Although road accidents are a common cause of concussions, they can also occur after a fall or sports activities temporarily interfere with brain function, and can affect speech, balance, memory, judgment, reflexes, coordination and sleep patterns. You can have a concussion and not realize it.

Winston, who a few weeks ago testified before a US congressional subcomitttee about traumatic brain injury, told the Post that the child brain is very vulnerable. A concussion affects every part of your body. It used to be thought there was no need for treatment if a child has not lost consciousness, but she said that if a child hits their head and shows much milder symptoms – such as muscle weakness, confusion, reduced alertness, vomiting, walking problems or unusual eye movements, he is likely to have suffered a concussion, she said, meaing that “the neurons and axons in the brain have been hurt.”

Many brain-injured children never reach the hospital. Even in US hospital emergency rooms – and most probably in Israeli ones – the possibility of serious brain injury despite minor symptoms is not always recognized, she said.

“You can’t always see it in an x-ray; it is more recognized by a physician who identifies subtle signs. Should a brain injury occur, timely and proficient acute care is vital. Delayed or inappropriate care can worsen the insult, resulting in secondary damage and upsetting the delicate balance needed for healing. For the more severe brain injuries, we often refer to the hours after an injury as the ‘golden window’ ... During this ‘golden hour,’ concussions have to be treated aggressively. If not, it could turn into a chronic, lifetime problem.”

A child who suffered a concussion but shows mild symptoms must get cognitive and physical rest, as it is not a truly mild injury, Winston insisted.

“Then they can slowly return to their to their routine and add aerobic exercise and sports activities and only later the other things.”

The American pediatrician also deals with psychological injury from car crashes and other injuries. Post-traumatic stress disorder (PTSD) often occurs in survivors of crashes, but many cases are not diagnosed. They must be diagnosed early.

“Israeli medical professionals, for obvious reasons, are very aware of PTSD,” she noted.

PTSD doesn’t even have to follow an actual trauma, only something perceived as one. Adults and children can feel fear, helplessness and horror after a crash.

“We interviewed people who have survived a road accident about their injuries, but realized that they had emotional wounds as well. They had no one to talk to about their feelings. Some 85% of children in car crashes – and their parents – suffer some emotional trauma.”

Winston also has a regular private practice as a pediatrician.

“I love my young patients. I’m like their aunt. I have patients whose parents were my patients when they were young. A huge part of my practice is prevention, and I use electronic health records to the fullest. The computer sends alerts when vaccinations and screening tests are needed. But there is always a shortage of time. For compensation, we have to see patients every 12 or 15 minutes.”

Tens of millions of Americans lack health insurance – not the rich who can afford it or the very poor, who are subsidized, but the employed with low wages whose employer doesn’t provide any or adequate health insurance. Fortunately, she said, Pennsylvania has state child health insurance program, so no child goes without health insurance.

“But that can’t be said based for young adults and the working poor who don’t have coverage,” she said.

The younger generation of American pediatricians has been trained holistically, according to Winston.

“Everything is in the curriculum, from child development to autism, screening for dental caries and of their mothers for postnatal depression, child abuse, spousal abuse and more. It’s part of pediatric training in the US; you can’t be board-certified without it.”

More than 50% of pediatricians in her state are women, but “there are wonderful male pediatricians.”