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Don't you do inpatient work? Would you not hit up an appy with Zosyn or (insert institutionally preferred drug here)?
Your fault, too. Lolz.
Your fault, too. Lolz.
Good God no, I haven't professionally set foot in a hospital since residency.Don't you do inpatient work? Would you not hit up an appy with Zosyn or (insert institutionally preferred drug here)?
Your fault, too. Lolz.
Good God no, I haven't professionally set foot in a hospital since residency.
I honestly do think that my PCP colleagues are much more responsible for c. diff than ED/inpatient folks are. There is a 4 doctor FP practice across the street and I bet they give out more broad spectrum antibiotics in a day than my wife's 60-bed hospital and 100-visit/day average ED does.
get all 4 and its' jackpot, bill for critical care time!Remember, the cardinal rule of EM is that any patient presenting to the ED must get at least one of the following:
1) Vanc and Zosyn
2) CT scan
3) Dilaudid
4) Consult
If they get more than 1, they get admitted.
If they get more than 2, they get admitted to ICU.
Many years ago, a wise attending told me that if you ever get stuck on a case, just use the 3 C's to figure them out:
1. Get a consult
2. Get a CT
3. Get another CT with Contrast
In all seriousness, my general approach to the young thin person with possible appy is do my own bedside US. If I find one, the US tech probably will. If I don't, they usually don't. So if I find one, then I order an US. In every case where I found an appy on a kid myself, the US tech confirmed it. If negative, I usually don't waste my time getting an US by the tech and I jump to CT.
I learned how to do appy US myself by watching the US podcast videos on it. The first time I ever did one on a kid, it was positive. I couldn't believe it!
I've often wondered that myself. I use to think crp >10 = something's brewing. but just heard EMRAP lecture and he said crp is crAp. so I dunno now.....What do you guys think of using esr/Crp in these kids? If they both come back negative, how likely is the kid to have any kind of -itis?
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What do you guys think of using esr/Crp in these kids? If they both come back negative, how likely is the kid to have any kind of -itis?
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The physical exam and documenting it well, are more important than in a lot of other things.
I've never liked ordering a test that doesn't answer the question. There is no blood test that rules out appendicitis. There's no imaging test that rules out appendicitis either, but they come closer to bloodwork. Getting a CBC, CRP, or ESR on someone right lower quadrant pain and stopping there if negative makes no sense to me.
Now in conjunction with imaging that is negative, I do think you have a much lower posttest probability. A normal inflammatory marker plus a normal ultrasound certainly lowers the post test probability. But does a really change practice? If the white count is high, or CRP is high, and the ultrasound is normal or the CT is normal, what are you going to do differently? Will a surgeon take the kid to the OR with normal imaging?
And on the flipside, people over order these tests on every kid with generalized abdominal pain, which will cause them to then over order imaging because of false positives. Every kid with gastroenteritis is going to be getting ultrasound and CT's and MRIs.
We definitely have a tendency to over order tests. And it hurts us medical legally. Either someone has a surgical abdomen or they dont at that moment in time. Relying on insensitive, nonspecific tests only hurts you. Excellent return precautions, talking to patients, re-examinations, etc. that's what helps.
Why do I say it hurts you. Let me give you two scenarios, one with a normal white count one with an abnormal.
Scenario one: child comes in with vague Abd pain and vomiting. You put an IV in to hydrate the child, and get a white count for some reason. The white blood cell count is normal. You assume he has gastroenteritis, send the kids home to follow up with his PCP in two days if not better. He returned three days later with a ruptured appendicitis. The white count only hurt you because it provided false reassurance. You can say it doesn't, and maybe it really doesn't, but it sure will look that way on the stand. If I was a lawyer first question I ask would be, "Dr. you know that a normal white blood cell count can occur in 20% of appendicitis right". To which you would answer yes. The lawyer with and ask why you would send a child home with a 20% of appy. You would say that you didn't think the child had an appy based on your exam. And this is where you'd be stuck. Because the next question the lawyer would ask is why you would order the white blood cell count if you didnt think an appy was possible. If you didn't think the disease existed, why did you order the lab. By looking for an abnormal white count, you were looking for a disease that in reality you didnt think exists in the first place, but instead it really just looks after the fact like you got false reassurance.
Scenario 2: child comes in with vague Abd pain and vomiting. You put an IV in to hydrate the child, and get a white count for some reason. The white blood cell count is high, but the child looks much better with the IV fluids so you just send him home with the same plan as above. Same bad outcome occurs. Now this looks even worse. You ordered a study screening for something, had a positive screening, and did nothing about it.
A much much better approach is a good physical exam, documenting that there are no physical signs of appy AT THAT MOMENT IN TIME but documenting good discussion with parents about early appy, good return precautions like return to ED in 8 to 12 hours for a re-exam instead of 2 to 3 days with your PCP. This will save you time, as you wont be testing kids with unnecessary bloodwork that wont change your management, and is a good safe approach to the problem.
That's in the kid with with more generalized pain or vomiting. In kids with actual right lower quadrant tenderness, I get imaging. Even if the imaging is negative, if they have a good enough exam I get a surgical consult.