Attn OMFS's: The Day the Gulf of Mexico Dried Up

[tx oms]

That's right, I got hot enough to flash boil all the water in the Gulf today while dealing with the friendly pediatricians at my school. I walk around at about 211.5 so it doesn't take much to push me over to boiling.

At ~11:45 this morning a 7yr old girl presents to the pediatrics clinic I'm rotating through. Her upper lip, left face, and lower left eyelid are swollen. The dad has taken her to two ER's, both of whom made incorrect diagnosis. The second ER referred the girl to us for treatment of a preseptal cellulitis.

Like I said, she gets to our clinic about 11:45. I'm already gone to lunch. When I get back at 1:00pm the attending is beside herself with agnst. When I enter the doctor's room the peds attending is on the phone with a peds ID attending discussing appropriate management of an abscessed tooth which looks "horrible", "involves the eye", and has "perforated the sinus". A resident is arranging for admission, CT, blood cultures, lab work, and IV antibiotics.

I'm beginning to piece the story together by this time and want to see the kid. A second attending noticed me and knew that I was both an OMFS resident and a med student and tells me to look at the kid. I see this girl, noticed she is afebrile, polite, and in good spirits. Her upper lip is moderately swollen, her left canine space and lower lid are mildly swollen. She is able to fully open her eyes and mouth. Pus is expressible from #F sulcus.

Slam dunk, it's a simple abscessed tooth with associated cellulitis. Extract the tooth and place on po PenVK.

Oh no my friends. Despite my best efforts (including completing an OMFS consult) this pt is "toxic" and admitted for IV abx, head CT with and without, blood cultures, and labs. I told the first attending that the case was being overtreated, the kid did not need admission, and did not need to be irradiated like a Chernobyl cockroach. She brushed me off, said that the ID people disagreed (they haven't even seen the pt!), and that OMFS would get involved later. The second attending later told me he was willing to following my recommendations but couldn't argue with the first lady.

So, I'm pissed b/c a seven year old girl is spending the night in a hospital for nothing. EVERY treatment she is receiving from peds is uneccessary. OMSRES saw her at 7:00pm, took the teeth out, and did and I&D. This girl was denied appropriate care for over 7 hours due to a foolish pediatrician! I'm at about 211.9 just thinking about it now.

Do you ever notice primary care doctors treat everything out of fear? A kid vomits twice and they might be a new onset diabetic in DKA. A girl has an abscessed tooth for one day? Damn, her sinus is perforated and she's going to die without a CT, IV abx, and blood cultures. I almost walked out of clinic today. At least they reminded my why primary care docs drive me up the wall.

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[Fullosseousflap]

That's right, I got hot enough to flash boil all the water in the Gulf today while dealing with the friendly pediatricians at my school. I walk around at about 211.5 so it doesn't take much to push me over to boiling.

At ~11:45 this morning a 7yr old girl presents to the pediatrics clinic I'm rotating through. Her upper lip, left face, and lower left eyelid are swollen. The dad has taken her to two ER's, both of whom made incorrect diagnosis. The second ER referred the girl to us for treatment of a preseptal cellulitis.

Like I said, she gets to our clinic about 11:45. I'm already gone to lunch. When I get back at 1:00pm the attending is beside herself with agnst. When I enter the doctor's room the peds attending is on the phone with a peds ID attending discussing appropriate management of an abscessed tooth which looks "horrible", "involves the eye", and has "perforated the sinus". A resident is arranging for admission, CT, blood cultures, lab work, and IV antibiotics.

I'm beginning to piece the story together by this time and want to see the kid. A second attending noticed me and knew that I was both an OMFS resident and a med student and tells me to look at the kid. I see this girl, noticed she is afebrile, polite, and in good spirits. Her upper lip is moderately swollen, her left canine space and lower lid are mildly swollen. She is able to fully open her eyes and mouth. Pus is expressible from #F sulcus.

Slam dunk, it's a simple abscessed tooth with associated cellulitis. Extract the tooth and place on po PenVK.

Oh no my friends. Despite my best efforts (including completing an OMFS consult) this pt is "toxic" and admitted for IV abx, head CT with and without, blood cultures, and labs. I told the first attending that the case was being overtreated, the kid did not need admission, and did not need to be irradiated like a Chernobyl cockroach. She brushed me off, said that the ID people disagreed (they haven't even seen the pt!), and that OMFS would get involved later. The second attending later told me he was willing to following my recommendations but couldn't argue with the first lady.

So, I'm pissed b/c a seven year old girl is spending the night in a hospital for nothing. EVERY treatment she is receiving from peds is uneccessary. OMSRES saw her at 7:00pm, took the teeth out, and did and I&D. This girl was denied appropriate care for over 7 hours due to a foolish pediatrician! I'm at about 211.9 just thinking about it now.

Do you ever notice primary care doctors treat everything out of fear? A kid vomits twice and they might be a new onset diabetic in DKA. A girl has an abscessed tooth for one day? Damn, her sinus is perforated and she's going to die without a CT, IV abx, and blood cultures. I almost walked out of clinic today. At least they reminded my why primary care docs drive me up the wall.

Good story and now you know why you are there - to make sure the next child is treated appropriately.

Have a better day tomorrow!

 

[TucsonDDS]

I know what you meen. Sometimes pediatricians greatly exagerage diagnosis and treatment. Other times they don't do enough. We had a 5 year old kid complaining of a headache on christmas day, was lethargic by that evening and brought into the hospital. By the time he hit the Pediatric ICU he was in status epilepticus, lined, on norepinephrine, intubated and receiving 4 or 5 antibiotics. He was dead by the next morning. The ID docs said that if he had gotten a dose of rocephin when he hit the ER he would probably still be alive. He ended up having Parvo Meningitis. Doctors are constantly overtreating patients but it is because of kids like the one above that they are so scared ****less. Now when it takes them 2 hours to get you insulin or pain med orders, that is just incompetance.

 

[Jediwendell]

Had a kid in my office a few weeks back that was seen by 3 docs in a box, an ENT and a general dentist for facial swelling, all who couldn't "figure it out." He'd had 2 CT scans, an MRI, steroids and an ass load of ABX. And with all this no change and no diagnosis. He came in to my office after being like this for a week, since someone finally got the bright idea to send him to a pediatric dentist. Needless to say we took a PA and it was soooo simple! Above mentioned general dentist had place a class II composite into the pulp a few months back and now was the tooth was abcessed. Bingo. A little extraction later and some plain ol' Amoxicillin and the kid was great! Pretty sad.
Emily

 

[omfsres]

The ID docs said that if he had gotten a dose of rocephin when he hit the ER he would probably still be alive. He ended up having Parvo Meningitis.

I'm not quite sure how rocephin could've prevented a parvovirus meningitis(just busting your chops), but I agree. I do think, however, if you have a specialist on board it might be wise to follow their recs instead of going out on your own. At this point standard of care comes into play. This is a blatant waste of public resources and could be cosidered medicaid fraud is this case. Especially in light of the OMS consult being present in the chart with the complete opposite of all recommendations done.

I treated this girl once she hit the floor. I had no knowledge of the consult at this time and diagnosed it from outside the room. Saw her this am and she is doing great. Facial swelling has decreased. She spiked a 100.8 fever about 2 hours after the procedure which I attributed to a trasient bacteremia. However my attending wants to keep her another day to rule out sepsis. I told him it was bogus but oh well. Blood cultures have been negative x 24 hours. Head CT revealed nothing(good call). They also have her on aqueous Pen G and Clinda per ID(covering the same bugs twice, another good call) against my recs. Man I think Darth Vader might have to choke a bitch after today.

 

[TucsonDDS]

I'm not quite sure how rocephin could've prevented a parvovirus meningitis(just busting your chops), but I agree. I do think, however, if you have a specialist on board it might be wise to follow their recs instead of going out on your own. At this point standard of care comes into play. This is a blatant waste of public resources and could be cosidered medicaid fraud is this case. Especially in light of the OMS consult being present in the chart with the complete opposite of all recommendations done.

I treated this girl once she hit the floor. I had no knowledge of the consult at this time and diagnosed it from outside the room. Saw her this am and she is doing great. Facial swelling has decreased. She spiked a 100.8 fever about 2 hours after the procedure which I attributed to a trasient bacteremia. However my attending wants to keep her another day to rule out sepsis. I told him it was bogus but oh well. Blood cultures have been negative x 24 hours. Head CT revealed nothing(good call). They also have her on aqueous Pen G and Clinda per ID(covering the same bugs twice, another good call) against my recs. Man I think Darth Vader might have to choke a bitch after today.

Yeah, I agree with you that many, many times people are mistreated (either over or undertreated) in the hospital. The problem is that attendings don't like to listen to residents or other providers. We have a couple of shi**y attendings and residents (more like hundreds) at the hospital I work at. Some of them I hate working with. Then again we also have some excellent docs that I would trust my kids lives with in a heartbeat. Sounds like you are going to be in the latter bunch. Just keep standing up to the attendings and looking after your patients and nurses like me will love working with you.

You got me thinking on the parvovirus? I could have swore that was what he ended up having but as you said the rocephin wouldn't make sense. Oh well, whatever it was it sucked.

 

[toofache32]

I got consulted on a Saturday by a pediatric dental resident at the Chirren's Hospital. He said this 6-year-old kid was admitted to the medicine service on Tuesday with left cheek swelling. Pediatric dental got on board Wednesday. They called us (OMS) on Saturday after 4 days of Clinda, a CT Head, and a f'in lumbar puncture complete with neurosurgery consultation (huh?). They said the swelling wasn't getting any better. I look in his mouth and see that #H is a root tip. I yank it, did an I&D, and placed a drain at bedside. He looked fine the next morning and we pulled the drain and sent him home.

I still don't get the LP.

 

[Jediwendell]

Oh no my friends. Despite my best efforts (including completing an OMFS consult) this pt is "toxic" and admitted for IV abx, head CT with and without, blood cultures, and labs. I told the first attending that the case was being overtreated, the kid did not need admission, and did not need to be irradiated like a Chernobyl cockroach. She brushed me off, said that the ID people disagreed (they haven't even seen the pt!), and that OMFS would get involved later. The second attending later told me he was willing to following my recommendations but couldn't argue with the first lady.

Probably a little MRB for the peds residents. They were pretty weak on my peds rotation, too.

 

[Jediwendell]

I got consulted on a Saturday by a pediatric dental resident at the Chirren's Hospital. He said this 6-year-old kid was admitted to the medicine service on Tuesday with left cheek swelling. Pediatric dental got on board Wednesday. They called us (OMS) on Saturday after 4 days of Clinda, a CT Head, and a f'in lumbar puncture complete with neurosurgery consultation (huh?). They said the swelling wasn't getting any better. I look in his mouth and see that #H is a root tip. I yank it, did an I&D, and placed a drain at bedside. He looked fine the next morning and we pulled the drain and sent him home.

I still don't get the LP.

So which residency are you at?

 

[toofache32]

So which residency are you at?

Parkland

 

[Jediwendell]

Parkland

That's what I thought. I appologize as a Baylor pedo grad for any ******ed resident you had to deal with. Was the kid medically compromised or anything? All I know is I would have gotten my ass chewed out by the director for letting a kid go that long while I was there and missing a root tip. Yikes. Did they think something else was wrong? Oh well hopefully that didn't scar you for life on us. I usally tried to keep you uninvolved, especially for infections, as I kinda knew firsthand how much crap you guys go through when you're on call. SORRY!
Emily

 

[toofache32]

That's what I thought. I appologize as a Baylor pedo grad for any ******ed resident you had to deal with. Was the kid medically compromised or anything? All I know is I would have gotten my ass chewed out by the director for letting a kid go that long while I was there and missing a root tip. Yikes. Did they think something else was wrong? Oh well hopefully that didn't scar you for life on us. I usally tried to keep you uninvolved, especially for infections, as I kinda knew firsthand how much crap you guys go through when you're on call. SORRY!
Emily

Oops, I didn't mean to name the program, but I guess you're the one who did. I actually have a lot of fun working with them, but this one threw me for a loop. I really like the female attending I see at Chirren's Hospital, but I can't think of her name...it starts with a "W"?

They knew the root tip was the source, but they were just going along with the medicine docs to treat with antibiotics only.

 

[Jediwendell]

Oops, I didn't mean to name the program, but I guess you're the one who did. I actually have a lot of fun working with them, but this one threw me for a loop. I really like the female attending I see at Chirren's Hospital, but I can't think of her name...it starts with a "W"?

They knew the root tip was the source, but they were just going along with the medicine docs to treat with antibiotics only.

That would be Carolyn Wilson. She is great and has a wonderful personality. You probably see Zurn some around too. God I don't miss that ED one bit (busiest children's ED in the country, thank you very much). I'm happy to know my program didn't start slacking off, and the peds people there have always been admit happy. We always stole them before they had a chance and shucked the teeth in our little room on the 4th floor!