Children Are Dying in Ill-Prepared Emergency Rooms Across America

[Kryptocoin]

I hate chronic pain patients coming into the ED. They say they are allergic to nsaids and want iv meds.

did they send them home with opiates?

Yup, after loading them up in the ER.

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[Brigade4Radiant]

Yup, after loading them up in the ER.

Dang I do sometimes just give a Percocet in the Ed since I need to keep my press Haney in check and doing that has kept my scores high

 

[Mount Asclepius]

They used to ding us if we didn’t make everyone’s pain 0 out of 10, and now they ding us if we ever give an opioid ever.

Regulation and metrics are making medicine worse. Sure there are bad doctors. And we should try to set the bar high so that everyone gets high quality care. Strict admission standards already accomplished that.

What people don’t understand is that outcomes aren’t guaranteed. People aren’t cars. You can’t just change the oil every so often and replace the transmission at some point to keep the car running. You can practice perfect medicine and people still get sicker and die. Medicine is an art. Life isn’t guaranteed America. Count your blessings. You aren’t suffering in Gaza. Our entitlement culture has to change.

 

[Birdstrike]

Of course children are dying in ill-prepared EDs across America. They always have. Like anything else, the fix is going to involve resources, such as extra staff, equipment, training, medications and dedicated facilities. But since critically ill and injured children are a very small percentage of patients, it's not PROFITABLE to the businessmen of Medicine to do commit the money and resources. Therefore it's not going to get done.

Of course the American media will, as always, blame the doctors saying they're stupid, ill-trained, greedy and don't care, while completely ignoring the actual source of the problem.

 

[TooMuchResearch]

Anyone who gives narcotics for migraine or non-traumatic back pain at my current job gets peer-reviewed. We had a few doctors (most were non-EM trained) in the past that were pretty liberal with opiates for headache and back pain and it turned the ER into a pain clinic.

I can fix basically every headache without opioids. I don't have the same success rate with back pain, and I don't feel bad about giving people a dose of an opioid to get them mobile enough to sleep in their own bed.

 

[RoyBasch]

But since critically ill and injured children are a very small percentage of patients, it's not PROFITABLE to the businessmen of Medicine to do commit the money and resources. Therefore it's not going to get done.

This is it right here. Any low volume pathology is going to suffer the same fate.

 

[wamcp]

Not the USA, but wondering what is the differential for something missed here in an 11 year old.

11 yr old girl sent home for “constipation”…dies hours later.

Some kind of missed perforated viscus? And…ick…too young for an ectopic pregnancy problem right?

Schoolgirl sent home from A&E after docs say she has constipation dies next day

Annabel Greenhalgh, 11, was discharged from hospital after A&E doctors said she had constipation - but just hours later, her dad found her unresponsive at home

www.mirror.co.uk

 

[JacobMcCandles]

Not the USA, but wondering what is the differential for something missed here in an 11 year old.

11 yr old girl sent home for “constipation”…dies hours later.

Some kind of missed perforated viscus? And…ick…too young for an ectopic pregnancy problem right?

Schoolgirl sent home from A&E after docs say she has constipation dies next day

Annabel Greenhalgh, 11, was discharged from hospital after A&E doctors said she had constipation - but just hours later, her dad found her unresponsive at home

www.mirror.co.uk

Anything you read in the news will be woefully lacking in actual details. It’s always sad when a child loses their life. The fact that the article said she suffered severe abdominal pain from 2017 to 2021 tells you there is much, much more to this story.

 

[BoardingDoc]

And…ick…too young for an ectopic pregnancy problem right?

I have no idea why you would assume an 11 year old is too young for an ectopic pregnancy. To be clear, I'm not saying I'm ok with that reality on any personal / ethical / parental / whatever level. I'm saying that I accept that it's a reality that occurs.

That said, as pointed out by @JacobMcCandles it seems there's likely a complex medical history at play given the reported several years of abdominal pain and hospitalizations.

 

[WilcoWorld]

The A&E doc might've had the right diagnosis at the time:

Tension Pneumoperitoneum Caused by Obstipation - PubMed

Emergency physicians are often required to evaluate and treat undifferentiated patients suffering acute hemodynamic compromise (AHC). It is helpful to apply a structured approach based on a differential diagnosis including all causes of AHC that can be identified and treated during a primary...

pubmed.ncbi.nlm.nih.gov

Fatal Abdominal Compartment Syndrome Due to Constipation: A Case Report - PubMed

Severe constipation is a rare cause of ACS, and there is a lack of evidence-based guidelines. Options for bedside decompression are limited. To reduce morbidity and mortality in this population, early recognition of ACS is imperative. Initial interventions should support hemodynamics and...

pubmed.ncbi.nlm.nih.gov

 

[Arcan57]

I have no idea why you would assume an 11 year old is too young for an ectopic pregnancy. To be clear, I'm not saying I'm ok with that reality on any personal / ethical / parental / whatever level. I'm saying that I accept that it's a reality that occurs.

That said, as pointed out by @JacobMcCandles it seems there's likely a complex medical history at play given the reported several years of abdominal pain and hospitalizations.

"Chronically ill child dies" doesn't hit quite the same way from a headline standpoint.

Doesn't make it ok either.

 

[Angry Birds]

The most shocking thing of this thread has been IM docs copying ER notes. Our notes look like nursing triage notes compared to theirs. I would consult hospitalists for an H&P if I could and bill it as their procedure.

 

[Janders]

The most shocking thing of this thread has been IM docs copying ER notes. Our notes look like nursing triage notes compared to theirs. I would consult hospitalists for an H&P if I could and bill it as their procedure.

It’s even better when they grab my extra stream of consciousness partially incorrect DRAFT HPI and make it theirs

(Again, most that I work with will quote a portion, especially ems / snf report / family that left, and attribute as such. This is great. A few just paste my drivel, add nothing, and complete their note. 🤷‍♂️)

 

[Socrates25]

As an outsider I have a different perspective here. I am med/peds residency trained but once I finished residency decided to stick with kids because I like them a lot more than adults.

Anyways, critically ill peds patients are on a steep decline over the last 20 years and the results are making even peds residents far less skilled in treating them.

Example: I had 3 PICU rotations during residency, and I did a total of 15 intubations across all 3 months. 25 years ago residents during PICU rotations would have easily quadrupled that number. Furthermore only had 8 codes in those 3 months.

In comparison with my 3 MICU rotations I had over 50 intubations across those months and 40+ codes.

Now with the new RSV biologic beyfortus staring to become mainstream, the number of critically ill kids will fall much further.

In my private practice peds practice in the last 10 years I have only had to send 4 patients to the ER. That's a far lower ratio than what happened 30+ years ago when sending kids to the ER directly from clinic was WAY more common.

It's a good thing that the number of seriously sick kids is decreasing, but it also raises a conundrum because there's good arguments to be made that the lack of exposure/training on critically sick kids is causing the existing critical patients to get substandard care.

Suppose you have a 5 day old infant show up in the ER with poor feeding, fussy/crying, etc but with no fever and with normal vital signs and normal exam other than being "fussy." How many of you would put that kid in sepsis protocol and be suspicious of meningitis?

 

[BoardingDoc]

Suppose you have a 5 day old infant show up in the ER with poor feeding, fussy/crying, etc but with no fever and with normal vital signs and normal exam other than being "fussy." How many of you would put that kid in sepsis protocol and be suspicious of meningitis?

Meningitis is always on the ddx for any kid <90 days old in the ER. Doubly so for < 30 days. That said, normal VS and normal exam besides "fussy" equals discharge with good return instructions and PCP followup. Are you suggesting that we LP these kids?

 

[TooMuchResearch]

Agreed. Normal vital signs no fever no concerning rash means call your clinic in the AM for a recheck.

 

[Socrates25]

Meningitis is always on the ddx for any kid <90 days old in the ER. Doubly so for < 30 days. That said, normal VS and normal exam besides "fussy" equals discharge with good return instructions and PCP followup. Are you suggesting that we LP these kids?

No I'm suggesting the line between normal baby and critically ill baby is razor thin. I've had 500 babies who had those symptoms and were completely fine. But I had one that went from "fussy" to refusing to eat at all to "irritable" within 2-3 hours and nearly died from group B strep meningitis, despite the fact that never had a fever and vitals were normal all the way up until the moment he had a seizure.

The line between "fussy" and "irritable" is hard to distinguish. Of course all babies cry sometimes but this baby went from normal fussy to truly irritable within a very short period of time. Infants, especially newborns with true irritability need an LP every single time, regardless of vitals or fever. Even pediatricians or peds EM docs with 20 years experience can have trouble picking up that difference.

 

[TelemarketingEnigma]

As an outsider I have a different perspective here. I am med/peds residency trained but once I finished residency decided to stick with kids because I like them a lot more than adults.

Anyways, critically ill peds patients are on a steep decline over the last 20 years and the results are making even peds residents far less skilled in treating them.

Example: I had 3 PICU rotations during residency, and I did a total of 15 intubations across all 3 months. 25 years ago residents during PICU rotations would have easily quadrupled that number. Furthermore only had 8 codes in those 3 months.

In comparison with my 3 MICU rotations I had over 50 intubations across those months and 40+ codes.

Now with the new RSV biologic beyfortus staring to become mainstream, the number of critically ill kids will fall much further.

In my private practice peds practice in the last 10 years I have only had to send 4 patients to the ER. That's a far lower ratio than what happened 30+ years ago when sending kids to the ER directly from clinic was WAY more common.

It's a good thing that the number of seriously sick kids is decreasing, but it also raises a conundrum because there's good arguments to be made that the lack of exposure/training on critically sick kids is causing the existing critical patients to get substandard care.

Suppose you have a 5 day old infant show up in the ER with poor feeding, fussy/crying, etc but with no fever and with normal vital signs and normal exam other than being "fussy." How many of you would put that kid in sepsis protocol and be suspicious of meningitis?

i've had similar thoughts when it comes to codes so far as a med peds resident. I've cared for a lot of sick kids, but for whatever reason I have yet to actually be present for a true cardiac arrest/respiratory arrest where more than like 10 seconds of CPR had to be done. this is at a major children's hospital with a lot of crazy pathology. I'd say it's true of the majority of my peds co-residents, I expect that many will graduate without ever having run a code themselves (in part because the PEM or PICU attendings/fellows would be running the ones that do happen). meanwhile over on the medicine side we've all been involved in dozens of codes at least and running codes is an expectation for residents.

Because we're a big hospital we do get the benefit of seeing a lot of critically ill kids, but something i've found interesting in the PICU is that kids can be sick as ****, but because kids are so resilient and have fewer comorbidities it rarely feels like we're managing an actively crashing patient for hours the way we do in the ICUs on the adult side. The decompensations happen rapidly in the field/ED (or on the floor) and then once they get to the ICU and intubated/on ECMO/whatever they just linger for days or weeks or months while we make little titrations on their vent or pressors or antibiotics. I've described so many of our patients on hand off as "stably incredibly sick"

 

[larpleston]

As an outsider I have a different perspective here. I am med/peds residency trained but once I finished residency decided to stick with kids because I like them a lot more than adults.

Anyways, critically ill peds patients are on a steep decline over the last 20 years and the results are making even peds residents far less skilled in treating them.

Example: I had 3 PICU rotations during residency, and I did a total of 15 intubations across all 3 months. 25 years ago residents during PICU rotations would have easily quadrupled that number. Furthermore only had 8 codes in those 3 months.

In comparison with my 3 MICU rotations I had over 50 intubations across those months and 40+ codes.

Now with the new RSV biologic beyfortus staring to become mainstream, the number of critically ill kids will fall much further.

In my private practice peds practice in the last 10 years I have only had to send 4 patients to the ER. That's a far lower ratio than what happened 30+ years ago when sending kids to the ER directly from clinic was WAY more common.

It's a good thing that the number of seriously sick kids is decreasing, but it also raises a conundrum because there's good arguments to be made that the lack of exposure/training on critically sick kids is causing the existing critical patients to get substandard care.

Suppose you have a 5 day old infant show up in the ER with poor feeding, fussy/crying, etc but with no fever and with normal vital signs and normal exam other than being "fussy." How many of you would put that kid in sepsis protocol and be suspicious of meningitis?

Back of the envelope math:

50 codes in your 3 months in ICU. You weren’t there 24/7, so let’s say 75 codes. That’s almost 6 a week. That ICU is being criminally mismanaged and probably needs to be shut down. Same for 40 intubations. Fellows and other residents were there as well. So 100 tubes in 3 months. An intubation every day? Are people getting extubated without SBTs or does bipap not exist there?

And 15 tubes just for you in 3 months of PICU. And 8 codes. Even more since they happened when you weren’t there. Many peds residents do 0 tubes and never see a code.

I know you’re presenting these numbers as “low” but they are actually disturbingly high. Was Christopher Duntsch your ICU attending?