IM or Peds case?

[JR]

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Hello everyone,

I am a preliminary medicine intern who just got home from a 30-hr shift last night. I had a very interesting admission dilema last night and I'd like to ask your opinions on it. At about 9 pm I was called down to the ER for a 19 yo male with h/o brain tumor (germinoma) at the age of 10 s/p resection and VP shunt in another country who came in r/o meningitis vs. IC mass. vs. etc., etc. When I walked in the room, the kid had an appearence of a 11 year old with body weight of 36 kilos. Per mom, he regularly sees an outside pediatrition and has been addmitted to local children's hospital multiple times. On exam, he looked moderately stable although his BP was on the lower side, he was more altered from his baselline and I was worried he may go south at any moment.

With all honesty, I did not feel comfortable taking care of this pt- even though he was 19, he clearly was a pediatric pt in my mind. All I could think about was if he gets worse, how do I intubate? what fluids does he need? how do i dose his pressors, etc, etc. And then there is a legal aspect- I am not PALS certified. Me and a senior resident decided to call Peds on call at our hospital- she laughed us off right off the bet: "19? WTF? Don't call me with that...". Now, we are at a small community hospital; one occasional problem we have is lack of adequate subspeciality support; we only have residents for g. surg and medicine in-house and only attending coverage for other services.

At this point, we decided to call Nurosurgery on-call to see if we can get help with tapping the kid (with h/o VP shunt and all). The on-call person was not really helpful: "Little kid w/VP shunt? WTF? He needs peds neurosurg...".

It was about 2 am at this point. The kids neck is getting a littile stiffer now, he is still altered, BP holding OK. My resident had a bright idea to call the local children's hospital to see if they can take a transfer. The attending who called back was actually really nice and agreed to take the transfer via ACLS ambulance granted that CT head was negative (it was).

Now, what do you guys think of this: peds case or medicine?

 

[GeneGoddess]

I would think pedi, since age is so arbitrary. Of course, I also think that there are some pedi problems that may be much better managed by medicine interns. However, if it was just because he was SMALL, I think more medicine. Don't you dose a 99yo 80lb LOL differently than a 300lb 25yo linebacker?

 

[JR]

I would think pedi, since age is so arbitrary. Of course, I also think that there are some pedi problems that may be much better managed by medicine interns. However, if it was just because he was SMALL, I think more medicine. Don't you dose a 99yo 80lb LOL differently than a 300lb 25yo linebacker?

What happened to "kids are not little adults"?

 

[GeneGoddess]

They aren't. A neonate or a three year old are not little adults. But when you get to post-pubertal kiddos, the lines get blurred. What makes a 17.9yo a kid and a 18.0yo an adult? It sounds like this patient is a small adult who had a (more commonly) pedi issue. I've also seen adults (in their 30's) with PKU who get Pedi consults because the Medicine interns weren't sure about PKU. And I've seen Pedi consult Medicine when a kiddo has a rare thing in kids (but common in adults). Heck, in pedi/genetics I've treated multiple generations at once.

 

[JR]

They aren't. A neonate or a three year old are not little adults. But when you get to post-pubertal kiddos, the lines get blurred. What makes a 17.9yo a kid and a 18.0yo an adult? It sounds like this patient is a small adult who had a (more commonly) pedi issue. I've also seen adults (in their 30's) with PKU who get Pedi consults because the Medicine interns weren't sure about PKU. And I've seen Pedi consult Medicine when a kiddo has a rare thing in kids (but common in adults). Heck, in pedi/genetics I've treated multiple generations at once.

Maybe I did not express myself clearly. This was not a small adult, this was a child who happened to be 19 chronologically. I looked at his CXR myself, all his bones looked like those of a 10 yo child. My point here is: we did not work so hard for 6 hrs in the middle of the night bc we didn't want to admit the pt; we did that bc we thought this was in his best interest.

I agree with you that we shouldn't just use age as a cut off. I have taken care of 15 year olds who looked 25 on an adult ward. In this case, I was just very surprised with pediatritian resistance to even look at this pt.

Oh, btw, he had Medical (Medicaid outside CA). That was probably the major obsticle.

 

[14022]

Peds vs adult is not the issue. The issue is who will give this person the best chance of surviving. Here is a good example. A person came into the university hospital in severe heart failure. He was a 30 year old male who was born with tricuspid atresia (essentially a univentricular heart- only the left ventricle is functional) and had a Fontan procedure (where they connect the SVC directly to the pulmonary arteries to bypass the right heart) as an infant. He hadnt seen a doctor in 9 years. When they brought this guy in, they did an echo and found a thrombus in the pulmonary artery. Although this guy was 30 (with every feature of a 30 year old) the adult cardiologists could not figure out this guy's anatomy. They got the peds cards doc from the children's hospital across the street to come over and cath the guy to figure out what they should do. Even though the pediatric cardiologist had probably never treated a 30 year old in his life, he was the most suitable person to take care of him since his knowledge of congenital heart disease blows that away of any adult doctor.

In the OP's case, I would think that a community hospital should be able to take care of fairly common problems in both kids and adults meningitis may not be extremely common, but the algorithm for managing this condition is well defined). Even if they cannot, I think it is ridiculous that the neurosurgeon didnt tap this person. He worked with kids at some point in his training and should be able to do a simple tap on a "10 year old." There are plenty of adult females towering at 4'10" 95 pounds, that are the size of some ten year olds out there that would surely be treated by an adult doctor. Granted they cannot take care of all of his problems, but a simple tap and culture/chemistries is warranted to get a proper diagnosis. They could transfer him after the tap and have a diagnosis by the time he gets to the children's hospital, hastening his treatment and recovery. Bacterial meningitis can be horrible if not diagnosed in a timely manner. He could die in transfer if nothing was done for him. Please tell me you at least got IV access and put him on empirical antiobiotic therapy prior to transfer.

Maybe I did not express myself clearly. This was not a small adult, this was a child who happened to be 19 chronologically. I looked at his CXR myself, all his bones looked like those of a 10 yo child. My point here is: we did not work so hard for 6 hrs in the middle of the night bc we didn't want to admit the pt; we did that bc we thought this was in his best interest.

I agree with you that we shouldn't just use age as a cut off. I have taken care of 15 year olds who looked 25 on an adult ward. In this case, I was just very surprised with pediatritian resistance to even look at this pt.

Oh, btw, he had Medical (Medicaid outside CA). That was probably the major obsticle.

 

[JR]

Peds vs adult is not the issue. The issue is who will give this person the best chance of surviving. Here is a good example. A person came into the university hospital in severe heart failure. He was a 30 year old male who was born with tricuspid atresia (essentially a univentricular heart- only the left ventricle is functional) and had a Fontan procedure (where they connect the SVC directly to the pulmonary arteries to bypass the right heart) as an infant. He hadnt seen a doctor in 9 years. When they brought this guy in, they did an echo and found a thrombus in the pulmonary artery. Although this guy was 30 (with every feature of a 30 year old) the adult cardiologists could not figure out this guy's anatomy. They got the peds cards doc from the children's hospital across the street to come over and cath the guy to figure out what they should do. Even though the pediatric cardiologist had probably never treated a 30 year old in his life, he was the most suitable person to take care of him since his knowledge of congenital heart disease blows that away of any adult doctor.

In the OP's case, I would think that a community hospital should be able to take care of fairly common problems in both kids and adults meningitis may not be extremely common, but the algorithm for managing this condition is well defined). Even if they cannot, I think it is ridiculous that the neurosurgeon didnt tap this person. He worked with kids at some point in his training and should be able to do a simple tap on a "10 year old." There are plenty of adult females towering at 4'10" 95 pounds, that are the size of some ten year olds out there that would surely be treated by an adult doctor. Granted they cannot take care of all of his problems, but a simple tap and culture/chemistries is warranted to get a proper diagnosis. They could transfer him after the tap and have a diagnosis by the time he gets to the children's hospital, hastening his treatment and recovery. Bacterial meningitis can be horrible if not diagnosed in a timely manner. He could die in transfer if nothing was done for him. Please tell me you at least got IV access and put him on empirical antiobiotic therapy prior to transfer.

yes, we did.

 

[J-Rad]

"Even though the pediatric cardiologist had probably never treated a 30 year old in his life"

Just a note: pediatric cardiologists see adults pretty frequently. As you noted adult cards doesn't do well w/ congenital heart dz. And these kids now live well into adulthood.