No emergencies in pediatric ''emergency'' medicine?

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Lexdiamondz

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Mostly a rant but I feel as if a depressingly large percentage of presentations to the peds ED are just cases of parents who can't parent. Even moreso than on the adult side of things.

Just came off a 8hr shift in the peds ED and the last 3 patients I saw had chief complaints of 'dry skin', 'running nose x 1d' and 'won't tie shoes'. The last parent though their 7 year old's refusal to tie shoes was 'new onset autism'.

I mean I guess I should be thankful the kids are okay and I havent had to code one in a few months but jeez this ESI 5 **** is soul crushing.
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I worked at a really large peds ED in part of my hospital back in the day as a non-physician. Let me tell you, the real emergencies with kids were terrifying. Not the sort of stuff that made my day, more like "I had no idea someone so small could bleed SO MUCH" kind of stuff. They were my least favorite ER shifts, because kids have so much less reserve. Whether they're bleeding, hypoxic, or septic, their vitals just move too fast and the decisionmaking was much less controlled, or so it felt to me at the time. There was so much more panic in general. 0/10, would not recommend.
 
Lexdiamondz said:
Mostly a rant but I feel as if a depressingly large percentage of presentations to the peds ED are just cases of parents who can't parent. Even moreso than on the adult side of things.

Just came off a 8hr shift in the peds ED and the last 3 patients I saw had chief complaints of 'dry skin', 'running nose x 1d' and 'won't tie shoes'. The last parent though their 7 year old's refusal to tie shoes was 'new onset autism'.

I mean I guess I should be thankful the kids are okay and I havent had to code one in a few months but jeez this ESI 5 **** is soul crushing.
Click to expand...

Add on to this that a majority of adult cases are simply cases of adults who can't adult, and you have 75% of the reason why I am Crispy.
 
but they “felt warm”!

I am old enough to say it was a lot more exciting (and scary) before HiB, Prevnar etc.

Epiglottitis, legit bacteremia etc

Rekt said:
Because 90% of peds that go to the ED are on medicaid. It cost the parent nothing except sitting the waiting room for hours to get Tylenol for their kids fever that started right before they came.
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Its not much better on the adult side for me. I haven't intubated an ER patient in 4-5 months. I have only admitted 2 patients to the ICU in the last 2 months. My admission rate has dropped from 25% down to 15% in the last 4-5 months.

I had a pt check in yesterday because the burger he ate was too hot and burned the top of his mouth, and thought it might be an allergic reaction. I had another who checked in because she said her belly button smelled bad. Another who claimed to be withdrawing from alcohol and needing ativan despite downing half a handle of vodka an hour before coming in. Another who stated "Give me 2mg of dilaudid for my headache or I will leave right now", she left immediately (amazingly other docs have been giving it to her). I'm just fed up with the job the last couple months. Feel like I need a change of scenery or maybe even a CC fellowship because I can't do this only seeing critical patients once a month. You would think a large volume referral center would supply such patients I am looking for, but it would appear not to be the case.
 
Other day I had a mom bring her seven children in requesting we test all of them for chlamydia so she could “prove to CPS their baby daddies (3 of them) were ****in around”

No symptoms or allegations of sexual assault. she just thought getting the test alone would prove that she alone should have parental rights, even if it was negative.
 
alpinism said:
Most Pediatric emergency departments are nothing but a giant scam and are built for no other reason than stealing money from the CHIP program.
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But what's the alternative? With Medicaid, they get seen for free, right away. Making doctor's office appointments takes time and planning. There is no disincentive to use the ER for every fever and runny nose.
 
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I get annoyed, but less of a big deal when I take it into context their adult (and most often young adult) counterpart. At least the majority of kids are just a history and exam, occasional tylenol/ibuprofen which is benign and relatively cheap, and I don't order the unnecessary CXR that my colleagues seem to love, compared to their adult counterpart who say enough (unrelated, and usually exagerated) symptoms that they get bunch of unecessary shotgun blood work, CTs of random parts which are a significant more cost drain and clog the throughput.
 
Rekt said:
Because 90% of peds that go to the ED are on medicaid. It cost the parent nothing except sitting the waiting room for hours to get Tylenol for their kids fever that started right before they came.
Click to expand...

"Oh, and can you write me a prescription for the Tylenol and Ibuprofen so Medicaid will pay for it?"

My first month when I transferred to my new program was Peds EM. Within the first 7 shifts I had diagnosed an 8 y/o with a medulloblastoma, and an 11 y/o with Leukemia. The nurses threatened to not work with me anymore.

Our campus is supposed to be "Women's and Children's", but a lot of people have figured out that there's relatively no wait compared to the other 2 campuses. Walk in on a Sunday morning to find only male patients. STD checks, fishhook removal, and other ESI 5 complaints. Attending says "Hey, call maintenance and tell them the WO is out on the sign, doesn't look like its says Woman's"

My personal favorite has to be the 20 something who came in with their mother because "I was sticking my tongue out and it hurts now", and then tries to show me a WebMD page... The MDM in that chart is a thing of beauty
 
CajunMedic said:
"Oh, and can you write me a prescription for the Tylenol and Ibuprofen so Medicaid will pay for it?"

My first month when I transferred to my new program was Peds EM. Within the first 7 shifts I had diagnosed an 8 y/o with a medulloblastoma, and an 11 y/o with Leukemia. The nurses threatened to not work with me anymore.

Our campus is supposed to be "Women's and Children's", but a lot of people have figured out that there's relatively no wait compared to the other 2 campuses. Walk in on a Sunday morning to find only male patients. STD checks, fishhook removal, and other ESI 5 complaints. Attending says "Hey, call maintenance and tell them the WO is out on the sign, doesn't look like its says Woman's"

My personal favorite has to be the 20 something who came in with their mother because "I was sticking my tongue out and it hurts now", and then tries to show me a WebMD page... The MDM in that chart is a thing of beauty
Click to expand...

At a women's & children's hospital? Fishhook removal should clearly be shown the door with the number for the nearest clinic unless you're bored & feeling charitable. I suppose you have to do an MSE on adult male patients and call 911 if it's indicated (which I expect anyone would do if they were at Target and some 24yo guy had anaphylaxis in front of them - at least I hope so).

But if they've got nothing emergent, here's the nearest UC's address bro: LMFGTFY
 
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CajunMedic said:
"Oh, and can you write me a prescription for the Tylenol and Ibuprofen so Medicaid will pay for it?"

My first month when I transferred to my new program was Peds EM. Within the first 7 shifts I had diagnosed an 8 y/o with a medulloblastoma, and an 11 y/o with Leukemia. The nurses threatened to not work with me anymore.

Our campus is supposed to be "Women's and Children's", but a lot of people have figured out that there's relatively no wait compared to the other 2 campuses. Walk in on a Sunday morning to find only male patients. STD checks, fishhook removal, and other ESI 5 complaints. Attending says "Hey, call maintenance and tell them the WO is out on the sign, doesn't look like its says Woman's"
Click to expand...
Kapi'olani Women's and Children's Hospital in Honolulu has an adult EM doc working in the ED due to the homeless guys that come in (regularly, and frequently).
 
GeneralVeers said:
But what's the alternative? With Medicaid, they get seen for free, right away. Making doctor's office appointments takes time and planning. There is no disincentive to use the ER for every fever and runny nose.
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You appoint @alpinism as the pediatric EM czar of America.
 
You can't expect to have the same acuity in what is essentially a 10k per year emergency department compared to a 60k per year emergency department with fast track and urgent cares siphoning off the level 4's and 5's.

I also think the constant argument about lazy, impatient patients going to emergency departments is nonsense. Working in a community where patients actually have ready access to primary care, I rarely see these sorts of patients. They come because our country doesn’t invest in its primary care infrastructure in most of the nation.
 
bravotwozero said:
You appoint @alpinism as the pediatric EM czar of America.
Click to expand...

There's a very simple and effective solution.

All ESI level 5 non emergency visits get charged a copay for using the ER as their PCP office.

It will never happen though because volumes would drop by 50% and Hospitals would lose millions of dollars.
 
DeadCactus said:
You can't expect to have the same acuity in what is essentially a 10k per year emergency department compared to a 60k per year emergency department with fast track and urgent cares siphoning off the level 4's and 5's.

I also think the constant argument about lazy, impatient patients going to emergency departments is nonsense. Working in a community where patients actually have ready access to primary care, I rarely see these sorts of patients. They come because our country doesn’t invest in its primary care infrastructure in most of the nation.
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Where I did residency the peds ER saw over 100K per year and the fellows still had to come to the adult ER to practice running codes.
 
alpinism said:
There's a very simple and effective solution.

All ESI level 5 non emergency visits get charged a copay for using the ER as their PCP office.

It will never happen though because volumes would drop by 50% and Hospitals would lose millions of dollars.
Click to expand...

I suspect based on current trends, low acuity Medicaid are not going to be worth the millions of dollars.

At least in my state is clamping down on Medicaid reinbursements, fining hospitals millions of dollars for "overordering" of tests and imaging based on their acutal ICD-10 codes. You can upgrade their ICD-10s and "complexity" but that is likely a band aid, and that is only their first step to not pay.
I doubt that is limited to my state and other state medicaid offices are going to look for other excuses to not pay.

At the end of the day it's better to get $0 (and no Press Ganey) than negative money from a Medicaid patient who is still going to dunk you on your PG because you didn't order enough tests.
 
Mad Jack said:
I worked at a really large peds ED in part of my hospital back in the day as a non-physician. Let me tell you, the real emergencies with kids were terrifying. Not the sort of stuff that made my day, more like "I had no idea someone so small could bleed SO MUCH" kind of stuff. They were my least favorite ER shifts, because kids have so much less reserve. Whether they're bleeding, hypoxic, or septic, their vitals just move too fast and the decisionmaking was much less controlled, or so it felt to me at the time. There was so much more panic in general. 0/10, would not recommend.
Click to expand...


As a PICU attending, I'd argue it's not that they have less reserve, it's actually that they have far more reserve but then fall off a cliff. Young hearts, young lungs and young kidneys are remarkably resilient, but will fool you into thinking they're okay when they aren't.
 
BigRedBeta said:
As a PICU attending, I'd argue it's not that they have less reserve, it's actually that they have far more reserve but then fall off a cliff. Young hearts, young lungs and young kidneys are remarkably resilient, but will fool you into thinking they're okay when they aren't.
Click to expand...
Maybe that's it, combjned with the fact that most kids weren't seeing us until they were *really* sick or injured when I would be involved
 
pkwraith said:
I suspect based on current trends, low acuity Medicaid are not going to be worth the millions of dollars.

At least in my state is clamping down on Medicaid reinbursements, fining hospitals millions of dollars for "overordering" of tests and imaging based on their acutal ICD-10 codes. You can upgrade their ICD-10s and "complexity" but that is likely a band aid, and that is only their first step to not pay.
I doubt that is limited to my state and other state medicaid offices are going to look for other excuses to not pay.

At the end of the day it's better to get $0 (and no Press Ganey) than negative money from a Medicaid patient who is still going to dunk you on your PG because you didn't order enough tests.
Click to expand...

You'd be surprised at how much the Children's Hospitals make off these patients.

It depends on the state but CHIP typically reimburses 80-120% of the hospital charges.

Your average pediatric ER visit costs next to nothing but will get charged hundreds of dollars.
 
Lexdiamondz said:
Mostly a rant but I feel as if a depressingly large percentage of presentations to the peds ED are just cases of parents who can't parent. Even moreso than on the adult side of things.

Just came off a 8hr shift in the peds ED and the last 3 patients I saw had chief complaints of 'dry skin', 'running nose x 1d' and 'won't tie shoes'. The last parent though their 7 year old's refusal to tie shoes was 'new onset autism'.

I mean I guess I should be thankful the kids are okay and I havent had to code one in a few months but jeez this ESI 5 **** is soul crushing.
Click to expand...

I hear ya brother you are correct. 98% of kids don't need to be there.

The only thing I'll say is that the parents who bring their kids to the ED tend to use the ER a lot as adults. It's really an educational and partly social thing too.
 
alpinism said:
There's a very simple and effective solution.

All ESI level 5 non emergency visits get charged a copay for using the ER as their PCP office.

It will never happen though because volumes would drop by 50% and Hospitals would lose millions of dollars.
Click to expand...

All the crap we are ranting about on this thread pays us 20% of our salary and employs 20% more ER docs than we ought to need.

(I still grumble under my breath)
 
thegenius said:
All the crap we are ranting about on this thread pays us 20% of our salary and employs 20% more ER docs than we ought to need.

(I still grumble under my breath)
Click to expand...

It's the "loss of faith in humanity" that's the real drag. Sure; they're easy dispos, but it's the games they (the parents) play that are soul-sucking and make it "just not worth it".

Addendum:

To think that there's a sizable majority of parents out there who are too dumb to calculate a tylenol dose is the one item that really gets me.
I have had so many mommies look at me with complete confusion and mouth open when I walk them through how to calculate a dose.
They give up once they realize that they have to do TWO "math problems" (milligrams per kilogram, and then milligrams per milliliter) and realize that they can bring their kid to the ER for "free" to have the doctor do all the *maths* for them.

Too dumb to live, let alone reproduce. Wait...
 
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I hear you my internet friend. Do you expect to live in a society of 330,000,000 who all know how to do parenting with all the same level of awareness and risk-tolerance? Little to no variance?

It is soul sucking. They shouldn't reproduce. But what you gonna do. They shouldn't drive. They shouldn't smoke. They shouldn't swim in a pool unattended. They shouldn't join gangs. They should take their health seriously. They shouldn't believe that Tang is good for you. They should shower with a higher frequency than once/week.

But what you gonna do. Totally change jobs and work on Wall Street? This kind of stuff is everywhere. You can't avoid it unless you work off the grid.
I vent because it makes me feel good. But I also vent knowing that venting is probably not what I should be doing, I should have a different attitude towards work and I would be happier. I believe I would be happier but I'm afraid to change. I'm afraid to take on a new persona and "accept" their stupidity and work with them and spend time educating them.

I try to focus on the things that make me happy. My family (sometimes)... Grateful Dead. Driving fast on an empty road. Playing golf. And occasionally I have good shifts at work.

And BTW, I don't expect any of my patients to be able to calculate dosages using 9th grade math. I mean c'mon they are in the ED for an itchy tooth. Or a runny nose for 45 minutes. I tell them to just take whatever the bottle says.
 
RustedFox said:
It's the "loss of faith in humanity" that's the real drag. Sure; they're easy dispos, but it's the games they (the parents) play that are soul-sucking and make it "just not worth it".

Addendum:

To think that there's a sizable majority of parents out there who are too dumb to calculate a tylenol dose is the one item that really gets me.
I have had so many mommies look at me with complete confusion and mouth open when I walk them through how to calculate a dose.
They give up once they realize that they have to do TWO "math problems" (milligrams per kilogram, and then milligrams per milliliter) and realize that they can bring their kid to the ER for "free" to have the doctor do all the *maths* for them.

Too dumb to live, let alone reproduce. Wait...
Click to expand...

“The armed forces has done a lot of work on IQ starting back in 1919. The reason is because if there’s a war, you want to get qualified people into positions as rapidly as possible or you’ll lose. In the last 20 years, a law has passed that it is illegal to induct anyone into the armed forces with an IQ of less than or equal to 83. With an IQ that low, there isn't anything you could be trained to do in the military that isn’t positively counterproductive. You gotta think about that because the military is chronically desperate for people, not many people are lining up to be inducted; and from a policy perspective, they wanted to take people from the underclass and move them up to the working/middle class. With an IQ of equal to or less than 83, it’s just not happening. How many people is this? 10% of the population. If that doesn’t hurt you to hear, then you didn’t hear it properly. What that means is that in a complex society like ours, and one that is becoming increasingly complex, there isn’t anything for 10% of the population to do.”

 
WilcoWorld said:
[AHEM]
Click to expand...

That child looks critically ill in the photo. Pale, lip cyanosis, doesn't look well. I can only imagine how she looked in real life (limp, tachypneic, etc.). Anyone who cannot recognize that has a major problem identifying sick vs not sick and should not be practicing in an emergency setting.
 
southerndoc said:
That child looks critically ill in the photo. Pale, lip cyanosis, doesn't look well. I can only imagine how she looked in real life (limp, tachypneic, etc.). Anyone who cannot recognize that has a major problem identifying sick vs not sick and should not be practicing in an emergency setting.
Click to expand...
VA Hopeful Dr said:
Proof that there are emergencies in EM I'm guessing since that was cross-posted from the NP thread.
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Apollyon said:
Oh, when I hit the arrow, it just took me to the post. I thought it was elsewhere in this thread. My bad!
Click to expand...

@VA Hopeful Dr identified my intention: Peds EM isn't all sniffles and school notes. Yes, there's a higher proportion of the worried well than on the adult side, but when you get one of those sick kids you really need to be able to bring your EM A-game.
 
Experience with my own kids....they seem to go from "not sick looking" to "holy crap they are fixing to die" in 30 seconds flat.
 
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