Peds ED management . .

[Homunculus]

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When you give a kiddo with RAD/Asthma albuterol nebs, and his sats get worse, please don't call the peds team and tell us "we have to admit because he/she is getting worse". give it some time. this is normal. 🙂

When a kiddo comes in with a fever, no tachypnea, no supplemental O2 requirement, no lung findings on PE, please don't get a CXR. 🙂

When a healthy looking kiddo comes in vomiting without a fever, don't get a blood culture. 🙄

When a kiddo has a diff of 81 segs, 4 bands, and 15 lymphs, it is *not* left shifted. Do not attempt to tell me a "left shift" is a predominance of neutrophils. I will laugh at you. 😛

just venting and attempting to unload some of the shotguns i've seen over the past few weeks, lol

--your friendly neighborhood consulting caveman

p.s. don't take any of this personally-- i deal mainly with attendings who probably aren't keeping up with the times. y'all aren't the problem 😎

 

[tonem]

To quote a wise man: Fatty McFattypants

p.s be wary of fleece wearing people that say "kiddo"

 

[kungfufishing]

To quote a wise man: Fatty McFattypants

p.s be wary of fleece wearing people that say "kiddo"

before this ball gets rolling....
homonculus is a good guy, he's not a troll. I mean, venting these things in an EM forum on the one hand risks a barrage of criticism, but on the other hand is a lot manlier (a word? a sexist? how about "of stronger character") than contributing to "the ED sucks, buncha monkeys, those idiots didnt even look for vonmecklingschnauzer colonopathy!" threads/discussions in other forums. You might or might not agree with the guy, but he isnt a trolling A-hole.

 

[edinOH]

When you give a kiddo with RAD/Asthma albuterol nebs, and his sats get worse, please don't call the peds team and tell us "we have to admit because he/she is getting worse". give it some time. this is normal. 🙂

When a kiddo comes in with a fever, no tachypnea, no supplemental O2 requirement, no lung findings on PE, please don't get a CXR. 🙂

When a healthy looking kiddo comes in vomiting without a fever, don't get a blood culture. 🙄

When a kiddo has a diff of 81 segs, 4 bands, and 15 lymphs, it is *not* left shifted. Do not attempt to tell me a "left shift" is a predominance of neutrophils. I will laugh at you. 😛

just venting and attempting to unload some of the shotguns i've seen over the past few weeks, lol

--your friendly neighborhood consulting caveman

p.s. don't take any of this personally-- i deal mainly with attendings who probably aren't keeping up with the times. y'all aren't the problem 😎

<A sigh while shaking my head>

I would expect better from an "administrator". 🙁

 

[southerndoc]

There are some places that consider >70% segs as a left shift, no matter what the number of bands present.

What happens when there is a significant bandemia that happened 3 days ago and now the patient presents with 92% segs and 0 bands? Is it no longer a left shift because there are no bands? Does this make the patient less sick?

I have traditionally been taught that only significant bandemias are considered a left shift.

 

[ERMudPhud]

If 'munc follows his stated career goal into Peds-EM he will have to do a month or two of adult EM and then we'll all have plenty of chances to give him some "advice." Until then we can cut him some slack. He must be having a bad month

In the meantime if you're like me you can recall seeing the few adult patients who wondered into the children's ED by mistake when you rotated there. The peds people were afraid to touch them. I also seemed to see all the teens with gyn problems. My top three:

An acute MI: You should have seen the whole place scrambling to find aspirin and nitro when I said, "yep she's having the big one"

SVT: I had to beg the attending and point out that it really wasn't any different from the peds version of the disease before they would let me push adenosine.

Etoh withdrawl: The drunk actually claimed the community hospital up the street told him to come to Children's for his DT's

To add to 'munc's list, if you don't want a serious yelling at then always culture the urine. It seems to be the only thing that can get a pediatrician (generally nice people) seriously pissed off.

 

[beyond all hope]

1) We admit kids for asthma obs all the time, whereas adults almost always go home. I don't know if there is any EBM to support this. And yes, sats dropping can be pretty scary if you're taking care of 15 kids at the same time, even though it may be a known phenomenon.

2) How many pneumonias have you missed on little kids? I've probably missed a few, and caught a few on CXR that I missed clinically. I just missed one the other day on an ADULT. Listened to him three times, and so did my attending. Can't get good breath sounds on 4 month olds. I agree they're usually febrile or tachypneic, but sometimes tachycardia is your only clue. Also, frequently when I'm admitting I get ancillary studies that I don't feel like I need myself (CXR, CBC, BMP) but I do it for my consultants who seem to like them.

3) Define vomiting. Spitting up with milk rolling down your chin, or projectile vomiting green stuff across the room? I might culture the second before I get studies/call surgeons.

4) Left shift is defined by some as >70% segs. I agree that it's pretty soft but since I'm not aware of any EBM that defines what a left shift truly is than it's hard to criticize.

We all need to vent, but it's easy to criticize the first doc to see a patient. As one of my attendings says, the last doc to see a patient is always the smartest.

 

[mikecwru]

As one of my attendings says, the last doc to see a patient is always the smartest.

Unless the patient dies . . .

mike

 

[docB]

If a kid looks sick peds is getting a call. Sorry but that's how it is.

If you guys don't want us calling you quit having your advice nurses and secretaries bounce everything that sounds sick or won't fit into the schedule into the ER.

On thing about consultants in general (from the perspective of the EP) is that they feel free to gripe when a borderline case comes in, does well and goes home happy the next day. They also feel free to testify for the plaintiff when a borderline goes home and goes bad. "If only the ER doc had told me how sick the patient was I certainly would have come in. Please drop my name from the suit."

One of the old guys in my group who does a lot of expert witnessing told me that getting sued is what it is but there are only two ways to immediately end your career: miss the big MI in a youg person or kill a kid.

 

[Homunculus]

so yeah-- not quite the reaction i was expecting. stirred up a bit of a hornet's nest, didn't i? 😀

if i offended anyone, i apologize. i figured as much as y'all mercilessly rib the IM folks, you'd be big enough to take a little good natured ribbing of your own. apparently i was wrong. 😛 maybe you guys didn't read the "don't take any of this personally" line at the end. should have known with all yer ADHD personalities you wouldn't read the entire post, lol (it's a JOKE!!).

you can pick nitpick my complaints and find theoretical counterarguments to them if you want, but i still stand by them. they're my current pet peeves, which i'm sure will be replaced with new ones in a few months. 😀

i see complaints about consultants "not wanting to work"-- then when i get consulted i see a blank chart with "Assessment: peds consult" written on it. 🙁

i see complaints about "too many lab tests" being ordered on inpatient services, then see willy nilly shotgunning of every kid that walks in the door with blood cultures, chest films, and ceftriaxone. (not a knock on rocephin-- that's some good **** qd IM dosing > all )

i see complaints about "treating numbers" then have people try to use some fringe definition of "left shift" or a transient decrease in sats on an asthmatic to get me to admit a patient. your mind trick does not work on me. 😛

i understand the stress. i understand having to have dispostition in your mind within 5 seconds of seeing the patient. 😱 i understand having to get them admitted or discharged so you can see the next patient who may *really* be sick. all i'm saying is the door swings both ways.

besides, as a group peds are a fairly easy going bunch to consult. at least *i* think so. 😎

anyway, please realize these things do not apply to any of you-- it's teh few bad apples out there that i'm currently stewing about. like all things it will pass. unless one is constipated, which as a pediatrician i'm all too familiar with. 😳

anyway, y'all need to lighten up. isn't that supposed to be an ED thing? laid back and cool? 😎

as a sidenote, i have been considering peds EM for awhile-- which is still up in the air. the military currently doesn't authorize peds EM so it will be awhile before i can do it if i do decide on it. i did an adult EM block back in the winter and actually found it enjoyable-- except for the gomers and drug seekers it was a good time. I definitely like peds better though, and give you guys props for putting up with the ED BS day in and day out.

--your friendly neighborhood going back to his cave now caveman