PICU Problemz

[The Knife & Gun Club]

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So I’m covering our Neuro ICU on nights these days and got what has to be one of the strangest calls I’ve ever received last night.

PED calls requesting to admit a pregnant 16 year old in DKA to our adult NeuroICU because it was refused by picu and MICU. No Neuro complaints.

So I call PICU to see what the hell is up.

Hello? Is this PICU Fellow? Can you help me understand why you all are refusing to admit a kid to the peds ICU who’s in DKA?

Yea. She’s pregnant and our peds endocrinologist is uncomfortable managing pregnancy related DKA, and I am not comfortable admitting someone in DKA without endocrines help. It could be unsafe.

So you, a PGY6 pediatric intensivist, would rather have me, a PGY2 EM resident, take care of this person? With my at home attending, who is an adult neurologist, as primary?

Yes. It has already been decided. We formally refuse the admission…

So I call the director of the NSICU, at home, on a Saturday night at 3am. Her response, god love her, “just admit her and close the damn gap.”

Kid gets admitted, I close the gap, and she’s ready to go by morning. Am I crazy for thinking this is absurd that a PICU fellow doesn’t feel comfortable doing DKA without an endocrinologist? It seems absurd to me.

 

[Radetzky]

Absurd.

It is true though that they tend to let endo manage everything. I did some time in picu and got blasted for stopping regular gases and letting E+D a kid who had a normal ph “without talking to endo”

Still absurd

 

[Rekt]

Pediatrics destroyed themselves with the amount of handholding they force on their trainees throughout their residency and fellowships.

 

[Brigade4Radiant]

Pediatrics destroyed themselves with the amount of handholding they force on their trainees throughout their residency and fellowships.

Yeah it’s crazy if they push back when I try to transfer to a pediatric hospital (asthmatic who they think is “too sick”)

I remember that they require a three year hospital fellowship to take care of their floor patients.

Also they have made an urgent care fellowship because some peds leaders don’t think their graduates have the skills to do urgent care.

 

[Lexdiamondz]

So I’m covering our Neuro ICU on nights these days and got what has to be one of the strangest calls I’ve ever received last night.

PED calls requesting to admit a pregnant 16 year old in DKA to our adult NeuroICU because it was refused by picu and MICU. No Neuro complaints.

So I call PICU to see what the hell is up.

Hello? Is this PICU Fellow? Can you help me understand why you all are refusing to admit a kid to the peds ICU who’s in DKA?

Yea. She’s pregnant and our peds endocrinologist is uncomfortable managing pregnancy related DKA, and I am not comfortable admitting someone in DKA without endocrines help. It could be unsafe.

So you, a PGY6 pediatric intensivist, would rather have me, a PGY2 EM resident, take care of this person? With my at home attending, who is an adult neurologist, as primary?

Yes. It has already been decided. We formally refuse the admission…

So I call the director of the NSICU, at home, on a Saturday night at 3am. Her response, god love her, “just admit her and close the damn gap.”

Kid gets admitted, I close the gap, and she’s ready to go by morning. Am I crazy for thinking this is absurd that a PICU fellow doesn’t feel comfortable doing DKA without an endocrinologist? It seems absurd to me.

Welcome to pediatrics in 2021

The current state of that field is lamentable. 3 years of residency to learn how to consult, then required 3 yr fellowships learning how to punt consults.

I chose not to see kids as an attending, and attitudes like the one you experienced are a big reason why.

 

[Dr Mantis Toboggan]

So I’m covering our Neuro ICU on nights these days and got what has to be one of the strangest calls I’ve ever received last night.

PED calls requesting to admit a pregnant 16 year old in DKA to our adult NeuroICU because it was refused by picu and MICU. No Neuro complaints.

So I call PICU to see what the hell is up.

Hello? Is this PICU Fellow? Can you help me understand why you all are refusing to admit a kid to the peds ICU who’s in DKA?

Yea. She’s pregnant and our peds endocrinologist is uncomfortable managing pregnancy related DKA, and I am not comfortable admitting someone in DKA without endocrines help. It could be unsafe.

So you, a PGY6 pediatric intensivist, would rather have me, a PGY2 EM resident, take care of this person? With my at home attending, who is an adult neurologist, as primary?

Yes. It has already been decided. We formally refuse the admission…

So I call the director of the NSICU, at home, on a Saturday night at 3am. Her response, god love her, “just admit her and close the damn gap.”

Kid gets admitted, I close the gap, and she’s ready to go by morning. Am I crazy for thinking this is absurd that a PICU fellow doesn’t feel comfortable doing DKA without an endocrinologist? It seems absurd to me.

At my old academic hospital (a giant one) once you were pregnant you were considered an adult. That said that kid ending up in a neuro ICU was lame.

 

[Dr Mantis Toboggan]

Yeah it’s crazy if they push back when I try to transfer to a pediatric hospital (asthmatic who they think is “too sick”)

I remember that they require a three year hospital fellowship to take care of their floor patients.

Also they have made an urgent care fellowship because some peds leaders don’t think their graduates have the skills to do urgent care.

I wonder if that’s a job market decision on some level.

 

[Lexdiamondz]

Yeah it’s crazy if they push back when I try to transfer to a pediatric hospital (asthmatic who they think is “too sick”)

I remember that they require a three year hospital fellowship to take care of their floor patients.

Also they have made an urgent care fellowship because some peds leaders don’t think their graduates have the skills to do urgent care.

Unfortunately, neither do the NPs that are seeing these kids. I kid you not, I had a outpatient peds "provider" send a patient to the ED to "r/o Basilar skull fracture" because the kid hit his head in recess and had a runny nose the following day. Literal boogers in a 7 year old. In winter.

 

[Kryptocoin]

It happens in the community as well. Our peds don't admit kids that look even remotely sick. Just the worried wells. We transfer anything requiring tele.

Peds would have been the perfect field for midlevel takeover. Fortunately, it doesn't pay well so they don't care.

 

[Birdstrike]

"The invention of vaccines took all the fun out of pediatrics."- Dinosaur Pediatrician

 

[RustedFox]

Absurd.

It is true though that they tend to let endo manage everything. I did some time in picu and got blasted for stopping regular gases and letting E+D a kid who had a normal ph “without talking to endo”

Still absurd

What's E and D?

Sorry for being sense.

 

[RustedFox]

Congratulations to:

The Knife & Gun Club​

That DKA patient is now safer because you have treated her, saving her from the dip**** pediatric endowhateverist.
This is a rite of passage for you.

- and yet, we EM folk are the dumb@sses of the hospital, and have limited fellowship options.

 

[Jabbed]

I still remember my PICU rotation where I was taking care of a 300 lbs 17 year old who was in DKA for 72 hrs because nobody wanted to raise the insulin gtt higher than 0.05 units/kg/hr for fear of cerebral edema...

 

[turkeyjerky]

Lol. This is so f'ing crazy but completely believable at the same time.

 

[Radetzky]

What's E and D?

Sorry for being sense.

Eat and drink

 

[RustedFox]

Eat and drink

I meant to type *dense*.

Got autocorrected.

 

[RustedFox]

Yeah it’s crazy if they push back when I try to transfer to a pediatric hospital (asthmatic who they think is “too sick”)

I remember that they require a three year hospital fellowship to take care of their floor patients.

Also they have made an urgent care fellowship because some peds leaders don’t think their graduates have the skills to do urgent care.

Explain this?
You (a community doc) is transferring a pediatric asthmatic to a pediatric hospital... and the pediatric hospital is saying that they're "too sick"?

 

[RustedFox]

Yeah it’s crazy if they push back when I try to transfer to a pediatric hospital (asthmatic who they think is “too sick”)

I remember that they require a three year hospital fellowship to take care of their floor patients.

Also they have made an urgent care fellowship because some peds leaders don’t think their graduates have the skills to do urgent care.

Also... this.

Seriously, they don't have the skills to do urgent care? URGENT CARE? The place where actual medicine goes to die? The place where Jenny McJennysons run wildly about with no idea what they're doing?

 

[DeadCactus]

Explain this?
You (a community doc) is transferring a pediatric asthmatic to a pediatric hospital... and the pediatric hospital is saying that they're "too sick"?

When I’ve run into this, it was a community hospital with a “Peds Hospital” (really a ward) that can’t really handle anything more than observation patients like dehydration or moderate asthma and have no PICU to escalate to. It’s good that kids don’t have to be transferred 4 hours from home just to get some IV fluids or albuterol and observation overnight but it makes for odd comfort levels.

Pediatrics chose to be a community specialty and try to have every healthy child seen by a pediatrician rather than leave that to FM and focus on having a limited number of pediatric specialists taking care of complex kids in referral centers. Now we’re seeing the fallout from that.

 

[RustedFox]

When I’ve run into this, it was a community hospital with a “Peds Hospital” (really a ward) that can’t really handle anything more than observation patients like dehydration or moderate asthma and have no PICU to escalate to. It’s good that kids don’t have to be transferred 4 hours from home just to get some IV fluids or albuterol and observation overnight but it makes for odd comfort levels.

Pediatrics chose to be a community specialty and try to have every healthy child seen by a pediatrician rather than leave that to FM and focus on having a limited number of pediatric specialists taking care of complex kids in referral centers. Now we’re seeing the fallout from that.

I hear you.
Or they could, you know, not suck.
We could do it.
We do it.
We do it all the time.

Make us eligible for more fellowships.
I say "more fellowships" because I'm not Jenny'd enough to think that there's no value in additional training.

 

[VA Hopeful Dr]

When I’ve run into this, it was a community hospital with a “Peds Hospital” (really a ward) that can’t really handle anything more than observation patients like dehydration or moderate asthma and have no PICU to escalate to. It’s good that kids don’t have to be transferred 4 hours from home just to get some IV fluids or albuterol and observation overnight but it makes for odd comfort levels.

Pediatrics chose to be a community specialty and try to have every healthy child seen by a pediatrician rather than leave that to FM and focus on having a limited number of pediatric specialists taking care of complex kids in referral centers. Now we’re seeing the fallout from that.

I've been saying for years now that once a kid hits puberty (assuming at a normal age) they need to switch to an FP. It'll prevent legions of teenagers from having to see OB/GYN just to get birth control or ortho for minor sports injuries.

 

[RustedFox]

I've been saying for years now that once a kid hits puberty (assuming at a normal age) they need to switch to an FP. It'll prevent legions of teenagers from having to see OB/GYN just to get birth control or ortho for minor sports injuries.

Pediatrics.
Truly ostriched.

 

[Dr Mantis Toboggan]

I still remember my PICU rotation where I was taking care of a 300 lbs 17 year old who was in DKA for 72 hrs because nobody wanted to raise the insulin gtt higher than 0.05 units/kg/hr for fear of cerebral edema...

Yes! The terror of cerebral edema. God forbid you bolus any fluids either…

 

[alpinism]

Heh be thankful you're not doing a rotation at Children's Hospital in Michigan. When I rotated there for residency the peds docs refused to even start treatment for the patients before consulting endocrinology. It was probably one of the most absurd things I've ever seen and resulted in the patients sitting there for hours till the endocrine attending called back with recommendations. I'm not even talking about toddlers with new onset diabetes but teenagers with known diabetes who just stopped taking their insulin and had already been admitted multiple times.

 

[thegenius]

So I’m covering our Neuro ICU on nights these days and got what has to be one of the strangest calls I’ve ever received last night.

PED calls requesting to admit a pregnant 16 year old in DKA to our adult NeuroICU because it was refused by picu and MICU. No Neuro complaints.

So I call PICU to see what the hell is up.

Hello? Is this PICU Fellow? Can you help me understand why you all are refusing to admit a kid to the peds ICU who’s in DKA?

Yea. She’s pregnant and our peds endocrinologist is uncomfortable managing pregnancy related DKA, and I am not comfortable admitting someone in DKA without endocrines help. It could be unsafe.

So you, a PGY6 pediatric intensivist, would rather have me, a PGY2 EM resident, take care of this person? With my at home attending, who is an adult neurologist, as primary?

Yes. It has already been decided. We formally refuse the admission…

So I call the director of the NSICU, at home, on a Saturday night at 3am. Her response, god love her, “just admit her and close the damn gap.”

Kid gets admitted, I close the gap, and she’s ready to go by morning. Am I crazy for thinking this is absurd that a PICU fellow doesn’t feel comfortable doing DKA without an endocrinologist? It seems absurd to me.

Yes.
100% absurd. No way to suggest otherwise.

 

[thegenius]

I still remember my PICU rotation where I was taking care of a 300 lbs 17 year old who was in DKA for 72 hrs because nobody wanted to raise the insulin gtt higher than 0.05 units/kg/hr for fear of cerebral edema...

Right. And magically when they turn 20 (or even 18) that fear just disappears?

Peds is ridiculous

 

[MechEDoc]

So I’m covering our Neuro ICU on nights these days and got what has to be one of the strangest calls I’ve ever received last night.

PED calls requesting to admit a pregnant 16 year old in DKA to our adult NeuroICU because it was refused by picu and MICU. No Neuro complaints.

So I call PICU to see what the hell is up.

Hello? Is this PICU Fellow? Can you help me understand why you all are refusing to admit a kid to the peds ICU who’s in DKA?

Yea. She’s pregnant and our peds endocrinologist is uncomfortable managing pregnancy related DKA, and I am not comfortable admitting someone in DKA without endocrines help. It could be unsafe.

So you, a PGY6 pediatric intensivist, would rather have me, a PGY2 EM resident, take care of this person? With my at home attending, who is an adult neurologist, as primary?

Yes. It has already been decided. We formally refuse the admission…

So I call the director of the NSICU, at home, on a Saturday night at 3am. Her response, god love her, “just admit her and close the damn gap.”

Kid gets admitted, I close the gap, and she’s ready to go by morning. Am I crazy for thinking this is absurd that a PICU fellow doesn’t feel comfortable doing DKA without an endocrinologist? It seems absurd to me.

It is absurd.

It'll get you ready for working a critical access hospital when you can't transfer out and can't admit patients like these. You might find yourself saying "f-it, I'll just keep them in the ER and do the right thing".

 

[GonnaBeADoc2222]

My ex-wife is a pediatrician (PICU).

Let me just say...little doctors for little people.

 

[Franzd'Epinay]

I must have really lucked out. The PICU attendings where I did residency were incredibly competent. One of them was actually a bit cowboy-ish, if anything.

I really hated how the peds floor would push for the ICU for the tiniest things. I came to learn that was usually due to nursing.

 

[DeadCactus]

Yea, sometimes it is the physician but a lot of times it’s nursing and administrative issues. And then it just cycles as previously confident and competent physicians and ancillary staff lose their exposure to any sort of acuity.

 

[Arcan57]

In many pediatric hospitals, the level of decision making never falls below the subspecialty attending (source: personal experience and having a wife who among other things has been a pediatric subspecialty attending at multiple academic centers). It sort of boggles my mind how you can drill into a trainee for 3-5 years to never act independently then expect them to be johnny on the spot the moment they're attendings. On the plus side, most of their clientele is either manifestly well or engaged in a years long train-wreck that allows plenty of time to get the "world's expert" on disease x involved.

 

[RustedFox]

Does anyone else notice this behavior in PEM folk? I do.

It's like they're fussy children who want the breadcrust cut off of their PB&J, or they won't eat it. And they will only eat PB&J. And only if their mommy makes the sandwich. And dear GOD, don't cut it diagonally.

 

[Lexdiamondz]

Does anyone else notice this behavior in PEM folk?

I think there's a generational divide in PEM (and most medical specialties) where older PEM folk who trained when kids actually got sick with some frequency are, IMO, less skittish & passive-aggressive and more assertive/decisive. May just be my personal experience.

 

[benem]

I think there's a generational divide in PEM (and most medical specialties) where older PEM folk who trained when kids actually got sick with some frequency are, IMO, less skittish & passive-aggressive and more assertive/decisive. May just be my personal experience.

A lot of that seems to stem from a lack of acuity in most EM settings. The Peds hospital next to me sees 60k a year yet has incredibly low acuity. It’s essentially a booboo factory for freaked out parents and people who have no idea how to care for their kids. If more pediatric groups had same day appointments or provided a wider range of urgent care type things I think you’d have far fewer of these ED visits. I can’t imagine practicing medicine where true emergencies are so rare. I think it’d make the real stuff a whole hell of a lot more frightening.

Peds EDs also shouldn’t really be treating most late teens. Those patients tend to be better served in an adult ED where providers have a better handle on dealing with almost fully grown people compared with the feverish baby and crying five year old in the peds ED.

 

[skougess]

Peds EDs also shouldn’t really be treating most late teens. Those patients tend to be better served in an adult ED where providers have a better handle on dealing with almost fully grown people compared with the feverish baby and crying five year old in the peds ED.

This x1000. PEM trained are fantastic at sick respiratory 2 year olds. They are frightening to watch with non-respiratory sick 17 year olds. At that age they might have a children’s brain, but they have adult physiology. It often borders on malpractice (yes definitely, let’s get a SINGLE blood culture only on a septic 17 year old because…peds? Or classic appendicitis in a 15 year old, peritoneal rlq pain with a fever. Definitely dick around with an ultimately inconclusive ultrasound for 4 hours instead of pulling the trigger on a CT). The age cutoff in the ED should honestly be around 12.

From what I saw in my PICU, they are straight assassins for major surgery post-op teenagers. Management that would make our adult Intensivists put out resumes after the first week.

 

[namethatsmell]

I trained at a place with a strong peds experience. We had our pick of 2 ivory tower PICUs within 15 minutes of each other. Instead, our leadership sent us a bit farther away to a super-busy PICU at a tertiary place with only a few in-house residencies.

It was intense. I still vividly recall a night with 2 kiddo codes at once. My PICU attending was running one room, and I was running the other while assisting a peds heart surgeon reopen a fresh chest.

Some PICUs are certainly lame, but there are some badass ones out there.

Only after I became a parent did I appreciate that there's no way I could regularly see/do what the docs in these high acuity PICUs experience without becoming an emotional wreck. Truly sick kids are the worst. I give most PICU docs a ton of credit (not including the ones who c/s endo on every dka as some of you describe...what's that about?).

 

[HemeOncHopeful19]

I (IM) had a similar issue with Peds in residency once. OB called is because Peds refused to see a 14 year old asthma exacerbation because she was pregnant. “Physiologically she’s an adult because she’s pregnant!”

They wanted IM to come to their SEPARATE PEDS/OB HOSPITAL and consult for Asthma. This ultimately got escalated to department chairs (lol) and the compromise was that a Med/Peds would see it.

 

[turkeyjerky]

What's even the point of calling endo for DKA anyway? The only thing I've ever had them say is, 'okay start the protocol'. Also, is there even much difference in pregnancy, other than the higher risk for euglycemic DKA?

Agree with the above. The age cutoff for actual medical issues is likely somewhere 12-14, that's how they do it for trauma.

 

[p1acebo]

What's even the point of calling endo for DKA anyway? The only thing I've ever had them say is, 'okay start the protocol'. Also, is there even much difference in pregnancy, other than the higher risk for euglycemic DKA?

Agree with the above. The age cutoff for actual medical issues is likely somewhere 12-14, that's how they do it for trauma.

Probably liability, get his/her name on the chart just in case there is a bad outcome. I agree though clinically it is pointless to consult them, just start treatment.

 

[emergentmd]

I did EM at a Receiving trauma center with a Peds hospital connected through a walkway. Going from the adult hospital to the Pedi hospital was a different world. Going from adult, do whatever you want, wild wild west, great learning experience to pedi where you could not touch anything. Hospital IM ward where you are by yourself all night to pedi side where all you could do is chart symptoms gunt work. Adult ER where you do any procedure you want and seeing sick where backups hate being bothered to Pedi ER where you essentially see walking well not able to see anything sicker than a cough.

Pretty stark difference the training.

Worked at a community receiving hospital with a Pedi hospital/ER attached. Pretty much the same. Was working in the PEDI ER and got a call from the floor nurse asking me to come put in a central line b/c the PEDI ICU doc could not. ummmmm hard no.

Transferred a new onset DKA 8 yr old and talk about micromanaging receiving hospital. Literally doc gave me specific orders for a 2 hr transfer ride, told me to give the medic their number to call with ANY problems.

 

[thegenius]

Well I'm glad to hear that i wasn't the only one with the same experiences listed above. My peds training was at a quarternary Peds hospital in Manhattan and we couldn't do anything. We were only able to give tylenol / motrin to kids. Anything else we had to run by the attending first.

It's real sad. The implication is trained physicians are more likely to harm the patient than help. It's so sad

 

[RustedFox]

I had a similar exchange with a Pedi online in a different forum regarding treatment for OM.

His contention was that my approach "was wrong" because it "wasn't best practices".
I reminded him that he could still "think for himself" and that all the answers weren't to be found published somewhere.
He hit me with something stupid like: "I'm a pediatric attending; you're wrong."
I couldn't help myself; let him know that I would take his input into consideration when he actually knew what to do with a sick kid.

You can't spell "pedantic" without P-E-D.

 

[turkeyjerky]

I had a similar exchange with a Pedi online in a different forum regarding treatment for OM.

His contention was that my approach "was wrong" because it "wasn't best practices".
I reminded him that he could still "think for himself" and that all the answers weren't to be found published somewhere.
He hit me with something stupid like: "I'm a pediatric attending; you're wrong."
I couldn't help myself; let him know that I would take his input into consideration when he actually knew what to do with a sick kid.

You can't spell "pedantic" without P-E-D.

This attitude also seems rampant amongst the peds-em trained on Facebook EMdocs.

 

[RustedFox]

This attitude also seems rampant amongst the peds-em trained on Facebook EMdocs.

At this point, being PedEM fellowship trained actually makes me hold that individual in less esteem with respect to cognitive ability.

 

[Lexdiamondz]

Don't worry PEM, we still love you

...even though one of you asked me to intubate a 15 year old because they were bit chubby and thus "a potential difficult airway".

 

[emergentmd]

Moonlighting as a 2nd year resident at a very rural area. ER was 3 beds, saw 3 pts in 24 hr shift. Docs would typically send their pts to the ER and manage them from the ER. Pedi doc sends pt in for R/O meningitis, needing an LP and didn't feel comfortable doing one but yet would let a 2nd yr EM who probably only saw one done in the helicopter Pedi ER.

Ehhhh, kids are just big adults. Popped a needle in, went back to bed.

 

[Brigade4Radiant]

I’m having flashbacks of minor lacerations on the face taking hours due to needing sedation and plastic surgery referrals.

 

[GonnaBeADoc2222]

It's kinda self selection. Like who self selects to see only kids all the time. It's sorta weird tbh...

 

[GassYous]

It's kinda self selection. Like who self selects to see only kids all the time. It's sorta weird tbh...

I wouldn't mind watching kids all the time

 

[turkeyjerky]

I wouldn't mind watching kids all the time