Why is it so hard for outpatient Ped's to provide good information?

[WilcoWorld]

Answering questions can be incredibly laborious and frustrating - especially when I feel that my judgement is being impugned. In what follows I don't mean to proscribe as much as I mean to describe.

I think that a lot of people just haven't been taught how to manage symptoms at home. The more you take ownership of education, the better your patients will do.

You know what would be a great public health intervention, that 100% we will never do in the US because any IRB would stop it cold?

Take every 18-21 yo that shows up to the ED with flu like symptoms and no respiratory distress:

Make 1/2 wait, sitting upright, in the WR for 4-6 hours. For good measure make them sneeze with a Q-tip and gag them with a longer Q-tip and then give them a diagnosis (upper respiratory infection without hypoxemia, acute pharyngitis without cervical lymphadenopathy, gingivostomatitis, likely viral in etiology). Give people "answers".

For the other 1/2: shuffle them to a recliner, give them 400mg ibuprofen, a warm blanket and a Sierra Mist. Tell them, "you're sick. I could run tests, but they don't give immediate answers and this is something I'm 99% confident that you'll get over. rest is your friend, so is advil."

In both arms, after 30-90 minutes dc everyone to home care.

See who feels better. See who stays home next time. See who does better overall.

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[Dred Pirate]

Advil makes it; it's called "Advil Dual Action".
I totally would have called it Turboprofen.

I totally forgot about that. And ya. Such an odd dosage thou.

 

[RustedFox]

Come to the Midwest and let me cook you a thick, well-marbled ribeye.

Please

Challenge accepted. Got any mountain biking around your parts?
And can I have some grilled asparagus? Kind of a favorite.

 

[Vandalia]

It has shifted around since yesterday, but it was ironic when this topic was listed directly under the one from the radiologist asking why EM physicians always order CT for gastroenteritis cases ...

 

[WilcoWorld]

Challenge accepted. Got any mountain biking around your parts?
And can I have some grilled asparagus? Kind of a favorite.

Yes and yes.

 

[RustedFox]

Yes and yes.

Sweet. Tell me where to ship my bike.

 

[RuralEDDoc]

Sweet. Tell me where to ship my bike.

You don’t mess around.
I’d be like “tell me where I can rent a ****ty bike”
You got a FedEx call slip and a custom molded bike case. I say this respectfully. I feel the same way about other endeavors.

 

[WilcoWorld]

Sweet. Tell me where to ship my bike.

Here's an option. Or here. Or...

 

[RustedFox]

You don’t mess around.
I’d be like “tell me where I can rent a ****ty bike”
You got a FedEx call slip and a custom molded bike case. I say this respectfully. I feel the same way about other endeavors.

bikeflights.com

We MTBers are rather attached to our rigs.

Just like, say; if you wanted to take a golf trip to a dream course, you want YOUR clubs, right? The ones that you know JUST how to hit? Custom length and grips and all? So you either check your clubs on the plane, or you use shipsticks.com and meet up with them there.

Same idea. Ship your bike to a local shop and pick it up there, assembled for you.

I would totally share my YouTube channel so you can check out my GoPro footage, but then I wouldn't be anonymous at all anymore.

I shred.

 

[Mount Asclepius]

I just finished up a bunch of shifts seeing a cesspool of pediatric viruses. COVID-19, influenza, RSV, rhinovirus, adenovirus, parainfluenza…

I don’t think it’s realistic in a busy ED to trend heart rates and temps on well appearing kiddos with viral URIs.

1 in 100, maybe more like 1 in 1,000, might end up becoming sick with something like bacterial pneumonia, sepsis or Kawasaki’s disease. I suspect it’s near impossible to identify those kids with trending vitals. So really it’s just for some sense of medicolegal protection. Odds are they aren’t going to have a really bad outcome or even sue. Sure, if all that bad luck aligns then you’ll probably settle and that’s what malpractice insurance is for. Keeping well appearing kids in the ED to trend vitals while tying up rooms when we’re inundated with viral disease doesn’t seem worthwhile. And that’s coming from someone who cares maybe more than some about persistent unexplained tachycardia in adults.

 

[TooMuchResearch]

I'm going to assume you are not a parent that has ever had to deal with a febrile toddler.

Honestly, it would be easier to give my preschooler IM toradol than oral meds. Had some success with dissolvable Tylenol in chocolate milk but it doesn't dissolve well and leads to some very chocolately puke.

 

[CoolDoc1729]

funny you say this- I had this exact discussion with my wife the other day - I was at work and I told her how much tylenol to measure - "but the box says?" - I told her the box is wrong - which is hard convince someone - especially when my daughter is like 25th percentile height and weight- and the box still under-doses her.

Does it drive you bonkers when you, a pharmacist, are questioned on ibuprofen dosing - it drives me bonkers when my inlaws act like I don’t know how to care for a splinter or abrasion lol

 

[CoolDoc1729]

I generally consider waiting for their HR to normalize as well. But I don't have them take up a bed. See them, write them up for DC, then have them sit in the WR. Recheck HR in an hour or two. Give the parents the option not to do this and just go home, and document the abnl HR was appropriate for the tachy and brief obs was offered to the parents to ensure correction etc etc... probably overkill but them taking up a chair in the WR isn't really increasing my cognitive load, its more annoying for the parents.

This is my method as well. I leave the dc papers with the nurses, so when they decide after 12 minutes that it’s not really necessary to wait, they can just go.
On the other hand I really hope they don’t go sit next to the neutropenic chemo lady …

 

[RustedFox]

Does it drive you bonkers when you, a pharmacist, are questioned on ibuprofen dosing - it drives me bonkers when my inlaws act like I don’t know how to care for a splinter or abrasion lol

Stepmom does this nonsense to me all the time.
I actually have told that woman that she "is what is wrong with America; a person with an opinion that knows nothing about the subject matter and can't wait to be outraged about whatever it is."

 

[greatnt249]

 

[Dred Pirate]

Does it drive you bonkers when you, a pharmacist, are questioned on ibuprofen dosing - it drives me bonkers when my inlaws act like I don’t know how to care for a splinter or abrasion lol

ya - our pediatrician actually gives out a dosing chart that is approrpaite based on weight and specifically tells parents to not follow the box.

Similiar conversation came up when one of the ED doc's kiddos was sick and his wife said "Don't you think they should see a doctor?" He replied "He just did"

 

[Ravizzle]

This is my method as well. I leave the dc papers with the nurses, so when they decide after 12 minutes that it’s not really necessary to wait, they can just go.
On the other hand I really hope they don’t go sit next to the neutropenic chemo lady …

Yeah the general practice in our PED is to atleast see some improving trend of HR for discharge. Doesn't need to be normal and doesn't need to be afebrile, but atleast trending the right way. Yes it's annoying, yes it's taking up a chair in the waiting room while they are waiting for repeat vitals, but I think medically and legally it's the right thing to do. If the kid is running around and super well the parents can just opt to leave and we just document that further observation was offered and strict return precautions given, parents opted for discharge home.

 

[Mount Asclepius]

Yeah the general practice in our PED is to atleast see some improving trend of HR for discharge. Doesn't need to be normal and doesn't need to be afebrile, but atleast trending the right way. Yes it's annoying, yes it's taking up a chair in the waiting room while they are waiting for repeat vitals, but I think medically and legally it's the right thing to do. If the kid is running around and super well the parents can just opt to leave and we just document that further observation was offered and strict return precautions given, parents opted for discharge home.

If it doesn’t trend quickly in the right direction does that change your management?

I suspect eventually it ultimately doesn’t change disposition and gives a false sense of medicolegal reassurance.

 

[skougess]

If it doesn’t trend quickly in the right direction does that change your management?

I suspect eventually it ultimately doesn’t change disposition and gives a false sense of medicolegal reassurance.

Have to agree. This is a false sense of security. At the end of the day we all take some risk by discharging any patient. Are you going to admit the kid with HR going the “wrong way” who’s eating and running around the room laughing?

 

[Apollyon]

Well, if a kid dies, everyone gets sued. That's about it.

 

[skougess]

Well, if a kid dies, everyone gets sued. That's about it.

Agree with this as well. People don’t sue for bad care. They sue for bad outcomes.

 

[Kryptocoin]

I get a lot of rocephin shot requests. Parents come to the ER demanding a shot for their febrile kids because they get those at the local peds clinic. They don't seem to care about viral vs bacterial infection pharmacology. Apparently rocephin fixes everything.

Outpatient peds is not only dead but now becoming dangerous.

 

[RustedFox]

I get a lot of rocephin shot requests. Parents come to the ER demanding a shot for their febrile kids because they get those at the local peds clinic. They don't seem to care about viral vs bacterial infection pharmacology. Apparently rocephin fixes everything.

Outpatient peds is not only dead but now becoming dangerous.

Dear God, man.

 

[WheezyBaby]

Its easy to blame the parents and I agree they probably hear what they want to hear and probably are getting bad advice from a nursing line more often than from a doc. But parents arent putting every kid with a cold on amoxicillin for a double ear infection either, so the prescribers share some blame. Magically when I look at the kids ears 12 hours later they’re tympanic membranes are always completely normal. Its easy to blame parents but I also think the Peds outpt folks (many of which are likely midlevels) fuel the fear that something more serious is going on by overmedicating young children unnecessarily for viral infections. Not every kid needs to be on Cefdinir and prednisolone for nasal congestion and have a BS diagnosis like “double ear infection” or “clinical pneumonia” to justify giving them abx. Maybe this is just regional practice, but I feel like over the past decade the amount of rampant abx use for clearly viral illnesses has gotten so much worse. And it fuels parental fear that everytime their child has a fever they must get seen right away bc everytime they get a fever they get put on all these medications for diagnoses they really dont have.

FWIW, CXR isn't recommended by IDSA as part of the work up for outpatient pediatric CAP. I have my own feelings about that, but in the context of a good history and exam I think that's reasonable. How often those things happen is another matter

 

[WheezyBaby]

Yeah the general practice in our PED is to atleast see some improving trend of HR for discharge. Doesn't need to be normal and doesn't need to be afebrile, but atleast trending the right way. Yes it's annoying, yes it's taking up a chair in the waiting room while they are waiting for repeat vitals, but I think medically and legally it's the right thing to do. If the kid is running around and super well the parents can just opt to leave and we just document that further observation was offered and strict return precautions given, parents opted for discharge home.

I'm not in the position of dispo'ing these patients anymore, but I've seen enough cases of unexplained or viral/febrile tachycardia turn into diagnoses of bacterial meningitis / purpura fulminans / myocarditis / bacteremia that I'd have a hard time sending bad vitals home. That n is still not high but theyre memorable. I'm not saying it's necessarily right or wrong, but I'd personally probably make them sit and wait for better vitals. Was generally the practice of our PEM people

 

[Mount Asclepius]

Your prevalence of pediatric acuity might be changing your practice pattern. If you work in PEM or upstairs at a Children’s Hospital you are going to see more sick kids.

When you work in a busy community ED that mainly sees adults, then you are going to see a lot of worried well parents with not sick kids. I’ll quickly see and discharge 2-5 well appearing kids every shift while the waiting room is backing up with patients including an elderly time bomb waiting to come back. I might see 1-2 sick kids a month, but triage usually recognizes something isn’t right and rushes them back. If I held on to non sick kids it would significantly limit my ability to take prompt care of sick adults.

Prevalence certainly might affect my decision making too, but I’d argue that kids overall have less odds of being sick than adults. I just doubt the utility of trending vitals in well-appearing kiddos in my practice environment.

 

[pkwraith]

This practice pattern would explain why our local Children's tertiary hospital has a Waiting room up to 100 for the last 3 weeks during influenza/rsv season.

My own practice pattern. If I can get a good trend to polish the chart and the ED is not busy, great. But influenza is going to have high fevers, and if they're on the upswing when they get to the ED, they can get higher in the ED even with apap/nsaid. Same goes with young adults with flu/covid. I'm more than happy to discharge them with a fever and appropriate tachycardia.

 

[Brigade4Radiant]

Most antibiotic use is for the food we eat. So even if people stopped prescribing there would still be resistance. The importance for antimicrobial stewardship is mostly for the inpatient setting

FDA: Antibiotic use in food animals continues to rise

www.cidrap.umn.edu

 

[WheezyBaby]

Your prevalence of pediatric acuity might be changing your practice pattern. If you work in PEM or upstairs at a Children’s Hospital you are going to see more sick kids.

When you work in a busy community ED that mainly sees adults, then you are going to see a lot of worried well parents with not sick kids. I’ll quickly see and discharge 2-5 well appearing kids every shift while the waiting room is backing up with patients including an elderly time bomb waiting to come back. I might see 1-2 sick kids a month, but triage usually recognizes something isn’t right and rushes them back. If I held on to non sick kids it would significantly limit my ability to take prompt care of sick adults.

Prevalence certainly might affect my decision making too, but I’d argue that kids overall have less odds of being sick than adults. I just doubt the utility of trending vitals in well-appearing kiddos in my practice environment.

I am 100% biased by selection, but you see a handful of awful things happen and it colors your perspective. I will say the ability of EM physicians to assess the degree of illness of a child seems widely variable, and I don't mean to be derogatory at all in saying that. As you were alluding to, truly sick children are rare, and the vast majority of the time a gestalt of "not sick" is going to be right. I think it's ultimately individual judgement whether it's appropriate to slow workflow and inconvenience a large number of families with additional length of stay to capture a tiny subset of children with abnormal vitals who have underlying meaningful illness not initially identified as such

 

[Arcan57]

I am 100% biased by selection, but you see a handful of awful things happen and it colors your perspective. I will say the ability of EM physicians to assess the degree of illness of a child seems widely variable, and I don't mean to be derogatory at all in saying that. As you were alluding to, truly sick children are rare, and the vast majority of the time a gestalt of "not sick" is going to be right. I think it's ultimately individual judgement whether it's appropriate to slow workflow and inconvenience a large number of families with additional length of stay to capture a tiny subset of children with abnormal vitals who have underlying meaningful illness not initially identified as such

The question I'd pose to you is how many bad outcomes that you've seen were actually preventable? We (and plaintiffs' attorneys) think that if we just got antibiotics on board sooner that the kid with the serious bacterial infection would have been fine. In reality, the already low incidence of bacterial infections as cause for fever is going to be extraordinarily tilted towards UTIs and pneumonia that probably have a couple of days before it matters whether they get treated. The bacterial infections in this population that kill quickly tend to have miserable morbidity and mortality by the time the differentiate themselves from viral causes. PA misses disseminated meningococcemia, sends pt home, and they die is a compelling story but that kid was going to have a rough go of it even if they had Osler as their doc.

 

[WheezyBaby]

The question I'd pose to you is how many bad outcomes that you've seen were actually preventable? We (and plaintiffs' attorneys) think that if we just got antibiotics on board sooner that the kid with the serious bacterial infection would have been fine. In reality, the already low incidence of bacterial infections as cause for fever is going to be extraordinarily tilted towards UTIs and pneumonia that probably have a couple of days before it matters whether they get treated. The bacterial infections in this population that kill quickly tend to have miserable morbidity and mortality by the time the differentiate themselves from viral causes. PA misses disseminated meningococcemia, sends pt home, and they die is a compelling story but that kid was going to have a rough go of it even if they had Osler as their doc.

I obviously can't crystal ball. I agree about some extent of morbidity generally being unavoidable, but with timely antimicrobials and good resuscitation, maybe 1/3 to 1/2 with pretty clear opportunities for reduced morbidity/mortality? I'd say the difference in QoL is significant between say, above vs below joint amputations, the neuro sequelae of meningitis vs meningitis complicated by diffuse CSVT, dead vs alive (depending on the condition you survive in). Again, this is operating on the supposition timely intervention reduces the likelihood of these things happening, but I think it does

 

[RoyBasch]

I'm not in the position of dispo'ing these patients anymore, but I've seen enough cases of unexplained or viral/febrile tachycardia turn into diagnoses of bacterial meningitis / purpura fulminans / myocarditis / bacteremia that I'd have a hard time sending bad vitals home. That n is still not high but theyre memorable. I'm not saying it's necessarily right or wrong, but I'd personally probably make them sit and wait for better vitals. Was generally the practice of our PEM people

You are a pediatric intensevist correct? The cohort of patients you see is dramatically different than the typical febrile kids showing up in community ERs. All you see are the “numerators” the 1/10000 kids that have myocarditis, septic shock, etc.

 

[WheezyBaby]

You are a pediatric intensevist correct? The cohort of patients you see is dramatically different than the typical febrile kids showing up in community ERs. All you see are the “numerators” the 1/10000 kids that have myocarditis, septic shock, etc.

Yes, entirely acknowledge that, but those rare presentations frequently first present to a community ED. I'm not sure with what frequency any given community EM physician comes across a genuinely ill child, but I'm sure it's exceedingly rare. Strictly speaking from a medicolegal standpoint, peds are one of the least frequently sued but with the highest payouts for a reason. Any given individual's risk tolerance / aversion is a personal decision, but if you discharge a toddler with ugly vitals and they have have an ugly outcome it's probably a fast track to an ugly check. The vast majority of PEM people I've worked with wait for pretty vitals to dispo, for whatever that's worth. I recognize there's a cost to doing that as well

 

[TooMuchResearch]

Well, if a kid dies, everyone gets sued. That's about it.

Every day I sit and wait...
2021 was a bad year.

 

[ScepticSkeksis]

The problem now is that most American children are on Medicaid......which is FREEEEE. Why wait days or weeks to get in to see your pediatrician when you can have it YOUR WAY, RIGHT AWAY NOW!

Americans just want someone else to do parenting for them. Why use your own brain to take care of your child when someone else can do all your thinking for you.

 

[allantois]

The root of all problems in this country is poor education (health literacy, etc)

 

[RustedFox]

Challenge accepted. Got any mountain biking around your parts?
And can I have some grilled asparagus? Kind of a favorite.

@HemeOncHopeful19 doesn't like asparagus.