Had my thoughts all along since this discussion was started.
Clinical decision making in ED is so important and experience of course is a
Tests should be done just to confirm, if at all.
Acutely ill children requiring our immediete attention will present as such and
with others the key is a good follow up.
It is only natural to feel good with a pick up of a chronic illness and beat
ourselves up if we miss one. I think we should be more humble and forgiving.
CRP will be elevated in any "itis" and is a sign of inflammation. Like sed rate
is a good one to follow if you are treating and need to see if your treatment is
working, like in osteomyelitis.
CRP has been studied to predict sepsis in newborn,appendicitis etc, an article
or two here and there. Surfaces in discussions now and then. As someone
mentioned a good ammunition for lawyers.
I remember reading, the adult world was using this as predictors of CAD.
What lies behind us and what lies before us are tiny matters compared to what
lies within us.
----- Forwarded Message ----
From: Marty Herman <[log in to unmask]>
To: [log in to unmask]
Sent: Mon, January 17, 2011 9:37:41 AM
Subject: Re: crp
Got to jump in too.
Many times I have been in this situation. Most of the times it's because a test
was ordered by the PCP or a resident and then the child sent in for us to figure
out what it means. Sometimes I do this to my self. Perhaps a weak moment,
perhaps just taking the easy way out, whatever..
i over heard a pediatrician once remark to a mother who complained that he did
not order enough tets that his job wasn't to please her every whim but rather to
do what was right for the child and in his medical/professional opinion the
child did not need the tests requested. She was free to gt another opinion ...
Of course there are times that I take a firm stance, only find out later that I
misssed something. THat's why I preach to the residents that they have remain
open minded, communicate and document their findings very well.
> Date: Mon, 17 Jan 2011 13:14:35 +0000
> From: [log in to unmask]
> Subject: Re: crp
> To: [log in to unmask]
> From: don zweig ([log in to unmask])
> > How do you use the crp in evaluating kids?
> --> I don't.
> > How do you interpret a high crp with low sed rate
> --> I am not the correct person to answer this, with only EM as my training.
> > ...8 yo with headache, decreased appetite and dizziness...
> --> Had one of those at home last week, when we woke him up for his first day
>of the school term... Resolved with chocolate.
> > crp ws 38. i was hoping for normal
> --> Having seen quite a few cases of meningitis/sepsis/other-itis/etc with low
>and normal CRP, I have long ago stopped "collecting" such cases in order to
>explain why I don't do it...
> The best way to avoid finding a high CRP is to not do the test! I always think
>of CRP as a 4-letter word with a vowel missing...
> > Should i go with my impressing that she is well
> --> You question appears to be "who should I trust - the experienced EP who has
>seen the patient, took a history and examination and a urine dip, etc, OR this
>one blood test?"
> If the answer could be to trust the blood test, then all you'll need for most
>patients is a phlebotomist at reception and most EPs would be out of a job...
> > I did labs because mother was concerned
> --> And now the mother is concerned because you have the blood test...;-)
> And so are you...
> I DO have sympathy for the atmosphere you work in, but I believe that this sort
>of testing is what LEADS to patients in your part of the world NOT trusting YOU
>when you reassure them, but only trusting tests.
> Sort of like how every time an EP oreders a test/imaging in order to prevent
>litigation that he/she ADDS TO the problem of why EPs are NOT trusted and
>lawyers SUCCEED in "beating" them with test results or with simply pointing a
>finger at the absence of a test!
> Although children ARE brought in by parents instead of being taken to primary
>care, there is no expectation in the UK for the ED to provide this care. Once we
>decide child is safe to continue with GP we direct the parent to make the
>appointment and send patient away...
> Also, I must admit I would not have done a CXR either, unless there was another
>reason which you had not mentioned in your description of the case thus far...
> From: Bergmann Terence ([log in to unmask])
> > Ignore it!
> --> This brings up the other interesting aspect...
> As much as I have just described why I would not have done a CRP, from my
>understanding of the medico-legal "mood" in the USA, once you HAVE done it, it's
>tougher to ignore the result...
> Imagine this child comes back the next day (or sees GP) and says "I feel
>perfectly fine" and actually LOOKS perfectly fine and remains so for the next
>couple of weeks... Even remains perfectly well for a couple of months... Then
>suddenly comes up ill with something really "horrible" and depressing... And
>the lawyer says that the EP "knew" this child had "something", as shown by the
>raised CRP, so why allow it to become worse? EP should have arranged follow-up
>and is repsonsible for checking to see that the CRP drops back to normal before
>"believing" the child is actually well...
> Then the EP would find himself as the one trying to say that the CRP does not
>mean that much...;-)
> Maybe someone on this List has the medico-legal (USA-style) knowledge to
> > fighting anxious parents is sometimes a losing battle
> --> Agree! A battle worthy of not being fought at all!
> Not sure that one can do it where you are, but here we'd say something to the
>effect of "I am satisfied that an emergency condition is unlikely in your case,
>but I would like to escalate things higher, for review and potential
>investigation, for which reason I am recommending that you go to your GP, where
>this process could be taken up. Here's your referal note."
> Granted, this is easier in a doctor-patient relationship which is NOT clouded
>by a consumer/customer--service-provider relationship...
> Here's my "business moto": The customer is always right; the patient isn't
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