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PED-EM-L  February 2008

PED-EM-L February 2008

Subject:

Re: dangers of subjectivity

From:

Julia Whitefield <[log in to unmask]>

Reply-To:

Julia Whitefield <[log in to unmask]>

Date:

Mon, 18 Feb 2008 07:41:07 -0700

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (8 lines)

I thank everybody for their input... and I appreciate the time and thought... After reading everybody's comments re rectal temps etc. I only have one concern: how do we change standards? It is indeed true that rectal temps up to a certain age are the standard... none of the 'protocols' are based on temporal or tympanic temps.... since we, the PEM docs are setting those standards and have set them, we need to continue doing so with clinical evidence base.. that would be my point against 'personal experience', which we all have.
Julia Whitefield
UNM
ABQ, NM> Date: Mon, 18 Feb 2008 07:06:17 -0500> From: [log in to unmask]> Subject: Re: dangers of subjectivity> To: [log in to unmask]> > Jim,> > Although I appreciate your use of "CSBM" (common sense based medicine) > if we base our practice patterns on anecdotal data, I fear that there > will be at some point a free for all regarding who/when/how gets > worked-up...allow me to explain:> > For those with considerable peds em experience, the decision to rely on > common sense over "literature pr oven dogma" is easier to make...and > probably in most instances the best for the patient....> > However, for those who do not possess this experience, instances when > to rely on that same common sense gets nebulous (see cases you posted > below) and by default this is where EBM steps in...> > what this means is that standardized EBM functions like a safety net of > sorts...oversensitive with poor specificity...this in essence is what > EBM in EM is about if you think about it...> > joe> > > > Quoting "Chamberlain, Jim" <[log in to unmask]>:> > > Allow me to clarify my previous posting (below), lest we have neonates> > dying of sepsis or Herpes encephalitis. As a good friend pointed out to> > me this evening, I have gone out on the proverbial limb here with saw in> > hand.> >> >> >> > The neonate is a special patient deserving of a very low threshold for> > aggressive workup.> >> >> >> > 1. The signs of illness are subtle.> >> > 2. The host is immunodeficient.> >> > 3. The organisms are virulent.> >> >> >> > Any neonate with a documented fever (and many without) deserves a full> > sepsis workup.> >> >> >> > I have used the Observation Unit in a handful of cases in which I> > doubted the presence of fever because the report of an elevated> > temperature did not make sense.> >> >> >> > Cases I can recall:> >> > The patient who presented to the Surgery Clinic for evaluation of a> > non-incarcerated inguinal hernia and had a routine temperature taken. It> > was borderline elevated. There were no neonatal risk factors. Exam was> > normal and repeat temperatures were normal.> >> >> >> > The patient who presented to PCP for routine checkup and had a> > borderline elevated temperature. Was referred in to ED. There were no> > neonatal risk factors. Exam was normal and repeat temperatures were> > normal. Parents did not want a sepsis workup. PCP and parents agreed to> > repeated assessments in Observation Unit.> >> >> >> > The mother who felt her baby was warm after a nap. She inserted her> > infrared ear thermometer in the baby's rectum (because the display said> > "Rectal" [equivalent]) and the temperature was elevated (again> > borderline). Temperature and exam were normal in ED and there were no> > neonatal risk factors. After Mom and I both stopped laughing, serial> > temperatures and exams in Observation Unit were normal.> >> >> >> > A similar story with an infant pacifier thermometer which simply read> > fever (it did not display a temperature). Assessment in ED was normal.> > Serial exams and temperatures were normal.> >> >> >> > The neonate who came to the ED with a lump on the clavicle and was> > bundled. The bump was a healing clavicle fracture. Exam was otherwise> > normal and there were no neonatal risk factors. The borderline elevated> > temperature in triage was repeated serially and was normal.> >> >> >> > Hope this clarifies.> >> >> >> > Jim> >> >> >> >> >> > James Chamberlain, MD> >> >> >> > Division Chief, Emergency Medicine> >> >> >> > Children's National Medical Center> >> >> >> > 111 Michigan Avenue, NW> >> >> >> > Washington, DC> >> >> >> > 202.476.3253 (O)> >> >> >> > 202.476.3573 (F)> >> >> >> > 202.476.5433 (Emergency Access)> >> >> >> >> >> > -----Original Message-----> > From: Chamberlain, Jim> > Sent: Thursday, February 14, 2008 9:06 AM> > To: Martin Herman; [log in to unmask]> > Subject: RE: Tympanic temps> >> >> >> > Well, looking at the article about bundling infants (which said a single> > isolated "fever" was OK as long as it went away with unbundling), I go> > with clinical assessment plus a repeat temperature > 38.> >> >> >> > To summarize:> >> >> >> > One elevated temp plus otherwise well-->observe for X hours of repeated> > temperatures (X depends on family/PCP situation)> >> > Two elevated temps or some other sign of illness-->sepsis workup> >> >> >> > I have no evidence for this, only clinical experience...> >> >> >> > Jim> >> >> >> > James Chamberlain, MD> >> > Division Chief, Emergency Medicine> >> > Children's National Medical Center> >> > Washington, DC> >> > 202.476.3253 Office> >> > 202.476.3573 Fax> >> > 202.476.5433 Emergency Access> >> >> >> >> >> > -----Original Message-----> >> > From: Pediatric Emergency Medicine Discussion List> > [mailto:[log in to unmask]] On Behalf Of Martin Herman> >> > Sent: Thursday, February 14, 2008 12:30 AM> >> > To: [log in to unmask]> >> > Subject: Re: Tympanic temps> >> >> >> > Jim,> >> > I like what I am hearing. Especially admitting to a OBS or Clinical> >> > Decision Unit for observation and serial temps. Just curious at what> > point> >> > do you intervene with cultures of urine, blood or CSF? Do you base that> >> > entirely on your clinical assessment? IS there a temperature ( method is> > not> >> > the issue now) at which you would routinely culture an infant? Does age> > make> >> > a difference. Say 0-29 days versus 30-90 days?> >> >> >> > Looking for enlightenment.> >> >> >> > Marty> >> >> >> >> >> > ------------------------------------> >> > Pediatric Emergency Specialists, P.C.> >> > Martin Herman, M.D.,FAAP,FACEP> >> > President> >> > [log in to unmask]> >> > PO box 637> >> > Ellendale TN 38029> >> > tel: 901 405 1407> >> > fax: 901 405 1524> >> > mobile: 901 219 9202> >> > ------------------------------------> >> >> >> > -----Original Message-----> >> > From: Pediatric Emergency Medicine Discussion List> >> > [mailto:[log in to unmask]] On Behalf Of Chamberlain, Jim> >> > Sent: Wednesday, February 13, 2008 10:58 AM> >> > To: [log in to unmask]> >> > Subject: Re: Tympanic temps> >> >> >> > I admit them to our Observation Unit for serial temperatures (q 2 h), no> >> > testing unless they get sicker...> >> >> >> > Jim> >> >> >> > James Chamberlain, MD> >> > Division Chief, Emergency Medicine> >> > Children's National Medical Center> >> > Washington, DC> >> > 202.476.3253 Office> >> > 202.476.3573 Fax> >> > 202.476.5433 Emergency Access> >> >> >> >> >> > -----Original Message-----> >> > From: Pediatric Emergency Medicine Discussion List> >> > [mailto:[log in to unmask]] On Behalf Of Foltin, George> >> > Sent: Wednesday, February 13, 2008 7:56 AM> >> > To: [log in to unmask]> >> > Subject: Re: Tympanic temps> >> >> >> > So now we come to the well appearing two week old with a 100.5 or 100.4> >> > temp. So precise but so inaccurate.> >> >> >> >> >> > George L. Foltin, MD, FAAP, FACEP> >> > Director, Center for Pediatric Emergency Medicine> >> > Bellevue Hospital and NYU Medical Centers> >> >> >> > Associate Professor of Pediatrics and Emergency Medicine> >> > New York University School of Medicine> >> >> >> > (O) 212 562-3161> >> > (F) 212 562 -7752> >> > (Cell) 917 842-5428> >> > [log in to unmask]> >> >> >> > ----- Original Message -----> >> > From: Pediatric Emergency Medicine Discussion List> >> > <[log in to unmask]>> >> > To: [log in to unmask] <[log in to unmask]>> >> > Sent: Wed Feb 13 00:31:30 2008> >> > Subject: Re: Tympanic temps> >> >> >> > We published norms on infrared ear temperatures in Annals of Emergency> >> > Medicine circa 1995. I would use those.> >> >> >> > The rectal site was chosen arbitrarily in the late 1800s. The thought at> >> > the time was that it was a core body temperature. We now know that blood> >> > supply is poor to the colon and stool has an insulating effect, thus> >> > damping any changes.> >> >> >> > For any who believe rectal temperature is accurate, there was a paper> >> > out of Israel in mid 1990s that showed that rectal temperature varied by> >> > up to 1 deg C, depending on depth of insertion.> >> >> >> > As far as a valid test to detect illness, temperature doesn't come close> >> > to anything we would normally accept for test performance. Sensitivity> >> > and specificity are both poor.> >> >> >> > So, why torture a kid and touch stool when the test is inaccurate> >> > anyway?> >> >> >> > Jim Chamberlain> >> > Washington, DC> >> >> >> > -----Original Message-----> >> > From: Pediatric Emergency Medicine Discussion List on behalf of Peter> >> > Auerbach> >> > Sent: Tue 2/12/2008 9:06 PM> >> > To: [log in to unmask]> >> > Subject: Re: Tympanic temps> >> >> >> > Thanks for making this point,> >> > with which I agree completely.> >> > It's not that a rectal temp is as "accurate" as a "core body temperture"> >> > (as if that matters anyway),> >> > it's that a rectal temperature is what has been used the most by the> >> > medical community to come up with arbitrary fever standards to help> >> > guide decision-making.> >> > If we all decide to use some other type of temperature measurement in> >> > very young infants, fine, but what are the chances that everyone's going> >> > to agree on that?!> >> >> >> >> >> >> >> >> Date: Tue, 12 Feb 2008 19:34:52 -0600> >> >> From: [log in to unmask]> >> >> Subject: Re: Tympanic temps> >> >> To: [log in to unmask]> >> >>> >> >> Isn't the rectal temp the "gold standard"? I mean isn't it the next> >> > best to> >> >> core temperature that we can access? I realize that core temp is the> >> > body> >> >> temp when measured via an indwelling probe and that the next best> >> > surrogate> >> >> is an esophageal probe but really isn't the rectal temp what the> >> > entire> >> >> medical community has used for decades to decide who is sick and who> >> > isn't?> >> >>> >> >>> >> >> Marty> >> >>> >> >>> >> >> ------------------------------------> >> >> Pediatric Emergency Specialists, P.C.> >> >> Martin Herman, M.D.,FAAP,FACEP> >> >> President> >> >> [log in to unmask]> >> >> PO box 637> >> >> Ellendale TN 38029> >> >> tel: 901 405 1407> >> >> fax: 901 405 1524> >> >> mobile: 901 219 9202> >> >> ------------------------------------> >> >> -----Original Message-----> >> >> From: Pediatric Emergency Medicine Discussion List> >> >> [mailto:[log in to unmask]] On Behalf Of Chamberlain, Jim> >> >> Sent: Tuesday, February 12, 2008 4:19 PM> >> >> To: [log in to unmask]> >> >> Subject: Re: Tympanic temps> >> >>> >> >> Rectal temperature is inaccurate compared to core body temperature.> >> > When> >> >> temperature is changing (as in febrile conditions), rectal lags behind> >> >> other sites (esophageal, oral, tympanic, and infrared ear thermometer)> >> >> by 20-30 minutes.> >> >>> >> >> Rectal temperature is also non-hygienic.> >> >>> >> >> James Chamberlain, MD> >> >> Division Chief, Emergency Medicine> >> >> Children's National Medical Center> >> >> Washington, DC> >> >> 202.476.3253 Office> >> >> 202.476.3573 Fax> >> >> 202.476.5433 Emergency Access> >> >>> >> >>> >> >> -----Original Message-----> >> >> From: Pediatric Emergency Medicine Discussion List> >> >> [mailto:[log in to unmask]] On Behalf Of Julia Whitefield> >> >> Sent: Tuesday, February 12, 2008 1:37 AM> >> >> To: [log in to unmask]> >> >> Subject: Tympanic temps> >> >>> >> >> Dear all, I am finally breaking down... while in favor of rectal temps> >> >> in < 36 months old... I don't feel like having to re-invent the wheel:> >> >> who of you do tympanic temps in your ED - do you have good literature> >> >> support? - and how many of you are in support of rectal temps? I> >> > thought> >> >> we had cleared that issue for once and for all - but I guess not!> >> > Would> >> >> you please give me your input?> >> >> Thank you so> >> >> Julia S. Whitefield MD, Ph.D.> >> >> UNM> >> >> ABQ, NM> >> >> For more information, send mail to [log in to unmask] with> >> > the> >> >> message: info PED-EM-L> >> >> The URL for the PED-EM-L Web Page is:> >> >> http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> >> >>> >> >> Confidentiality Notice: This e-mail message, including any> >> > attachments, is> >> >> for the sole use of the intended> >> >> recipient(s) and may contain confidential and privileged information.> >> > Any> >> >> unauthorized review, use, disclosure or distribution is prohibited.> >> >> If you are not the intended recipient, please contact the sender by> >> > reply> >> >> e-mail and destroy all copies of the original message.> >> >>> >> >> For more information, send mail to [log in to unmask] with> >> > the> >> >> message: info PED-EM-L> >> >> The URL for the PED-EM-L Web Page is:> >> >> http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> >> >>> >> >> For more information, send mail to [log in to unmask] with> >> > the message: info PED-EM-L> >> >> The URL for the PED-EM-L Web Page is:> >> >> http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> >> >> >> > For more information, send mail to [log in to unmask] with the> >> > message: info PED-EM-L> >> > The URL for the PED-EM-L Web Page is:> >> > http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> >> > Confidentiality Notice: This e-mail message, including any attachments,> >> > is for the sole use of the intended> >> > recipient(s) and may contain confidential and privileged information.> >> > Any unauthorized review, use, disclosure or distribution is prohibited.> >> > If you are not the intended recipient, please contact the sender by> >> > reply e-mail and destroy all copies of the original message.> >> >> >> >> >> > For more information, send mail to [log in to unmask] with the> >> > message: info PED-EM-L> >> > The URL for the PED-EM-L Web Page is:> >> > http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> >> >> >> > ------------------------------------------------------------> >> > This email message, including any attachments, is for the sole use of> >> > the intended recipient(s) and may contain information that is> >> > proprietary, confidential, and exempt from disclosure under applicable> >> > law. Any unauthorized review, use, disclosure, or distribution is> >> > prohibited. If you have received this email in error please notify the> >> > sender by return email and delete the original message. Please note, the> >> > recipient should check this email and any attachments for the presence> >> > of viruses. The organization accepts no liability for any damage caused> >> > by any virus transmitted by this email.> >> > =================================> >> >> >> > For more information, send mail to [log in to unmask] with the> >> > message: info PED-EM-L> >> > The URL for the PED-EM-L Web Page is:> >> > http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> >> >> >> > Confidentiality Notice: This e-mail message, including any attachments,> > is> >> > for the sole use of the intended> >> > recipient(s) and may contain confidential and privileged information.> > Any> >> > unauthorized review, use, disclosure or distribution is prohibited.> >> > If you are not the intended recipient, please contact the sender by> > reply> >> > e-mail and destroy all copies of the original message.> >> >> >> > For more information, send mail to [log in to unmask] with the> >> > message: info PED-EM-L> >> > The URL for the PED-EM-L Web Page is:> >> > http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> >> >> >> > For more information, send mail to [log in to unmask] with the> > message: info PED-EM-L> >> > The URL for the PED-EM-L Web Page is:> >> > http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> >> >> >> > Confidentiality Notice: This e-mail message, including any > > attachments, is for the sole use of the intended> > recipient(s) and may contain confidential and privileged information. > > Any unauthorized review, use, disclosure or distribution is > > prohibited.> > If you are not the intended recipient, please contact the sender by > > reply e-mail and destroy all copies of the original message.> >> >> > For more information, send mail to [log in to unmask] with > > the message: info PED-EM-L> > The URL for the PED-EM-L Web Page is:> > http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> >> > For more information, send mail to [log in to unmask] with the message: info PED-EM-L> The URL for the PED-EM-L Web Page is:> http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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