>This is one area where we have
>differences amongst ourselves and probably that impedes proper resident
>education in this subject.
I would suggest that this IS part of the proper resident education on this
subject - what I tell the EM and Peds residents I work with is " if you feel
like you get a different approach from each different attending, then you
are paying attention."
The issue is complex, IMHO, because we are looking for a very rare, but
non-zero incidence of devastating illness in children who are smiling and
cheerful at the time of the initial evaluation. I think the fact that
clearly bright, competent people have different practices in similar
situations is strong evidence that there is not a "right" answer.
I find that my practice tends to vary depending on a number of subtle
factors. Just one example: If it is saturday night and I know the patient
cannot be seen by their pediatrician until monday, I am more likely to get a
cbc than I would be in the same patient with a pediatrician who will see
patients on sunday morning. (And yes, I do want them ALL to f/u the next
day, and offer the ED as an alternative - it is just that so few people come
back to the ED that I do not consider it a reliable resource for a recheck
in this scenario.)
There is one plan, however, that I try to convince residents is wrong: to
get the CBC and then not address the results. When they present a patient
who fits the occult bacteremia age and symptom picture, and want to get a
cbc, I ask : what will you do if the WBC is 7,000? What if it is 27,000?
If the 27,000 wbc does not, in the resident's mind, warrant a dose of
rocephin, I ask why get the cbc at all? (There may, in fact be a reason - we
have some pretty savvy residents, but not as a screen for occult bacteremia)
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: