Maybe we should talk to our pediatrician colleagues who deal with this issue every day. Having worked in private practice as well as Peds EM, I can categorically say that our colleagues practice medicine way different than we do and it's not just because "they know the patient and family". IF you take the time to get a really good hx (not starting a sepsis workup when the babe hits the ED and the nurses start before you even see the kid to save time! - and I know it's done that way!) and a really good physical, you know which kids are septic and which aren't. Our colleagues see these kids all the time and DO NOT send all of them to the ED for "evaluations". It's costly in time and emotional trauma to the family. How many kids have you seen that have already had several sepsis workups before their 3-5 mos old that use the EDs as their PCP? TOO many! Maybe I'm jaded but what happened to good clinical skills? Those of us old enough remember learned that most of your "exam" was your careful history and observation/interaction of the child and you could often tell what was wrong with the child before you ever laid hands on them. Letting the nurses start your "protocol" workup just helps lessen our place in the equation. We become superfluous and it's all cookbook and the PA and NP can do that as well as we can WITHOUT us. But I digress. Sure studies show the there is a miniscule incidence of UTI's and SBI's in these infants with many final cultures being negative. Did these kids die in the past? Probably not. If we tested everyone we would find abnormalities but are they important? Remember:


Learn to take a superior hx and do a superb physical, not memorize protocols. Good medicine in the ED is the same as good medicine in private practice.

Pamela Beach-Reber, MD, MBA, FAAP, FACEP
40+ years in medicine
----- Original Message -----
From: "Jay Fisher" <[log in to unmask]>
To: [log in to unmask]
Sent: Thursday, January 20, 2011 12:27:23 AM GMT -05:00 US/Canada Eastern
Subject: pediatric sepsis protocol

We do not have written guidelines for the *identification* of sepsis or
shock but we discuss it here every day and have for 19 years.

For the treatment of sepsis (the easier part IMHO) we follow the Critical
Care guidelines Dr. Foland shared.

With all due respect to Dr. Carcillo's outstanding lifetime of work in this
area, it is interesting to note that all the clinical gems on the early
diagnosis of sepsis have been unearthed through the retrospectoscope of the
intensivists- who get to see the patient when the cat is out of the bag.
The problem is that the progress to MODS in shock is non-linear (see Proulx
et al. Chest 1996 I believe) and requires more time than we typically have
in the ED
to figure out much of the time.

Trying to identify which febrile patient is in soon-to-be-severe-sepsis in
the ED is like
trying to identify which falling snowflakes are going to dissolve before
hitting the ground. Try it some time, it's fun.

Nietzsche (paraphrase)- "Conviction is a greater threat to the the truth....
than lies".

Jay Fisher MD
Medical Director
Pediatric Emergency Services
Children's Hospital of Nevada

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