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This has been my experience all along. I even did a small multi-institutional survey back when I was a resident based on this topic. Inpatient caregivers want a packaged patient, even when that sizeable differential simply won't fit into a nice little box!

DLooneyMD

> Date: Sat, 2 Jun 2012 11:19:23 -0400
> From: [log in to unmask]
> Subject: Re: mastoiditis imaging
> To: [log in to unmask]
> 
> How do others feel about this "uncomfortable" word that seems to have creeped into our lexicon?    I hear it more and more and I find it annoying every time I do.  I here it from consultants and hospitalists and in most cases I think it means:
> A) I want the patient packaged and wrapped with a bow before they get to the floor.
> B) I want a definitive answer before I see or accept the patient.
> The peds ED director where I did my residency, always said that the work up of a patient should not end at the door of the ED and I firmly agree with this.  It adds to LOS in the ED, ED crowding and I have a hard time believing it improves patient outcomes.
>  Thoughts?
> Mike Falk,
> New York, NY
> Sent from my iPhone
> 
> On Jun 1, 2012, at 10:17 PM, "Goetz, Kathleen" <[log in to unmask]> wrote:
> 
> > My first plan of action (and what I told parents) was IV, labs, CT, admit, IV abx, ENT consult.  I am aware of the possible complications, have seen venous cavernous sinus thrombosis, though have not seen a case of mastoiditis in several years now.
> > Radiology said no to the CT, too much radiation.  Even suggested that a head CT would be less radiation (than temporal bone scan) and would still show the mastoids.  Wanted ENT input.
> > ENT (older, quite experienced) said no need to CT, would not change management, would see first thing in am for tympanocentesis and/or PE tubes.  Said all OM includes some mastoid involvement.  Try IV abx and drainage 1st.
> > Hospitalist also uncomfortable with no CT, called ENT back, same response (after midnight by now).
> > IV Unasyn & Vanco started.  WBC 30, CRP 7.7
> > This am PE tubes placed, MEF cultured, clinical appearance improved by afternoon.
> > 
> > Of note this child was seen the day before his ED visit with no signs of mastoiditis by PCP.
> > Parents said he looked fine that am, low grade fever, then when they picked him up from daycare his ear was sticking out and scalp red.
> > This was the happiest, most playful, most comfortable child I have ever seen with mastoiditis.  He was blowing bubbles at me during the exam, no tenderness or warmth, just erythema and a markedly protruberant ear on exam.  EAC erythema, edema and suppurative OM probably the most impressive signs of infection.
> > Blood, MEF and MRSA cultures pending.
> > 
> > It would be interesting to hear from our ENT colleagues.
> > kg
> > 
> > 
> > Kathleen Goetz, MD
> > Medical Director
> > Swedish Pediatric Emergency Services
> > Office:  206-386-3313
> > ED:  206-386-2573
> > Cell:  253-370-7571
> > ________________________________
> > From: Darrell Looney [mailto:[log in to unmask]]
> > Sent: Friday, June 01, 2012 4:51 PM
> > To: Goetz, Kathleen; [log in to unmask]
> > Subject: RE: mastoiditis imaging
> > 
> > Would definitely image looking for any extension whether cutaneous or for intracranial changes. Concerned because of persistent symptoms despite antibiotics.
> > 
> > DLooney, MD
> > 
> >> Date: Fri, 1 Jun 2012 07:19:50 +0000
> >> From: [log in to unmask]
> >> Subject: mastoiditis imaging
> >> To: [log in to unmask]
> >> 
> >> 9 month old healthy immunized child with 17 days OM. Treated with Amoxil x 7 days, cefdinir x 10 days, presents with protruding right ear, suppurative ROM, post auricular erythema, fever, otherwise well appearing.
> >> Would you image this child who has clinical mastoiditis?
> >> If so - CT?
> >> Has your practice changed due to increasing concerns about CT/radiation exposure in infants?
> >> Kathey Goetz
> >> 
> >> Kathleen Goetz, MD
> >> Medical Director
> >> Swedish Pediatric Emergency Services
> >> Office: 206-386-3313 ED: 206-386-2573 Cell: 253-370-7571
> >> 
> >> 
> >> 
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> > 
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