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I am interested to know, if you routinely use a WBC count to determine if you would perform an US to look for appendicitis. Many times I perform a RLQ US based on clinical suspicion and thus I don't perform a CBC on many children before imaging. I usually order a CBC if I think a child has enough pain to warrant IV fluids and medication but in these cases I will admit that I typically order the CBC with the US. We have US available 24/7 and I think that anecdotally our technicians are pretty good. We rarely, almost never, do CT before US but if US is equivocal and suspicion is high then will proceed to CT. I work at a hospital that is part of a larger system where other hospitals (without 24/7 Pediatric EM) are doing appendicitis scoring on all abdominal pain. Obviously not everyone has high enough suspicion of appendicitis to warrant a score and I would assume that many patients with abdominal pain are discharged without a work up. However, the healthcare system can not compare data of appendicitis outcome comparing pre diagnosis low, moderate, and high suspicion cases because the providers at my hospital are not completing a pediatric appendicitis score. A CBC is required for the score to be completed in the EMR and thus for it to be retrievable in a report without a chart review. 
It has been questioned whether our process adds cost and I am in the process of obtaining cost for US compared to lab. I take into consideration that we rarely perform blood work without an IV on children and I am sure this can be questioned but we try not to "poke" a child for a CBC only to return and "poke" for an IV. Our turn around time for US is vey good. And also this may be questionable but I feel that US for appy is very operator dependent and the process has helped in that our rates of US where the appendix can not be visualized has improved. I know this previous sentence is not a justification for US on children but I would also say that we have many patients referred to our hospital with inconclusive or borderline measurements of an appendix where an US at our hospital sometimes provides clarity. 

Thank You for your thoughts

Christian Rocholl MD

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