Thinking horses not zebras

[tniuqs]

Unfortunately, the list of differentials for low grade fever, sore throat, and generalized myalgia in the pediatric patient is quite long. You would be hard pressed to narrow the problem down to streptococcal pharyngitis versus meningitis simply based on the said signs and symptoms.

If I had to care for somebody with these signs and symptoms, I would obtain an in depth history and perform a physical exam and assessment along with a complete set of vital signs before narrowing down the differential.

<snip>

chbare.

Agreed !

Just me but I would be looking for Kernigs or Brudzinskis sign AND look at the Throat for a big beef Uvula with white pustules (as this is a bit of a free bee) Absolutely a good physical exam is mandatory, just becase a temp is up a tad is in no way can one put a finger on a Dx, and just how was the temp obtained tempanic, axilla or rectal ???

Neonatals respond to sepsis in other wierd ways like DIC and coagulopathys, color or mottling as croaker mentions in my estimation is by far a better indicator of how sick the child really is. No matter what the suspected DX transport for medic or emt level urban or rural, unless you are very remote clinic setting and can load with bug juice as then clinical bedside observation without labs becomes very, very important. (ps It sounds like this instructer has never been deployed in that situation, quite clearly)

Back in school my lecture instructor and I had a debate. He was saying if you have a child with a low grade fever, over all disconfort, and a sore throat to think it's spinal meningitis. I disagreed and said strep throat. Keep in mind I work in early childcare and have been in that field for close to 5 years now. I don't even want to begin to think of how many kids I"ve seen with strep that show those signs/symptoms.

Arguing this senseless instructors 'senario's' is a waste of breath, just what was the point the instuctor was attempting to make ? superiour knowledge ? head butting ? or stimulate debate of the statistical occurance ? Strep vs Menigitis ? It sounds like a big fat fail for the instructor quite clearly demonstrates their depth of his or her knowledge and experiance in paediatrics

This is not a horse or a zebra, my dx would be this is a jack ass te he.

cheers

Edited May 2, 2009 by tniuqs

[Gypsy]

Ya we went back and forth for maybe 2 minutes then I remembered, "oh ya you know this guy is nuts. That's why you go home and read and home school yourself." I just wanted to see if I was in the wrong and he really was right.

[Doczilla]

To clarify, a "zebra" is not just unlikely, it's unlikely and rare. And this statement is common among internists but not emergency physicians.

Emergency medicine is patently different from other specialties in how we approach a complaint and form a differential diagnosis. Most specialties look at what is "most likely" the cause of the patient's symptoms. As the "health care safety net", emergency care providers are the last chance many patients have to catch a potentially life-threatening disease. Our ability to perform an intense, broad evaluation in a very short period of time lends us the ability to quickly diagnose something that may take a primary care physician (if the patient even has one) much longer, and perhaps too long, to find. We can't afford to say that the burning retrosternal chest pain is probably GERD and leave it at that. We have to make sure it isn't something far worse, like MI, or TAD, or PE, or pneumonia, or pericarditis. Speaking from experience, there are few feelings worse than finding out later that your diagnosis was incorrect and you missed something dangerous. The hair stands up on my neck anytime one of my partners says, "Hey, you remember this patient you saw the other day..."

When confronted with a diagnostic dilemma (and they are all dilemmas until you think through it), think about not only what is most likely, but what is perhaps less likely but potentially lethal. It is our job to consider the potentially life-threatening cause of every complaint. Nausea? You'd better think about MI. Back pain? AAA should be somewhere in your mind. That's not to say that every patient with nausea gets an admission for serial enzymes and a stress test, but you've got to think about it. That's also not to say that every kid with a fever should get an LP, but it should be considered even if just briefly.

While you might be correct that ultimately the patient will turn out to have a non-worrisome diagnosis, your instructor's point is a good one.

'zilla

[crotchitymedic1986]

As someone who worked in a pediatric hospital's ER, and had the opportunity to treat all of the children who had meningitis who had been sent to the doctors office or local adult ER by car, at the direction of EMS, I would caution you to always think menengitis when you have fever. Note: I said "think", not treat. The rash and stiff neck are late symptoms, and most kids in the 2-4 year range may not be able to describe a "stiff neck" or are too scared to tell the room full of firefighters and medics who have just barged into his home.

Until we have the ability to do a white count in the field, we should not be so quick to diagnose all fevers as ear infection, teething, strep, or a virus.

[tniuqs]

To clarify, a "zebra" is not just unlikely, it's unlikely and rare. And this statement is common among internists but not emergency physicians.

Emergency medicine is patently different from other specialties in how we approach a complaint and form a differential diagnosis.

<snip>

While you might be correct that ultimately the patient will turn out to have a non-worrisome diagnosis, your instructor's point is a good one.

'zilla

So a query zilla:

So just how with this very "scanty" information presented in this hypotherical senario could or would affect the treatment in any way to an EMS provider in the field ?

These are not ER MD's, these are Paramedics and EMTs capable of supportive care ONLY and no where near close to definitive Dx or treatment unless life threatning situation occurs ie ABCs ... sounds far more of a dog / instructor chasing its tail, instead of clearly pointing out and factoring in all the possible diff Dx.

If one read's the OP's following post he "went to the books" to differentiate between Meningitis vs Strep not the entire gambit of febrile paeds patho ... heck zilla your right, but it could be Malaria or Cow Pocks too just saying the instructor failed to make his point clear and I have a sneaking suspicion the OP chose to use the horses vs zebras as a title for the tread.

I guess I was in error attempting to introduce some teaching i.e. meningeal signs and cardinal signs of Strept Throat, ps I do like the way croaker presents his views.

As someone who worked in a pediatric hospital's ER, and had the opportunity to treat all of the children who had meningitis who had been sent to the doctors office or local adult ER by car, at the direction of EMS, I would caution you to always think menengitis when you have fever. Note: I said "think", not treat. The rash and stiff neck are late symptoms, and most kids in the 2-4 year range may not be able to describe a "stiff neck" or are too scared to tell the room full of firefighters and medics who have just barged into his home.

Until we have the ability to do a white count in the field, we should not be so quick to diagnose all fevers as ear infection, teething, strep, or a virus.

Quite obvious that crotchitymedic in his following post jump on the kid "complaining of sore neck ' a room full of figher fighters and further tangents and totally missed the boat AGAIN .. Brudzinski or Kernigs Signs, are Signs NOT Complaints ... sheesh.

Honestly crotch you scare me, I put my money on you worked in pediatric hospital's ER as a porter.

I wonder why I even bother to post these days.

[AnthonyM83]

And okay, those two signs you listed aren't complaints.

What percentage of the time do they appear? Can you rule it out based on the classic signs of meningitis being absent?

Symptoms are important as well....

And yes, Cow Pox should technically be on your mind. Doesn't mean you need to treat for it...that was addressed in the Doctor's post.

But I guess I'll let him handle ya

[tniuqs]

'AnthonyM83

And okay, those two signs you listed aren't complaints.

What percentage of the time do they appear?

Well someone did some investigation ... Anthony... even when your sick with Human Swine Flu your sharp ! te he ... did you get to write exams ?

These Signs can be observed when one has meningeal irritation its not a matter of % its a matter of severity or progression of the disease, the cause ? Another point as meningitis can be bacterial and/or viral and many EMS providers believe that meningitis in itself is a diffinative dx ... hmmmm.

Not until the pathogen has been identified through virology or C+ S cultures (usually Post mortum) unless you have a dang good ER MD, and using a shotgun approach but then MOST do the Peads Consult Flip.

Group B Strep (70%) in the neonate under 2 months is most common horse and non vacinated older kids you could be looking at H. Inflenza.

STREP can be paediatric pharnygitis OR Strep pnemonia, my previous post refered to the common EMS (mis) understanding, hence my suggestion in looking down a gullet and futher evaluation as chbare suggests.

Can you see now why this instructor was so off base ... well just in my perspective ?

Can you rule it out based on the classic signs of meningitis being absent?

Your talking Nuchal ridgity in paeds, it is highly unlikely the 2 to 4 y/o will describe their neck hurts upon flexing, Nuchal ridgity is when the pt. cannot flex neck or involuntary neck muscle spasm limits passive neck flexion .. much more likely this is vocalised or a complaint in an older patient.

Symptoms are important as well....

Will not disagree BUT Kids when febrile "usually" don't cooperate cause there to damn busy crying (which is a GOOD sign btw) crying kids are moving air, quiet kids are BAD.

And yes, Cow Pox should technically be on your mind.

Doesn't mean you need to treat for it...that was addressed in the Doctor's post.

Cow Pox, Malaria IS the point ... that is the Zebra's ... the Horses are Meningitis, Strep Throat, Otitis media for most common on the hit parade for fever.

But I guess I'll let him handle ya

Oh no doubt ... a dumb ass Paramedic contesting any MD will recieve wrath right or wrong. I have made a few look silly but usually pay for it in the long run ... they have this tendancy to get even

Crotchity will I have no doubt have a come back as well ... usually pointless drivel ... but that is just cheap entertainment after all

cheers

Edited May 3, 2009 by tniuqs

[Richard B the EMT]

One of my old program director's favorite questions was, "If you hear hoof prints, what do you look for"?

I'd be looking for an appointment with the audiologist.

You HEAR a hoof PRINT, not a hoof beat? You must have a very loud fingerprint, currently being looked at, and listened to, by the Las Vegas (Nevada, USA) CSI unit of the LVPD.

Sorry, I just couldn't resist that! LOL.

[AnthonyM83]

Well someone did some investigation ... Anthony... even when your sick with Human Swine Flu your sharp ! te he ... did you get to write exams ?

Naw. A lot of those exception type factoids just happen to stick in my mind. I think that one was from an ERDoc or Doczilla at some point. My theme in my EMS career seems to not generalizing and contrarian type comments.

Anyway, my point is that in this case since we can't fully rely on signs AND we can't elicit even the classic symptoms AND the zebra would be a very very acutely dangerous zebra, we have to consider zebras a bit more than usual. Doesn't mean treat the zebra (like rush code 3 to ER), but rather make sure child gets to ER with parents that day (versus going to personal doctor if it doesn't get better in a few days).

Like Doczilla was saying, it's all a balancing act. You treat it mainly like a horse, but juuust enough like a zebra, so that if it is, you can still prevent it from making its kill.

AKA sending the CP home with tx for pleurisy, but keeping him in ER just long enough to get labs back.

-And naw, haven't gotten to write the exams yet, but did get some questions thrown out...and the daily reference source during lecturers' brain farts

(I say that with love if my instructors ever read this)

Edited May 3, 2009 by AnthonyM83

[Doczilla]

So a query zilla:

So just how with this very "scanty" information presented in this hypotherical senario could or would affect the treatment in any way to an EMS provider in the field ?

These are not ER MD's, these are Paramedics and EMTs capable of supportive care ONLY and no where near close to definitive Dx or treatment unless life threatning situation occurs ie ABCs ... sounds far more of a dog / instructor chasing its tail, instead of clearly pointing out and factoring in all the possible diff Dx.

If one read's the OP's following post he "went to the books" to differentiate between Meningitis vs Strep not the entire gambit of febrile paeds patho ... heck zilla your right, but it could be Malaria or Cow Pocks too just saying the instructor failed to make his point clear and I have a sneaking suspicion the OP chose to use the horses vs zebras as a title for the tread.

I guess I was in error attempting to introduce some teaching i.e. meningeal signs and cardinal signs of Strept Throat

Okay, I'll bite. As has been demonstrated in several scenarios here on EMTCity, you can't diagnose a patient without looking at them. With the two pieces of information given by the OP (presumably all that was given by the instructor), you can't diagnose strep, or meningitis, or carotid artery dissection, or peritonsillar abscess, or anything. My point was more regarding the general approach to patients by emergency care providers. Perhaps these were the points the instructor was trying to get across.

How could this affect the care provided? What if the medic told them it was just strep, and was wrong? The patient (or parents, in this case), based on that assumption, decide not to go to the ER tonight. Care could be delayed, and harm could result. Many patients do, in fact, look to EMS for medical advice rather than just transport. Considering the possible life-threatening diagnoses will help the provider to guide the patient to the right decision.

You weren't in error adding some teaching on meningitis vs. strep throat. You and I were talking about totally different things here.

'zilla