PEM Source

Your source for all things Pediatric Emergency Medicine

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Tips and Tricks

Tripledemic is coming. Here are some tips for keeping your ED moving (please add more in the comments!)

1) Dispo is King. Often when many patients are waiting to be seen, it’s tempting to sign up for several more. But nothing slows down the ED more than not having rooms available, so remember to make dispo rounds and get patients either sent home or admitted

2) Order stuff from triage – either assign someone to screen and order or empower your nurses to initiate certain orders

3) Before ordering anything, ask yourself, “Does the patient really need that?” Example: flu or RSV test when the answer wouldn’t change your other work-up or treatment

4) Identify the bottleneck. Sometimes, you are shorter on nurses than anything else, and if you really want to keep the ED flowing, doctors will have to pitch in and escort a patient to xray or hand the patient a urine collection cup

5) Buff up your EHR templates, auto-text, and other shortcuts to charting now. Do it on less busy overnight shifts. Do you find yourself typing the same medical decision-making for minor closed head injury where no CT was done over and over? Do it once, select, save as auto-text or dot-phrase, and repeat repeat repeat for all your commonly used text

Harbor-UCLA Emergency Medicine Residency grad and all around great educator Tom Fadial has made some highly useful apps that you absolutely need. The latest, Fractures, is a comprehensive library of fracture types along with radiograph images, pearls, a guide to choosing the appropriate splint, and recommended orthopedics follow-up. The Sutures app reviews the basics of suture materials and anesthetic dosing, and includes links to video walkthroughs of suture techniques from another one of our favorite sites, Closing the Gap. The apps are available on iOS and Android, and some also have web-based versions. Go to fadial.com to check them out!

Having trouble finding the ICD-10 code in your electronic medical record? Do a Google search "ICD 10" + whatever diagnosis you're looking for. For example, searching "ICD 10 parent concern" turns up "Z 71.1 Person with feared complaint in whom no diagnosis is made." Here's another useful one "R 68.11 Excessive crying of infant (baby)." Hope everyone has a Happy Thanksgiving, and no one feels the need to use "Z 63.1 Problems in relationships with in-laws."

PEM Questions

(Click the link to comment and to vote - voting not working through email, sorry!)

[yop_poll id="282"]

(Click the link to comment and to vote - voting not working through email, sorry!)

A PEM group is performing a quality improvement initiative to improve ED flow in the busy evening shift of their 12-bed PED. They implement a fast-track using three patient care rooms, one nurse, and one physician. They gather data after implementation but find that ED flow is not improved because of the loss of ¼ of their patient care rooms to the new fast track. They then adjust their initiative to using only two rooms and re-gather data. 

[yop_poll id="277"]

(Click the link to comment and to vote - voting not working through email, sorry!)

[yop_poll id="274"]

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You are seeing a critically ill 4 week old with bilious vomiting, abdominal distension, and shock. You have a high suspicion for volvulus. You have resuscitated the infant and improved hemodynamic stability but you are at an ED with no pediatric surgeon available and no PICU. The nearest children’s hospital with these capabilities is 100 miles away. There is a light rain but the road conditions are good and there is no traffic. 

[yop_poll id="265"]

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A 17yo boy presents with fever, myalgias, headaches, swollen cervical lymph nodes, and a maculopapular rash that became vesiculopustular on his face, torso, and extremities including palms and soles. You are working in a small community ED. The triage nurse expresses concern for monkeypox. 

[yop_poll id="257"]

Controversies

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Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!

How should ED's handle patients with mild URI symptoms who mostly want a COVID test?

[poll id="68"]
(Click the link to comment and to vote – voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! With the COVID-19 pandemic, PED volumes are low nationwide. A recent SAEM COVID-19 national grand rounds webinar suggested that PED's, to help out inundated adult ED's, might see adult patients up to age 35 years. I tried to pick the most common ages, but feel free to comment with specifics! [poll id="47"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Couldn't put every possibility, so pick the one closest to what you are doing. Also, your choice may depend on your hospital's recommendations and your PPE availability [poll id="46"]

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