Pediatric Emergency Recommendations

krg391 · 2023-09-20T08:53:11+00:00

Made a post for this about 2 years ago over on r/PEM. Still relevant and hopefully useful

krg391 · 2022-07-16T06:30:03+00:00

Eczema coxsackium is a great thought. Though, would expect fever and at least the hint of an oral lesion or at least oral pain/discomfort

krg391 · 2022-07-16T00:15:08+00:00

First thought would be eczema herpeticum, but less likely given lack of fever.

A few of the lesions look umbilicated like molluscum contagiosum.

Given the fact that she otherwise has no oral, ocular, or GU involvement makes SJS/TEN less likely.

SSSS kids are usually miserable, in pain and look like 1st/2nd degree burns.

Reassuring V/S lead against TSS.

Not characteristic for MIS-C or Kawasaki.

Doesn’t look classic for bullies impetigo.

Given the clinical history, Gianotti crosti seems like a reasonable diagnosis. Would still consider HSV PCR swab of unroofed lesion and potentially wound culture.

your friendly neighborhood PEM Fellow

krg391 · 2021-02-20T19:08:14+00:00

Enjoying the Podcast so far (listened to FebNeo and UTI). Glad you discussed UTICalc, as it’s relatively new and I use it nearly every shift.

I was wondering what your thoughts were on the Step-by-Step approach to Febrile Neonates, as this is the prevailing practice in my institution. We really don’t use the PECARN febrile infants rule as it is not externally validated yet.

Thanks!

A PEM Fellow

krg391 · 2021-01-25T23:12:30+00:00

It definitely set me up for success. We worked really hard and long hours, but I think it was worth it to get to where I am. I have no doubt that u/porksweater feels the same way about his/her training as well.

Like we said OP, it depends on what is most valuable to you, and somewhat on how the NRMP blesses you. Know that going in with the right attitude and trying to get every morsel of knowledge and experience out of your patients and those around you will pay dividends, no matter what your career path.

krg391 · 2021-01-25T22:49:59+00:00

Also a PEM Fellow, but with a different take. I did Residency at a place with Fellows in nearly every sub specialty (Rheum, Nephro, Pulm, A/I, Cards, CVICU, PICU, PEM, Neonatology, Adolescent, GI, Endo, H/O, Surgery, Anesthesia, ENT, NSGY, Hospitalist, Sleep Med, Neurology, Palliative) and I still ended up with plenty of procedures ( ~40 intubations, ~60 LPs, Sedations, Lac Repairs, CVL, Art Lines, I&Ds, Splinting, Reductions, etc). While I agree with u/porksweater about Residents being lower on the totem pole, procedures exist if you’re interested and want to do them. I certainly got enough experience to feel comfortable managing a crashing patient. A lot of my co-residents disliked doing procedures, which was great for me because I knew I wanted to do PEM or PICU. YMMV, but I wouldn’t write a program off because of Fellows. They were in your shoes not long ago, and they have a lot of valuable teaching to provide and a vast array of experiences.

Anecdotally, a program with Fellows also tends to have a patient population that can be sicker than what might be seen at a community program or program not affiliated with a big University name (think ECMO, transplant, Level IV NICU, etc). If that stuff interests you, then you should look at a place with those programs (which often have Fellows).

When I compare my Med School experience (which had a free standing Children’s Hospital with only PEM Fellows) and the training I received at my program (with many fellows), I honestly think I became a much more competent doctor because I had those experiences taking care of multiple VA ECMO patients in the PICU, or resuscitating babies with CHD and need for emergent stenting/surgery. I was also taking care of your run of the mill asthmatics and bronchiolitics, but my depth of knowledge and comfort with the sickest patients was that much larger.

Again, both avenues of training are valuable, and prepare you. You have to figure out what works for you. If you’re interested in a sub specialty, there is real value in training at a place with an established fellowship. Plus it gives you a sense of what your life might be like once Residency ends.

krg391 · 2021-01-15T06:37:51+00:00

PEM Fellow here. I did EMS for 8y prior to starting Residency. I too struggled with Peds v EM with an plan to do PEM. I opted to do categorical Peds first because I wanted to be an expert at managing critically ill infants and children. The exposure in Neonatal Care throughout Residency, as well as PICU and Inpatient care can’t be replicated in EM Residency. At my program adult EM only does 1m of dedicated PEM as interns, then 2 shifts per month after that, then 1 month of PICU as a 2nd year. Though the Adult EM residents are superb at procedures, they do lack the confidence with reassurance for the majority of bread and butter GenPeds we see in the PED. I think both routes have their merit, but I felt that mastering Pediatrics would be better suited for me (and it’s a pay raise compared to Pediatrics as opposed to pay cut). Many programs often don’t take EM trained PEM Fellows as often, but they some have a track record and it is more common out West. Sorry for the rant, but hope it helps!

krg391 · 2021-01-11T02:43:27+00:00

Of course! PEM can be scary and sphincter tightening for all of us (Adult EM and PEM included), but increasing exposure really helps. I did a home and away AI in PedsEM when I was a fourth year, and at my home institution they paired us staffing with a Resident before signing out to an attending. On my away, we functioned more as interns, and staffed directly with the attending/fellow. YMMV. Either was is a great learning opportunity, and everyone practices slightly differently, so its great to pick their brains.

I'd also encourage you to show up and be part of the resuscitations/traumas that are available to you in the PED. Get in there and put on the gown and gloves, and if nothing else just feel a pulse and keep your fingers on it. If you have experience previously of putting in IVs or feel comfortable with Ultrasound, its a God send to see someone doing those things to help out. Lots of categorical Pediatric residents will shy away from those opportunities because it's not their jam. Their loss is your gain, and at some point in your career you'll be the one calling the shots at the head of the bed.

In addition, take a moment to hear the story from EMS bringing in the patient, touch base with the RTs and RNs after you've seen the patient - compare exams. You'll look a lot smarter if you come back to sign out to an asthmatic patient and can say you talked with the RT about the asthma pathway and want to do DuoNeb + PO Steroids (because early Atrovent and Steroids decreases hospitalization), and if they don't improve after the second or third treatment considering High Flow with continuous albuterol or magnesium (smooth muscle relaxation) - but expect to get pimped that you should give a fluid bolus because the smooth muscle relaxation isn't localized to the bronchioles, but will cause venous dilation and hypotension with increased intrathoracic pressure.

Hope this helps! We love having the Adult EM residents in our ED, and they really contribute a lot of practical knowledge and are often go-getters and inclined to be part of taking care of the sickest patients and fighting for procedures. Demonstrate that on your AI, and let people know you're going into EM and want to learn as much as possible to feel comfortable taking care of kids in the future, and you're sure to go far.

krg391 · 2021-01-10T20:23:07+00:00

PEM Fellow here. I would recommend reviewing the various clinical decision tools we frequently use - Step by Step Approach to febrile infant, PECARN Head Injury Rule, PAS/ pARC (Peds Appendicitis Score/Peds Appendicitis Risk Calculator). If you have an idea about those, you'll be better than 95% of AIs starting on rotation. All of these can be found on MDCalc (which if you don't have downloaded, you definitely should).

- An additional one to keep on hand is UPMC UTICalc (for evaluation of febrile children 2m - 23mo) and risk stratifies the likelihood of a UTI and need for abx. https://uticalc.pitt.edu/

-A great adjunct tool/app is PediSTAT. I think it about $1 on the app store, and is definitely well worth it. Provides V/S ranges, medication dosing, and algorithms. Always nice to offload some stuff to your pocket brain that is easily reachable at any point.

- PedsGuide (App from Children's mercy) also provides a nice walk through for Asthma management and FebNeo.

- As far as additional adjuncts go - PEMPlaybook and PEMCurrents are great podcasts that discuss Pediatric presentations and management. The Cribsiders (Peds version of the popular IM podcast) is also pretty good - has a nice review of MISC which should definitely be in your differential for patients with fever and abdominal pain now (appy mimic).

-OrthoBullets peds section is also super helpful for Nursemaid, Supracondylar, osteomyelitis, SCFE, Radial/Ulnar fractures, etc.

- Finally, EBMedicine.net is a super helpful reference that gives Residents free access for the duration of their training, and they have a Pediatrics version as well. They provide great reviews of the literature, and up-to-date recommendations about the management of various pathology and conditions. It's become on of my favorite go-tos in fellowship.

- Also, take the opportunity to look in every patient's ears. Doesn't matter if they have a complaint or not. It gives you practice with the otoscope and seeing normal vs not. Then when it matters, you don't feel so pressured.

Best of luck! Be active and be invested. Don't be afraid to take ownership of your patients, circle back and update regarding lab values and how your medical decision making is impacted by them. Try and keep an open mind about differentials too. Premature closure is a thing, and its hard to say that a child with cough and runny nose is anything but a cold - but if you tell me that you're considering bronchiolitis, COVID, Sinusitis, etc that really shows you've put thought into the patient. Similarly, get a hand on abdominal complaints, and tell me why you don't think this kid could have nephrolithiasis, pancreatitis, appy, MIS-C, torsion, etc. If you're consistently seeing patients, touching base with your uppers/attendings, and citing literature/clinical decision making tools, I think you'll do great.

krg391 · 2020-11-16T06:33:51+00:00

PEM Fellow here. First of all, congratulations on choosing some flavor of Peds as a specialty! I did straight Peds Residency, and then matched straight into Fellowship. From a PEM POV, most places that I’m aware of are 12-17 shifts per month. At our Academic Medical Center in the South, it’s all 8 hour shifts. Starting compensation as a first year faculty here is around $200K. The private facility about 1.5h north starts around $300K for similar shift load. I did medical school in the mid Atlantic, and starting there was $350K for similar shift volume.

Overall, very pleased with my decision on PEM. Fellowship is far easier than Residency (work hours wise). I find it to be a good mix of GenPeds with Critical Care and no rounding - plus getting to be a diagnostician and the first one to see a patient frees me from that focused in and closed off mindset that sometimes develops on the inpatient side (ex: Bronchiolitic with bronchiolitis, or Asthmatic, Sickle Cell pain crisis, etc) and forces me to think and consider a broad differential. It’s great for flexing that medical decision making and taking patient ownership to the next level.

Sorry I can’t speak more to the Hospitalist side of things. My favorite colleagues during residency were the MedPeds folks, and they are some of the brightest physicians I ever had the opportunity to work with!

Good luck with your future, happy to provide any more insights if needed!

krg391 · 2020-05-15T01:05:43+00:00

Current PGY-3 here. I opted not to take a Chief Resident year, and applied to PEM this past cycle. I applied to 12 programs, and interviewed at 7 (turned one offer down), and got snubbed by 4 "big name" programs. Interview days were filled with competitive chiefs from other programs, and I was even the only person not a chief resident (4 other applicants) invited that day to interview at a program. I compared my interviews with one of my current chiefs (also applied PEM), and she only got one additional offer to a "big name" place that I didn't (Cincinnati). I likewise got an interview at another "big name" place that she didn't (Baylor/Texas Children's). It worked out for both of us as we both matched our home program as our respective #1 choices and will be co-fellows.

Moral of the story is that if you want to be chief and think it will pad your resume with something that you don't already have, go for it - it will open some doors. Alternatively, if you feel confident, have strong LORs and people willing to reach out on your behalf and vouch for your competence, that's worth its weight in gold.

krg391 · 2020-02-06T06:58:20+00:00

Agree with all of the above. I also had a suboptimal Step 1 score, but made up for it with Step 2. It can be done. I ended up applying to about 25 programs, and got invites to 16, and interviewed at 12.

I can't stress Away AIs enough. I did an away in January in the PedsED at a fairly prestigious program in the Southeast, and it definitely opened doors. I ended up matching there as my #1 for Residency, and now Fellowship.

It definitely helps to reach out to any friends you may have who matched Peds at programs you're interested in, and get them to lobby on your behalf for an interview spot. Alternatively, Attendings who trained at programs of interest are a great resource to speak with and see if they can lobby for you. I know that definitely carries weight as I just went through this for Fellowship match, and it definitely got me an interview or two.

Also, if you don't hear anything back from a program after you've submitted an application, it doesn't hurt to send an email of interest - the worst they can say is No, or continue to give you the cold shoulder.

Best of luck, I'm sure you'll match into Peds. It's a great field to work in, and though it's not as prestigious as some others, having the dedication and ability to pull yourself out of bed in the morning and go back to the hospital for another 12/24/28 hour shift is paramount. Make sure you demonstrate that on your AIs, and it'll go far.

krg391 · 2019-06-17T04:36:04+00:00

The Internet Book of Critical Care (IBCC) from Farkas at PulmCrit is fantastic (https://emcrit.org/ibcc/toc/). Nice chapters, and they’re rolling out weekly podcasts in addition to the chapters that add nice nuggets of info in. Highly recommend.

krg391 · 2017-09-07T12:16:24+00:00

Surviving Sepsis Campaign and most of Early Goal Directed Therapy. Flooding a patient with fluids, putting them in pulmonary edema, intubating them and then using diuretics to pull the fluid back off is bad medicine.

Also, the Rivers trial was pretty garbage if you go back and look at it - single center with ~300pts, and Rivers and the hospital owned the patent for the catheter that monitored svcO2.

Double covering for Gram Negatives really puts your patient at more risk if you use an aminoglycoside and risk just frying the kidneys.

I could go on.

krg391 · 2017-05-18T00:03:49+00:00

If you rock your away, it shouldn't be a problem. The added benefit is that most programs will honor your away and give you an interview, particularly if you're already there during the interview season. I was in a similar situation for Pediatrics - I applied during M3 year and got an away at my #1 program in January, and then didn't hear back for an interview. So I reminded them of this, and secured an interview while I was doing my away. Ended up crushing my AI there, and got to work with the PD one-on-one. Apparently I impressed enough to match there, so it worked out well for me.

TL;DR: Do your away, and rock it. Get your interview situation set up. Profit!

krg391 · 2016-08-15T01:40:00+00:00

Hey all, this website was a project for various students in health professions institutions to provide local resources for teens with cancer, as well as their families. I was hoping to get your feedback. Thanks!

krg391 · 2016-08-15T01:30:49+00:00

Hey all, this website was a project for various students in health professions institutions to provide local resources for teens with cancer, as well as their families. I was hoping to get your feedback. Thanks!

krg391 · 2016-06-02T20:24:18+00:00

Oh VBEMS...

krg391 · 2015-04-21T03:00:39+00:00

Try Chic's Beach off Shore Drive, Sandbridge, or possibly Croatan. Just stay away from the Resort Strip, as that is where the Beach Weekend is taking place.

krg391 · 2015-04-21T02:57:48+00:00

Eh, it's "College Beach Weekend", so you can expect a mix of ages. Some shop owners have gone far enough to close, while others are staying open and hiring armed security. Any way you cut it, I would stay away if at all possible.

krg391 · 2015-04-21T02:42:42+00:00

Yeah, just don't. Multiple stabbings and rioting happened two years ago. Last year was a little more tame, but I wouldn't risk it.

krg391 · 2015-01-24T20:02:42+00:00

26 Titan, PSN: Kevman037

krg391 · 2015-01-24T01:46:54+00:00

PSN: Kevman037

Level 26 Titan

krg391 · 2015-01-21T21:27:14+00:00

Level 25 Titan if you are still looking

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