Clinical Grind 13 Pediatric Fever

Post by Spencer Willette, OMS-III

One of the great aspects of practicing emergency medicine is having the privilege to care for all types of patients, including our pediatric population. Regardless of what emergency department you work in, pediatric patients will find their way to your department and it will be up to you to comfort both the patient and their parents.

Our guest Dr. Yaron Ivan practices pediatric emergency medicine in Orlando FL, and discussed his high yield tips when caring for pediatric patients.

Dr. Ivan’s Rules for the pediatric patient:

1. “It’s not the patients job to prove that they’re sick, it’s your job as the clinician to prove that they’re not.”

Oftentimes children can’t advocate for themselves. As a pediatric provider in the ER, the role you play is to make sure that the chief complaint is not secondary to a life-threatening, serious condition and that the child is safe to be discharged home. Yaron likes to say that “We’re not in the business of winning, we just don’t want to lose.” That is, we don’t necessarily need to diagnose every problem but we most definitely don’t want to miss anything major!

2. “Less is more”

After a thorough history and exam, more times than not, the child will get better on their own no matter what. The reality is that most children presenting to the ER, present with normal behavior that is misinterpreted by parents as serious, dangerous or secondary to a disease process. Education and reassurance can be very comforting and beneficial in these situations. Additionally, regarding pediatric fever encounters where symptoms of runny nose, cough and congestion are present, a viral illness is most likely for which there is no recommended treatment. Order tests that will guide your differential and give you answers.

3. “Look at the Growth Chart!”

This can be a great indicator of immunodeficiencies or nutritional deficits leading to failure to thrive. Inquire and ask the parents if the PCP has ever expressed concern about weight loss or failure to thrive. This can cue you in on the urgency of the situation. Communicate that the single most important indicator that a child is healthy is his or  her weight gain. Classically, kids with immunodeficiency don’t grow, thrive or gain weight.

4. “Worried parents don’t go home”

Many parents in the ED feel like nothing is being done for their child. Reassure and tell them that you’re committed to the patient’s health care. Conversations are key to quality pediatric care. Being upfront and explaining that a blood test in the ED today is very unlikely to reveal the problem or diagnosis and since there are no red flags etc there is really not indication for a work up. Direct conversations and communication are key to a successful pediatric care encounter. Giving parents instructions such as what to look out for can be helpful in guiding their care at home. Giving them a list of potential symptoms that would be worrisome in their child and warrant a visit back to the ED can educate and reassure them at the same time.

 

High Yield Red flags to tell parents to keep an eye out for:

  • Losing weight or lack of weight gain
  • Vomiting nonwhite substance – vomiting bile or blood
  • Blood in the stool

Take Homes:

  1. Take-Home 1: “It’s not the patients job to prove that they’re sick, it’s your job as the clinician to prove that they’re not.”
  2. Take-Home 2: “Less is more”
  3. Take-Home 3: Conversations are key to quality pediatric care.

 

Listen in as these topics are discussed in more detail.

 

About Our Guest:

Dr. Yaron Ivan is born and raised in Israel, graduated from military service in 2000 (infantries) and went to college at Northeastern University in Boston majoring in Biotechnology.

He received his medical degree from Technion Institute of Technology in Haifa Israel in 2010. Dr. Ivan completed Pediatric residency at Baystate Children’s Hospital in Springfield MA followed by Pediatric Emergency Medicine fellowship at the Children’s Hospital of Pittsburgh. Dr. Ivan joined the Emergency Medicine faculty in 2018 and has special interests in medical education. Since joining our faculty, Dr. Ivan has received two teaching awards from Pediatric and Emergency Medicine residencies. In addition, Dr. Ivan is the host and founder of PEM Rules, a dedicated Pediatric Emergency Medicine podcast.

 

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