Art of Medicine Video: Discussing Mild to Moderate Croup with Parents in the Emergency Department

This is the first video in the ongoing Art of Medicine series common . The goal is these videos is to share a demonstration of how I would talk to parents about common conditions encountered in the Emergency Department. I could think of no better topic than mild to moderate croup without stridor at erst. In less than 4 minutes you can review:

  • Etiology
  • Pathophysiology
  • Why kids present to the Emergency Department looking fine when they were scary looking at home
  • Rationale for treatment
  • Return precautions

I’d love feedback on which conditions to cover in the future.



In adults calculating the ankle-brachial index (ABI) is a relatively simple way to confirm the clinical suspicion of lower extremity arterial occlusive disease. In pediatric lower extremity limb injury patients where vascular compromise is a concern (think bad fractures, lawnmower calamities) it may also be a helpful test.


  • Measure the systolic blood pressure at the ankle

    Place a blood pressure cuff just above the ankle and listen to either the dorsalis pedis or posterior tibial artery signal with a continuous wave Doppler probe. Insufflate the cuff to a pressure above which the audible Doppler signal disappears. Then release the pressure in the cuff just until the pedal signal returns. Record that number as the systolic pressure.

    In adults the other pedal vessel (either the DP or PT, whichever you didn’t use first) on the ipsilateral extremity is then measured. You then repeat on the contralateral extremity – using the highest value.

  • Measure the systolic blood pressure at the brachial artery

    Place the blood pressure cuff around the upper arm and use the Doppler probe in a similar fashion to the lower extremity

    Again, as is the case in adults you should repeat on the contralateral extremity

  • Divide these two numbers

What the numbers mean for vascular disease in adults

  • ABI ≥0.9 to 1.3 is Normal
  • ABI >1.3 suggests the presence of calcified vessels in adults and the need for more testing
  • ABI ≤0.9 is 95% sensitive and 100% specific for occlusive arterial disease in adults with claudication or other signs of ischemia
    • 0.4 to 0.9 suggests a degree of arterial obstruction often associated with claudication
    • ≤0.4 is worrisome for multilevel arterial disease (iliac, femoral or tibial)

The ABI in Trauma

In the emergency or trauma setting, an ABI is useful for the evaluation of a patient who is at increased risk for lower-extremity arterial injury, as follows:

  • An ABI ≤0.90 suggests a need for further vascular imaging. Go with angiography in a stable patient, and operative exploration by a vascular surgeon in an unstable patient.
  • An ABI ≥ 0.90 is associated with a lower likelihood of an arterial injury. You can observe or repeat the ABI later if you are concerned. Immediate arteriography is not warranted.

The above procedure specifies that you should be using both extremities. On a healthy pediatric patient with no peripheral vascular disease you can just perform the ABI on the injured lower extremity.

Fracture Fridays: Getting a leg up on the competition (Re-post)

The Case

An 80 pound 12 year old soccer star tripped in a hole while challenging for the ball. Another player on the pitch stumbled in the same (big) hole and landed awkwardly on the first player’s leg. Even the fans on the next field over heard the snap. EMS was called and an obviously uncomfortable 12 year old male with intact distal foot pulses and sensation presents to your ED. You do what you normally do and get an X-Ray.

It looks fine, right?

It looks fine, right?

The Diagnosis

OK, so obviously this is a midshaft femur fracture that is displaced and foreshortened. Despite the shortening it is an oblique fracture, which is leg-length stable (more on that in a minute). Overall though the prognosis is actually pretty good. Your initial management centers around pain control, and immediate Ortho consultation. If they are close by there is no need for traction. If you anticipate a long transport, or if there is neurovascular compromise then it should be considered. In addition to narcotics a long leg posterior splint can provide temporary support. Ultimately, this young man had some ‘Home Depot’ action performed and had a great recovery after placement of intramedullary nails.

Nailed it!

Nailed it!

Overall the risk of complications is low with leg length discrepancy the most common. It usually appears within 2 years of the injury and Orthopedists will accept approximately 2cm of overgrowth or shortening in patients <11. Nonunion is very rare in little children, but can occur in kids older than 11 years who weigh more than 49kg.


This fracture goes to the OR – nuff said. So, don’t all femur fractures go to the OR? Well, not so fast my friends. In contrast to adults, the management of midshaft femur fractures differs by age.

Under 6 months

Pavlik harness and early spica casting

7 months to 5 years

<2-3 cm shortening – early spica casting >2-3cm shortening, multiple/open fractures – Traction with delayed spica casting, ORIF, flexible nails or external fixator

6-11 years

Length-stable (transverse or oblique fractures) – flexible intramedullary nails

Length-unstable (very proximal/distal, comminuted or spiral) – ORIF, external fixation

>11 years (approaching skeletal maturity)

Length-stable & weighs less than 100 pounds – Flexible intramedullary nails

Length-unstable and & weighs greater than 100 pounds – Antegrade intramuscluar nail with trochanteric or lateral starting point, ORIF

Want to read more? Check out the excellent Ortho Bullets site.

Clinical features of benign causes of non traumatic chest pain in the pediatric ED

In contrast to Emergency Departments in which the clientele are mostly grown ups, patients with chest pain in the Pediatric Emergency Department have mostly benign causes. I wanted to review some of the findings associated with benign causes of non traumatic chest pain.

Tenderness to palpation of the chest wall

In children tenderness of chest chest wall very much suggests a musculoskeletal cause. These include costochondritis, muscle strain (get a history of recent exercise or ongoing cough), or slipping rib syndrome. This type of pain does quite well with rest and analgesics like Ibuprofen. I often analogize, and compare this pain to a sprained ankle. I also let parents and patients know that a sprain feels better when you rest t, but unfortunately completely “resting” your chest involves not breathing which is not recommended. Thus, this pain can last a little longer. I feel that this helps address some of the ongoing frustration.

Chest pain with fever and cough

If you clinically or radiographically diagnose a community acquired pneumonia recognize that many children will not have chest pain. It could be musculoskeletal due to coughing as well.

Chest pain with history of cough with exercise and/or at night

This suggests asthma – especially if they have a history of it. Chest tightness or difficulty breathing may be called “pain” by a child who doesn’t understand the difference.

Chest pain associated with heart burn

I find that many patients don’t actually know what heart burn feels like. Again, pain that occurs in the chest is often feared to be “from the heart.” Describing the pain and explaining why relationship to eating, laying down etc,. changes pain can go a long way. You should also ask about feeling of “food getting stuck” whether in the past or now. The feeling of having something stuck in the throat is known as the globes sensation. If patients cannot handle swallowing saliva or liquids an impacted foreign body is suspected. You should start with a plain film – though food is radiolucent – and either consult GI or consider a contrast esophogram. Patients with a history off recurrent impacted food suggests eosinophilic esophagitis.

Pain in the breast tissue

In females the differential includes fibrocystic disease, mastitis, pregnancy and gynecomastia and thelarche. Remember that boys heading into adolescence often get gynecomastia, which can lead to tender tissue.

History of stressful event and hyperventilation

To us, this is readily apparent. It’s a panic attack. Sometimes it’s mild pain that freaks the patient out and causes the period of hyperventilation etc,. You need to take a good history, provide reassurance, and most of all make the the patient and family know that they aren’t having a heart attack, pulmonary embolus pneumonia etc,. The ED is about what it is as well as what it isn’t.

Art of Medicine: Bringing angry parents back from the brink

This post originally appeared in a slightly different form on the excellent PEM Fellows Network Blog.


Suppose that you are an attending, fellow or senior resident precepting in the ED and your shift has been going well. You supervised a first-time LP—only 2 RBCs (Chardonnay tap?)—and helped with a patellar reduction. With your fellow mojo at an all-time high the last thing you want is a “social disaster.” Unfortunately, a resident comes out of the exam room and says that the mom wants to speak with his supervisor. When you ask why, the trainee says, “I don’t know…” and shrugs. There are strategies that can help a fellow serve as a facilitator and problem-solver and not just middle management.

Sample the room temperature

Instead of directly asking what’s the matter, you may want to consider if there are any external complicating factors. It’s possible that they’ve been waiting a long time. Perhaps they are frustrated and already came from another facility or their PMD’s office. It could also just be that they are scared and want answers.

I also find that it’s easier to diffuse the tension if you pay careful attention to your tone of voice and body language. Be polite, come all the way into the room, and sit down! This will give the impression that you are not in a rush. Use all of those history taking skills you’ve honed and be a good listener. Perhaps the parent just wants to be heard.

Respect their time and knowledge

You may be expert in PEM but the parent is the expert in their child. Try not to subconsciously roll your eyes or shift your posture when they say things like “she has a high pain tolerance” or “he’s so lethargic” when he’s batting a balloon glove. Many conditions have waxing and waning symptoms. Plus, things always look worse at home without the halo-effect of the ED.

Recognize the anger for what it is

Most often it is frustration. Unless someone outright insulted the family or patient (which happens but fortunately very rarely), find out exactly why the parent is upset. Some common scenarios I’ve dealt with include:

“Why did I have to tell the story again?”

Be honest. Getting all of the details is the first step in helping their child. Let them know that repeating some questions is just us physicians being careful and making sure that we don’t miss anything.

“I want test X but your resident/student said we didn’t need that even though our doctor said we did.”

In my experience what parents really want to know is what is going to happen next. They likely trust their primary care doctor based on their ongoing relationship. This can be an opportunity to discuss the specific reasons why you’re proceeding with your plan and educate the parents on the roles and capabilities of the emergency department.

“This hospital missed condition X in the past / my other child chronic medical issues because this facility ignored them.”

What you’re dealing with here is likely a lack of trust. The baggage that parents bring with them can make this a challenging scenario. Make sure that the focus is on the child in the room.

“I just know something’s wrong but no one has been able to figure it out.”

This can come up when a patient has been dealing with symptoms for weeks or longer. An example is the teenager with months of abdominal pain. You ultimately need to be honest with parents about what you’re able to accomplish in the ED. It is important to state that the goal of this emergency department visit may not be to give them “The Answer” but instead to rule out other conditions. Sometime simply ruling out pyelonephritis, pancreatitis, hepatitis or other conditions is enough to put the parents mind at ease as long as you have a plan in place for what’s next. It can be dangerous to promise the moon especially when it comes to easy access to subspecialists. Many parents are under the impression that they will get to see a gastroenterologist when they set foot in the ED.

Should you take the resident/student you are supervising in with you?

If at all possible I say yes. This is a great opportunity to teach good “customer service” and reinforces the team concept we work so hard to foster. When it comes time to make a medical decision in the room—like getting an ultrasound for the evaluation of belly pain or watchful waiting—the junior trainee should be the one who verbalizes the decision. This is a way for you to vouch for them and shows the family that residents can be trusted.

It helps to have discussed things beforehand, but sometimes the plan fluidly develops in the room. This can happen when the resident has been unable to gather sufficient history or has missed physical exam findings. Use this as an opportunity to teach.

What if they ask for your boss?

This is rare but it happens. Try to diffuse the situation, but if you hit a brick wall by all means get the attending/CEO/president. Discuss the situation, and then go back in with the boss. Maybe the parent only trusts somebody with a faculty name badge. This could be due to past experiences or a limited understanding of the hierarchy. Nevertheless don’t let it bruise you ego. Chances are your attending has dealt with something exactly like this before.

Hopefully these tips will enable you to deal with some difficult scenarios while precepting. I’d be happy to continue the conversation online.