The art of medicine: Getting testy

There are many demands in the emergency department, some of which come from patients and their families. This post in the Art of Medicine series looks at those situations in which patients/parents are requesting – nay demanding specific tests.

As I noted in a previous post in this series the ED is an emotionally charged environment. Often parents are seeking an answer as to why their child is ill. That answer may come in the form of a specific diagnosis or further elucidation as to the reason for particular symptoms. I’m sure that many of you have encountered a parents asking for a “test” to tell them what’s wrong with their child. Perhaps they’ve even asked for it by name. “I just want a CBC.” or “She needs an MRI.” Let’s explore this conundrum in a little more depth, shall we?

Why are they demanding a test?

Because they are scared. Sense a theme here? Coming to the ED is oftentimes a frustrating, terrifying experience. Uncertainty drives many a visit, and in order to mitigate concerns parents are seeking answers. In many ways we have been taught to seek out objective evidence. In an era where any test is possible parents may be conditioned to think that the only path to a diagnosis is through a confirmatory test. Empiricism this is not. So before getting that test explore why the parent is “demanding” it in the first place. I’ve found that it is frequently possible to convince the parent that your diagnosis is justifiable based on H&P and clinical reasoning alone. All that this takes is time. Before ordering any test you should answer the following questions:

  • Is it justifiable based on the clinical scenario?
  • Is it justifiable from a billing standpoint?
  • Will it make a difference in the patient’s clinical care?
  • Is the risk worth the potential benefit?

Don’t they trust me?

Unless they explicitly say so the answer to this one is no. Many patients have been to multiple providers/had multiple visits before coming to the ED. Keep that in mind, and you will better empathize with a certain degree of skepticism that surrounds select encounters. Also, know your limitations. It’s cliche for sure, but trust is earned. You should always be honest with the family about what you think is going on and why you need/don’t need to pursue testing.

What if the referring physician said they should get a test, but you disagree or feel that a different test would be better?

Let’s consider the example of a belly CT for abdominal pain. Sure, it’s a great imaging modality, but the risk of exposure to ionizing radiation is great. Remember that to work in the ED is to work in a place where the worst case scenario should be considered and ruled out. This begins with an appropriately thorough H&P and selection of the best tests to aid in situations where the diagnosis or next course of action is still uncertain. Lot’s of things hurt inside of the belly. You don’t need imaging in a child to diagnose pancreatitis – so if the amylase/lipase are abnormally high skip that CT.

Also, you should always call the referring physician in any instance where a child has been sent to the ED. Perhapsthe referring provider has only spoken to the family on the phone. It’s quite possible that they said to the mother of a child with a barky cough  - “Sounds like croup. The ED might have to give a breathing treatment or get an XRay.” Consider for a second that all a frightened parent might have heard is “My son needs an XRay to tell me why he’s coughing so bad.” Pretty different than leaving the room with the mindset that “Dumb PMDs don’t know what they’re doing – asking for XRays in a well appearing child with croup.” Telephone medicine is hard!

What should I do if the parent won’t leave without a specific test?

This is where your skills as a negotiator can help. But, if the family absolutely, positively won’t leave without a test then think about the risks and benefits. A test like a rapid strep is a no-brainer. The risk (unless you count sputum in the face) is small. The downsides of sending a CBC include pain from the venipuncture, and the chances that you’ll have to account for some aberrant results (false positive in the well appearing child). This could lead to more testing in the future. Plain radiographs are unlikely to cause harm and in my view are OK to order in these circumstances, but still don’t serve as a substitute for a thorough explanation of diagnostic though processes and clinical reasoning. I don’t think that one should be ordering CT scans, MRIs or performing more invasive tests (like lumbar puncture) just to placate a parent.

Should I document that I disagree with the ordering of the test?

No, because you shouldn’t been ordering something that is unnecessary in the first place. If you’re not sure ask a colleague or more experienced provider for help.


 

So, in summary I urge you all to address patient and family concerns head on. Find out why they want a specific test. This will help you better understand their thought processes and concerns and allow you to provide better, more informed care that is evidence based and likely to educate.

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Geographic tongue

Geographic tongue is a common oral finding. It is AKA benign migratory glossitis and is seen in up to 1/30 of the human population. Females have it twice as often as males. It is thought that inheritance is polygenic. There is a slightly increased risk if the patient has psoriasis. Most are asymptomatic – though it may cause mild sensitivity to spicy foods. The treatment is reassurance and education. It may come and go for a brief period of time or persist for months to years.

Conditions that geographic tongue can be confused with

Oral candidiasis Hand, foot and mouth Fissured tongue Cancer of the tongue Chemical burn Contact stomatitis

Examples of Geographic Tongue

Totally a geographic tongue Perfectly mapped out geographic tongue (from NEJM) Wavy geographic tongue

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Synconvulsions: Just how common are convulsions in syncope?

Certainly we’ve all taken care of of the patient with the  chief complaint “possible seizure.” Upon history and examination many of us will discover that the patient had syncope.  So, the purpose of this post is to examine how we differentiate between convulsions in a epileptic seizure versus those that occur when a patient faints. Read on!

What actually happens when a patient faints?

There is a brief loss of consciousness that is associated with transient global cerebral hypoxia.  The most common causes of syncope in the pediatric population are:

  • Vasovagal (neurocardiogenic): 50% of cases that present to the ED. Often precipitated by prolonged standing and physical or emotional stress. Most patients experience the typical prodrome, which includes lightheadedness, dizziness, pallor, diaphoresis, nausea and visual changes. The reflexes that govern heart rate and vasomotor tone are exaggerated, and a drop in BP leads to global cerebral hypoperfusion.
  • Breath-holding spells: Seen in toddlers and triggered by emotional stress (tantrum) or minor painful stimuli. They can lead to loss of consciousness and brief posturing or tonic-clonic convulsions. Read here for more.
  • Orthostatic hypotension:  This is syncope that occurs with postural changes (prolonged standing, just standing up upon being supine for a prolonged period of time). An abrupt drop in BP may result from dehydration, pregnancy (venous pooling in the lower extremities), anemia, anorexia nervosa and certain medications (diuretics and other BP meds).

Other causes for fainting include:

  • SVT
  • Bradycardia
  • Arrhythmia
  • Pulmonary hypertension
  • Basilar migraine
  • Seizure
  • Hyperventilation
  • Conversion disorder
  • The choking game
  • Narcolepsy

What is convulsive syncope?

A common variant of syncope that is associated with brief tonic or myoclonic activity. These convulsions are thought to occur because the brain doesn’t like to be oxygen deprived. The early stages of hypoxia appear to induce motor centers in the brainstorm reticular formation. Studies from the 1950s in experimentally induced syncope of humans showed no epileptiform activity on EEG when fainting patients convulsed. Maneuvers used to induce syncope include forced valsalva, hyperventilation + valsalva, acceleration on a centrifuge (whee!), venipuncture, ocular compression and more.

What does it look like?

Almost immediately after “passing out” patients will experience anything from twitching of the mouth to violent four extremity jerking. Myoclonic jerks are often seen. It can be multifocal and asynchronous, as opposed to the rhythmic convulsions of generalized tonic clonic epileptiform seizures.

Children that have breath holding spells often have dramatic opisthotonic posturing. Some patients will have tonic posturing early in their syncope and fall to the ground as if they were “stiff as a board” rather than slumping down. Some patients will even have complex motor movements like fumbling of the hands, arching out lip licking and more. Some patients moan and growl.  If the eyes are open you may note upward turning of the eyes (rolling back in the head). This can also be accompanied by subtle downbeat nystagmus or transient deviation.

Syncopal convulsions are almost always brief, lasting less than 30 seconds. Patients DO NOT have a protracted postictal period and “come to” relatively quickly. They often recognize that they fainted, or ask “what happened.”

I’m not sure why it is filed under “Entertainment” at NeurologyNerd.com – but these videos of German students with induced syncope are incredibly demonstrative when it comes to giving you an idea of all of the different motor eccentricities of syncope. I think that it’s a must watch.

How common is it?

The short answer is VERY. The overall incidence varies quite a bit according to dozens of studies, and may depend on the precipitating cause. The initial studies were done almost 70 years ago – and though I did not read them upon initial publication I do think that our physiology has not changed, thus they still hold water. Overall the incidence falls somewhere in the range of 5-15% but could be as high as 50%. Many of these studies are retrospective reviews, case series or video-based studies of induced syncope.

Should we be more worried if the patient has convulsions with syncope?

If the patient has returned to a normal neurologic status and has a reassuring cardiac history and exam – NO. An EKG is an excellent screening test that will allow you to rule out heart block, long QTc, WPW and right heart strain form primary pulmonary hypertension.Perhaps in adults we should, as some studies have indicated that convulsive syncope may be associated with underlying arrhyhtmia (see Kanjwal, 2009 and  MacCormick, 2011) – but in children and healthy adolescents there is no increased associated with cardiac pathology in convulsive syncope versus nonconvulsive fainting.

What should we tell patients and families?

I can’t think of anything more terrifying for a family to witness than a seizure. The first thing you need to do is clearly explain what you believe happened, and why you are reassured based on your H&P and available tests. Find out what the patient/family’s experiences are with seizures (maybe they have an uncle with epilepsy for instance), and dispel common myths. Use your knowledge of epidemiology and pathophysiology to discuss why neuroimaging is not warranted. And don’t say “they just fainted, they’re fine.” Of course the family wants to know that their child is OK, but their are more deft and tactful ways to do it. And, as with any other patient with syncope, discuss ways to prevent further episodes – like staying adequately hydrated, eating regular meals and recognizing the symptoms of presyncope.

There’s also a companion podcast to this post – check it out here!

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PEM Currents strikes again with a podcast on convulsive syncope

Don’t swoon with excitement because the latest episode of PEM Currents, the Pediatric Emergency Medicine podcast is here! The focus is on convulsive syncope – essentially patients who faint and have movements that could be construed as seizures. You’ll learn how common convulsions with syncope are and what to do if you encounter them in the Emergency Department.

Check it out on iTunes

Or stream it right here with the embedded media player

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Briefs: Mesenteric Lymphadenitis – A cause of pain or an excuse?

Allow me to present a common clinical scenario. The patient presents with right lower quadrant abdominal pain. Appendicitis is in the differential diagnosis. After an appropriately thorough H&P you have ascertained that it is not gastro/UTI/strep/pneumonia/constipation/porphyria/pregnancy etc., etc,. and obtain an ultrasound which shows a normal appendix but reveals the presence on enlarged mesenteric lymph nodes.

from Radiopaedia.org

from Radiopaedia.org

With the negative ultrasound you have ruled out appendicitis. But, mom is still adamant that she wants to know why her child is having abdominal pain. Thus, can mesenteric lymphadenitis in a child with right lower quadrant abdominal tenderness be the sole reason for the pain?

This is the question that I wanted to answer. Teleologically it makes sense that swollen lymph nodes hurt. We see them cause pain in the neck, groin, armpit et cetera. It turns out that this is a pretty common finding, though the true incidence is not specifically known because not every patient with belly pain gets imaging or laparoscopy. In some adult studies up to 20% of patients had swollen mesenteric nodes upon laparoscopy for appendicitis. It is thought that mesenteric LAN is more common in children and adolescents overall, and can be precipitated by a number of causes including gastroenteritis, inflammatory bowel disease and appendicitis. It also appears to have an association with Yersinia, so find out if your patient has been eating raw pork. Associated history and symptoms (as you’d expect) are varied and sundry and include:

  • Abdominal pain – right lower quadrant or diffuse
  • Fever
  • Antecedent UTI or URI – cervical LAN is also seen in 20% of cases. It is hypothesized that swallowed sputum travels to the gut and induces an immune response
  • Nausea and vomiting
  • Diarrhea
  • Anorexia

So, yes mesenteric nodes can be enlarged, and can be presumed to be the cause of pain in a patient with right lower quadrant tenderness in which you’ve ruled out another cause. Interestingly the nausea and vomiting often precedes abdominal pain as opposed to coming after the onset of pain as seen in appendicitis. The list of specific etiologies is long, including beta-hemolytic streptococcus, Staphylococcus species,Escherichia coli, Streptococcus viridans, Yersinia species (responsible for most cases currently), Mycobacterium tuberculosis, Giardia lamblia, and non– Salmonella typhoid (Medline – Mesenteric Lymphadenitis). In my experience it is often discovered in an effort to rule out appy on imaging (ultrasound and CT). Other diagnoses I have ruled out during the discovery of mesenteric LAN include:

  • Appendicitis
  • UTI/pyelo
  • Ectopic pregnancy
  • Cholecystitis
  • PID
  • Ovarian torsion
  • Intussusception

Interestingly Frisch et al, in a large Swedish cohort study found that the presence of mesenteric LAN in childhood was associated with a significantly decreased risk of ulcerative colitis later in life.

Patients that are not septic do not need antibiotics, provided that you have not identified a proximate bacterial cause (like UTI). In the patient with peritonitis you should still get surgery involved even if you’ve ruled out appendicitis. Likewise, labs (like a CBC) are also not necessary unless you the patient is ill appearing. If the patient is well hydrated and the pain is manageable with oral meds then they can be safely discharged home. Return precautions include worsening pain, vomiting and dehydration or ill appearance. Repeat imaging is not necessary to confirm resolution, especially since most cases self resolve within 1-2 weeks (many sooner).

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Fracture Fridays: Can’t put a finger on it

The Case

An athlete presents to the ED with an injured pinky finger. He says that he struck it on a teammate during practice and “it bent back.”  The pinky finger is abducted and jutting out at an extreme angle. It is making dad nauseous. The XRay shows the following:

Extra Octave fracture

Diagnosis

This is a Salter-Harris II fracture of the proximal 5th phalanx. The physis is stressed during impact and it is fractured because of the pull of the collateral ligament. You will often see an abducted, angulated digit. This is the most common proximal finger fracture in children. When it occurs in the 5th digit as seen in this example it is known as an extra-octave fracture. The term alludes to abducting the pinky finger to try to reach piano keys that are too far away.

The initial degree of angulation can be severe, often 60 to 90 degrees. You should also make sure that there is no rotational deformity, which can be better appreciated if the patient makes a fist.

Rotational deformity

Management

In general, any fracture angulated >10 degrees needs to be reduced. This fracture requires emergent involvement of a Hand Surgeon if:

  • The fracture is open
  • Tendon, nerve or vascular injury
  • Intraarticular fracture that is unstable or significantly angulated/rotated

Angulation is more tolerated at the MCP joint as opposed to the PIP and DIP. The MCP joint is built to allow for a degree of side to side motion. Thus, following reduction <10 degrees of angulation is OK. However, there should be ZERO rotational deformity. Reduction should occur only after appropriate analgesia. Sedation is not necessary if the patient is cooperative and appropriate local/regional anesthesia applied. For the case example an Ulnar Nerve Block could be a good option. This procedure can be performed via ultrasound guidance.

Reduction is achieved by applying traction to the digit, gently flexing the MCP joint and then adducting the distal phalanx. After reduction patients should be splinted with radial or ulnar gutter splints (depending on the injured finger). For the young man in the case example an ulnar gutter would suffice. The MCP joint should be in  70-90 degrees of flexion in the properly applied splint. The PIP joint should be extended.

Ulnar gutter splint

Patients that undergo successful reduction should be reevaluated in one week. The Hand Specialist will look for post-reduction displacement, shortening, angulation and rotation. Fractures with any of those findings may require operative intervention. Follow up for stable injuries will then occur at 1-2 week intervals until healing is satisfactory – often 4-6 weeks.

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