In the practice of medicine, mistakes are inevitable. However, careful reflection about our missteps can be valuable and help us become more competent physicians.
As emergency medicine physician Richard Cantor shares in his lecture “Pediatric Emergencies: Diagnostic Dilemmas and Lessons Learned,” now available for CME credit through AudioDigest, “not one of [us] has not driven home from a work day and not thought about what [we] have overlooked. What we didn’t order. What we have ordered too much of. An interaction with a family that does not go well.”
In his presentation, Dr. Cantor shares diagnostic dilemmas that can arise in pediatric emergency medicine and what he learned from these circumstances.
Abnormal Mental Status
How many times have you written “non-focal neurological examination” in your documentation — or better yet, what is your approach to evaluation of a patient with a focal neurological deficit? A standardized approach for evaluating patients who present with a focal neurologic deficit, lethargy or abnormal mental status can keep you from missing a diagnosis. A good mnemonic for this is AEIOU TIPS:
- Alcohol, acidosis/alkalosis
- Endocrine, electrolytes, encephalopathy
- Insulin (surplus or deficit), intussusception
- Trauma (head injury, hemorrhagic shock)
- Intracranial pressure, infection
- Poisoning, psychiatric
- Seizure, syncope
Dr. Cantor shares a pediatric emergency pearl: Always get a bedside glucose for any sick child. Hypoglycemia can present in a myriad of ways, but most importantly, it is the only metabolic cause of focal neurologic deficits.
There is a mantra in pediatric emergency medicine that if there is knee pain, there is hip pain. Not all causes of hip pain in the pediatric population will be identified through screening studies, joint tap or orthopedics consultation.
In addition, the pain doesn’t have to be limited to the bone. Hip discomfort can be secondary to inflammation of the hip flexors such as the psoas muscle. Psoas pain can mimic hip disease, as can appendicitis.
Fever and throat discomfort can lead to a range of diagnoses. Most often, a sore throat is due to a bacterial or viral source, and in the age of immunizations, more nefarious pathologies such as H. influenza epiglottis are quite uncommon. Torticollis is a diagnosis that very rarely warrants significant work-up.
However, torticollis and fever in combination warrant further evaluation with imaging modalities, as that’s the best way to identify the underlying pathology.
In pediatric emergency medicine, erythroderma is a tell-tale sign of a staphylococcal or streptococcal infection. These infections may cause systemic manifestations without bacteremia due to toxin-mediated processes. If there is any concern about either infection, it’s important to ensure stable vital signs.
Not all patients who present with abnormal movements are in status epilepticus. The differential for seizure isn’t very extensive, but an often-forgotten possible diagnosis is tetanus, and this should be considered for all nonimmunized patients. (A pro tip for pediatric emergency medicine: Confirm immunization status for all patients.)
We strive to avoid all clinical missteps, and this goal is an honorable one. But all of us will be involved in medical errors — many small but some significant. These experiences help to make us more astute physicians. As Dr. Cantor says, “May all your mistakes — and you’re going to make them — be minor, number one; self-limited; terrifying, absolutely hair-curdling; and ultimately harmless. And if that all fits, you’ll never make the same mistake twice.”