It’s vital not to miss a key diagnosis than consistently being proven correct.
I was introduced to “The Rules” of PEM by Dr. Richard Saladino and his team during my Pediatric Emergency Medicine Fellowship at Children’s Hospital of Pittsburgh of UPMC.
This became the inspiration behind my podcast, PEM Rules. On the podcast, I reflect on my experience as a fellow, experience in the ER as an attending as well as my role in teaching residents, medical and PA students. Though I like to call them rules, they are really guidelines or advice one can follow in medicine and sometimes even in day-to-day life.
Rule Number 1: It is not the patient’s job to prove that they are sick. It is your job to prove that they are not.
This is Rule Number 1 because it is arguably the most important rule in Pediatric Emergency Medicine (PEM) and the foundation of Emergency Medicine. It simplifies the role of a PEM physician and informs what must be done for each and every patient: prove that he or she is not sick.
In other words, prove that the chief complaint or presentation does not represent a serious, surgical or life-threatening process. How this is done can vary greatly, depending on several factors such as the reliability of the history and physical exam, the chief complaint itself etc. Often a quick history and physical can be sufficient, but if not, one must use other tools to prove that the patient is not sick.
Example A: A three-week-old infant presents to the ER with chief complaint of fever, but is otherwise healthy and well-appearing. Assuming that the patient tested positive for Rhinovirus as part of the workup, one might think that Rhinovirus is the cause of the fever and not pursue further testing (ie blood culture, urine culture or lumbar puncture).
However, swabbing the infant and getting a positive respiratory viral panel does not actually prove that he or she is not sick. It simply indicates that the patient has a viral process, and for treatment will likely will do very well with supportive measures only.
One still must demonstrate that the patient does not have a serious bacterial illness (SBI). Since sepsis rule-out in a newborn is not done with a positive viral swab, one needs to obtain negative cultures. Therefore, despite a positive respiratory viral panel, one should still follow AAP guidelines for Evaluation and Management of Well-Appearing Febrile Infants (updated in summer 2021).
Example B: A 16-month-old previously healthy toddler who is up to date on vaccinations presents with complaints of fever, vomiting and diarrhea for the last two days. In the ER the temperature is normal, but heart rate is increased to 167 while crying.
While the crying during the evaluation may account for the tachycardia, this could also represent dehydration or possibly sepsis. One must consider cap refill time, mucus membrane changes and even mental status to prove there is no dehydration or shock / sepsis before deciding this heart rate is acceptable.
It is not the patient’s job to prove that they are sick, it’s your job to prove that they are not.
Rule Number 2: You are not here to win, you simply don’t want to lose.
This rule is related to Rule Number 1 above. Although the use of the Pediatric ER and the role of the PEM physician has changed over the years, it is still ultimately about ruling out life-threating conditions in patients and either sending them home or admitting them to the hospital (not lose) versus trying to find the exact diagnosis behind the chief complaint (win).
The first order of business is to provide acute care. Oftentimes in the Pediatric ER that can be done with oral analgesia or a PO challenge. Then you need to confirm that the chief complaint is not secondary to a serious, life-threating etiology. Figuring out the exact reason behind the chief complaint may not always be realistic or necessary at the time of the ER visit. As first-line providers, it is more important to not overlook (lose) than to know exactly what is the reason behind the chief complaint (win). It is more important to know what it is not, than what it actually is.
Many children present with the chief complaint of vomiting to the Pediatric ER. After providing acute care, the order of business is to make sure the vomiting is not secondary to a surgical abdomen or another serious etiology. The differential diagnosis of serious causes of vomiting will be determined by age; for example, intussusception is more likely in an infant or toddler and appendicitis more likely in a child or teenager.
To do this one needs to know the “red flags” for vomiting and then rule them out through history and physical exam. Make sure it is not RLQ, that there are no peritoneal signs, the child is able to jump, etc. If the history and physical exam are insufficient to prove “not sick” then work the child up. Do whatever is needed to prove the abdominal pain is not appendicitis, small bowl obstruction or any other form of surgical abdomen.
If the child has a benign condition such as abdominal migraine, or constipation that goes undiagnosed, the child will be safe. However, if one misses appendicitis and sends the child home, there is likely to be a bad outcome.
Another good example is the newborn who presents with a rash. As a former pediatric resident working in the newborn nursery, I recall coming across several newborn rashes all of which are benign and do not necessitate any treatment. Now that I am almost 10 years out of residency I must have forgotten them all and oftentimes do not recall the exact name of a rash.
But as EM physicians, we don’t have to necessarily win (name that exact rash) but we really don’t want to lose (miss a case of HSV for example). Recognize and check for all the red flags of pediatric rashes (Positive Nicoklsy sign, vesicular, none blanchable etc) and if the patient has none of these, reassure the parents and send them home to follow up with a dermatologist.
You are not here to win, you simply don’t want to lose.
- Blaschke AJ, Korgenski EK, Wilkes J et al. Rhinoviurs in Febrile Infants and Risk of Bacterial Infection, Pediatrics , 2018
- Pantell H, Roberts KB, Adams WG, et al. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics, 2021
- Rose, Emily, Life-Threatening Rashes: An Illustrated, Practical Guide 1st ed. 2018
- pemrules.com Episode 2