Thinking horses not zebras

[Gypsy]

I wasn't sure where to ask this but here looked good.

Back in school my lecture instructor and I had a debate. He was saying if you have a child with a low grade fever, over all disconfort, and a sore throat to think it's spinal meningitis. I disagreed and said strep throat. Keep in mind I work in early childcare and have been in that field for close to 5 years now. I don't even want to begin to think of how many kids I"ve seen with strep that show those signs/symptoms.

If you were presented with a child such as that which would you think?

[rdelisle]

I may be wrong but, I always thought if they have over all discomfort, low grade fever and a sore "neck" to think meningitis. Strep is usually just a low grade fever and sore throat or discomfort on swallowing.

[Gypsy]

THat is part of the "joy" of workig with kids. Pain becomes very generalized. They don't issolate it like we do. If their throat hurts they say the whole body but worse there. Actually alot of kids will say they neck hurts but point to their throat. Just to make it harder. lol

[Eydawn]

I'd have an index of suspicion for meningitis but it wouldn't be my very first thought... strep sounds much more likely. I'd take a look at their throat to see what it looked like if it was me! I know what strep throat looks like. Also, if they didn't want to move their head around I'd have more of a leaning towards the meningitis... but that's up to the doc to decide, not me. I'd mention my concern, but I wouldn't come in screaming bloody murder... people freak out at the word meningitis, I've noticed.

Wendy

CO EMT-B

[Kaisu]

Bacterial infections usually present with high fevers, viral with low. Strep is a bacterial infection, so I would lean towards either a viral sore throat or possibly viral meningitis, neither of which are as serious as the bacterial versions of either.

[Katiebug]

One of my old program director's favorite questions was, "If you hear hoof prints, what do you look for"? Inevitably, the new people would say "horses". He would say, "No! You're looking for zebras"! It was his philosophy that you should always look for the worst case scenarios first.

I happen to disagree with him on this one. Why would you intentionally overlook the most common and likely things to seek out what is most likely not there? It is my contention that you should look for what it probably is and go from there. I don't pretend to be Dr. House. I say let's start from what it probably is, not what it's probably not.

My .02 anyway.

[croaker260]

A couple of thoughts,

1- Meningitis, esp bacterial , progresses very rapidly (faster than strep) , with alterations in LOC rapidly apparent.

2- Strep throat, with the associated difficulty swallowing (and thus drooling) is more likely to be confused with epiglottitis than meningitis.

3- When we see a condition constantly, we tend to suffer from the cognitive error called expectation. We see strep a lot, or train a lot to look for it, we begin to subconsciously expect that the neck discomfort, fever, chills, and listlessness is another case of flu or strep, missing Meningitis and possibly having a bad outcome. Conversely, we see or are conditioned (trained/educated) to look for life threats, we will miss the stuff like strep. A humorous example of this is the scene in "Doc Hollywood" (Micheal J Fox) where the young urban docs suspects a kid is suffering from a life threatening heart condition and the kid actually just swallowed a load of his dads chew. The young doctor diagniosed a condition because that is what his expectation was.

In this thread, both sides of the argument are correct, yet both sides are potentially misleading and even dangerous.

The best defense against cognitive errors like this is an unwavering, uncompromising adherence to a systematic approach/assessment wich leads me to my next point......

4- Strep, Epiglottitis, Meningitis, even simple gastro-enteritis...all can lay a kid low (some sooner than others), make the kid inconsolable, make the kid pale, make the kid look like CRAP, make the kid limp, develop shock and dehydration, AND IN GENERAL MAKE THE KID APPEAR "SICK" by any PALS/PEPP/PCC standard you care to endorse. Therefore the treatment is all based on symptomatic and objective assessments, ranging from blow by O2 through fluid challenges to adv airway management and vaso-pressors. In this case the diagnosis, while important, takes secondary place to recognition of "sick" vs "not sick yet" ..."stable" vs "Unstable"...which Strep can manifest itself as easily as meningitis too.

Therefore the right treatment and sense of urgency is as imprtant as the diagnosis.

NOTE: I am a hearty beliver in EMTS and PARAMEDICS thinking beyond their scope and making diagnosis ,...but the smartest medic who cant take care of the basics, isnt a medic in my book...

Edited May 1, 2009 by croaker260

[AnthonyM83]

I think the point of the lesson is always assume the worst until you can rule it out.

Similar to assume every unilateral abdominal pain in females to be ectopic pregnancy.

Assume every unilateral wheezing child to have aspirated something.

Eventually, you can rule it out...but if you can't, you have assume it's the worse, because the consequences are so dire for the patient, especially bacterial meningitis. Having the child wait out the rest of the school day until parents pick him up, could mean that child's death.

I guess the best method would be to treat as a horse, but always assume you haven't eliminated the zebras. Make your treatments and decisions based on that mindset.

[Katiebug]

[quote name='AnthonyM83' date='May 1 2009, 06:31 PM' post='213422'

I guess the best method would be to treat as a horse, but always assume you haven't eliminated the zebras. Make your treatments and decisions based on that mindset.

[chbare]

Unfortunately, the list of differentials for low grade fever, sore throat, and generalized myalgia in the pediatric patient is quite long. You would be hard pressed to narrow the problem down to streptococcal pharyngitis versus meningitis simply based on the said signs and symptoms.

If I had to care for somebody with these signs and symptoms, I would obtain an in depth history and perform a physical exam and assessment along with a complete set of vital signs before narrowing down the differential.

I am actually not a fan of assuming the worst case scenario on each patient. Always be ready for the worst case scenario; however, looking at every patient with viral syndrome like signs and symptoms as a worst case scenario can actually lead to the dreaded tunnel vision and making hasty decisions that are not based on solid evidence. I prefer taking a more pragmatic approach to patient care. This also includes sick people.

Case in point:

Some years back I transported a patient with a pericardial effusion out of a small hospital to a larger sub-specialty facility. My partner began focusing on the "tamponade" problem almost at the point of patient contact. From the history, this was an ongoing problem that slowly developed over a period of several weeks. I disremember the specific history, however.

The patient was alert, awake, and in pain. His blood pressure was around 100 systolic upon initial contact. In flight my partner became anxious continuously focusing on the diagnosis of pericardial effusion. The intubation kit was out, my partner had drawn up RSI medications, and pulled out the BVM. My partner continued to say, "this patient is going to crash." I administered pain medication and a little oxygen. Along with monitoring, I did nothing else for the patient.

At one point, the patients pressure was in the 90 systolic range, following a few doses of fentanyl. My partner look at the monitor, then looked at me while grabbing the RSI medications and stated loudly, "aren't you going to do something about that!" I stated "nope." I told my partner everything was" ok," and the transport was completed without incident.

While being prepared for the worst is good, focusing on the worst case scenario without considering the big picture is myopic and can lead to poor decisions and the consequences of those decisions.

Take care,

chbare.