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DartmouthDave

Worried Mother!

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It depends on the Peds facility cut off for age.

I believe in KC MO the cut off for Peds at Children's Mercy is 18 but it may be older if the patient is an established patient there.

Children's National Medical Center will more than likely not take this mother but they will be happy to tell you to go next door with her as Medstar Health has a perfectly good hospital for adults right next door and it's only 25 seconds of an eta lesss.

So more than likely any pediatric specific facilty will NOT take a non-established adult patient except in specific circumstances.

I would suspect some of those would be but not inclusive of medical conditions that occur inside the hospital that require prompt intervention in the hospital, falls outside on the ground of the peds facility, cardiac arrest outside or inside the ped facility and other non-defined reasons.

But to walk in to the hospital and request to be seen in the ER of the ped facility, sure they will find you a bed, do a quick medical screening and then put you in an ambulance and take you to a facility that can appropriately manage your ADULT medical complaint.

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Would anyone take mom to the peds ER?

I don't like her O2 SAT at all but frankly I think she will get better care at the other ED which is only 5 minutes more down the road and I doubt they would admit her there. I would certainly consider it IF she needed an airway but that does not seem to be the issue. She has been this way for a while, a few minutes to get her to the right place will save a critical care transport later.

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Not all doctors that work in the ER are trained on peds. We still have IM trained guys that work in ERs. They have no formal training in peds other than their 6-8 week rotation as a med student. ER and Family med trained doctors have plenty of peds training, though the FM guys may not have much peds critial care experience.

The Australasian College for Emergency Medicine requires a paediatric logbook to be completed during training which must have at least 400 paediatric patient encounters; 100 of which must be status one or two (critical or serious) triage categories and at least half (200) must be in ED

We have only one childrens hospital here in NZ (Kidzfirst/Starship) which is on the Auckland City Hospital site

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But to walk in to the hospital and request to be seen in the ER of the ped facility, sure they will find you a bed, do a quick medical screening and then put you in an ambulance and take you to a facility that can appropriately manage your ADULT medical complaint.

I'm not arguing with you Ruff, so please don't take it that way. I'd say DKA is something the peds guys should be able to handle, even in an adult (they may even be better at it). Now, if we are talking an MI or CHF, it may be a different story. We see adults in the peds ER when they come in but then again we are all ER trained. I admitted a 65y/o diabetic with an infected foot ulcer (obviously they went over to the adult hospital).

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Oh by all means they should be able to take care of DKA as well as a myriad of other complaints in the adult patient. I hope that you didn't think I was arguing with you on that at all.

If I was driving down the road in a unfamiliar area and started to suffer from a low blood sugar (which I have IDDM), and I came upon a pediatric facility and didn't know where the nearest adult facility was, I'd stop at the peds facility and request medical help. A hospital is a hospital. But I know that once I'm stable I'm heading to the appropriate facility to take care of me.

So no I wasn't arguing wit ya at all either.

Every hospital should be able to take care of anyone in the beginning stages of a life threatening illness and then get them to the appropriate facility. Just because the hospital has Children's in it's name really makes no difference to the patient.

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While I am aware that there are hospitals specific to the care of children, they are usually a building on a hospital "campus complex" with adult care usually within a 30 second walk. Most other hospitals have a Peds ER area, secluded from the main ER, so the sick and injured young'uns won't see the rest of the adult stuff we bring the ERs, sometimes to the point of a separate entrance

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So I am curious to know what our Resident Emergentologist (who is actually a Consultant trapped in a funny tawking Attending Physician's body yo) thinks about airway management in this lady

Whether or not to intubate her is pissing me off; I thought about it a bunch today. I asked the House Surgeon, he said to ask the Reg, the Reg said to ask the ICU Consultant since he would be accepting her, the ICU Consultant asked who in the bloody hell I was, how I got into his office and when security was coming ... prick

I really want to shove a tube down her gob as an SPO2 of 90% is kinda bad y'know but I am reminded of the times I have screamed in a blinding rage to people that ventilation is not oxygenation. Just because we intubate her does not mean we are going to do any better job of ventilating her lungs; she's got heaps of chunky bits (Coneheads anybody?) and vomit in there and neither the LMA nor an ET tube is going to fix the obstructive problem preventing adequate oxygenation.

Gah .. I tell you what I'm going to get out teh kettymainz and put it in my juice box like can be done for paeds or those who have no IV access; hopefully when I wake up the scenario will have been fixed up and I'll have had some nice nightmares!*

*The incidence of ketamine nightmares is actually quite low [citation needed] so I don't want to hear anything about it ...

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I would tube this lady as quick as I could. She has been down an unknown amount of time, but long enough for her baby to become very dehydrated. She is in DKA and is probably profoundly acidotic. With the crap in her airway, I think she has pretty much proven that she cannot protect her airway so I am going to take that responsibility away from her. Have suction ready and get down as deep as you can. I don't think the issue is so much oxygenation/ventilation as it is just controlling the airway in this woman. If there is crud further down in the lungs there is not much you are going to be able to do about it unless you can do some deeper suctioning when she is tubed. Secure the airway and do the best you can from there.

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Would you stop encouraging him Doc.

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I was actually curious what his take on her acid/base status was and what effects he thought this had on her mitochondria as well as the regulation of tRNA.

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