The Rise and Fall of Vaping

Lauren Middlebrooks, MD Pediatric Emergency Medicine Physician

Vaping-Related illness has plagued over 2,000 people this year alone, and has claimed the lives of now 47 innocent victims.  Several deaths have been linked to the explosion of vape pen devices, however of greater concern is a “mysterious respiratory illness” that the CDC is now calling EVALI—e-cigarette or vaping-related lung injury.  

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I am sending you to the ED!-Reflections on how to refer to Children’s ED

Mike Greenwald, Pediatric Emergency Medicine Physician

CME 1.0 credit available complete after reading all 3 articles-Link at the end !

Those of us who practiced medicine in the previous century (“OK Boomer” – there, I said it) can tell our younger colleagues stories about the limitations we used to face in treating sick and injured children.  We recall a time before we had eradicated some deadly diseases with vaccines, before we had pediatric specific approaches to trauma and many medical diseases and before we developed so many ready options for imaging and other studies.  Yes, 2019 doctors struggle with different challenges.  We all still work very hard.  EMR has solved some problems and created others.  Perhaps just as challenging – we are not quite as tight nit a medical community compared to when we were smaller.  We rely on a growing number of often unfamiliar colleagues to help care for children in our community.  That distance naturally leads to challenges and even barriers in communication and collaboration.

So this article is an attempt to share some issues from one side of a relationship.  We asked faculty in our group to answer the question: “What do you wish referring primary care providers would better understand to improve the care we deliver to our patients?” Like any survey – this one has limitations.   We recall negative experiences more vividly than positive ones.  The truth is that the vast majority of referrals we get are clear, appropriate and helpful.  What follows is a summary of observations of what might make a more effective transition of care.  Perhaps none of these apply to you – but we hope that at least some of what you read here makes sense and you find useful.  As always – we welcome your feedback and on-going collaboration with us so we can improve our role in helping care for your patients.

  • Be explicit in your concern.   The families sent in to see us often assume that we have comprehensive knowledge of their medical issues.  They may bring with them a brief note with vague information or simply neglect to tell us that you sent them in.  Like a game of telephone the details can easily change. 

What exactly is the purpose of this referral? If your concern is based on test results please share those details – especially growth chart data for the failure to thrive concern and lab or radiology results outside the CHOA system. Be clear in your call in whether you want a call back and provide the best contact number possible (ideally a direct #).  If you haven’t heard from us please don’t hesitate to call the transfer center to speak with the treating physician.  We may have every intention of calling you as requested but neglect to do so in the flurry of a busy shift.

  • Use the Transfer Center (404-785-7778). When you call in a patient you have the option to simply leave a message or to speak with one of us. Either way – your call in information is recorded in the chart and highlighted by the patient’s name with a letter “C” next to their name.  This reminder is intended to guide us to your note.

We understand that you are busy and sometimes it takes more time than we’d like to speak with someone in the transfer center.  Like the ED volumes – the transfer center calls can vary dramatically.  In fact – the CHOA Transfer Center is the busiest Pediatric Hospital Transfer Center in the Country!  It is staffed with 1-5 nurses at a time 24/7 based on volume patterns – with plans to increase staffing with our up coming move at the North Druid Hills campus. In addition, they are actively working on new ways to streamline the process. 

  • We want to speak with you!  We often get patients with a concern that could have been addressed with a conversation on the phone with either an ED doc or other sub specialist.  Some of the patients could have been a direct admission; others would eventually be sent to a specialty clinic. Not sure if ED referral is the best option for this patient? Call us! The Transfer Center can facilitate this – typically in less than 15 minutes.  

Please understand when you are waiting to speak with us the Transfer Center nurse is diligently requesting us to answer the call.  Your wait is only because we a caring for patients; but when we are at a desk charting we will stop and pick up the phone. We would much rather spend 5 minutes chatting with you about your concerns rather than explain to your patient why we can’t do what was expected when they finally get into a room after a long wait.

  • Sign out patient info to your on call colleague.  It seems to be a common occurrence that when we call a practice after hours the on call doc knows nothing about the patient sent in by their colleague. That can make our evaluation more challenging than necessary.  A brief sign out can go a long way to ensure accurate communication and effective follow-up.
  • Be clear and careful regarding expectations.  You might be surprised at how often we get a family who says they were told they would see a subspecialist in the ED or get a specific study performed.  (Yes, we know that they may have distorted what you told them).  We don’t dispense nebulizers and seldom can get an MRI.  While we can speak by phone with our subspecialty colleagues, it is simply not feasible (nor necessary) for them to see each patient presenting in the ED.  Also, we try to follow guidelines to reduce unnecessary testing so head injured patients may be assessed clinically without imaging and children with flu-like illnesses may be diagnosed clinically rather than with a flu test.

If you have an urgent question for a specific sub specialist consider using the transfer center to speak with them.   Contact radiology if you want to expedite or ask about a specific imaging study.  Like the surgeon who evaluates abdominal pain or the cardiologist who assesses a murmur, the ED physician will choose tests and treatments for patients based on their training and experience. 

  • Be judicious about sending in contagious or vulnerable patients such as neonates.  This is particularly important this time of year when the waiting room may be filled with children experiencing influenza.  Each year it seems we get a surge of flu positive patients who were recently seen in our ED for an unrelated problem.  They may have presented without the flu but left with it!  Also in that waiting room are neonates and immuno-compromised children.  If you are concerned about a dangerous infection such as TB or Measles – lets talk before sending in the patient!

CLICK on Link below to receive CME Credit after reading all 3 articles!!!!

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Children’s Transport: Bringing critical care to pediatric patients




CME CREDIT NOW AVAILABLE-See the end of the article

By Jennifer Plagemann, Paramedic; Ryan Sullivan, RN; Simeon Smith, Paramedic; and Rebecca Ogrin, RN

The Children’s Healthcare of Atlanta transport team is excited to spread the word about our Transport Program. As a direct extension of the Children’s Emergency Departments and Intensive Care Units, we pride ourselves on providing the highest level of pediatric care. We look forward to introducing our team and explaining some of the capabilities that separate us from other transport options.

Transport requests begin in our Communications Center, where communications specialists are advanced EMTs and paramedics with specialized training in triage and pediatric critical care. They work in collaboration with the Children’s Transfer Center to expedite dispatch times and facilitate appropriate modes of transport. Our communications specialists also keep our teams connected to Children’s emergency physicians and intensivists for real-time consultations and care recommendations.

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Updates on HIV non-occupational post-exposure prophylaxis (nPEP)


AMA PRA Category 1 Credit FOR EACH ISSUE (2 ARTICLES)!!!!!!

By Atsuko Koyama, MD, MPH and Lauren Middlebrooks, MD

According to the 2017 Youth Risk Behavior Survey (YRBS), almost 30% of 9th to 12th graders reported being “currently sexually active,” and only 54% used a condom at their last sexual encounter [1]. Despite improved antiretroviral regimens and HIV pre- and post-exposure prophylaxis (PrEP and PEP), adolescents and young adults continue to make up a quarter of new HIV diagnoses (21%, n=8,090), with the majority of these cases being secondary to male-to-male (MSM) sexual contact [2]. Given the prevalence of sexual activity amongst adolescents who present under a variety of circumstances disclosing past sexual activity, knowledge about non-occupational HIV PEP (nPEP) is relevant and important for all pediatricians.

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Beat the Heat


AMA PRA Category 1 Credit FOR EACH ISSUE (2 ARTICLES)!!!!!!



By Thuy Bui, MD

CASE – Part 1:

You are volunteering at the SuperHero Sprint – CHOA’s summertime 5K race.  A 12-year-old male running in his first race is brought to the medical tent by his mother.  He is diaphoretic and vomiting.  What are you concerned about?


All heat-related deaths and illnesses are preventable.  However, despite this fact, each year an average of 658 people die from extreme heat per the CDC’s Morbidity and Mortality Weekly Report.

In the United States alone, there were 8,081 heat-related deaths from 1999-2010 according to the Centers for Disease Control.  And more recently, according to the National Safety Council’s Injury Facts, 87 people died in the U.S. in 2017 from exposure to excessive heat.

Children, because of multiple factors including their lower sweat rate and higher metabolic heat production, account for approximately 4% of heat-related deaths.  In fact, heat stroke is the 3rdmost common cause of exercise-related mortality for U.S. high school athletes; and since 1998, 619 children have died in vehicles from heat-related issues in the U.S. Continue reading

Fever Clinical Practice Guideline Update-What’s new in managing fever in children under age 2?


by Becky Burger,

The Children’s Healthcare of Atlanta Clinical Practice Guideline (CPG) on fever in infants and young children was updated in November 2018. The updated guidelines are available on Careforce:

Here are the changes based on age:

For children 0-28 days:

  • The recommended empiric antibiotics are Ampicillin and Gentamicin IV (If there is no IV access, ok to give first dose of both IM)
  • If there is concern for meningitis, give Ampicillin and Ceftazidime (this is for CHOA Emergency Departments only, Urgent Cares do not have Ceftazidime in their pharmacies)
  • If there is suspicion for HSV, it is recommended that HSV PCR be sent from blood, CSF and any suspicious skin lesion. Also nee d to swab eyes, nose & rectum for HSV
  • If patient has diarrhea, send GI PCR panel (GI PCR panel replaces stool culture)

For children 29-60 days:

  • If CRP is obtained, there was consensus on CRP>2 mg/dl as the new cut off for abnormal
  • Urine WBC cut off for abnormal is >9 WBC hpf or Nitrite positive or LES ³2+
  • Preferred antibiotic is still Ceftriaxone, but if there is suspicion for bacterial meningitis add Vancomycin (this is for CHOA Emergency Departments only, Urgent Cares do not have Vancomycin in their pharmacies)

For children 2-6 months:

  • Urine WBC cut off for abnormal is >9 WBC hpf or nitrite positive or LES ³2+; if any one of these abnormal values are present, urinalysis will reflex to urine culture automatically
  • The recommended empiric antibiotic for UTI is Cephalexin 25mg/kg/dose TID x10 days (alternative regimen if concern for compliance with TID dosing is Cefprozil 15mg/kg/dose BID)
  • If there is suspicion for UTI and plan to treat for UTI, ensure that urine culture is ordered (if urinalysis has not already reflexed to culture). As always, urine culture should be from an acceptable specimen (bag specimens not adequate for urine culture)

For children 6-24 months:

  • Same updates as 2-6 months as listed above

If there are any further questions about the Fever CPG 2018 updates, feel free to contact Dr. Becky Burger ( or Shabnam Jain (

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Non-Accidental Trauma Tips


By Erin Wade







Child physical abuse is a serious health problem that affects many children in Georgia and the United States. Along with the potentially devastating trauma of physical abuse, we now know that adverse childhood experiences can cause other issues that can affect a child’s health and well being throughout their lives. Appropriate identification of non-accidental trauma is of paramount importance for all pediatric healthcare providers. Thus, as April is National Child Abuse Prevention month this article gives you a few tips to utilize.

Research has shown that a large number of infants who present with severe injuries secondary to abuse had recently been evaluated by a healthcare provider and had demonstrated subtle injuries during those initial evaluations[i]. These subtle injuries, or sentinel injuries, when detected, give healthcare providers an opportunity to intervene and prevent more serious harm from befalling the child, and should warrant a trip to the Emergency Room for further evaluation.

The Ten-4 rule is a great guide when evaluating small children for possible non accidental trauma[ii].

  • Any bruising to the Torso, Ears, or Neck is highly concerning for abuse and requires further evaluation
  • Bruising anywhere on a child 4-months of age or younger is highly concerning for abuse and requires further evaluation. This is true of any child that is not yet cruising, regardless of their age.

In addition to the TEN-4 rule, other highly concerning physical exam findings include[iii]:

  • Fractures with a high specificity for abuse[iv]
    • Classic metaphyseal lesions (bucket handle fractures, corner fractures)
    • Rib fractures, especially posterior
    • Scapula fractures
    • Spinous process fractures
    • Sternal fractures
  • Multiple fractures at various stages of healing
  • Patterned injuries (burns, bruises, healed skin injuries, etc.)
  • Loop marks
  • Bite marks
  • Immersion burns
  • Significant injury without a plausible reported history to account for the injury

The identification of sentinel injuries in children of any age requires further evaluation for non-accidental trauma. A thorough history, physical exam, and photographic documentation, along with appropriate radiographic and laboratory analysis are of utmost importance. If a provider is unable to complete such a work up, the child should be evaluated in the Emergency Room as soon as possible in order to complete the necessary non-accidental trauma work-up.

For further non-emergent questions contact us at 404-785-3820; for emergent questions call the Children’s Transfer center at 404-785-7778

[i]Sheets, L. K., et al. “Sentinel Injuries in Infants Evaluated for Child Physical Abuse.” Pediatrics, vol. 131, no. 4, 2013, pp. 701–707., doi:10.1542/peds.2012-2780.

[ii]Pierce, M. C., et al. “Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma.” Pediatrics, vol. 125, no. 1, 2009, pp. 67–74., doi:10.1542/peds.2008-3632.

[iii]Christian, C. W. “The Evaluation of Suspected Child Physical Abuse.” Pediatrics, vol. 135, no. 5, 2015, doi:10.1542/peds.2015-0356.

[iv]Kleinman PK ed. Diagnostic imaging of child abuse 2nd ed Mosby 1998

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Heavy Menstrual Bleeding Guideline



by Mona Kulkarni


Case: 15-year-old otherwise healthy adolescent presents to your office complaining of a menstrual cycle lasting longer than 10 days. She has been changing her sanitary pads hourly at times and passing heavy clots.  Now she’s feeling a bit dizzy.

What is the work up that we need to do?  The Heavy Menstrual Bleeding guideline was created by our team to help guide us in the evaluation.

Heavy Menstrual Bleeding (HMB) is one of the most common adolescent gynecology complaints we see in the ED.  The differential diagnosis is broad including anovulatory cycles, hypothyroidism and underlying bleeding disorders (up to 20% of cases). The importance of early recognition and determination of the underlying cause can positively impact the teen’s quality of life, school attendance and sports participation.



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Behavioral Health ED Visit: Expectations and Limitations



By: Kristin Weinschenk, MD and Michael Lowley, MD

The primary goal of the psychiatric evaluation in an ED setting is to assess the safety of the individual, and to connect them with resources at the appropriate level of care. This begins at triage with a screening tool called the ASQ (Ask Suicide-Screening Questions to Everyone in Medical Setting), a five-item questionnaire which flags patients for risk of recent or current thoughts of self-harm. A positive screen will then trigger referral for amore detailed evaluation by either the psychiatric social worker in the ED, or by a member of the Psychiatry Consult Liaison service. The MH professional will conduct a psychosocial assessment, and complete a more detailed suicide risk assessment tool called the BSSA. Once level of risk is established, the treatment plan will reflect the need for appropriate safety and monitoring, whether at an inpatient psychiatric hospital or in a less restrictive care setting.




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Head Injury Update 2018


By Micheal Greenwald

Research continues on a number of fronts regarding head injury evaluation and management.  Below are highlights from 2 of these articles and a summary of a recently published set of guidelines from the CDC.  The articles were exceptionally large studies that pertain to important factors in deciding when to use CT in evaluation of head injury in children. The CDC guidelines explain levels of evidence for a variety of issues regarding diagnosis, prognosis management and treatment of concussion.

Vomiting as a predictor of intracranial injury1

This large sampling (19, 920) of pediatric head injury patients in Australia and New Zealand (2011-14) looked at association of clinically important TBI (ciTBI) and vomiting.  This study supports previous research showing that vomiting is common following head injury, especially under 2 years of age; however, vomiting is rarely an independent predictor of ciTBI.

Patients with skull fractures, altered mental status, and headaches more likely to have ciTBI with vomiting (OR 80.1; 95% CI 43.4–148.0; OR 2.4; 95% CI 1.0–5.5; and OR 2.3; 95% CI 1.3–4.1, respectively).


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