PSOTBLOG

Frenotomy Part Two

On Mon, Dec 29, 2008 at 7:26 PM, <Wmrodney@aol.com> wrote:
 
I do one or so per year. The perception of a tight frenulum seems to color the parent's outlook on everything else. Every time the child won't eat, or spits up, or has colic, the frenulum must be to blame. Some of the tongues do seem quite extreme. The last frenulum I clipped extended out to the very tip of the tongue.

It's interesting that we physicians can have such angst about performing a minimally invasive, safe procedure that may have some benefits, but we don't have much heartburn about doing a circumcision based solely on the parents' request.

These are very easy, especially since the most distal portion is typically a very thin membrane. As others have noted, a little viscous lidocaine on a Q-tip is sufficient. I usually crush the membrane with a straight clamp and snip with an iris.

Two pearls. Tell Mom ahead of time that there will be some bleeding for 5-10 minutes and a bit of crying, but it will be fine.

Second. Have Mom bring a popsicle or something similar for the child. The crying will stop quickly, Mom will feel better, and the cold may encourage some vasospasm.

Our better insurers pay around $150. Why should the ENTs get all the fun. Unless you have a very thick, vascular frenulum, this really is a see one, do one, teach one.

Easton Jackson, MD
Delta, UT

Guess you all don't follow the literature on this...it is actually quite strong, though recent.  Some great work done by family physicians in Minnesota and several pediatricians.  There is a video produced by a family physician in Canada, Evelyn Jain, which is on the web at www.drjain.com.
 
Citations copied from various sources below, apologize for the formatting but did it quick because I'm between things this morning.
 
Anne M. Montgomery, MD, FAAFP, FABM 
(fellow of the Academy of Breastfeeding Medicine)
Faculty Physician---Family Medicine Spokane

Midwifery. 2008 Sep;24(3):353- 7. Epub 2007 Feb 5.

Case series of 148 tongue-tied newborn babies evaluated with the assessment tool
for lingual frenulum function.
Madlon-Kay DJ, Ricke LA, Baker NJ, DeFor TA.
  D epartment of Family Medicine and Community Health, University of Minnesota
 Medical School , 2615 E. Franklin Ave, Minneapolis , MN 55406 , USA .
madlo001@tc. umn.edu
J Pediatr Surg. 2006 Sep;41(9):1598- 600.
Immediate nipple pain relief after frenotomy in breast-fed infants with
ankyloglossia: a randomized, prospective study.
Dollberg S, Botzer E, Grunis E, Mimouni FB.
J Am Board Fam Pract. 2005 Jan-Feb;18(1) :1-7.

Comment in:
    J Am Board Fam Pract. 2005 Jul-Aug;18(4) :326; author reply 326-7.
Newborn tongue-tie: prevalence and effect on breast-feeding.
Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA.
Regions Family and Community Medicine Residency Program, University of Minnesota
 Medical School , St. Paul , MN , USA .
Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound
Donna T. Geddes, PhDa , Diana B. Langton, BSc, IBCLCb , Ian Gollow, MBBS, FRACSc , Lorili A. Jacobs, MScd , Peter E. Hartmann, PhDa and Karen Simmer, MBBS, FRCPH, PhDe

http://pediatrics. aappublications. org/cgi/content/ abstract/ peds.2007- 2553v1

Ankyloglossia: Assessment, Incidence, and Effect of Frenuloplasty on the Breastfeeding Dyad Jeanne L. Ballard, MD* , Christine E. Auer RN, IBCLC and Jane C. Khoury, MS

PEDIATRICS Vol. 110 No. 5 November 2002, pp. e63
http://pediatrics. aappublications. org/cgi/content/ abstract/ 110/5/e63

Oops, full title for ultrasound article, which is fascinating- -I've seen the real time videos at a talk:--Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound

Anne M. Montgomery, MD, FAAFP, FABM
Faculty Physician
Family Medicine Spokane

 
Very good - a true academic in our midst! Small studies but interesting reading.

Paul Davis-Alaska

Mark Clapp use to do A LOT of these in Jamestown - something genetic perhaps - and the real work is done by the nurse/assistant who held the newborn's tongue (with gauze) and jaw. Then the hemostat and sharp scissors. I never saw much bleeding.

While there I delivered a Hispanic child who was markedly tongue tied - there was a groove in the end of the tongue. While discussing this with the family in broken Spanish, I noted that the child may have trouble trilling his erres at some point. You should have seen his Abuela's eyes light up as she launched into a story of how the father and all the males in his family shared this same speech impediment.

For what it's worth.

WR Grailamrd
Medicos Nashville
 
 
 Index--tongue tie surgery, frenulotomy blog #2

Frenotomy

  

Dr Rodney:

I had a 4 mo old F with this problem today. She had an indentation of the tip of the tongue and a tight frenulum. I ended up refering her to ENT.
Do you guys perform frenotomies at the office?

I never have done one. I found this at the AAFP journal. http://www.aafp.org/afp/990115ap/conference.html

If you do so, what is the room setting (instruments) to do it?
 
Reply Medicos J club-(wmr):

Frenulotomy has been performed rarely in the Medicos offices, but probably there is no scientific reason to support it. Mothers say that the "tongue tied" infant has difficulty feeding, but there has never been any growth chart data to confirm this. Your case report suggests that the infant was failing to gain weight.
 
Snip, snip and it is over. Never seen one bleed, but we have done maybe five in the last ten years. Good luck if you hit one of the major veins down there on the base of the mouth or tongue. You will need to have your gauze, needle holder, and suture(vicryl 4-0 on FS-1 needle) ready to go. Electrosurgery and cryo will not help here.
 
Otherwise curved Metzenbaum or Mayo scissors are the best choice, but suture scissors are more commonly used because most family physician's do not stock Metzenbaums and Mayos in the office. Keeping the surgical field stable with good exposure is always a real treat in a 4-12 month old infant's mouth.
 
I have not seen one case with a clear indication. Usually our physicians have caved in to the mother's anxiety and the fact that the mobility of the tongue seems restricted by a tight frenulum. I have reviewed two articles on this topic in the last thirty years, and both were rejected. The reference you cited was a case report, but not a peer reviewed publication in the scientific literature.
 
Other experiences and comments would be appreciated.
With best wishes for a Joyous New Year,
 
Wm MacMillan Rodney MD
Clinical Professor of Family Medicine
Adjunct Professor Surgery/Emergency Medicine
Meharry/Vanderbilt School of Medicine

Medicos para la Familia
Memphis, Nashville and rural Tn.
www.psot.com

Jairo:

I have one case several years ago in the hospital. Nurse already told the mother "the Plastic surgeon is the one who take cares of this". When I asked about you said that he does it "just the same as Bill said"..................

Also add "No clear indication but you will not convince the mother" :-). If you do procedures, this will be very simple: if I'll have one today, I'll do it with the "caut-coag" of my LEEP machine, with the straight small electrode tip.
The "maestro Bill" approves? :-)

Eduardo Scholcoff Md
Rockford, IL

Used to do them all at StoneCrest - probably a dozen or more in the 4 years I was there.  Never had a problem.  Neonatal nurses referred them all to me until a couple of Med/Peds (Perkins and McCollum - you know him, Bill) yelled at the nurses and said only ENTs were qualified to do them.  They then went to the CEO and I was made to quit under threat of peer review.  Still did them in the office though.

So - a bit of gelatinous lidocaine 2% on a q-tip around the frenulum for 3 or 4 minutes (till you get set-up).  Then a straight hemostat to crush the bit you want to cut, followed by a quick snip with iris scissors and it's done.

Omar
__
Omar L. Hamada, MD

Omar: I did not think of the thin hemostat. Good idea !!!

Eduardo.

Hi all…The ENT’s do all of their frenotomies in the OR here.  So, the pediatricians and lactation consultants send them all to me. I turn a few away but do about 10-12 a year.  Some are maternal anxiety but I’d say half of the cases make a definite difference in feeding.  Others will have an improved speech pattern.   I’ve done them up to 5-6 years of age…all in the office.  A little more of a challenge when they have teeth.  One little guy couldn’t lick an ice cream cone.  He came back an hour later with a cone, asked to see me, and proceeded to lick it big time….grinning the entire time.   “Priceless.”  Meet Rodney’s criteria?  Maybe not, but met mine!  Also have done several sent by speech pathologists.  Bottom line, it makes a difference most of the time.  In one case of a three week old, I told the family I really doubted it would help.  I would never have sent the kid to the OR, but it’s so easy to do in the office, and the lactation consultant suggested it, so, I did it.  Within 24 hours the kid was breast feeding without difficulty.  I know, case report.  Means nothing. Okay. But, it works.

Look at the chapter in our book.  Gary Newkirk wrote it.  I had never seen one done but did one after reading the chapter.

Put some Cetacaine on a Q-tip.  Apply it to both sides of the frenulum for a few seconds.  They hate the taste even though it smells good.  Don’t spray into the mouth… Too much gets in.  Use good tissue scissors…I use the 5” Metzenbaum’s.  Snip through the thin membrane.  I have never seen a significant bleed although most will have a little bleeding.  I allow the mother’s to nurse after 10 minutes.  Child can go home when bleeding stops. For older kids with teeth, some will need sedation.  Put a rolled up 4x4 in the mouth to prevent them from biting on your finger or the instruments.

For what it’s worth.  YOU can do it…don’t send them to an ENT.

Jack Pfenninger

I do them in the hospital.  You can bovie the bleeders and have full control over your surgical field.That being said, an office approach is very practical.  However Bill's point regarding performing this procedure on a "moving target" coupled with a concerned parent who may end up being an assistant may deter an optimal setting. Our ENT's do them in the hospital.

Thomas A Kintanar

Index--tongue tie surgery, frenulotomy

Oscar Nominaions For Residencies List

I have been digesting the dialogue on procedure rich programs and want to respond in more detail. Since students who wish generic primary care can succeed in all programs, my research seeks to help those who have ambition for the more difficult to obtain training in Family Medicne-OB-ER-mission surgery.
 
The surveys based on popularity contest methodology are proven failures. Surveys have merit as a preliminary step IF the surveyors are directed to seek objective answers to specific questons on EACH program they visit.
 
I have better predictability by directing each student to obtain straight up and down answers to a few basic questions. The rest is too easy to manipulate.
 
The basic approach was attached in my previous post. My staff is willing to support this effort. More to follow.
 
In response to the following:

Bill, 

Are you willing to share your list at our Summit?  Maybe we can modify and distribute under umbrella of our group as part of an academic exercise in helping medical students identify the right fit for them---knowing full well we will create some controversy,  yet accepting that all controversy around this challenge can only help,  right?

The STFM Group on Procedure and Hospital Medicine List of High Level Procedural and Hospital training Famliy Med Programs 2009: Some disclaimers that the list has been developed by group consensus only and is a work in progress.  We annually update the list.
 
We do not have staff to verify the accuracy and we state that clearly. As med students peruse the programs we list,  we begin to get updated feedback, allow them to vote "the most procedural program in the U.S." from med student / resident view every year on a simple website.  Or maybe "the top 10 of 2009". Let the students and the residents vote this so it is a "consumer award" and not coming from us stodgy folk looking to promote our list.
 
Do the same for hospital care,  maybe evolve into rural training (not an area of expertise for me,  we are currently training more folks for urban, suburban underserved and remote and global).
 
By having the consumers create the list we can remove our worries about our own biases (after we've produced the first list which we acknowledge as flawed yet distribute it anyways as it's better than nothing which is what students have right now).
 
J

Comment:

I found your post on the web re family medicine residencies. I'm a 3rd yr med student trying to sort through the 400+ family residency programs and am interested in the list you have. Could you email me a link to the list or mail me a copy. Thanks.
 
REPLY (WMR):
 

Congratulations on getting to to the next level in the academic world of Dungeons and Dragons.Students and residents are welcome to receive access to the RONA's 2009 contingent upon disclosing their professional goals, midrange educational objectives, and likely geographical preferences. Mountains of information produce lesser amounts of useful knowledge. Occasionally wisdom is achieved. At this point, widely broadcasting the "list" is not in the best interest of all involved.
 
With best wishes for a Joyous New Year,
 
Wm MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural
www.psot.com

Index--Predoctoral, career choice, residency selection, RONA list

OB Delivery Numbers

Question:

Our chair of OB (and fellow FP) wants to know if there is a national standard for number of deliveries that allows for most FP's to get privileges for OB with OB back-up in family-medicine "friendly" systems?   For example,  Colonoscopy is somewhere between 50 and 150 depending on what group you inquire with.  Other than the 40 minimum for RRC is there a number out there considered adequate for OB basic privileges nationwide?
 
Jeremy

REPLY (wmr):

Although numbers as a standard cannot be defended intellectually, they represent a political compromise.
 
Dave Holden who was RRC Chair at the time, went around the RRC panel and asked those of us who were delivery capable "At what point did you generally feel comfortable with deliveries"? Our average was 40. Rodney WM. Historical observations from the RRC 1994-2000: Maternity care[OB] training in FP. J Am Board Fam Pract 2002;15:255-56. Rodney WM.  Obstetrics enhanced family practice: an endangered species worth saving! Florida Fam Phys 1993; 43(1):8-9.
 
It was a miracle that we held the line on OB which was under incredible pressure from the " I hate OB" crowd. Forty is a good number even though I had an incredible letter from the director of XXX residency NOT recommending that one of his resident  graduates be allowed to deliver babies
(because the residency director didn't have those privileges he refused to recommend thereby making almost imposssible to remove the stigma of a "bad" recommendation). THIS IS AN EXAMPLE OF ONE OF THOSE PROGRAMS WHO HAVE ONE FP DOING OB WHILE ALL THE REST REALLY DON'T COME NEAR IT. At the RONA awards this program is listed among the "Hall of Flame Programs".
 
We supplement the OB delivery # with the requirement of passing one ALSO and NRP course. Then they receive provisional priviges which are reviewed at 12 months contingent upon performance the physician receives active privilges for 2 years which is the regular JCAHO cycle.
 
With best wishes for a Merry Christmas and Joyous New Year,
 
Wm MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural Tn.
www.psot.com

Index--privileges hospital, OB average risk

Work Rule Bias and Procedure Rich Programs

First, academic medical centers have become sleep deprivation factories due their dysfunctional design and ownership by physicians who have never actually done any non-institutional medical practice. Look at the "primary care" leadership panel in this week's New England Journal. We might as well have a gifted group of librarians from Iowa designing a curriculum in trans-oceanic sailing. The inmates have gained control of the asylum.
 
The ACGME and IOM data suffer from selection bias and absolutely no curriculum time devoted to efficiency of practice. The Medicos model uses community medicine standards whereby the nurses function as interns on behalf of the physicians. Medicos physicians are not required to follow silly rules that require on the floor attendance for every patient in active labor/induction. (This was the actual rule at a Nashville teching hospital during my Chairmanship 2000-2004. Finally got it changed in 2006.)
 
Medicos published a study on the amount of hospital time necessary 2300-0600 and # of phones calls received during "sleep time" 2300-0600. consectuaive years have been studied since 2000(Y2K) and the data ranges from 72 deliveries/yr to 440 deliveries per year. All fellows are required to answer their cellphones all the time. No answering service. Call averages every 3-4. Twice a year we have 4-5 deliveries in one 24 hour period. The average physician is up to deliver 2300-0600 once or twice a month. In 9 years, we have NEVER had a physician up all night. This year Medicos will do about 370 of its own deliveries and another 200 scheduled sections for other physicians. Reprint available.
 
Second, while part of the UCLA School of Celebrity Medicine, I created "Rodney's Oscar Nomination Awards[RONA]" for those students seeking residency training where procedures were enthusiastically taught. At the Phoenix Summit 2006, I talked about my "Defining Dozen".
 
In a forward to the annual RONA ceremonies, I point out that the addition or loss of one procedural faculty can be a sea change for over ninety percent of programs. Therefore, the list is a dyanamic set of probabilities. But, there are 6-8 questions which are useful for the students who wish to interrogate in a systematic way. Here is the preamble from the 2008 RONA Awards Ceremony.
 
The potential for procedural excellence exists in some, but not all residencies. If you guess incorrectly, do not fear. A 12 month post-residency fellowship can usually get you where you want to go. Ironically some rural programs are incredibly weak and some urban programs like Contra Costa seem incredibly strong. (A malignant Dean or hospital administrator can destroy a beautiful program like Maricopa.)
 
During my highly excellent adventure at UCLA, I developed what came to be known as the Oscar nomination list for students who sought to fulfill their search for the Holy Grail--The universal antidote to procedural helplessness. I told students to search for solar systems where they might encounter enthusiastic effectiveness rather than politically correct, but hollow, promises. This list has been updated annually since 1984.
 

The Oscar nomination list is distributed to medical students with the disclaimer that the half life of accurate information in the residency reputation world is 18 months. Several programs are listed as a "strong" recommend on the issues which proceduralists(FAMILY MEDICNE-ob-er) view as important. But, when a strong director leaves, programs can change dramatically. Students, residents, fellows, and faculty are asked to update this information and respond to the suggested process. I request that post interview students let me know where additional editing should occur.

The list is not for widespread public dissemination. Undoubtedly there are some good programs that I have not listed accurately and I do not wish to offend those who have struggled to improve their programs. My ignorance of their efforts is not an intentional omission. Although I sat on the RRC for 6-7 years, the list is used internally in my department to help counsel medical students on the process of residency selection through meaningful inquiry.

This document contains generic advice as the central theme, but each year feedback is solicited as students interview and gather information on the most recent status of these programs. The Oscar nominee list" is an adjunct to the process of interview recommended in the preamble. 

I.General Guidelines

 A.Identify what is likely to be important in the community practice you may have.  Since the teaching of procedure-enhanced Family Practice is “the    road less traveled,” this report will focus on locating this special subset of programs.

   However, there is a list of programs where deliveries and OB are not emphasized. Call me for an up-to-date list.

 B.Be tenacious and protect time for this investigational task.  There are some exceptional training opportunities, and some are average at best. A    motivated individual can always overcome mediocrity.

   Do clever things to investigate the quality of support your future patients will receive.

   Examples:

   1. Pretend you’re a patient who wants an appointment today for a repair of a six inch laceration on your leg. Tell them you think you might have a       fracture. Call and see if you're referred to the ER.

   2. Tell them you want to pay cash.  Ask how much you should bring.

   3. Tell them that Dr. (fill in a real name) resident or faculty member has been recommended to you.  Can you be seen today[open access] or do you       have to go to the ER? As a resident you want these acute care skills in your family medicine office.

 C.There are special features that quickly allow the applicant to identify environments where acquisition of clinical skill is more likely.

   1.Hospital privileges are currently held by family physicians and active teaching is done by FP faculty in Labor and Delivery. Literally this is a      watershed issue for a whole variety of scope of practice issues ranging from the ICU to the ER and beyond.                                   

   2.At least four FP faculty are OB-capable and actively help supervise deliveries. Applicant’s question:  “Do the FP faculty actually come into the      hospital between the hours of 10:00 pm and 6:00am to help you with delivery and/or management?”

   3.Ultrasound capable FP faculty with an ultrasound unit, perform these services and teach in the FP office.  Applicant question:  “Is there an      ultrasound machine located in the office and can the residents use it (with or without supervision)?” "Are you allowed to bill?(i.e., Is it for      real?)
   4.If FP faculty do not even teach colposcopy, office surgery, and short colonoscopy, they are not dedicated to providing a procedural curriculum.      Cesarean sections, EGD and/or colonoscopy-capable FP faculty are a bonus.

   5.Ask to see an average Letter of Completion (see Appendix A). When you graduate from residency, what will your letter contain?

   6.Is there an electronic medical record which works well?

 D.Use your contacts at the AAFP/STFM, 1-800-274-2237.

   1.Request the STFM Fellowship Directory to locate residencies with fellowships in FAMILY MEDICINE-er-ob. These suggest curricular resources which      enrich the residency experience.

   2.Are residents encouraged to attend clinically helpful courses (CME) available from the American Academy of Family Physicians (AAFP)?

     a)Annual Scientific Assembly (4 days in late Sept/early Oct, call for location). Various procedural courses in endoscopy , office surgery, and        more.

     b)CME on various topics throughout the year (ask Dr. Rodney for mailing list or check his web page www.psot.com).

   3.How to select a practice locale.

     a)Hospital Fair Play-on-Privileges List. (community selection)

     b)Developing a “critical mass” of like-minded peers. Onesies and twosies are have shorter half lives. Choosing a partner.

     c)Selecting limits on your lifestyle, family, and call

 E. In the teaching environment, watch out for warning signs and symptoms of  “procedural helplessness”  (also known as taught helplessness).
  
    1.“Everybody here gave up OB a long time ago because of the malpractice.”

    2.“Most of this teaching is done on the subspecialty rotations where the residents learn from an expert.”

    3.“Procedures are important, but we are concerned that too many procedures will deflect residents from spending sufficient time on the        psychosocial issues.”

    4.“We’ve recruited someone (i.e., a single person) to teach procedures.” or  “We have one faculty who still does OB.”

    5.“Anything that takes you out of the office loses revenue for the practice.” “Procedures are not time efficient!”

    6.“Nobody in practice does OB or hospital work anymore.” or “None of our graduates want to do OB once they get into practice.”

    7. There are so many underemployed specialists that we’d all be better off referring procedures to them.

    8. Others.

Dog bite To Face- Day 6

 

REPLY #9

Admit- IV ATB- open a few stitches at least.
If admit is not an option: Open a few stitches in the office, IM Rocephin Daily for 7 days and daily checks.
 Scholcoff, MD

 

reply #10

Great work ......IM antibiotics with daily check is great and gutsy yet for the right reasons !Shows I haven't been working in ED enough anymore---you start to lose your courage in my experience.

 

Hospitals are security blankets for us docs---ability to sense control of follow-up is assured. Also,  working in a large system what if the patient didn't come back the next day, they didn't have a phone, that sort of stuff.

 

Small is beautiful, and small + clinical excellence + courageous care for the underserved = Medicos ![Ed-note: Thanks]

 

WMR WRITES ON DAY 6--Child received two days of IM antibiotics and then faithfully took the cleocin po tid. No return of fever. Scab has now buried large parts of the 6-0 vicryl sutures, and suture removal would be a traumatic experience with no probable benefit. We really appreciate that the ER doc did not use prolene or ethilon. Note blackening of ischemic flap.

MEDICOS OFFICE SURGICAL CURRICULUM

Mission medicine has taught Medicos that much of American medicine is driven by fear rather than logic. Continuity is dead in the medical school and residencies. Indoctrinated physicians never actually experience any form of longitudinal community medicine, and therefore, the statistical assumptions are skewed in favor of expensive and dramatic interventions which are inaccessible for large parts of the world.
 
This child was given IM antibiotics(Ancef 400 mg and Gentamicin 60 mg IM) and seen one day later. As on day one, the child was afebrile. and interacting appropriately. The eye was less swollen and conjugate gaze was documented. The wound was clean and dry. He received a second series of IM antibiotics. Even in native Spanish, the family misunderstood the directions and never gave the Cleocin which was prescribed. They started the Cleocin po day 3 after the second series of injections. Medicos will take the sutures out at 5 days. Note the photo on day three below. Excellent Yale Observation scale scores and a totally focused mother-father pair.

Eye and scera are now partially visible and seem to be tracking. CT needed? Yes this was periorbital cellulitis, but there were extenuating traumatic circumstances which makes the prognosis less ominous. Cost prevention over $12,000.
 
One of the advantages of Medicos is the intense level of the procedural skills and this includes office surgery, fractures, and all of the children who cannot find care anywhere but Medicos. Additionally there is the constant followup on a variety of cases currently not available in residencies or in the hospital-employee practices under which Family Medicine withers.
 
Ultrasound cases of this week have included over fifty pregnancies but also an omphalocoele, gallstones, AIUGR, and testicular hernia. We follow all GDM with NST, AFI, EFW in the office by our fellows under faculty supervision.
 
Medicos physicians are unified in the concept of Family Medicine-OB-ER, but we have maintained the liberty of running these activities within one family medicine group. Medicos is now doing over 30 deliveries a month in Memphis with excellent backup. Additionally the fellows scrub another 15-20 Cesareans monthly from other physicians. Medicos physicians should understand basic surgical principles.
 
 
REPLY #1:

I guess I'll take a crack at it:
Go to Hospital, go directly to hospital for IV abx for peri-orbital celullitis maybe removing a few sutures.  Got some necrosis (hopefully superficial) .   They probably flushed the hell out of it, yet on the face I can't see how they didn't send him out with Abx but I haven't done ED work for a while and I know dog bites are supposed to be pretty clean (compared to humans and cat punctures).
 
Can the kid see out of that left eye? 
 

reply #2:

My first thought was: Can the kid move the eye?

If he can, then periorbital cellulits is a likely diagnosis. Oral antibiotics are probably OK, may just give the kid a loading dose of something IM, like Rocephin, then start po antibiotics. But in this case some imaging would be warranted because of the bite, a CT scan is the usual, maybe a ultrasound could be done instead, not sure.

Need to rule out an abscess. Releasing a few sutures may be just the ticket. Close follow up is a must on this case.

If the kid cannot move the eye, it is orbital cellulitis, needs to go to the ER emergently. Ophthalmological consultation becomes a must for orbital cellulitis.

-JP

REPLY #3:

Augmentin, standard dose, at the very least, plus/minus 50mg/kg ceftriaxone, possibly relieve any pressure by removing a suture or two.
 
Shoot the dog.

WRG
 
REPLY #4:
 
Is hospitalization an option?  culture the wound, and IV Unasyn, if no PCN allg.
 
Or are you asking b/c that is not an option....
 
thanks for sending these to a larger group.  I have learned from ALL your emails!
 
-SUE MAGEE
Director Maternal Child Health Fellowship
Brown University/Alpert Medical School
 
REPLY #5:

Option 1. Rocephin and recheck closely 12-24 hours.
Option 2. Back to the hospital for IV therapy and consultation with surgeon or EENT.

Culture the Dogs mouth?
 
REPLY#6:

1.  Admit the patient
2.  IV antibiotics broad spectrum  (Ampicillin-sulbactam)
3.  CT Head/looking for  orbital/preseptal cellulitis??
4.  Get Surgery involved
 
J.Macias

REPLY #7:

Bill
I would be concerned about the presence of a preseptal infection and would proceed as if it were present.  Imaging should be obtained and AB therapy instituted and carried forward until all cleared.  C & S of any exudate/drainage would be most important to me as well.

Skip Felmar MD

REPLY #8

Sadly when you have "good" results like this[ed note: ie; without hospitalization], many (paranoid) mainline thinkers only allow you to be "lucky," not good or better than average. They think of you as a risk-taker, cavalier or ignorant of all the bad things that could have happened had things not gone so well. At times, I grow weary in the battle, until I remember these words, "And let us not be weary in well doing: for in due season we shall reap, if we faint not."

John Spencer MD

A Side Note:

A child who continues to receive immune competent mother's milk even at this age, will also be less likely to have infections of all types, especially those involving mucous membranes. Both pictures show the use of the bottle which is associated with increase likelihood of cutaneous infections. We could speculate that had this child still been receiving his mothers milk he may not have had the infection in the first place. We could also speculate that had his mother been nursing her prolactin levels would have been higher and she would have been more protective and the dog bite may not have occurred. Realistically speaking and sadly so, many people don't want to hear that.

Sadly when you have "good" results like this, many (paranoid) mainline thinkers only allow you to be "lucky," not good or better than average. They think of you as a risk-taker, cavalier or ignorant of all the bad things that could have happened had things not gone so well. At times, I grow weary in the battle, until I remember these words, "And let us not be weary in well doing: for in due season we shall reap, if we faint not."

www.psot.com
Index--Medicos ER, Office surgery curriculum, Med4Uninsured cost Prevention

FAMILY MEDICINE ER J CLUB

63408 14 months of age boy who was bitten at 1100 by a neighbor's dog yesterday. Growth and development have been normal, and his immunizations are up to date. Medicos is a rural simulation and in the city.
 
The dog is being observed, but rabies is not suspected. The boy was immediately taken to the children's hospital by his parents where the laceration was repaired, and he was observed for 12 hours. He was released at 2200 with a bottle of tylenol with codeine syrup and no other medications. He was given a followup appointment in surgery clinic 8 days later.
 
At 0200 the boy awoke crying and the mother felt he had a "temperature". Also the eye was swollen shut and there was a question of pus draining from the wound. They came to your office because they know you speak Spanish, and no appointment is needed. In the office, the boy was noted to have a temperature of 102.3 degrees F and the WBC was 14.2 with increased immature WBC percentage. After removal of a large head encircling Kerlex head bandage, these pictures were taken.
 
Any suggestions for management?

With best wishes for a Merry Christmas and Joyous New Year,
 
Wm MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia

Option 1. Rocephin and recheck closely 12-24 hours.
Option 2. Back to the hospital for IV therapy and consultation with surgeon or EENT.

Culture the Dogs mouth?

Admit- IV ATB- open a few stitches at least.
If admit is not an option: Open a few stitches in the office, IM Rocephin Daily for 7 days and daily checks.

 Scholcoff, MD

Flu and Cold News 2008

Why the flu patients come to see the physician for a self limited illness:

In this month's sample from Medicos, one of the major reasons is a relentless and sleep-depriving cough. Generally the dextromethrophan syrups are not strong enough to allow a night's sleep. Medicos has searched for this season's "medicaid permitted" stronger cough syrups. Tussionex is good hydrocodone syrup but its average cost for 4 0z is over $60 for an uninsured patient.

They cheapest and ostlikely to be allowed cough syrups are:  

1. Lortab elixir whose strength is hydrocodone 2.5 mg per 5 cc with some acetaminophen and       
2. Robitussin-AC which contains codeine.

I prefer the hydrocodone which is slightly more predictable, and I warn adults that, although the prescription is written for the government accepted dose of 5 cc per 6 hours prn cough, most will require double or triple this amount to get through the night.

--wmr

Majority of flu virus samples tested are resistant to Tamiflu

H1N1 Tamiflu Resistance Clade Exchanges in Hawaii?
Recombinomics Commentary 19:02
November 28, 2008
Twenty of 21 influenza A (H1N1) viruses tested were resistant to oseltamivir

http://www.recombinomics.com/News/11280802/H274Y_X_Hawaii.html

Dr. B courtest Dr Bucek , Somerset NJ

Wm MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural Tn.
www.psot.com