Taking pictures for youth protection purposes

If you need to use the departmental camera to document possible physical evidence of abuse, these are the steps to follow:

1. If you are seeing the patient on a regular weekday, pictures should be taken by audiovisual.  Call loc. 22368 to make arrangements for where the pictures will be taken.  Fill out the audiovisual form indicating what you want them to take a picture of, and a signed consent to take the picture (keep in mind that the only people who have the right to consent are legal guardians such as parents, or the DYP worker if they have been given the mandate to do so).
2. If you are seeing the patient off hours when audiovisual services are not available, the patient is able to return the following morning and it is unlikely the evidence you wish to photograph will change substantially, then you should prepare the above papers, and have them return to audiovisual the following morning. Social services should always be consulted for child protection cases and will serve as the patient liaison if you are having someone return the following day to get pictures taken in audiovisual.
3. If having the picture taken by audiovisual is not possible, the ED camera is available in the upper cupboard closest to the secretary’s station in the physician’s area.  The key to this cupboard is at the secretary’s desk; ask them for it.
4. Before you take any pictures make sure to obtain a signed consent.  Review the images and delete obviously unhelpful shots.  Then clearly document the patient’s unit #, the number of pictures you took, and that they were for youth protection purposes in the binder accompanying the camera.
5. After you have taken your pictures, remove the memory card from the camera and place it in one of the available small envelopes, fill out the identifiers on the envelope, seal it, and leave this envelope in the box that contains the camera, envelope and extra memory cards.
6. Either call to involve social services in your case (if indicated) and at the very least make sure to leave a message with social services (loc. 22508) indicating that you have taken photos, so that someone is sure to pick them up from the camera box the following day.
7. Our social workers are a very important and valuable resource.  They should always be consulted for child protection cases. In addition, there is always a physician on call for child protection at the MCH.  You can have them paged should you have any questions about the most appropriate way to manage a specific case.
8. If you feel that it is vitally important to take photographs and the parents are refusing consent; alternatives are for DYP to sign or to consider involving the police as they are permitted by law to take the pictures without consent.

Thank you to Dr. Laurel Kimoff of the MCH Child Protection Service for this information.

Nebulized 3%NaCl for bronchiolitis

A few key points to remember:

• Nebulized 3%NaCl to be used for children with bronchiolitis, ie. mainly < 2 years of age (no lower age limit)
• No contraindications
• While studies have used anywhere from 2-4 ml /nebulization, as there is no down side, I would recommend we all use 4 ml
• The theory is that it breaks up the thick mucous that is stuck in the bronchioles, therefore it has the ability to improve oxygen saturation, decreased work of breathing (both respiratory effort and RR), therefore you gauge efficacy based on any improvement in these parameters. There is no benefit to using it "back to back", it either works or doesn't. If it works you can use it again if whatever parameter that had improved before worsens again. Based on what I have read (as I do not have much personal experience with it), it seems that if it works, the mucous does not build back up to the previous level that quickly, and you probably won't be using it more often that every several hours (though you can, it is safe). 
• There is a theoretical risk of it inducing bronchospasm, and the way you would detect this is your patient's respiratory status worsening after the treatment. While this is always sited as a theoretical risk, newer studies have shown that it is in fact not really that much of an issue clinically. Therefore, know it can happen, but don't worry about it too much. If you think you are seeing it frequently, you are probably overcalling something…
• Keep in mind the most compelling evidence is that it decreases length of admission, therefore we should be using it for patients who require admission, or who might require admission, but not in those patients who are well enough for discharge home.

Group A strep pharyngitis

As you all know, penicillin V in oral suspension has been off the market for some time. Since that time we have largely been prescribing amoxicillin for patients with suspected GAS pharyngitis, for them to fill if their culture ends up being positive.

It seems the new check form prescriptions are at the printers, and will be stocked in the ED in short order.

In the meanwhile, I wanted everyone to know what we should be prescribing to these patients, both for simplicity's sake, and to assist in standardizing our practice for this common problem.

For penicillin non-allergic patients give:

• <27kg, amoxicillin suspension or chewables, 250 mg po BID x 10 days
• >27kg, amoxicillin suspension, chewables, or tabs, 500 mg po BID x 10 days

For penicillin allergic patients give:

• azithromycin suspension or tabs, 12 mg/kg/day, in a single daily dose x 5 days (max. 500 mg/day)

Thank you to Dr. Ilana Greenstone for her work on this initiative, and for providing the information included within.