How much is peds?

[Apollyon]

Hey folks - I'm not oto - I'm a practicing EM doc. I was just thinking of something recently: the only time I need ENT in the ED is for nosebleeds, but I see tons of kids with tubes in the TM. So, I was wondering - how much of your practice is kids? Could you just say "no more peds patients"? Could you survive only on adults, or would that mean only more complex naso-facial carcinomata and such, making your life a bit worse?

There is no purpose to my question - I just don't have any otorhino folks to ask my question.

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[resxn]

The avg ENT in private practice sees about 30% peds. I prefer to see more and am about 40-45%. Personal preference, that's all. It would be easy to say "no more peds" and survive. Many do. In fact, I have partners that don't see hardly any peds and do just fine with rhinology, otology, H&N, etc. Life being worse is all in perspective. I prefer more peds because I think kids are just fun. I don't deal with the airway disasters, syndromic, or immunocompromised ones so much so mine tend to get better fast with good results and happy parents. It is the fun part of my day when I've seen 2-3 dizzies and then I get a run of kids with ear stuff I can fix within days.

 

[Apollyon]

Thank you! It was just an avocational question.

 

[Leforte]

I would actually say that Peds ENTs have a worse lifestyle than most ENTs (except, of course the microvascular H&N ENTs).

In my training, the Peds ENTs were always coming in late at night for tonsil bleeds, airway issues, neck abscesses, foreign bodies, etc, etc. I always hated getting the call from the Childrens hospital because I knew I'd be there for hours.

 

[ZagDoc]

I would actually say that Peds ENTs have a worse lifestyle than most ENTs (except, of course the microvascular H&N ENTs).

In my training, the Peds ENTs were always coming in late at night for tonsil bleeds, airway issues, neck abscesses, foreign bodies, etc, etc. I always hated getting the call from the Childrens hospital because I knew I'd be there for hours.

Depends on the institution I suppose. At my workplace, all faculty in the dept are in a common call pool, faculty take between 1-3 weeks of call per years depending on seniority. Whoever is on call takes everything that comes in for that week, adult or peds. As a result, the peds guys have a pretty nice lifestyle, most are out of hospital by 5-6 every day. There are a few peds airway specialists who are basically always on call if we have a really hairy baby airway born/transferred from the outside, but those are pretty rare events.

But any time a flap goes down the micro guys are coming in regardless of whose on call.

 

[Pir8DeacDoc]

Depends on the institution I suppose. At my workplace, all faculty in the dept are in a common call pool, faculty take between 1-3 weeks of call per years depending on seniority. Whoever is on call takes everything that comes in for that week, adult or peds. As a result, the peds guys have a pretty nice lifestyle, most are out of hospital by 5-6 every day. There are a few peds airway specialists who are basically always on call if we have a really hairy baby airway born/transferred from the outside, but those are pretty rare events.

But any time a flap goes down the micro guys are coming in regardless of whose on call.

This was my residency program except faculty were all on call equal amounts and it was more than a few weeks a year.

 

[Apollyon]

I guess I've forgotten all about academics - having been in the community for the past 7.5 years makes me use that light to see everything. I get the vibe about seeing a kid to raise the morale a bit.

I was just wondering because in SC, HI, and PA, in all the places I was, the oto guys were, bar none, solo practitioners (but 4 in SC, so q4, plus facial trauma call rolled in, and, in HI, it was two Chinese guys, and they were q2). If they said "no kids", there wouldn't be any other option.

Thanks all for the perspective - the more I know, the better I can be with my colleagues.

 

[neutropeniaboy]

Yeah... Highly dependent upon a lot of things.

Some of my partners refuse to see kids, and that's fine because there are peds oto Faculty (they refuse to see adults... Heh!).

Some will see kids if they are referred from the peds otos in the department, of course, and others will see kids when on call.

For us, it's obviously a mixed bag.

There are quite a few private practice guys out there that I know who don't see kids either. Some have booming sinus practices or plenty of adult general oto to keep them busy. Some lament that they don't see kids because parents want pediatric anesthesiologists, and that's not an option for some of the guys out there.

 

[DrBodacious]

I'm learning at my community hospital that 3 out of 4 of the anesthesiologists are pretty uncomfortable with peds. I had 18 month old with a tonsil lesion that I did a tonsillectomy on this week and the anesthesiologist basically called me reckless for not sending him to the peds hospital a hour away. (I already think this anesthesiologist is a ***** - he keeps trying to put a sled on my side of the table to protect the blood pressure cuff.)

I generally don't do anything other than tubes on the really little ones (under 2), but jeez that seems a little weak on the anesthesiologist's side. I know there are probably a lot of opinions on how to manage children under 3. In my training one of the faculty would put SDB kids in the ICU overnight, whole at another private hospital they would discharge the kiddos home. Anybody care to share their criteria or some good evidence on managing kids under 2-3? Inpatient vs outpatient? ICU observation?

 

[Pir8DeacDoc]

In residency, we admitted all kids with significant co morbid issues (I.e. Downs, obesity) after tonsillectomy, usually to picu. Then we kept all kids under 4 overnight, even if healthy, generally on peds floor.

I tend to do "healthy" kids now in practice (but plenty of chunky kids). I follow the same criteria as my training except I don't have a picu so super obese or downs kids would go to the academic hospital. Haven't had that come up yet in 1.5 years.

 

[Pir8DeacDoc]

What sort of tonsil lesion did this kiddo have? If he was otherwise healthy kid then your gas man is a donk. Tell him to grow a set

 

[neutropeniaboy]

What sort of tonsil lesion did this kiddo have? If he was otherwise healthy kid then your gas man is a donk. Tell him to grow a set

It was probably a 10 cm lymphatic malformation in a FTT kid with stridor and hypercarbia / hypoxemia... The usual ****.

 

[DrBodacious]

It ended up being an inclusion cyst. About 1 * 1.5 cm. It looked benign, but not like a mucoucele (it was a keratin cyst, not a mucoucele) and it was significant enough I didn't feel like watching it was a good idea. I diagnosed the kid with a submucosal cleft, and he had speech delay (I did tubes and eua of his adenoids on him about a month ago and that's when I found the cleft and this mass). I had a CT done to make sure it wasn't a branchial malformation or some other "tip of the iceberg" situation. So, he wasn't 100% normal. The thing that made me pretty comfortable is that he was big for his age and had very good tone. All this said, it was just a routine tonsillectomy, he did splendid postoperatively. The only thing he would have benefited from at the children's hospital an hour away is a better anesthesiologist. (And of course, I don't have a PICU, but I really think the PICU would be overkill).

I definitely don't want the reputation of being a cowboy amongst the community and especially the pediatricians. So it has been an eye opener to see some other opinions on how uncomfortable people can be with these kids. I guess if there ever was a bad outcome it kind of negates any number of successes in the past, whether there is a judgement error or not. And it's not really my limitations but I can't do the anesthesia myself. I have considered talking to the head of the anesthesia group, but I live with them every day, so I've been trying to go with the flow so far.

 

[neutropeniaboy]

How long have you been out in practice?

I think after a year or two of a steady reputation as a safe and reasonable surgeon gives you some leverage to enact some changes that you need to see happen in order to grow.

 

[DrBodacious]

Yep, this is year #1. I don't really want to throw a fit right now.