San Marco’s Gina and Scott Schimpff felt fortunate that their three children were pretty healthy most of the time. While their daughter Isabel was born with progressive hearing loss, and that has led to some challenges, the Schimpffs have rarely needed pediatric medical services. Still, says Gina, one of the reasons they moved into a home in San Marco was, in part, to be closer to the area’s only children’s hospital.
Just three days after she turned 10 this past May, Isabel was sent home early from school because she was feeling sick to her stomach. Since her daughter was so rarely ill, Gina called the pediatrician. Although it seemed to be a clear-cut case of a stomach virus, when Isabel’s symptoms worsened, her doctor sent her straight to the Wolfson Children’s Emergency Center.
“They took her back right away once we arrived,” remembered Gina. “They had to push on her abdomen to help determine the cause of her symptoms and even then, Isabel said her pain level was only a five out of 10. The doctor said most kids would’ve jumped off the table, but she didn’t.”
Isabel’s pediatric emergency medicine physician ordered an ultrasound, which was read right away by a pediatric radiologist with Nemours Children’s Health, Jacksonville, which helped confirm doctors’ suspicions that she was suffering from acute appendicitis. Isabel was taken right away to the Wolfson Children’s OR for an appendectomy.
Only as Isabel was being prepared for surgery did the Schimpffs learn that their neighbor, Daniel Robie, MD, chief of Pediatric General Surgery for Nemours Children's and Wolfson Children’s Hospital, would perform her procedure.
“He was surprised to see us, too, but he recognized her name!” said Gina. “Isabel was super anxious about having surgery until she saw Dr. Robie. It also helped that the nurses told her what to expect. Isabel is really smart, and if you tell her what you’re doing, she’ll be OK with it. Because she’s hearing-impaired and does a great job lip-reading, it was important that the surgical team make eye contact with her so she could understand what they were saying.”
Dr. Robie removed Isabel’s inflamed appendicitis before it ruptured. She was admitted to Wolfson Children’s Hospital overnight as a precaution, but was feeling so well the next day that she was discharged at 9 am.
Appendicitis is the most common acute surgical condition in children, and among kids ages 10-17 years of age, it results in rupture10-20% of the time. Children with ruptured appendicitis are at risk for a severe intra-abdominal infection and small bowel obstruction, and can have a prolonged hospital stay of several weeks or more.
While the condition itself poses some risk, so does the associated radiation that may come with the diagnosis at many U.S. ERs. Robert DeFlorio, MD, a pediatric radiologist with Nemours Children's and Wolfson Children’s, said that appendicitis is not easy to diagnose since “the symptoms aren’t always obvious. While nausea, vomiting and abdominal pain can indicate appendicitis, these symptoms also can indicate other abdominal conditions. That’s where accurate diagnostic imaging makes the difference, particularly in kids.”
The appendix is a tubular structure that is normally less than 7mm in diameter. It may not even be visible when it’s not inflamed. Even if it is infected, the appendix can be hidden behind other abdominal structures. While ultrasound is not easy to use as a diagnostic tool for appendicitis, in the experienced hands of a pediatric sonographer and pediatric radiologist, it can help kids avoid a CT scan and accompanying radiation exposure.
“What many people may not be aware of is that radiation is cumulative,” said Dr. DeFlorio. “That’s especially important in children because, while there are clear benefits to the diagnostic accuracy of pediatric imaging tests like CT scans in some cases, there is also some risk, particularly over a child’s lifetime. Parents and clinicians want to avoid radiation exposure to children whenever possible. That’s where pediatric expertise and experience become factors.”
Dr. Robie said Wolfson Children’s Hospital’s “Safe and Sound” initiative, which he is leading, is not only helping kids avoid CT scans, but it’s doing so without sacrificing accurate diagnosis of appendicitis. That means kids avoid unnecessary surgery.
“Through our initiative, we compared the outcomes of children who came through the Wolfson Children’s Emergency Center with abdominal pain to other ERs and to national quality benchmarks set by the American College of Surgeons’ and American Pediatric Surgical Association’s National Surgical Quality Improvement Program (NSQIP),” he said. “Many community ERs across the country are evaluating pediatric patients with possible appendicitis primarily through CT scans, exposing them to unnecessary radiation despite safer, accurate and less costly clinical and radiographic alternative. We’re making progress in using ultrasound first, not going right to CT, and that is safest for kids.”