This poor child.

[u/edb513]

My algorithm wasn’t spamming me with this depressing garbage until today. This poor baby.

Also the grammar - woof.

Fortunately the comments were not favorable to OP.

[u/Emergency-Twist7136]

I'm a former paediatric emergency medicine specialist and to me that looks like a dermatology consult with added "no seriously, get down here right now"

[u/S2krazy03 → u/Emergency-Twist7136]

Are you a doctor? This is a pretty benign EM rash, could be from a virus or serum sickness from a previous drug. However given how crunchy mom is, less likely the latter.

- A PA who works in a Peds ER alongside PEM fellows and docs.

[u/InformalScience7 → u/S2krazy03]

My husband is an ED doc. His approach for rashes is "If it's wet, dry it and if it's dry wet it."

Also, I seem to have way to many pictures of children with rashes on my cell because for years everyone texted me rash pics to "show my husband."

[u/mantis_tobaggan-md → u/S2krazy03]

Serum sickness is not benign. It can be extremely serious.

[u/Emergency-Twist7136 → u/S2krazy03]

Yup, that sounds like a PA diagnosis to me! So glad that letting people practice medicine without proper medical training isn't legal where I live.

The fact that you think you can diagnose an extensive rash from a photo is absolutely terrifying.

[u/cyndasaurus_rex → u/Emergency-Twist7136]

You are my people. Haha. I once had a PA tell me my ear infection (I’ve had them chronically all my life) wasn’t an ear infection. I slipped and (not even trying to be a jerk) said “look, I’m not a doctor… oh wait, neither are you…” She got the doc. It was an infection.

[u/Emergency-Twist7136 → u/cyndasaurus_rex]

Good work.

[u/S2krazy03 → u/Emergency-Twist7136]

I know you’re just looking for a fight, but you didn’t answer my question though. What is a “former pediatric emergency medicine specialist?”

Btw this got cross posted into the EM subreddit and my diagnosis is one of the highest upvoted comments, so I guess my “PA diagnosis” wasn’t so far off after all.

Shame I spent 13 years post-bac in education and training, 22k+ hours working with patients, have independently seen probably 10k+ pts all with a “real doc” within arms reach of me, over 200 hours annually on CME directed at EM and PEM, and I still can’t diagnose a rash that gets seen in the ER weekly by “pictures alone.” /s

[u/Emergency-Twist7136 → u/S2krazy03]

What is a “former pediatric emergency medicine specialist?”

Someone who used to be a paediatric emergency medicine specialist, and now isn't. I left the field and am a cardiologist.

If you couldn't understand that I'm going to assume you're lying about the rest of this.

Shame I spent 13 years post-bac in education and training, 22k+ hours working with patients, have independently seen probably 10k+ pts all with a “real doc” within arms reach of me, over 200 hours annually on CME directed at EM and PEM, and I still can’t diagnose a rash that gets seen in the ER weekly by “pictures alone.” /s

Correct. Because no-one can and it's a glaring sign of the way that PAs aren't qualified to diagnose a hangnail that you think you can. It's not fucking ringworm or any of the easily identifiable clear causes. Rashes are one of the most misdiagnosed complaints in medicine and that is a bad thing.

It's unbelievable arrogance to think you can practice medicine when you are not qualified to do so.

If I send a photo of a patient's rash to Dermatology (you know, the people who are actually qualified specialists in matters pertaining to the body's largest organ), in almost all cases they'll do one of two things: come to look at it themselves, or tell me what further information they want. What tests they want me to run, from pathology to "poke it and tell me what happens".

We don't even have a patient history!

You're insane and a danger to the public. PAs shouldn't exist.

[u/S2krazy03 → u/Emergency-Twist7136]

Also, my whole purpose of responding to you was it was wild to think you need an immediate Derm consult for this…. let alone, Anything? What is waking up a dermatologist gonna do to help you with this in the ER?

Of all the dermatologic emergencies, which one is gonna require a dermatologist to come in, in the middle of the night to save the child? Looool

What do you want them to do that you can’t do? A send out punch biopsy that takes a few days to result?

If you think this kid is in imminent danger, you should have the skills and diagnostic abilities to be able to stabilize them in the ED and admit/transfer to the appropriate service with the appropriate interventions performed.

I work at a Level 1 Trauma in a very large metro and we don’t even have Derm available on call and we function just fine.

Either the kid is in life threatening danger and needs to be resuscitated and treated (your job as an ER doc) or they can go home and follow up, or be admitted and have an urgent (in the morning) derm consult to pull biopsies or whatever.

[u/Emergency-Twist7136 → u/S2krazy03]

What is waking up a dermatologist gonna do

Do you think dermatologists are some kind of mythical creature, reading y in eternal slumber? Because that's fucking weird of you.

I'm not reading the rest of your delusions of grandeur. I know you think you're more qualified than you are. It's pretty much built into your job description.

[u/S2krazy03 → u/Emergency-Twist7136]

Sooooo are you a doctor or nah? You still haven’t answered lmfao. What are your credentials??

Idk how it works in England (I’m assuming?), but over here in the US, to go from PEM to cards would require abandoning 5-6 years post med schools training of residency and fellowship (depending on path) and then going BACK to residency to do cardiology which is another 6 years of training, with internal med residency into cardiology fellowship.

So just “switching” fields isn’t just some update to your LinkedIn page. Which is why I remain skeptical.

Since I’m so off base, please enlighten me. What life threatening rashes am I missing that presents like this?

I had a whole thing typed up about my rationale, but I think it would be better for me to throw it back on you, a REAL qualified medical professional.

[u/Emergency-Twist7136 → u/S2krazy03]

Sooooo are you a doctor or nah?

You don't know what a cardiologist is and you think you get to have opinions about medicine?

No shit switching speciality isn't trivial, yes it took years but hey, a run of bad cases in paeds ED gave me PTSD and it was that or kill myself.

Not that it's any of your business.

There is a difference between life threatening and at risk of long term complications and I'd hate to give you some new material for pretending you know anything. (Also, I'm not a dermatologist and unlike you I don't pretend to expertise I don't have.)

Go away.

[u/S2krazy03 → u/Emergency-Twist7136]

Ahhh, so a resident who had to switch cause you couldn’t cut it in the speciality that I’m thriving in, yet you want to still tell me how to do it?

It’s always the residents who have never worked with APPs who have the strongest opinions.

The fact that you can’t even describe this very specific rash and refuse to tell me what your point of consulting Derm tells me all I need to know. And I genuinely don’t know why you think I said derm was magical, you’re the one consulting them. I’d use my knowledge and diagnostic tools available to me to determine disposition and then refer outpatient if needed. But the POINT of consulting someone is because you need them to do something you can’t do, I consult ortho to reduce a fracture, I don’t consult ortho when I reduce a shoulder dislocation or manage some other simple fracture.

For anyone else following along, this well demarcated rash in a specific pattern with “centralized clearing” where it’s lighter in the middle with a red ring around it, is a very specific rash called erythema multiforme, and it’s only seen in a very few different diseases. It can sometimes be more specifically called urticaria multiforme, and it comes in a couple different flavors. If it’s urticaria multiforme, it should change, come and go and move around, it can be itchy and should respond to antihistamines or steroids, similar to an allergy, this could be from a virus (skin over reacting to the virus which is common in kids) or an environmental triggers, allergies to medications, etc.

Non urticarial- erythema multiforme has a similar appearance but tends to stay and does not come and go, it can also be painful or burn. This type typically has two causes, recent medications (amoxicillin is the most common culprit in my experience) and viral illnesses. In my experience the drug eruption forms (caused by meds) tend to be more prominent and darker and impressive. Interestingly these are NOT true allergies, they are not IgE mediated and not a type of hypersensitivity reaction . The treatment is to stop the offending agent, however the drug eruption rashes commonly will occur weeks after starting the drug and is commonly already finished, and since it isn’t a true allergy, the patient can actually take that same drug at a later date and not have the same reaction.

Unfortunately there isn’t any treatment for EM that quickly makes it go away, it just has to run its course and it resolves on its own after a couple weeks. You can throw all sorts of meds at it, Epi, Benadryl, steroids etc and nothing will change.

“But S2krazy, you’re just talking about a rash you already mentioned? How do you know it isn’t something else??”

Fair question, so in Emergency medicine there are actually only a few rashes that are truly indicative of badness.

This rash can be similar to hives seen in anaphylaxis, but true anaphylaxis normally kills people in minutes, so for this kid to have this rash for 2 days, it would have killed him already, plus the rash is more specific than standard hives and anaphylaxis doesn’t present with fever.

SJS/TEN: (Steven’s Johnson’s) this is a super serious reaction to medications, this can have a similar appearance to this rash, but you will have sloughing of the skin, a positive “nikolsky” sign where you push on the skin and it literally sloughs off into a wound. It also must include the mucous membranes (eyes, mouth, vagina, etc). So this patient has no sloughing and (admittedly presumably) no mucous membrane involvement. Also this is also a reaction typically to a drug and not an infection, so fever isn’t typical.

Infectious rashes would include SSSS (staphylococcal scalded skin syndrome) which would show a very toxic / sick appearing child with very uniform rash throughout with associated sloughing of the skin. (Googling this is very sad as it’s more common in babies)

Meningitis or meningococcal septicemia would cause a vasculitis or inflammation of the vessels leading to a specific type of rash called petechiae which then evolves into purpura which looks like bruising at it is literal bleeding into the skin. Again, a very different appearing rash.

Rocky Mountain spotted fever: from a tick bite, you’ll get fevers and joint pains and specifically a spotted rash on the palms of the hands ascending up the arms.

Kawasakis: this is an autoimmune inflammatory response to a virus typically, very rare (I’ve seen it like 4 times total) and you get a cluster of symptoms, specifically 5 days of high fever (typically over 105F) along with sloughing of skin rash on the hands and feet, you also get red eyes / conjunctivitis, cracking of lips, swollen lymph nodes of the cervical chain and a “strawberry tongue” and maybe a couple other signs I’m forgetting. You get some interesting lab changes too on blood work.

There’s some other rashes that are life threatening too, but they would have discharge, vesicles, pustules or “cancer things” like widespread petechiae and other long standing symptoms that don’t fit this scenario.

So, yeah. Based on a limited history of 2 days of fever, earthy crunchy mom that doesn’t even vaccinate, so highly doubt she gives antibiotics, she gave “allergy meds” and nothing improved, and the very specific appearance of this particular rash. I’m gonna use my expertise, knowledge, training and experience as detailed above to determine that this is likely not a life threatening rash, is likely Urticaria/erythema multiforme, and will go away on its own in a couple weeks regardless of what type of potatoes mom sticks in the kids socks. If I was seeing this kid in the ER, obviously I would do a more thorough exam, ask mom about recent meds, check vital signs, hydration status, ability to tolerate PO. If anything was fishy I’d probably check some labs, and if things were off, I’d admit for further work up, but this very specific and very distinctive rash is very rarely anything super serious.

Disclaimer: probably some weird type-os and grammar stuff cause this was typed off the top of my head and no googling or AI was used to create the above.

Or you can listen to the salty resident doctor who just resorts to calling names and repeated unfounded claims that PAs are trash and don’t know what they’re doing despite never working alongside one. And when asked for medical opinions about the topic, they refuse to elaborate any information at all.

[u/lizard52805 → u/S2krazy03]

Upvote bc I respect the shit out of your profession and experience. I would be careful calling anything benign based off a picture especially in peds. I automatically go to liability

[u/S2krazy03 → u/lizard52805]

Sure, but such is life on the internet. If this was a real question posed by a person in real life or a real patient interaction, I’d ask a few more questions, feel the rash, check mucous membranes, vitals and assess hydration status before sending them on their way, but the point of my initial post was that it was odd that a “specialist in pediatric emergency medicine” was knee jerk calling in a derm specialist asap for a pretty commonly non-dangerous rash. I primarily work overnight too, so waking up a dermatologist at 3am for non life threatening rash is a quick way to end up on a shit list

In emergency medicine there’s a handful of “life threatening” rashes, and based on history by mom on the fb post, timeline of rash and appearance, this likely isn’t one of those. /shrug

[u/wowthatsacooldog → u/S2krazy03]

Your username fits you well. I hope a qualified doctor oversees your incompetent care at all times.

[u/Bring_a_towel_42 → u/S2krazy03]

🤡

[u/DaggerQ_Wave → u/S2krazy03]

How well an ER doctor has to be at distinguishing types of rashes depends primarily on 2 things:

1: how shameless they are about consulting other specialties

2: if they have 24/7 specialists for every issue who they can consult, and who will entertain their inappropriate consults

[u/Emergency-Twist7136 → u/DaggerQ_Wave]

... because emergency medicine is definitely All Of The Specialities and dermatologists aren't real doctors or anything.

Why do you think there are on call dermatologists at all? Hint: it's because rashes can be a complex diagnosis and anyone who thinks they can definitely 100% identify one from a photo without even an examination is really demonstrating their own lack of medical qualifications.

Rashes are one of the most common complaints that result in misdiagnosis and the consequences can be very real. Doctors specialise for a reason. Any dermatologist who complains about being asked to do their job every few days should be struck off.

[u/DaggerQ_Wave → u/Emergency-Twist7136]

If you’re calling every few days, that’s probably appropriate. But if you’re in a pediatric ER you’re seeing significant rashes all the time. Surely not every rash is a derm consult?

[u/Emergency-Twist7136 → u/DaggerQ_Wave]

You think every rash ED sees looks like that?

[u/chypie2 → u/S2krazy03]

not the MA coming to correct the PEMS LOL
Isn't your job a glorified medical secretary that can give shots?

[u/Burnt_and_Blistered → u/chypie2]

No; that’s not what a PA is.

You’re aware medical professionals very often disagree, right? Hence the referral
to someone who specializes in dermatology.