Welcome to the my inaugural posting of pediatric EM potpouri.  This blog will eventually take better shape (hopefully with your feedback), but for now it is just an amorphous blob of my thoughts from the smaller gentler side of the ER.

Ok, I admit that chest pain in a 40-year-old makes me want to  vomit, but vomit in a 4-year-old can also give a lot of EM docs chest pain.

Today I’m gonna give some tips on examining kids.  I hate to overcook a cliché, but pediatrics is not medicine for “little adults”.  And beyond knowledge of their unique physiology, anyone who treats children needs to have a bag of tricks to help with their evaluation.  Some folks are born with the magic touch,  but even if butterfly stickers and funny voices aren’t your thing, using these tricks can help you get a better physical exam. (By the way, I think pediatrics may be the last bastion of good physical exam skills–since we think long and hard  before ordering tests that may cause unnecessary irradiation or needle  sticks).

Top 5 approaches to examine the frightened child

1.  Start far away

Children are in touch with their primitive instincts.  When you enter to find a frightened face, just pretend you happened upon a wild tiger and avoid any threatening moves.  No eye contact, no babbling baby noises, take a few steps back, and maybe even turn your back to them.  After they get acclimated they will be pissed that you are ignoring them, and fear will be replaced by curiosity about you.  That’s when you make your move!

2.  Share and play nice

If you are not sure what is scaring the child, take time to find out.   White coats are already passé in peds, but stethoscopes and otoscopes are still around to scare the crap out of kids.  Change the familiar script by doing something novel with your stethoscope.  Take it off your neck, place it on your leg, or the table, or parents leg.  Hand it to the child. Once they see it as a toy,  see if they’ll let you (or mom) hold it to their chest.  Putting it in your  ears is the last move you make, and hopefully by then they no longer feel  threatened.

3.  Back down

When the tears start welling up, some people assume the war is lost  and just go for broke: pinning the child down, and forcing an exam.  Sure,  that is sometimes necessary, but it is usually an inadequate exam and things get missed or unnecessary workup results.  When you see a child startle, my advice is to act more startled, back away, put down your stethoscope and cower in the far corner.  The child will often become curious about this weak creature that it scared away and you then get a second pass to come in for a smoother landing.  If you smell fear the moment you open the door, then just turn  around a close it (confuses the crap out of ’em).  You can then reenter while they are in a “cry refractory” daze of confusion.

4.  Head to toe? no no no

Ok, most people know this one cold.  But at the risk of stating the  obvious, save the invasive stuff for last (things in ears, things in throats,  pushing on bellies, opening diapers.  My exam changes every time depending on  what the child lets me do first.  Try and get your auscultating in early  while the child is cooperative and quiet.

5.  Crinkle paper

I don’t know why, but kids love the sound of crinkled paper, and no  paper crinkles better than the bargain sheets that cover our exam tables.   Grab a piece, smush it up, throw it around.  Distraction is your best friend  when it comes to kids.

Ok that’s it for now.   In my next post, I’ll go over some tricks for pediatric access IV access/phlebotomy.

Thanks for reading, and please send me your questions, critiques, ideas, and suggestions for what else you’d like to see here.


Mini-mə is an educational resource that highlights the essentials in pediatric emergency medicine care. Each entry will focus on ways you can improve your practice in pediatric emergency medicine.

2 Responses

  1. excellent!

  2. […] of the luxuries of an ER is that you can always play the “wait and watch” card.  My last posting had some tips for the getting a good exam from a child.  But sometimes you can’t stop the […]

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