“Not just veterinary medicine”
Ah yes, this is of the more common epithets ascribed to my profession.
When spoken disparagingly or jokingly I don’t mind. But I have often heard this phrase used in a peculiar context, as an excuse for not getting a good exam on a patient. As in: “was the abdomen soft?” resident shrugs and says aforementioned quote. I am no expert on the clinical skills of those who care for animals, but I can say that just because a patient cannot speak to you it does not turn the entire physical exam into a guessing game.
True, many of the subtleties of the pediatric physical exam come with experience.
Without even laying hands, most experienced PEM physicians can tell you when they suspect a child may have a c-spine fracture or peritonitis with a decent sensitivity (*hint 2 year olds with c-spine injuries don’t thrash around and try to rip their collars off).
So if the pediatrician is not worried about it (and we worry about everything) then chances are you don’t need to irradiate the child. But even without years of experience once you recognize the idiosyncracies of various pediatric presentations, you will be on top of your game.
When you see a pediatric patient first it is important to stop and shift gears. If you view them through the “grown-up goggles” they may all just look like runny noses. But remember the trick is not recognizing really sick or really not sick, the trick is to pick up those needles in the proverbial haystack that are on the slippery slope towards being sick but don’t look it yet. Or to realize that sometimes, even though a patient is not on death’s door it is a serious ailment may lead to complications, and in pediatrics our threshold of monitoring and trying to prevent complications is, well, different.
Everything is relative.
Yes, children also get liver failure, cancer and other serious illnesses, but they also get simple pneumonias. And sometimes a simple pneumonia will progress to a really bad pneumonia and a para-pneumonic effusion and a lifetime of chronic lung disease if it is not properly managed or picked up early. Think about each child as if it is your own, and you’ll have the right perspective.
Here are some common perspective pitfalls I’ve seen:
“4-year-old male, mild intermittent asthma, got 1 neb –is running around the room—looks great.”
From around age 4 to 8 there is some sort of idiot gene that makes children run around the room despite their growing respiratory distress. Don’t forget to focus on the facts, respiratory rate, retractions, oxygenation and breath sounds.
“3-yo female with vomiting. Was crying for my abdominal exam so I can’t really localize. I want a CT to r/o appendicitis.”
One 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 tears. Usually after a little time, the tears dry up the juice box comes out and the child appears miraculously better. If the child persists in being miserable, then let the detective work begin. When watching a child it is important to watch them! Don’t leave them in a room with a closed door, because every time you open it they will cry.
“6-yo male, tells me it hurts diffusely wherever I press”
Most toddlers and young children will tell you that something hurts if you ask them. In medical school we are taught the gospel that if a patient reports pain we must document it as medical fact. For me, it doesn’t count as tenderness unless the child is distracted with sponge-bob questions and jumps off the table with a slow pressure on the spot of interest. If the child is verbal and you want to test their reliability go ahead and ask them a rapid fire of “does this hurt” questions and include queries about their nose, eyeballs and tail.
Ok, I promise next time, tips for IV access in children.
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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.
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