Mini-me

mini-me

“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.

Keep sending me feedback on what you want to read about!
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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.

7 Responses

  1. 1. An older infant with nuchal rigidity will tend to sit with a straight spine as they don’t want to flex the neck.
    2. I was taught to simply watch children and infants interact with the parent to learn a lot regarding severity of illness, respiratory distress, and determining what hurts.
    3. Always have a child undressed to do a full exam and have the gown off to watch for respiratory distress.

  2. I am a veterinarian and let me tell you something – we are well aware of the value of a physical exam. We do in fact perform physical examinations of our patients. I am not sure I understand the quote “not just veterinary medicine.” My childrens’ pediatricians and I have often joked about how similar our professions are, and how difficult it can be to attempt to determine a diagnosis when the patient cannot verbalize the problem, and often is actively aggressive toward you, and isn’t potty trained. These roadblocks prevent neither my colleagues nor yours from doing careful and complete physical examinations. What exactly is the point of the quote that leads off this article?? I can tell whether or not my patient’s abdomen is soft and nonpainful, or if there is mild or significant guarding of the abdomen present. I can tell if there is an abdominal mass. I can tell if there is a distended bladder. I can tell if the kidneys or small or OMGWTF humongous. Veterinarians do perform physical exams. Hmph.

    • Not sure if you completed the article, but I am in fact agreeing with you completely. Thanks for the comment!

  3. I read the article a few times to make sure that I understood your point. I get that you (the blog author) aren’t the one making the remark about veterinary medicine… I just guess i do not understand what the remark is supposed to mean in the given context. “Was the abdomen soft?” leading in to the response “hey, this isn’t just veterinary medicine…” ?? What does that mean?

    • I can’t really speak for those who use this quote, but my impression is that they are insinuating that examining animals and children are similar and that getting a reliable exam in both is impossible. Something which I obviously disagree with, and you and I agree about. Examining animals or children is an art–and just because a patient cannot speak to you, it does not take away our ability to examine that patient and develop an impression.

      Would love to hear more of your tricks for examining animals, I’m sure we could all learn a few things from each other.

  4. Oh. Well, that makes some sense I guess. OK well obviously certain things are what they are – heart rate, respiratory rate, heart rhythm, pulse quality – obviously if the patient is seriously anxious, painful, distressed, terrified, or similar then the vitals are affected, but still generally measurable. Other things can be really hard to assess depending on the patient. “Does it hurt when I do this” type exams – these can be tough. say I’m looking for a reason for a hind limb lameness. I can examine one dog and get screaming every time I touch the dog anywhere on the body, and maybe the injury is a 1 cm diameter mild cellulitis on the knee totally covered by hair that takes forever to find, and I can examine another dog who stands there stoically and makes no cry or attempt to get away or look at me funny or anything and he turns out to have a ruptured cranial cruciate ligament, which I figured out only due to a mildly palpable effusion, because the dog is so tense that I can’t overcome his muscle resistance to appreciate any cranial drawer when I try to move the tibia relative to the femur. Very aggressive animals require sedation to examine safely for me and for them, in my opinion. Those situations are probably less likely in peds 🙂 but maybe I just don’t know enough about your job. One thing I have noticed is that some highly anxious animals do better when their owner is present and speaking to them in a comforting and calm tone of voice, while other highly anxious animals do better when separated from their owners. Often the ones who do better away from the owners have highly anxious owners, or owners who (hopefully inadvertently) are reinforcing the anxious behavior by rewarding it with a lot of “good dog, that’s ok, the mean doctor won’t hurt you, here have a treat sweetie” (all of that going on while the dog is cowering in the corner and lifting its lips and snarling out of a sense of desperation/anxiety). But I don’t imagine kids ever do better separated from their parents. Unless – oh. Well, I can’t let myself think about THAT. I have small kids myself. Examining an animal basically comes down to following a routine – I almost always start at the nose and work my way back to the tail. I narrate my exam as I’m doing it – even assuming the pet doesn’t understand me at least the owner does and it calms them down and creates what I think is a reassuring vibe. I move calmly and deliberately. If I am going to have to do anything painful or unpleasant (blood draw, rectal exam) I have my nurse provide gentle restraint (“hug” the dog, chest to chest, so dog is unable to turn and bite and feels calmed). I also give tummy rubs when appropriate 😉 and I find that that is helpful with palpating the abdomen of a tense pet. A lot of times I start with tummy rubs and then when they start wanting to roll over I can put one hand on the other side and squeeze and they don’t realize I’m not just doing a very aggressive tummy rub 🙂

    • Wonderful description, and much can indeed be applied to pediatrics (especially the parent in the room). But I am grateful my patients don’t bite (often).

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