“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!

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.



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.