Pediatric Proficiency

I have always liked children, but even more so since I have had the opportunity of raising a little one of my very own. Victoria has put me in touch with the changes that take place as she has grown and has developed into this neat little miracle of a person. Through her I understand much more than I could ever have appreciated by studying developmental psychology and pediatric medicine texts. My experience with my daughter also has helped me to identify with and appreciate the attitudes and behaviors of parents in the ED. I also know the feeling of frustration a parent can have when your baby is sick or hurt.

Many EMPs are uncomfortable dealing with sick children. Perhaps this is because of their limited exposure to this special population or perhaps it is a lack of experience with children of their own. Perhaps it’s a little of both. Simply taking PALS will not close this gap. While there are some important differences to remember regarding our pediatric patients, the basics of caring for them are really very similar those of our adult patients.

1) Establish a rapport with your patient. Enter the room calmly, so as not to startle the child. Interact with the parents. If the child sees that mommy and daddy are comfortable with you, then most likely they will be too. Smile at the child and approach at their level. Talk to them, even if the parents are the ones that answer.

2) Unless the child is really ill, relax the pace of your exam. Tell the child what you are doing as they often understand more than they can verbalize. I’ll often reverse my exam and go from toe to head. Smaller children are sensitive about stuff up in their face, so by the time you get there they have figured out that you're not going to hurt them. Little children can be distracted with a tongue blade, a penlight, or a glove balloon. Older children cooperate better (usually). If a verbal child has a pain compliant, ask them to show you where before your palpate there and make it the last thing you do. Blow gently in their ear before inserting the otoscope (it tickles) and don’t dig the speculum in there. When you’re palpating the belly, give a little tickle. If they giggle it’s a good sign. If the tickle hurts, it’s more likely something serious. Getting good breaths during chest assessment can be a challenge in a pre-verbal child. Try putting a little pressure over the upper belly for a couple of seconds while you place the chest piece. It doesn’t hurt and they’ll reflexively take a deeper breath.

3) Watch the child during the evaluation. Give them a toy or a book or some other fun stuff. If they’re pink, act normal and attentive, drink the pedialyte (not that unflavored stuff), juice or the popsicle, then they’ll likely be fine. If they look puny or uncomfortable, won’t drink much, then they’ll need a more extensive exam. If a child is listless, lethargic, pale, mottled, refuse po and even worse, virtually ignore the blood draw or cath UA, then you have a seriously ill child.

4) To a degree, you can blow off a little tachycardia with a fever or some other pain/discomfort as long as the patient is active, pink and drinking. These should resolve with the appropriate medications and modest oral rehydration. If not, watch closely for other signs of trouble; persistent tachycardia, tachypnea, delayed capillary refill are all significant signs. Children compensate for illness very well, right up to the (very) bitter end. It's important to intervene early in these cases.

5) Children get a lot of rashes when sick. Most will be a light viral rash. Amoxicillin may case a rash, but if there is no urticaria, it’s likely not allergic. Don’t over look the important rashes; the streptococcal “sandpaper” rash, the desquamating rashes of staphylococcal infection and Kawasaki disease, and the “tick” rashes. Be especially vigilant for the petechial rash of meningio-coccemia.

6) Unless you suspect a surgical issue, let the child drink. If they can’t and there are clinical signs of dehydration, use an IV and hydrate them well. If time permits, use EMLA at procedure sites (IV, LP, etc) and lots of “vocal anesthesia”. If they’re really sick and you can’t get an IV, use the IO before it’s too late to help. “Hydrate to urinate” or “drink until pink.” Don’t neglect the glucose. Kids need sugar and sick ones go through a lot of it. Most kids don’t store glycogen well and have less body fat to weight ratio (or at least they used to).

7) Know the color-coded (Broselow-type) tapes and get in the habit of using them. As a rule of thumb, if you can’t weight the patient and they look a little bigger than average, go up to the next tab. If they’re really bigger than normal, consider going up a couple.

8) For trauma, know that kids have big heads and weak necks, that they can get severe chest injuries without rib fractures and that their liver and spleen are very vulnerable to injury. Know the numbers for fluid resuscitation (20cc/kg) and blood (10cc/kg), and for the nearest trauma center. The drugs you can dose from the tape as appropriate. Know the differences between the adult and pediatric airway, and remember that it takes less absolute blood loss to produce profound hemorrhagic shock.

9) If everything looks fine, but something doesn’t sit well in your gut, call the pediatrician. Even if the child doesn’t get admitted, make sure that they will be seen within a day. If the pediatrician can’t make it happen, have the parents return them to the ED for recheck. If you think the child should be admitted, and the pediatrician won’t get on board, consider keeping them in the ER until you can discharge them directly to the pediatrician’s office.

10) Never forget the other patient(s) in the room. Like the child, the parent(s) have a lot of fear and uncertainty when their child is sick or injured. Talk to them. Tell them what you are doing and why. Explain study results with them and the necessity for each intervention. They need to be kept informed and involved in the care of their child at all times. Let them know that this is what you would expect for your own child. In exchange, they will give you the confidence and trust you need to care for their child.