This blog post is based on a talk I’m giving to a mixed group of adult and paediatric emergency physicians. I was asked to talk about something I thought both groups needed to know. I could have got stuck into the role of steroids in pre-school wheeze or antibiotics in otitis media but they can be rather dry topics to talk about over dinner. Instead I decided to focus on what children would want us to know…
They feel pain
Children feel pain from the moment they are born. And whilst a lot of doctors liken the management of pre-verbal infants to being a vet it is worth remembering that all children feel pain. There are lots of tools we can use to determine the level of pain, from the FLACC score to the traditional Wong-Baker faces scale and I am fascinated at how infrequently we actually rate a child’s pain. We ask adults with stubbed toes to rate their pain and may dish out an Endone when they score it as 8 out of 10. But, for some reason, we like to try to guess what a child is feeling ourselves, as if we have some mystical power to feel their pain. According to a study by Robb et al. published in CJEM last year examining use of analgesia in children with suspected appendicitis only 61% received any form of pain relief in the emergency department. Over a third of these had to wait until after their surgical consultation (43%) or after their abdominal ultrasound was performed (43.7%). Even then their morphine dose could be regarded as sub-optimal at 0.06mg/kg. Given that the age of inclusion was 3 to 17 years of age a dose of 0.1-0.2mg might be more appropriate. A 2011 Cochrane review concluded that analgesia does not hide important clinical findings in adults so why should it be any different in children? Poonai et al. found that 92.1% of physicians, including those with extensive paediatric training, state they would offer immediate analgesia in a case of suspected appendicitis but there is a huge disconnect between what they say they would do and what they do in practice
And we are even worse with our tiniest patients. We apply local anaesthetic creams and emollients to infants but when it comes to cannulating the (possibly) septic baby we offer lolly water. Read Justin Morgenstern’s rant on its use over at First 10 in EM. Perhaps the signal towards benefit is more about our general approach to the baby and the fact that we seem to be caring rather than anything else?
So, what should we change? We should try to assess the level of pain in all of our patients, verbal or otherwise, using a standardized approach. If we are going to use a faces-based scale then we could use stickers to denote the degree of pain the child is in – an unhappy face sticker placed at triage, followed by a smiling face when they are reassessed after analgesia. We should offer analgesia to all children in pain, at the point of first contact. If you are unaware of how well, or badly, your department is doing then consider a simple audit of practice.
They feel stressed
Looking back, it is easy to have a rose-tinted view of your childhood. The stress of a year 12 exam seems nothing compared to the stressors you are exposed to as an adult, but, at that time, it was THE MOST IMPORTANT THING EVER. I’ve seen adolescents with all manner of physical complaints that, on further questioning, were all physical manifestations of stress writ large. But if you don’t ask then you won’t find out. Think about using something like the HEADSSS tool to screen for those previously hidden psychosocial determinants of illness. An Australian primary care based study showed that although only 12% of patients (aged 15-24) presented with a psychological complaint, 50% displayed a degree of psychological distress and 22% had significant levels of suicidal ideation. These questions may be tough to ask, and to deal with, but that does not mean they should not be asked.
Just as we commonly ask our adult patients about smoking and alcohol use in our history taking, the HEADSSS assessment can lead to the opportunity to provide brief, targeted interventions and education in order to prevent downstream attendance. A barrier to its use, like a lot of screening tools, is lack of familiarity. Is there something we can do to make it easier? Whilst your patients might love to spend their time staring at their smart phone, the image of a physician scrolling through a checklist on theirs will do nothing to help maintain rapport, especially when it comes to the trickier subjects of sex and sexuality.
This is even more important if the child you are seeing has refugee status. As David Levitt pointed out in his talk from DFTB17 the incidence of mental health problems in refugees is appallingly high. According to the 2014 National Inquiry into children in immigrant detention 30% of children were described as always sad and 25% as always worried. Compared to a normal community prevalence of around 2%, 34% of children in detention scored highly in a mental health rating scale. These problems do not disappear once children have made it to the ‘Lucky’ country.
They love silly jokes
If you have seen the original iteration of our website then you will now that we love jokes, and the more groan-inducing the better. If you don’t have Henry Goldstein on speed-dial then there are plenty of on-line resources for clean jokes. Breaking the ice with a laugh and smile always helps, especially if you might be performing a potentially painful examination. Sian Spencer-Little has a great list of cheap distraction ideas for you all in this great post.
It helps if you can communicate with your patient at a level that they understand. You now have permission to go to your local comic shop and buy some key texts and write them off as legitimate research.
Observation is an investigation
One of the reasons I left the NHS was the introduction of the 4 hour targets. When the adults are queuing up out the door you might switch to rapid assessment mode, ordering blood tests and x-ray before even seeing the patient. You can’t do that in children. You have to take your time, put on some local anaesthetic cream and use your best distraction techniques before you even get close with a needle. All of this takes time. And then you might not even need the cannula that you have sweated over. A recent paper by Hollaway, Broeze and Borland suggested that 22% of peripheral IVCs, placed in children, are unused
In most departments the majority of our young clientele get discharged without invasive tests because we understand that…
As Keijzers et al. put it in a recent issue of the EMA, this deliberate clinical inertia can be a hard force to fight. We want to do something, anything, but this needs to be coupled with the real potential to cause harm.
If you see an adult with undifferentiated abdominal pain the surgeons often ask for a CT abdo and pelvis. You just can’t do this with children. We use the ALARA principle when it comes to radiation exposure in children. Take a look at these potential cancer risks for a CT abdomen in a 6 and a 12-year-old child (as calculated on XrayRisk.com.
In the world of paediatrics we like to look at our patients before we arrange imaging. Do you really need to have an ultrasound to confirm testicular torsion or is clinical examination just as good? Do you need an x-ray to see what is going on in the chest? The answer is, invariably, “No”.
One of the nicest things about looking after children is that, in the main, they get better very quickly, Many a parent has sat in the waiting room in the middle of the night to get their croup child seen only for them to be magically better once they cross the threshold into the examination cubicle. Masterly inactivity, coupled with observation is often all most children need.
You don’t have to be a paediatrician to look after them
I sometimes joke that I get more peace at work than I do at home. I might be surrounded by screaming, vomiting kids but at least I can sedate them and, at the end of a shift, I get to go home. I am no different from many of those that deal with children. Other than a stint as a paediatric emergency registrar I am not specifically paediatric trained. I just happen to have taken an interest in paediatrics and bring the practical skills of an adult emergency physician to the floor.
A study in Victoria showed that only 7 per 10,000 presentations in children required any form of critical procedure. 83% of the doctors working in the department did not perform any in the time frame looked at. Even in Victoria’s largest paediatric centre, the Royal Childrens Hospital, intubations outside of theatre are infrequent and not without complications. That cannot be said of my adult practice. Familiarity with apneoic oxygenation, positioning and equipment, coupled with the use of checklists and crew resource management techniques might mean that we adult emergency physicians are better/safer at intubating children. (Ed. note: I’m happy to be listed as an author should anybody want to perform the study.)
For those doctors that infrequently see children there are a huge number of evidence-based online resources that can help guide management. Whilst some clinicians might be reluctant to use such guidelines they have been shown to reduce clinical error. Take a look at the Victorian state-wide guidelines here.
Children are not so scary after all.
Conflict of interest: The author sits on the evidence-based subcommittee of the Victorian Paediatric Clinical Network
*A gummy bear
Children feel pain
Bellieni CV, Buonocore G. What we do in neonatal analgesia overshadows how we do it. Acta Paediatrica. 2017 Oct 23.
Manterola C, Vial M, Moraga J, Astudillo P. Analgesia in patients with acute abdominal pain. The Cochrane Library. 2011 Jan 19.
Poonai N, Cowie A, Davidson C, Benidir A, Thompson GC, Boisclair P, Harman S, Miller M, Butter A, Lim R, Ali S. Reported provision of analgesia to patients with acute abdominal pain in Canadian paediatric emergency departments. Canadian Journal of Emergency Medicine. 2016 Sep;18(5):323-30.
Robb AL, Ali S, Poonai N, Thompson GC. Pain management of acute appendicitis in Canadian pediatric emergency departments. Canadian Journal of Emergency Medicine. 2017 Nov;19(6):417-23.Manterola C, Vial M, Moraga J, Astudillo P. Analgesia in patients with acute abdominal pain. The Cochrane Library. 2011 Jan 19.
Children feel stressed
McKelvey RS, Pfaff JJ, Acres JG. The relationship between chief complaints, psychological distress, and suicidal ideation in 15-24-year-old patients presenting to general practitioners. The Medical Journal of Australia. 2001 Nov;175(10):550-2.
Paxton G, Tosif S, Graham H, Smith A, Reveley C, Standish J, McCloskey K, Ferguson G, Isaacs D, Gunasekera H, Marais B. Perspective:‘The forgotten children: national inquiry into children in immigration detention (2014)’. Journal of paediatrics and child health. 2015 Apr 1;51(4):365-8.
Van Amstel LL, Lafleur DL, Blake K. Raising our HEADSS: adolescent psychosocial documentation in the emergency department. Academic emergency medicine. 2004 Jun 1;11(6):648-55.
Zwi K, Mares S, Nathanson D, Tay AK, Silove D. The impact of detention on the social–emotional wellbeing of children seeking asylum: a comparison with community-based children. European child & adolescent psychiatry. 2017 Nov 24:1-2.
Children love silly jokes
Observation is an investigation
Cohen MD. Point: should the ALARA concept and Image Gently campaign be terminated?. Journal of the American College of Radiology. 2016 Oct 1;13(10):1195-8.
Gledstone‐Brown L, McHugh D. Idle ‘just‐in‐case’peripheral intravenous cannulas in the emergency department: Is something wrong?. Emergency Medicine Australasia. 2017 Dec 6.
Hollaway W, Broeze C, Borland ML. Prospective observational study of predicted usage of intravenous cannulas inserted in a tertiary paediatric emergency department. Emergency Medicine Australasia. 2017 Dec 1;29(6):672-7.
Keijzers G, Cullen L, Egerton‐Warburton D, Fatovich DM. Don’t just do something, stand there! The value and art of deliberate clinical inertia. Emergency Medicine Australasia. 2018 Jan 12.
Sodhi KS, Krishna S, Saxena AK, Sinha A, Khandelwal N, Lee EY. Clinical application of ‘Justification’and ‘Optimization’principle of ALARA in pediatric CT imaging:“How many children can be protected from unnecessary radiation?”. European journal of radiology. 2015 Sep 1;84(9):1752-7.
You don’t have to be a paediatrician to look after a child
Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Pediatric Anesthesia. 2014 Dec 1;24(12):1204-11.
Nguyen LD, Craig S. Paediatric critical procedures in the emergency department: Incidence, trends and the physician experience. Emergency Medicine Australasia. 2016 Feb 1;28(1):78-83.