Sick-kid Season

I love kids. Always have and always will. And when it comes to sick kids, I feel fortunate to have been trained in a demanding EM residency program where the pediatric emergency department was directly attached to the main trauma center. As a result of such exposure, treating ill kids became as natural to me as treating ill adults. Those little buggers, with their fevers, snotty noses, abdominal pain, and piercing shrills, don't scare me. Some get an "A" for effort, though, pulling out all of the stops in their vain attempt to get me out of their room. Regardless, because of my comfort, I try to see the really sick kids that come through our doors during my shift.

Over the holidays, with the flu season in full swing, I treated many children who were swept up in the epidemic. Some parents simply needed reassurances that they were giving their little Johnnie and Susie all the proper care, while other parents, with their heavy concerns, were right to bring their children in for a workup, including some IV hydration and anti-emetic medication. All-in-all, there was a much heavier flow of pediatrics than what we typically see.

Walking into Room 22, then, thanks to an alert by the nurse, I knew I was about to face another sick child. "This one is 'punky', Doc," she had said, "he hardly flinched when I started his IV." Never a good sign.

I quietly pulled back the curtain to the room and entered, finding a fatigued two-year-old boy sprawled on his back on the medical cot with his cotton sheet kicked into a ball at his feet. His oversized hospital gown had one loose tie in front, opened to reveal his skinny frame. His blond bangs were sweaty, matted to his forehead, and his skin was pale. Before introducing myself to his parents, I walked up to him and felt his forehead with the back of my hand. He was "burning up," as we say and, more importantly, didn't even shrug to a stranger's touch.

I shifted my focus to his parents, walking up to the young mother sitting in a chair alongside her son's cot. She looked as wiped-out as her son, the livelihood of her existence threatened by her son's illness. She was tearful, a mother's angst clearly etched into her face. I took her right hand in the both of mine, squeezing it reassuringly. "We'll get him feeling, better," I said, nodding to her sleeping son as I spoke. She dabbed her eyes with a Kleenex and gave me a feeble smile.

Next, I walked up to the father, his disheveled baseball cap barely clinging to his head as he paced three steps back and forth in a tight corner of the room. We shook hands and I held his gaze for a few extra seconds, trying to silently reassure his concerns. He, like the mother, was young, worried, and quite upset over his son's circumstances. He looked me in the eyes and took a deep breath. "Can you really make him better, Doctor?" he asked, a glimmer of hope escaping his watchful eyes.

"Let me talk to you both, do a thorough exam of your son, and order some tests and treatment for him, okay? But yes, I do think we'll get your son to feel better by the time we are done treating him." Their son looked like several other patients we had recently treated for influenza.

Between the two of them, I learned that they were first-time parents and married. Although neither of them were ill, their son went to daycare two days a week, where they thought "a bug" was going around. He had been born full-term and was up-to-date on his immunizations. This was his first major illness, barring a few past ear infections. Over the past few days, they watched their son eat and drink less, urinate less, become less active, and start a fever that they couldn't control. Eventually, all of their son's symptoms worsened and became boggled in their minds, totally confusing them (like any first-time parents) as to what symptoms were most serious and needed addressed immediately.

That's where we came in.

After a thorough exam on this patient, I had no suspicions for focal illnesses (such as pneumonia, bronchitis, or strep throat) on this patient. His temperature was quite high (103.7) and he appeared clinically dehydrated, so we treated him with a Tylenol suppository, aggressive IV hydration, and some IV Zofran, a God-sent anti-emetic that helps control nausea and vomiting. Then we sat back and waited--one, to see how the child would respond to our interventions and two, to review the results of our blood and urine tests as they returned.

Within the hour, I was walking into my work station with another patient chart only to find Dad standing at the counter, waiting to talk to me. He was smiling.

"He's doing better already?" I asked. "Come take a look," Dad said, practically grabbing my hand and pulling me towards his son's room.

We got back to his son's room and, before opening the curtain, the father stepped aside, sweeping his arms as if welcoming me to step into his home.

Pushing aside the curtain, I was extremely happy to find their son sitting upright in bed, licking an Italian ice while watching a cartoon on the TV. He looked at me with apprehension, turned to his mother who gave him a reassuring wink, before turning his attention back toward the TV, continuing to lick his popsicle. He was a new kid.

The mother jumped from her chair, then, and rushed me, giving me a big, grateful hug. "I can't believe how good he looks," she said, muffling her words into my shoulder. "Yes," I said, happily agreeing with her, "he looks great!" She left my side and went back to her cot-side chair, sitting clumsily down before wrapping her hands back around her son's torso. Her face held the most genuine expression of thankfulness and love that could ever be.

Within the next hour, as the patient's labs returned with adequate results, the nurse and I took turns going into the room to educate the parents and answer their questions.

How frequently are they supposed to use Tylenol and ibuprofen?
What doses of Tylenol and ibuprofen are they supposed to use?
How should they use the Zofran prescription we'd be sending them home with?
What type of fluids should they give their son?
What foods would be okay to reintroduce back into his diet?
How much sleep should they let their son get?

It's easy to see how confusing it can get the first time your child has a serious illness. Their questions for us were endless and repeated several times, but we, in the medical field, all know that education and knowledge is most empowering to recover from an illness. Our patience in the parent's education is paramount. Besides making sure each of their questions were answered, we also wrote down their instructions for them to take home.

By the time we were ready to discharge this patient, he was a new kid, running around his room, drinking watered-down juice, coloring the staff pictures, and covering himself in the stickers we gave him.

To us, another successful but predicted response to our interventions with a child with the flu. To the parents, though, this was nothing short of a miracle. The clouds had parted, the rays of sunshine had dispersed before refocusing on the head of their sick child, and the gods had sung. Anyone who has had a sick child recover knows these feelings of exhilaration that follow the many pangs of doubts that haunt us during our child's illness.

I've been there...have you?

The nurse and I stood together at the counter and watched this young family walk out of our ER after being discharged. Three big smiles, plus two more if you count ours.

It was another good day in the ER...

As always, big thanks for reading. I appreciate the nominations and support for the 2010 Medgadget awards for best medical weblogs...thank you, thank you. I hope this finds you well...

Abdominal Pain in Children

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Belly pain is a very common Paediatric ED presentation, so how do we sort the plain old tummy-ache from the more serious causes?  Common conditions like gastroenteritis and constipation can mimic more significant diagnoses such as appendicitis and intussusception.

In this PEMcast we take a quick tour through the causes of abdominal pain in children.
To listen, click below or subscribe via iTunes or RSS…

Outline: Abdominal Pain in Children

[CP] hello, disclaimer, introduction/background

Approach & Differentials

(with reference to McCollough & Sharieff 2006, and our own experience):

[KB] Approach to assessment

[SF] Extra-abdominal causes of belly pain:

  • Infections:
    • pharyngitis / URTI = mesenteric adenitis
    • pneumonia
    • sepsis
  • Toxins:
    • spider bite (probably not Red Back Spider)
    • ingestions eg iron
  • Metabolic:
    • HUS
    • DKA
  • Other:
    • HSP
    • abdominal migraine
    • abdominal epilepsy ??
    • functional
    • torsion testis / ovary

Tsalkidis A, Gardikis S, Cassimos D, Kambouri K, Tsalkidou E, Deftereos S, Chatzimichael A. Acute abdomen in children due to extra-abdominal causes. Pediatr Int. 2008 Jun;50(3):315-8. PubMed PMID: 18533944.

Causes of Abdominal Pain in Children

[CP] Main concern for parents and doctors is appendicitis (difficult diagnosis, medicolegal concerns, signifcant morbidity, high rate of perforation in younger children)

Other causes: (brief sketch of each):

[KB] Gastro

[SF] Constipation

[CP] Mesenteric adenitis

[KB] Functional & recurrent Abdo pain

[SF] Abdominal Migraine

[CP] Intussusception

[KB] Bowel Obstruction & incarcerated hernia

[SF] Meckel’s diverticulitis

[CP] Infants: “Colic”

(Pyloric spenosis, malrotation with midgut volvulus, NEC) – pain is not the predominant symptom

[ALL] Comments on abdo pain differentials, colic, infants & neonates

[CP] Summary, goodbye

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