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That’s a perfectly legitimate reason to bring a child to the ER

January 25, 2008 at 9:11 pm (Clinical rotations)

As I continue through the pediatrics rotation, I’ve been thrust into the emergency department so that I can enjoy the faster paced side of this field. One of the problems with my school is that medical students are only assigned low acuity cases. I can see paramedics roll a 10-year-old down the hall who is seizing and get to watch in awe as the residents proceed to take over and run the case. While I’m enjoying the show, an attending will invariably tell me, “Okay, it’s time for you to go check on that kid with a running nose.”

While I love emergency medicine and think that I might want to pursue it as a career, pediatric EM certainly makes me want to go running and screaming in the other direction. I had a mother come in this week with all three of her children registered as patients. Patient #1’s complaint: cough. Patient #2’s complaint: sneeze. Patient #3’s complaint: watery eyes. I asked the mother why all three of the children had to be brought to the emergency department. She replied, “They had today off of school, so I figured I would bring them all in to get checked out.”

There are two routes to becoming board-certified in pediatric emergency medicine. The first method is to go through residency in emergency medicine, and then pursue subspecialty training and pediatric EM. The second method is to do pediatrics first, and then pursue an emergency medicine fellowship. I can always tell who took the EM route based solely on their sense of humor. If one of our cold and flu patients is seeking a prescription or a workup, the reply of the attending physician quickly tells me what kind of training he went through. If he replies, “Let’s do a full sepsis workup including blood cultures, urine cultures, blood count, and then watch the child to see if we need to do a lumbar puncture or a chest x-ray,” then I know he took the pediatrics route because of his willingness to over order to test while wringing his hands over a possible diagnosis. If on the other hand, the attending wants out of the patient’s room and calls out, “I don’t want to see anyone writing a prescription for this person,” then I know that he doesn’t play around with unnecessary tests and procedures—he went the emergency medicine route.

Since we serve as an urban trauma center, we get to see the worst case scenarios. Because of that claim to fame, I’ve also seen quite a few child abuse cases. A 3-month-old came in suffering a seizure. We ran her through the CT scanner and found that she was bleeding into her brain. We then did an eye exam and saw that she had multiple spots of bleeding in her retina. Apparently, the father had thought that she was crying too much and decided that the best way to calm her down was my shaking her vigorously. He was arrested, and the mother—and who was completely oblivious to the father’s treatment—took over as the sole custodian.

Our peds department comes up with many ideas to improve patient satisfaction, particularly while the family waits. In the emergency department all of our patient rooms are private with a television set in each room. When I walk in the TV’s volume is usually on the highest setting. Whenever I try to ask questions everyone in the family merely gives a “uh-huh” without looking away from Dora the Explorer. I once watched a physician get so frustrated with the nine-year-old’s ability to pay attention that he said, “I’ve seen this episode; Diego makes it,” and then turned off the TV.

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Oh pediatrics

January 14, 2008 at 7:34 pm (Clinical rotations)

Over the past few weeks have been on the pediatrics rotation. I’ve written before that don’t really care for peds as a medical specialty. You see, I dislike working with children. Nothing compares to walking into a child’s room and saying, “Hi, good morning,” and then the kid immediately begins screaming and crying.

There is a stereotype that the field is dominated by women who want nothing more than to play the role of an overeducated babysitter. And while there is some great research that goes into the field, many of the practitioners do fill a bit of those stereotypes. I’ve met quite a few female residents who say they want nothing more than to get married, raise their children as a stay-at-home mom, and then work part time as a pediatrician.

A few days ago, my team needed to meet with our intern before we could check out for the afternoon. We called her to find out where she was, and she replied, “We’re playing with the babies at the nurses station.” I thought she was just kidding. But when we found her, sure enough, every resident and gone into a patient’s room, grabbed a baby, and was found at the nurses station rocking them and playing with them. Now I’m not scared of babies, but I was a little put off when one of my teammates came to me and handed me a six-month-old to hold.

She said, “Talk to him. He needs stimulation.”

“What should I say?”

She replied, “It doesn’t matter. He’s deaf.”

“Then why should I say anything at all? Especially if he can’t hear me?”

“But you never know, he could regain his hearing.”

And now you know what I’ve been working with. My whole team is filled with women who want to go into the specialty. I’m the only one who wants to practice on adults. While most of the kids are fairly benign, I ran across one child earlier this week whose parents had used screaming, profanity, and threats of violence as a way to discipline their child. My assigned three-year-old picked up many of their bad habits. I sat outside his room copying down vital signs when I heard, “Shit shit shit shit.”

I thought to myself, there’s no way he was just saying that.

Then I heard it again: “Shit shit shit shit.”

I walked into his room and introduced myself by saying, “Hi there, Arnold. My name is Half M.D. I’m going to be taking care of you while you’re here in the hospital.”

He replied, “Shut your mouth. I’m going to beat your ass you son of a bitch.”

To the outside observer a cursing three-year-old might seem pretty funny. However, I had to be the one to deal with this mess. I asked the mother where he had learned such words. She said, “Not from me. Sit down, child! I’m going to slap you!”

The kid then raised a royal tantrum and started throwing things. I managed to calm him down for a bit so I could go through the physical exam. I gave him my reflex hammer and told him he was supposed to hit a spot on the bed when I told him to, and then stand absolutely straight after hitting that spot. I found that for many children, letting them play with my reflex hammer and turning it into a game is the best way to calm them down. I’ve also discovered that for children who have a phobia of stethoscopes, if I let them listen to my heart first, they’ll usually let me listen to theirs next.

When the exam was over, I needed to take back my reflex hammer. As expected, he started screaming. I then said, “Goodbye, Arnold. I’ll see you a little bit later.” He responded by spitting at me and saying, “I’m going to beat your ass.” I think that the child is going to be in prison by age 12.

I was growing pretty worried during rounds because I was scheduled to present my case last. I was wondering how I was going to tell everyone, “This is a three-year-old child who presents with cough and fever of two days’ duration. Social history is remarkable for a lot of profanity.” Luckily for me, while we were standing in the hallway outside of a patient’s room, Arnold walked by with his mother saying, “Bitch bitch bitch bitch…” and there went my patient.

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