It’s ok, you’re not alone. The paediatric patient is a challenge, not only because of all their weird pathology, but also because they can’t tell you what’s wrong & scream when you touch them. Here are a few tips ’n’ tricks for making dealing with the not-little-adults a bit easier. (I know, a lot of this is totally obvious. But still, most of it is worth thinking about every time.)
Start Out Right
The Afrikaans have a saying, ‘kyk noord en vok voort’. This is not the one you want to be thinking when you’re presented with a kid with a possible disease. The saying you want on replay in your head is ‘kortpad is langpad ’.
I know how it goes: you have a busy clinic with a queue that seems to be already out the door & growing by the minute, your pager’s going wild about drips & bloods in the ward, & you know you have ten pre-ops to clerk before lunch time. The temptation is to whisk the baby out of the mom’s arms the second she passes through the door, thunk him on the examination table, rip off his nappy & confirm the presence or absence of testes in the scrotum. This is the Wrong Thing To Do.
Take your time at the start. Invite the parents to sit down, & offer the patient a chair if he or she is old enough. Introduce yourself, show them your photo on your ID tag (kids love tags & photos). Let the kid play with your tag if they want to. Take a proper history — from both the parents & the child themselves, if they are able to talk. Act calm, even if the kid is trashing your room. Don’t rush at the start, because then the kid will freak out for sure, & then the rest of your consult will be impossible. You won’t be able to listen to their chest or look in their ears or palpate their scrotums. Your consult will be a disaster.
For lap-sized kids, I try to do as much of my exam as possible with the child on the caregiver’s lap. You can assess so much with a child in this position: ears, noses, throats, chests, necks & limbs. You can even exclude peritonism. In fact, the only part of a small child’s body you really can’t assess well while they’re seated is their groin & perineum, and they do need to be supine for a thorough abdominal exam. Starting with a gentle, non-invasive exam on a caregiver’s lap, however, is a good way to break the ice, before hauling them off to the examination table. For a small, irritable baby I encourage the parents to give them a feed to calm them down, & do what I can while they’re focussed on this.
After I’ve gotten all the information I can with them in this position, I ask the caregiver to put the child on the examination table. If it seems necessary I’ll give them my phone or something to play with (see ‘Distractions’, below), & I try to get the caregiver to still be the ‘closest’ person to the child. So, I’ll ask the mom or the dad or whoever has come in to stand on my left, near the child’s head, while I do what I need to.
The Examination Table
So this is where the child who up till now has been reasonably co-operative, freaks out. They think you’re going to separate them from their caregiver, prod their gangrenous appendix & then stab them with a needle. Often they’re right. Your secret weapon here is distraction, distraction, distraction.
In younger children who can’t hold a conversation, I open a video on my phone & hand it to the caregiver, or directly to the child. This actually calms a significant number of children down immediately. It’s amazing. The video doesn’t have to be anything special (the current №1 on my phone is a 30 second clip of my youngest child eating fish fingers) but I would recommend the clip be 30 to 60 seconds long, at least. Very often though, they don’t care about the video: the mere sight of a smart phone puts kids into such a trance-like state that you can give every one of their solid organs a proper squish, & they don’t bat an eye. (Side-note here: if you are going to use your phone as a weapon of mass distraction, invest in a screen guard & protective cover. Also, give it a bit of a D-Germ wipe between patients.)
In the older child, I literally make inane conversation. ‘How old are you? What school are you at? Oh really, what’s your teacher’s name? And is she strict or not too bad? How many brothers do you have? And sisters? What are their names? What’s your favourite food? If I gave you a hamburger right now would you eat it?’
By the time they’re done being distracted by this very detailed & unexpected line of questioning, you’ve examined the child’s whole abdomen & determined whether or not they have loss of appetite. Ta-dah! Some kids really open up at this point: they tell you all sorts of long & complicated stories & barely notice your hands on their tummies. Some will interrupt themselves mid-sentence to grimace & wince. Guess which one has appendicitis?
Involve the children & their caregivers when you end the consultation
Whatever happens at the end of the consult — the taking of consent for an operation, a discharge home, a referral to another specialty — tell both the child & their caregiver what you are doing & why. You want your paediatric patients to trust you, not only because it’s always better if patients trust their doctors, but also so that things are easier for the next health care provider they encounter down the road.
Sometimes a child is accompanied by a caregiver who does not make things easy. These come in various shapes and forms. There are the parents who are angry at having to wait, & those who are angry about perceived mismanagement from before. There are those that are stressed out of their minds about what is happening & those who seem to be enraged with their child, sometimes smacking or scolding them as they walk through the door. Some are terrified of needles & other painful objects, & cannot bury this fear for a few seconds in order to provide a brave face as their child is subjected to a painful procedure. Some don’t understand the whole distraction thing & keep answering the Inane Questions on the child’s behalf.
You need to try to settle these parents as soon as possible. You are not trying to negate their concerns or diminish their complaints, but you need to establish a relationship with them in such a way that the child perceives you as someone who is not ‘the enemy’. If they’re angry about something that happened before, take a moment to listen to their complaint, say you’re sorry that thing happened to them or that they feel that way. The start of a consultation with a child is not the time to become overly defensive or even antagonistic, even if you are dealing with a very unreasonable person. If the caregiver seems incredibly stressed, try to be reassuring & tell them that you’re all going to start at the beginning together, & work your way through the problem. If they’re shouting at their child, tell them it’s going to be ok: whatever happened is just a thing that happened that you’ve seen a million times before & is no big deal. Crack a joke. Make everyone smile.
And painful procedures? For small babies, I send the parents out. Their presence is of no use, & it is traumatic for them. In the older child, the ideal situation is a calm, sensible parent who can hold their child as blood is taken & say ‘It’s going to be ok.’ If you don’t have a parent like that, don’t try to force them to be that way right then. Send them out or let them sit in the corner, get an extra pair of hands, & do what you need to do as quickly as possible.
by Dr Karen Milford
Paediatric Surgeon, Cape Town