The Pediatric Emergency Medicine Mindset

Author: James C. O’Neill, MD (Associate Professor of Emergency Medicine, Wake Forest Baptist Health) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Pediatric versus Adult Emergency Medicine: The general rule in adult emergency medicine, and a reason that we all love it, is that being aggressive is almost always rewarded.  Early interventions such as early intubation for a neck hematoma, early intubation of a severe pneumonia, or an aggressive nitroglycerin drip for a congestive heart failure patient is almost always the right thing to do.  In the pediatric emergency department, we generally take a step back and are slower to act.  We know that trauma is one of the most dangerous things that children face: you should consider iatrogenic harm a source of trauma.  Children generally need more supportive care than aggressive care.   In fact, we know that most of our patients will do fine without intervention, whether it is a buckle fracture that doesn’t need treatment or an otitis media that is most likely viral.  Something as simple as IV fluids given to a 7 kilogram infant carries inherent risk.  We limit blood draws, avoid radiation, and attempt to use non-invasive ventilation much more than in the adult population as we consider risk of the procedure itself.

Procedures: All procedures in emergency medicine require you to have appropriate preparation and setup to be successful.  Pediatric procedures seem to require even closer attention to setup and positioning.  Having closely available tubes for a lumbar puncture or a wire for a central line is necessary as you have a smaller margin of error for movement causing loss of flow.  Your holders and assistants are very important and often determine your success.  Procedural success is often determined by teamwork (nurses, nursing assistant holders, child-life distractors, and respiratory therapists) than individual procedural prowess.  Thank your helpers accordingly.

Interacting with Parents: Some physicians find one of the most difficult parts of taking care of pediatric patients is dealing with parental concerns and expectations.  Most of what has informed me about dealing with parents has been my own adventures as a parent of a pediatric patient.  I wouldn’t have had developed my thoughts about this without learning the hard way.  When a parent takes a child home from the hospital, you quickly realize that there are no instruction manuals for these little people that are worth a damn.  This is especially apparent for the second or third time parent that has a child with a much different personality than their first.  There is one overwhelming feeling that a parent has, which is, no one else on this planet is going to advocate for this child unless you do.  People love children, there is a safety net in the community, but still if you don’t “lean in” for this little person, no one else will.  Adults that visit the emergency department (and run out the door when they hear their own issue isn’t an emergency) will take your advice that their child is fine with a lot of suspicion.  Most emergency physicians will sheepishly admit that occasionally an x-ray or blood draw was done because the parents wouldn’t buy-in to the child’s care otherwise.  Once you meet the extremely rare parent that doesn’t care about their child, the vast majority of parents that love and care for their children get any benefit of the doubt they need.

If a parent has an overwhelming concern that something isn’t right or something important hasn’t been found, I have learned to pay very close attention.  Early in my career, I felt this more of a challenge to my decision-making.  Now I see this as the person who knows this child best giving me another chance to think through the patient and possibly even admit for observation or arrange close follow up.  Over the years, I learned that listening to parents (especially parents of chronically ill children) and believing their instincts has saved the patient (and me) a lot of trouble.  The longer I work in the pediatric emergency department, the more I listen to and believe a parent’s hunch.

Finally, talking to parents and explaining pediatric illnesses is an art.  I had an attending during fellowship that had the best explanation of what a febrile seizure is and what it meant for the child.  It took her 15 years to develop her teaching points and 5 minutes for me to steal them (I always give her credit when I pass along the teaching).  When you get a chance during a pediatric emergency medicine shift, listen to how your attending explains simple things like fever, viral infections, febrile seizures, etc.  You will learn from their years of experience and mistakes made along the way.

Care of Chronically Ill Children: As a medical student, I found parents of chronically ill children difficult to build rapport with.  I wanted so much to help, but since they knew the system so well, they didn’t want to waste time with anyone that wasn’t helping them make decisions.  This gets much easier as you are a resident and attending.  Parents of chronically ill children are, more often than not, incredible caretakers.  Care of their child is a huge part of their life, and they know more about their child’s disease than you do.  It is more important to have a general approach to a chronically ill child than it is to have an encyclopedic knowledge of all chronic genetic illnesses.  The last place in the universe that the family of a chronically ill child wants to be is in the emergency department.  If they have come to see you, it means they have exhausted all of their home resources.  Listening to these parents and engaging them in decision-making is always helpful.  I often tell these parents, “You know more about your child’s illness than anyone.  I’m going to work with you to make sure we make decisions together to do the best thing for your child.”  I’ve often seen disagreements about care disappear once you acknowledge that parents are making the decisions with you.  Sometimes these parents need a respite and rules of admission are sometimes adjusted if they are exhausted and worried.