The Angry Toddler Whisperer

Few tasks are more challenging than getting a reliable abdominal exam on an upset child. Over the years I have developed a strategy that has increased my success rate exponentially and it can be distilled down to a few key factors.

Know what you’re up against

As the great sage G.I. Joe once said “knowing is half the battle.” Many children are upset and resistant to being examined for the simple reason that they are uncomfortable or in pain as a result of their illness. They have also learned in their few years of life that the doctors office often leads to pain in the form of uncomfortable exams or shots. On top of that you are a new strange person to them and your simple presence stimulates significant stranger anxiety. Clearly the deck is stacked against you.

Set things up to your advantage

If you can, be sure that these children are evaluated in a space that caters to them. I have the luxury of a dedicated pediatric ED but many community EDs have pediatric rooms or at least private rooms where you can work in a quieter and less anxiety producing space.

Whenever possible I allow the child to stay in the caregiver’s lap or embrace. I find that this reduces much of the stranger anxiety these patients have when I start the exam and it helps keep the parents involved and in control of what is happening.

Get on their level

There are two parts to this one. The first is obvious – try not to tower over these little people! Sit next to them on the bed or sit in a chair. When you don’t seem so big you also don’t seem so scary.

The second part has to do with how we speak to small patients. Whenever possible I try to engage them in conversation related to something they like. Parents love this and will almost always try to help you out. Kids start to see you as a person and not The Scary Doctor (service mark pending).

Cartoons

copyright Casey Glass, all rights reserved
Even my 10 month old can do it!

Really I mean “distraction” but that isn’t a catchy heading. Our rooms each have a television in them and usually I walk in to the middle of Sponge Bob or Bob the Builder or some other Bob-related cartoon in progress. When possible I will move quickly through the above steps and then proceed directly to the abdominal exam. If the kiddo spooks a bit I’ll start talking to them about what they’re watching and keep examining. I can’t remember the last time I wasn’t able to get a good exam when Nurse Sponge Bob was in the room.

Sometimes the TV isn’t on or the child hasn’t really zoned out into the screen yet. In these cases I will usually combine the exam with the conversation step above. Another option is an iPad or phone type game. We keep an iPad in the department for just these types of encounters with various kid-appropriate apps ready to go.

Take your time

When I perform an abdominal exam on a small child I usually spend at least 2-3 minutes palpating the abdomen. I start out with a light touch and the distraction techniques described above and proceed to deeper palpating and more focus on the relevant abdominal zones as the exam goes along. Although I’ve never kept count I would estimate I cover the entire abdomen about 10 times in an exam. By the end of it the child is so accustomed to your touch that they tend to give reliable feedback on the location of pain and relative discomfort of the exam.

Altogether I suspect that my process adds 2-3 minutes to the visit but the payoffs in diagnostic accuracy and patient satisfaction are totally worth it. What tips do you have for the pediatric abdominal exam? Let us know in the comments below!

Featured Image adapted from from Rich Johnson on Flickr and via Creative Commons.

Aortic Dissection – What’s the Party Line?

In this month’s issue of Emergency Physician Monthly Dr. Cedric Lefebvre reviews ACEP Clinical Policy: Aortic Dissection for the evaluation of potential aortic dissection. It has always been difficult to make the diagnosis of aortic dissection as the condition is rare and the presenting symptoms can be quite variable. Dr. Lefebvre does an admirable job of pointing out potential pitfalls in the guidelines and limitations of the current diagnostic options. Check it out!

Pulmonary Contusion and the Hyperimmune Response

Faculty member Dr. Lane Smith’s comments on his paper that was published in the Journal of Trauma and Acute Care Surgery, titled, “SIRT1 mediates a primed response to immune challenge after traumatic lung injury:”

My research interest focuses on methods to modulate/modify the immune system in sepsis to create a less destructive response. We have identified certain injury patterns as priming events for downstream infection. Pulmonary contusion is one of those events that lead to a hyperimmune response to infectious insults that occur a few days after injury. Not only does priming result in a more destructive acute phase in early sepsis, it also hampers the later adaption and recovery phases.

A class of molecules know as Sirtuins play a role in the inflammatory and metabolic responses to sepsis by inactivating pro-inflammatory genes. Sirtuins are also metabolically active and drive mitochondrial oxidative phosphorylation and fatty acid beta-oxidation during the later adaptive phases of sepsis. Sirtuin activity and number are decreased by antecedent injury and play a major role in priming the immune system for badness after and injury. Basically, the body can’t tamper the hyper-immune response and switch to efficient metabolism in the adaptive phase of sepsis when the sirtuins take a big hit.

Our lab hopes to better understand this pathway and someday find a treatment that can be given at the time of injury (i.e. in the ED) to prevent priming. So far, certain compounds such as resveratrol and even n-acetylcystein are candidates since they activate sirtuins.

See the citation on Pubmed…

Featured image courtesy of University of Liverpool Faculty of Health & Life Sciences via flickr and creative commons.