dominic lucia md pediatric emergency medicine. ›not a very “sponsorable” topic....
TRANSCRIPT
Dominic Lucia MD Pediatric Emergency Medicine
Delivering Bad News:“Your Child is Fine.”
Strategies for managing the worries of acute common childhood
illnesses in your ED
› Not a very “sponsorable” topic.
› “Cheaper” approach
› Nothing to disclose
› Medical judgement and opinions are my own. Every case can be slightly different.
Disclosure
› Our Adventure:
– The big picture: Changing the mindset– Overall concepts– Specific conditions– “Special” situations– Summary
“Here we Gooooooo…” -Peter Pan
› Don’t.
› Approach
› Considerations
› Swimming “with” the current
› Time to exercise listening and compassion
› Enjoy your patient!
“Why are they here…?”Changing OUR Mindset
› Have they waited a long time?
› What are they doing right?
› What else can they do?
› How good does the child look?
› Refraining from joining in the “phobia”.
› Setting alliances in the room.
› Using all of your advantages.
Invest the effort and time at the beginning
› Effort to rule out SBI.
› Monitor hydration.
› The biggest part of that is…?
› This is why you must do that part, and be thorough.
› The value of time and attention.
› Teach on disease process.
› Length of time/illness.
› Anticipatory guidance.
What do we do?
› The following almost never need anything other than:
› A good H&P
› Parental education
› Follow up (if indicated)
-Notice no labs or imaging needed**
Specific Conditions
› Pain
› Stress
› Waiting time
› $$$
› Unintended consequences
› Fanning the flame of worry
The true cost of labs and imaging
› Healthy appearing immunized child over 6 months
› Viral Panels….WHY?
› Education.
› Expectations.
› To Do Lists for parents
› Proactivity
› Declaration
Fever
› Assessment
› Explanation
› Physiologic reserve
› Gut is best
› Cost of kneejerk IV hydration
› Zofran is a friend*
“Not drinking/eating…”
› Extremely common complaint
› Setting the tone for the process
› The immune system explanation
› Things to watch out for
› Quit rubbing stuff on it!
Rash
› Proximal to Glans
› Often circumferential
› Rarely an infection
› Can they pee ? (most of the time…yes!)
› Watchful waiting.
Penile shaft edema
› A little trickier
› Often not infectious
› Areas of thin skin swell readily to minor insults
Eyelid Edema
› Trauma
› This is almost never a bleeding disorder when isolated
› Acute care
› Home care
Bloody Nose
› Freaks the kid out
› Can’t have drainage
› Not hot or painful
› Time monitoring
› Pediatrician follow-up
Teenage male nipple lump
› “probably” don’t need labs
› Non-toxic
› Following an illness
› No focal pain/swelling
Post-Viral Polyarthralgia
› Also…freaks everybody out..location
› You don’t HAVE to drain.
› ENT referral as an outpatient
Ranula
› Well appearing 3y/o fever and day 3 of antibx
› Scary looking diaper.
› Hemoccult
› What was that antibiotic again…?
Spicy Cheetos Poop
› Strep ?
› Any other signs?
› Immunization
› Age
› Neck, back, photophobia
› Discussion with parents
Fever and mild-moderate isolated headache
› Excellent H&P as well as family history
› +- EKG or CXR
› Tenderness
› Lengthy
› Education on chest wall tenderness (pleurisy) in youth vs grandpa’s chest pain
› NSAIDS
› Return warnings
Costochondritis
› Conversion disorder of breathing
› Clues early on
› Don’t buy into the hype!
› Talk to the patient.
› Distraction.
› Time
› Do you really need that albuterol…?
Vocal Cord Dysfunction
› “Crazy” Parent (oft overused)
› Repeated visits
› Language or cultural barriers
› Unique patient groups
› New parents
› Young parents
› “The golden child.”
› Prior family tragedy
Special Situations
› Vaccinations are a great protector…but.
› Pay attention to subtleties.
› Pay attention to red flags.
› Be careful of writing off persistent parents.
*Remember: Children DO actually get sick..
› Prolonged fever
› Unexplained injuries
› Delayed presentation
› Persistent Vital sign abnormalities
› Big picture
› Follow up.
Beware
› Descriptors
› No signs of dehydration or SBI
› Unnecessary labs and radiology
› Return warnings
› Follow-up
A word on documentation
› Approach with compassion
› Enjoy the infant/child.
› Don’t overwork-up a child that does not need it.
› Use the time for a great H&P
› Document well. Beware of clones.
› Have fun!
Tie it together