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

My “informal” training:

› Not a very “sponsorable” topic.

› “Cheaper” approach

› Nothing to disclose

› Medical judgement and opinions are my own. Every case can be slightly different.

Disclosure

McLane Children’s Hospital

› 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

› Parameters

› Musts

› The issue with Benzos in FS

Febrile Seizure

› Assessment

› Explanation

› Physiologic reserve

› Gut is best

› Cost of kneejerk IV hydration

› Zofran is a friend*

“Not drinking/eating…”

› Extremely frustrating for child/parents

› Lengthy and unpredictable time course

Hives/Urticaria

› Okay….and…

› “Malignant” constipation

› To KUB or not to KUB

“He hasn’t pooped”

› Extremely common complaint

› Setting the tone for the process

› The immune system explanation

› Things to watch out for

› Quit rubbing stuff on it!

Rash

› Hydration

› Pan control

› Beware Lidocaine in little ones

Herpangina/Coxsackie

› 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

› Congratulations!

› Abscess analogy

› Avoid drops (most of the time)

Ear drainage

› 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..

Not adding up…

› 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

› My Family

› My teachers

› My patients

Thank you!

› dlucia@sw.org

Questions or discussion?