It is a busy Friday night in your emergency department. You have just finished caring for a critically ill trauma patient and the 57-year-old man with a pulmonary embolus, and a very nice (but very needy) family has just made it to the critical care unit.
You look at your watch, the shift is nearly over, and you are feeling physically and emotionally spent. As you pick up the next chart, you hope for something easy and straightforward. When you look at the chief complaint, it seems that your wish has been granted. A 6-year-old with a sore throat; what could be easier? But as you walk into the room, there is a sense of foreboding, something inside of you says that this may not be as simple as it seems. On the examination table is a child who seems way too large to be six. He weighs at least 75 pounds and is built like a linebacker.
Even the greenest resident has experienced the challenge of performing a procedure on an unwilling child
After an introduction and a basic history, you approach your patient. By now you know that his name is Michael, and that he is indeed only 6. You also know that previous physicians have had a “hard time” examining his throat and ears. So much for an easy end to your shift.
You press on, and in your best and friendliest way you say, “Aw, come on, Mike, I'm just going to take a quick look down there, and see what's bothering your throat.”
Michael does not answer. Instead he folds his arms across his chest and presses his lips together, daring you to proceed.
Even the greenest emergency medicine resident has experienced the trials and challenges of attempting to perform a procedure or a physical examination on an unwilling child. Each year as a new class of interns joins our training program, I am called upon to give them a lecture about approaching pediatric patients. I always begin this lecture by reading aloud a story called “The Use of Force” by the great American author and poet William Carlos Williams.
The story relates the travails of a young physician who is attempting to examine the throat of a child who refuses to cooperate. The examination is important because the physician is attempting to determine whether the child has the telltale sign of diphtheria, a gray membrane covering the posterior pharynx. As I read this story, I see heads nod and slight smiles on the faces of these new doctors. They certainly understand the problem, as do we all, but understanding the problem does not make us better at handling these situations when they arise. The purpose of this special report is to impart some techniques and a little bit of hard-won advice to those physicians who must from time to time perform procedures upon children, whose unwillingness or fear put the common into the realm of the unusual.
The first step is to consider your objective in light of the child's age and developmental level. As you think about what you need to do, you should ask yourself some questions. Is this procedure really necessary right now? Are there several ways of accomplishing the same goal, and if so, which would be best for this particular child? If the procedure is likely to be accompanied by some degree of discomfort, what can be done to minimize this? Is there a role for sedation? Alternatively, is there undue risk to sedation?
Finally, the parents can be invaluable in preparing for the procedure. They can often provide information about the child's previous experiences and reactions. If they tell you that the child has fought every examination in his life, it is unlikely that you will be the doctor for whom he chooses to cooperate. It is not necessarily comforting to know that, but as the old saying goes, “Forewarned is forearmed.”
Age and developmental level have an enormous impact upon the ability to gain cooperation. Infants are unable to voluntarily cooperate with procedures, but on the other hand, they are not physically strong enough to resist effectively. Furthermore, they are not troubled by issues like stranger anxiety that add to the challenge of caring for toddlers. Instead, babies are most likely to respond to discomfort. This obviously includes pain, but can also include cold, hunger, and fatigue. Attending to these needs can be very helpful.
A pediatric surgeon I know offers an excellent example of this approach. Babies with hypertrophic pyloric stenosis are generally ravenously hungry. Their hunger makes them fussy, and this in turn makes it difficult to identify the hallmark “olive” on physical examination. This physician passes a very small nasogastric tube into the baby's stomach and then allows the child to suck from a bottle of 5% dextrose in sterile water. As the child sucks, he relaxes and becomes easy to examine. At the conclusion of the examination, the stomach contents are quickly aspirated through the nasogastric tube leaving the patient ready to have his pyloromyotomy within an hour or two. It is important to remember that babies do feel pain, and appropriate analgesia should be provided for painful procedures and conditions.
In contrast, older children, especially those in the toddler age group, do recognize the difference between their own parents and strange adults (and few adults are stranger than those of us who work in emergency departments). They also are beginning to develop the first hints of personal modesty, and may be uncomfortable without clothing. Cooperation is likely to be hit-or-miss at best with toddlers. There are some ways for the emergency department staff to stack the deck in its favor, however.
Unless the situation is a dire emergency, the best approach is a gradual one. Allowing the child to remain on his parent's lap, offering an age-appropriate toy, and spending a moment or two letting the child play with the medical equipment can go a long way toward establishing rapport. When it is time to perform the examination, try to save anything that is remotely uncomfortable until the end of the examination. These young children are unlikely to understand explanations about how things might hurt or be uncomfortable.
Finally, there is sometimes a role for a brief period of restraint. I find this to be particularly useful in performing a thorough, non-traumatic ear examination. I usually begin by explaining to the parents the importance of a good look in the ear. I explain that if the child fights the examination, he risks a minor injury to the lining of the ear canal and some bleeding from the ear and that to prevent this we might have to help the child to hold still for a minute or two. Then I make an attempt without restraint.
During this attempt I make every effort to be very gentle and I talk to the child while I'm trying to look. If this fails, restraint is called for. This works best with a papoose board or other similar device, but two adults (in addition to the examiner) can be nearly as effective. One adult pins the child's shoulders against the examination table with the arms over the child's head while the other pins the knees. The examination can then be conducted with less trauma and better accuracy.
This is a good time to discuss the wax-filled ear canal. There is no completely comfortable way to remove wax from the ear canal. In my experience, irrigation with warm (not hot) water is tolerated better than most other techniques, arguments about the possibility of an occult perforation (almost nonexistent in my experience) not withstanding. Many physicians prefer to use a cerumen spoon instead. If this technique is chosen, the physician should use a soft spoon under good control, and the parents should be warned in advance about the possibility of accidental trauma to the ear canal. This technique requires a very cooperative patient, and restraint is very likely to be required.
The school-aged child can usually understand what must be done, but is also large enough to resist effectively. They have a well-developed sense of modesty and should be examined in a gown so that only the necessary part can be uncovered. Honest explanations should be given and cooperation should be sought, but in some cases the child will simply refuse to cooperate. The physician will then be left with a choice of deferring the procedure, using sedation, or attempting to restrain a fighting school-aged patient.
To quote Shakespeare: “Discretion is the better part of valor,” at least sometimes. There are some cases in which it is best to defer the procedure. For example, imagine that you're examining a child with an earache. As look through your otoscope, you see not the red tympanic membrane that you were expecting but instead a big pastel bead that is lodged well down the external auditory canal.
Being an emergency physician, you have a natural desire to intervene. You can see the bead right there, and you'd love to grab it and listen to the solid clunk of plastic on plastic as you drop the bead into that mustard-yellow kidney basin. The truth is, however, that it will be virtually impossible to get the bead out of the ear without causing a great deal of discomfort unless a significant amount of sedation is used.
Furthermore, there are real risks associated with a failed attempt to get the bead out while it is unlikely to cause the child significant harm in its present location. Finally, this whole process is going to take some time and won't help the flow in the emergency department. In my experience, you and the child are almost always going to be better off by offering pain medication and allowing the child to follow-up with an ear, nose, and throat specialist who will take the bead out in the operating room using a microscope.
Fish Hook Removal
In many cases, the task at hand can be accomplished in more than one way. One of the best examples is the child with an impaled fish hook. There are at least three ways to remove a fish hook. The traditional approach is to use local anesthetic, and then push the hook the rest of the way through the skin where the barb can be cut off and then the remaining parts can be pulled out.
Another approach involves using a hollow needle to cover the barb on the hook and then advance the needle as the hook is withdrawn. This approach requires anesthesia. Either of these two methods may be required to remove a deeply embedded hook, but for many embedded hooks the string technique shown in the photographs works very well and without the need for anesthesia. To perform the string technique, the physician has an assistant apply downward pressure to the barb of the hook. This serves to release the barb.
Dealing with children, especially toddlers, can be hit-or-miss, but ED staff can stack the deck in their favor
A piece of string (O silk suture works very well) is then passed around the hook at the bend and pulled taut. A quick, firm yank on the string usually removes the hook. When faced with a choice of several ways to perform the procedure, think about the child and his level of development. Determine as best you can whether he will cooperate better with one method than another.
In a previous series of columns, I discussed sedation in great detail. Pediatric sedation has been a hot topic in recent years, and most emergency physicians have had ample opportunity to gain some familiarity with a variety of sedative techniques. The truth remains that the emergency physician will often have to decide whether a particular procedure should be performed under sedation and how best to sedate the patient. This is especially true for very brief procedures.
The issue of restraint vs. sedation is often raised in these cases because the emergency physician has to weigh the risk of brief discomfort against the potential dangers of sedation. Furthermore, sedation has some potential operational consequences. A 30-second procedure with two hours of recovery time is very different from a 30-second procedure. If the patient must be absolutely still, if the brief procedure is not guaranteed to succeed in one or two attempts, and if there is likely to be significant pain that cannot be controlled with local anesthetic agents, then sedation should be considered.
1. Williams, William Carlos. The Doctor Stories
. New York, NY. New Directions, 1984.
2. Henretig FM, King CC, eds. Textbook of Pediatric Emergency Procedures
. Baltimore: Williams and Wilkins, 1997.
3. Dieckmann RA, Fiser DH, Selbst SM, eds. Illustrated Textbook of Pediatric Emergency and Critical Care Procedures
. St Louis: Mosby–Yearbook, 1996.