I met a terrified young mother recently. She leaned forward earnestly when I entered the room and inspected me with a serious but warm face. She looked about 25 and appeared exhausted.
Next to her on the bed laid a 6-year-old boy, sleeping soundly. Only his forehead and sneakers peeked out from either end of a fleece blanket. I pulled a rolling stool up to the bed, so that the mother and I were face-to-face over his slumbering form.
“What brings you to the hospital today?” I whispered.
She looked down at her son. “I dropped off Jeremiah at the kids' afterschool center today. They called me and said they found him curled up in a ball on the bathroom floor crying and saying his head hurt.”
She explained that Jeremiah had experienced three headaches in the past month, each lasting for two days. Between headaches, his behavior was normal. He did not get headaches regularly and was otherwise healthy. He had not complained of visual changes, numbness, tingling, neck pain, fever, congestion, or weakness. He did not display lethargy or confusion. He had not been introduced to new medications, foods, or environmental substances, and had not travelled or been injured. There was no family history of migraines.
“I'm just really scared,” she said wearily, with tears in her eyes. “This is not like him.”
Jeremiah slept through most of my physical exam, which seemed appropriate because it was past midnight. His mother roused him up for the neurological exam, and watched intently as he followed my commands and walked without difficulty. I did not appreciate a deficit. He laid back down, and I pulled up my chair again.
“How does your head feel now?” I asked him.
“Where does it hurt?”
He slid a hand across his forehead. “Here.”
I paused for a moment, contemplating him. He was a beautiful child. He rolled toward his mother, dozing off again. I covered him with the blanket. It was impossible not to see my own son in him and myself in her anxious face. I related, deeply, to her fear. I also thought he was entirely fine.
Peace of Mind
“I did not find any abnormality in his neurological exam,” I said. “He does not have a fever or stiff neck, he's not vomiting or behaving abnormally, and he's not lethargic. That's all very reassuring.”
“OK,” she said plainly and looked down at Jeremiah. “What about a CAT scan?”
“That's something to consider. In general, we try to be conservative about ordering CT scans on kids. It really is a lot of radiation, so it's important to make sure it is indicated.”
Her body stiffened, and she kept her eyes fixed on Jeremiah, obviously bracing for a confrontation. She was here for a CT scan, and had anticipated that I was going to block her.
I tried to include her in my thinking process. “A CT scan can sometimes show bleeding or increased pressure on the brain. Based on his exam, I don't think he has either of those things going on. There's a good chance a CT scan would give us no valuable information at the cost of substantial radiation to Jeremiah.”
Her gaze was still fixed on her sleeping son.
She wasn't buying it, and, to be honest, I was tempted to order the CT just to put her at ease. There was no doubt I empathized with her plight. I'm an anxious mother myself. But, at this early point in my career, only a few months out of residency, I'm also trying to order tests judiciously. There wasn't much objective evidence for an emergent head CT.
“I would like Jeremiah to see a neurologist in the next few days. I could help arrange that for you by calling him now, and he could lend some guidance about imaging. He may recommend a CT, but he may say we should schedule an MRI as an outpatient. Would you mind if I called him now?”
After what seemed like an eternity, she looked up at me. She took a deep, fortifying breath. “That's fine,” she said, “because I don't want to go home and have something happen to my baby.”
Her unconcealed vulnerability pulled at my heartstrings. She had already imagined the worst: a brain tumor. She came to the ED desperate for peace of mind. I couldn't help reaching out to her personally. “I have two boys of my own. I've been with them in the emergency room. I know you are very concerned right now.”
Acting on Empathy
Despite the late hour, the neurologist returned my page immediately. He was a typical pediatric specialist: approachable, motivated, and thoughtful. It was refreshing.
“I'm calling you about a 6-year-old boy who presents with a severe frontal headache. His mother is very worried because this is the third such headache he's had in the last month. His history has no red flags. I'm not inclined to CT his head as he has a completely non-focal neurological examination and is so young. I am touching base with you to plan for outpatient imaging.”
“I really appreciate you calling before ordering a head CT on a child,” he said. I felt prematurely reassured, anticipating that he would suggest an outpatient MRI. He continued, “But we may not be able to get out of this one, just to give mom some peace of mind so she can sleep. But please tell her that we see migraines in children all the time, and it's almost certainly nothing to worry about. You can tell her to follow up in our clinic this week.”
Jeremiah was fine. I knew it, and by his comments, I gathered the neurologist was pretty sure of it too. We were doing the CT for mom.
I ordered the head CT, and it was negative. I gave Jeremiah a migraine cocktail, and his headache dissipated. The mother appeared visibly relieved, and she asked to take him home.
EPs may err on the side of scanning too often with adults because we believe long-term effects of radiation are less likely to be severe. If there's any question about a diagnosis in an adult, generally speaking, we order the CT. The stakes are higher on both sides of the argument, however, when it comes to children. We are taught to base decisions on an objective history and physical. The data reassure us to forgo the CT and the radiation that comes with it when there are no red flags.
I wrestled with ordering a CT on a neurologically intact boy who was sleeping peacefully. I could have made the decision against CT myself. But something compelled me to reach out to a more experienced physician, who I assumed would give a fact-based answer. He surprised me by acknowledging the data but deferring to the wishes of the mother.
The head CT was, of course, a defensible action. No matter what the history and physical exam showed, I could not say definitively that the child did not have intracranial pathology. After three severe headaches, no one could fault pursuing an answer.
It was interesting to me that the neurologist's direction seemed entirely based on his empathy for the mother's plight, and was, by his own words, not driven by objective findings. Maybe he had had a bad outcome after turning down another parent's request for CT. Maybe he watched his own child suffer, and couldn't bear to think of another parent enduring that torture. Or perhaps he had been a pediatric specialist long enough to know the only acute issue was the mother's fear. Whatever his reason, he cut to the chase: Do the CT so mom could rest easy.
The literature boasts a wealth of evidence-based guidelines, but there are no criteria to objectify a mother's gut instinct for use in our decision-making process. I reached out to my former mentors at Advocate Children's Hospital in Oak Lawn, IL, to learn more: Omar Sawlani, MD, the medical director of pediatric emergency medicine who has been a primary care pediatrician and an emergency physician for 36 years; Mila Felder, MD, the vice chair of the emergency department who has been an emergency physician for 11 years; and Andrea Carlson, MD, the assistant residency program director and an emergency physician and a toxicologist with 17 years of experience. I asked how they approach pediatric patients, how they interact with parents, and what principles they use to make decisions about diagnostics and treatment.
Intuition Complements Science
First and foremost, they said, know the limits when using guidelines from the medical literature. Clinical recommendations are based on the majority, Dr. Carlson explained. “According to medical opinion derived from evidence-based research, if all the findings of a disease are absent, then in the majority of patients the disease will be absent.” This principle gives them confidence to follow guidelines and reassure parents. By definition, however, this implies that “there's always the chance that the person you're examining, with totally normal findings, has a brain tumor.” The parents may sense something is drastically wrong. You have to match the medicine to the mankind in those cases, she said.
“That's the hardest part to teach,” said Dr. Salwani, who is devoted to understanding what he calls the science of intuition. “We learn about CT scans, radiation, and cancer,” he said. “But we get stuck with the academics. The softer side of this is intuition: a state of balance between listening, feeling the emotions, and seeing what is in front of you.”
When a parent's fear nudges them to reconsider their evidence-based plan, he suggests, they may be using their intuition. “Everybody has his or her own intuition. We all have cases where [we] have used our intuition. We access our intuition best when we are self-aware,” he said.
Parents See More
Dr. Sawlani said the main thing that triggers his thought process to say “maybe this is serious” is the parent. He recalled a 6-week-old patient who came in with vomiting. “Everything pointed to reflux,” Dr. Sawlani said. “There was a tiny functional murmur, and the mother seemed very worried. She said, ‘I was trying to have children for years, and I adopted this child. I know nothing about the family, and I feel like something is wrong.’”
Moved by the mother's concern, he ordered an echocardiogram. “The kid had cardiomyopathy,” Dr. Sawlani said. “There is no science there. When you go into the exam room, you have to know there is a lot of stuff you don't know. When you close your mind to an idea of any diagnosis, then you are not feeling the parent. The parent might be right.”
Dr. Carlson agreed, “Parent alarms go off for a reason. They see things we don't see. To figure out what's medically indicated, I find out what they are worried about.”
She remembered a young girl who was brought in by her parents after being awake at a sleepover all night. The parents thought she was acting abnormally. “In this case, I did a complete exam and it was normal until I asked her to count backward from 100 by sevens. She could not do it.” Dr. Carlson thought it plausible that a fatigued young girl might stumble over math after being awake all night. “But for the parents, that was a real red flag. So I scanned her, and she had a big GBM,” she said.
“You have to go in with the understanding that you're already missing things as a non-parent. The parents are going to see it before anybody else,” she said.
Often parents clue them in to subtle things they miss. “Most parents have a sense when there's something to worry about. This is overlooked and condescended [by physicians] sometimes.”
My mentors suggested that EPs listen with the same discernment they use to examine patients. In other words, evaluate the parent to get to the root of an issue in a child.
“They are both patients when they show up in the ER,” Dr. Felder said. “One is registered and one is not. But they are both patients. It is important to treat it that way. I will assess the child and also assess the parent,” she said.
Dr. Felder gauges the level of concern that the parent shows for the child, the parent's ability to understand her reasoning, and the family's access to care. These criteria, she said, can drive her either way. “I'm more likely to order a CT [if a parent's behavior is unusual] even if the rule does not suggest it because of the concern I'm missing something.”
Dr. Sawlani assesses parents by asking for answers directly from children. “When you insist on getting the story from the child, and the mom cooperates with that, then that makes me think this is a good, functioning relationship. Sometimes the kid turns to mom or mom won't let the child answer. Those are clues to the relationship between parent and child. That might open up other reasons for [the chief complaint],” he said.
Dr. Carlson added that evaluating parents also affects the child after the visit. “For some parents, the ‘not knowing’ cannot be tolerated. In certain parents, not doing the test has some risks,” stressing the value of shared decision-making with the parent. “If a parent is capable of going home and functioning until getting an MRI, then I will agree to that,” she said. “But if they are worried enough to come to the ED, and they need some type of definitive test, I would never say, ‘I'm sure it's nothing.’ What is best for the child is to have a parent who is able to reassure them when they aren't feeling well. I don't always know what [the family's] access is. In the time they have to wait for a definitive test, the parent could spiral, and that could impact the child.”
Dr. Sawlani said his intuition about parents is enhanced by his own experience as a parent. “I remember practicing before I had kids. My wife was a pediatric nurse. She would catch me and tell me to put myself in their position. ‘If your child was having these symptoms, you would be just as much concerned.’ After I had kids, I changed my response to parents.”
Dr. Felder agreed. “I relate to scared parents feeling hopeless, and most definitely helpless, very often in our system. I've been on the other side where it feels like it doesn't matter what you think. The older my kids are, the more I want to take the time (to listen to parents). I want to know why they are so worried.
“You can't tell them ‘I know how you feel’ because you don't,” Dr. Felder said. “But at the same time you can feel how they feel. So when I see tears, I sit down,” she said. Strong parental emotions prompt her to learn more. “I hold their hand. I touch their child. And the conversation will go around what is making them feel so overwhelmed.”
Dr. Carlson added, “When you're a parent, there is no way not to connect with another parent who is scared to death.” As long as appropriate boundaries are maintained, she said, relating deeply to the parent can enlighten EPs toward a more effective treatment plan for the child.
In listening to my case, all three of them disagreed with calling the neurologist to avoid a head CT.
Dr. Carlson said calling consultants to ensure follow-up is helpful, but calling a consultant to decide on a CT on a patient in front of you is typically not warranted. “It is in our wheelhouse to make this decision. The consultant can't see the patient, so you're going to get a conservative answer.”
“They don't get many calls about three episodes of headache,” Dr. Felder said. “To them, the fact you're calling means you're more concerned.” In other words, a phone consultant is only as objective as the picture we portray.
Dr. Sawlani pointed out that using phone consultations this way can also be risky. “There's something to be said about the conviction you develop in the presence of the parents and child. A specialist on the phone might say, ‘Don't worry, this is nothing.’ If then they come in and see the patient, they may change their mind completely.”
Dr. Sawlani said if I'm trying to talk myself out of doing something by calling a consultant, I might do better to listen to my own intuition. “Anybody can talk you out of anything on the phone,” he said. “Phone consultation in the ED should be used mostly to do more, not less.”
Clinical guidelines are not the same as having a crystal ball, and there will always be false-negatives in our midst. When evaluating children, physicians cannot see everything parents see. When we thoroughly assess a child, we should spend an equal amount of effort to feel out the parent. This allows us to use our intuition, nurtured by our own life experiences, to see past the obvious. By treating both patient and parent, we can make clinical decisions that are more informed and, ultimately, more beneficial to our pediatric patients and their families.
To Drs. Carlson, Felder, and Sawlani, I extend deep appreciation for their generosity and ongoing commitment to education. The names and details of all those in this case were changed to protect their privacy.Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.