Author: Heather Boynton, MD
UC San Diego Health System
Originally Published: Modern Resident February/March 2016
With pediatric cases, we often say that we have two patients: the child and the parent. How does our approach change when the parent is the patient, and the kids are in the room too?
On a recent string of overnight shifts, I noticed I was seeing a lot of single parents who told me they decided to come to the ED at night so that their children would sleep through most of the visit. My first patient was a young, single, working mother with two small children. In tears she told me how she had been having rectal bleeding for over a week. During the day she worked at a new job, and was afraid to take time off to go to a clinic; at night she had no one to watch her kids, and money was tight, making a babysitter feel like a sacrifice. Her toddler had been outfitted with headphones and was deeply engrossed in a cartoon; the older child, a girl maybe five or six years old, looked at her shoes. My sexual history taking, usually easy with frank, plain language, halted and stumbled. I put off a bimanual exam. When I returned with a pelvic cart and someone to watch the kids, they were asleep in the bed I wanted to use for my patient, and she was in a chair.
Another patient, also a single mother, was roomed with her two young children around 11:00pm while her two older children waited in the waiting room. She, too, had been having symptoms for about a week, complaining of a bad headache with nausea. I sent labs and started fluids. I decided to order Compazine without Benadryl, concerned that the combination would be too sedating. When I checked on my patient twenty minutes later, she was standing on her bed, screaming and pulling her clothes off. Now all four children were in the room, and the youngest two were crying. Fortunately, more fluids and a small dose of benztropine resolved things.
A few pearls:
- Make sure your patient is in the right room. A room with a door helps keep young children calm in an otherwise chaotic environment. A small family camped out for the night can wreak havoc on department flow, so think early about your plan for discharge or admission.
- Identify up-front what parts of your assessment would be best completed without children. Ask your ancillary staff for help when you need a sexual history, pelvic or rectal exams. Twenty minutes may be hard to come by, but five minutes is usually doable.
- Use the equipment available to you. Paper, pens, warm blankets and small containers of milk from the patient food refrigerators go a long way to smooth over a late-night visit. If your ED has reclining chairs, try to get one into your patient’s room. Encourage the patient to tuck a child into a soft chair or cot instead of the patient bed.