This post was inspired by a teaching session I run for our junior doctors during their induction (orientation) to our Children’s Emergency Department. I shared some of the content with Liz Crowe and thanks to her amazing insight she has shaped this into a immersive #FOAMed experience. We really hope this will challenge all of those who work with Children to think that bit harder and look that bit closer. I’m hugely grateful to Liz for her patience and input.
In paediatrics we cannot always rely on the patient to give the history, explain symptoms or give a complete story and may be dependant on the parents or caregivers to give us information, especially historical symptoms, about the children we see. It is not just the narrative we are told that is important though, it is the way we are told it. Family context is a major indicator as to the wellbeing, safety and potential compliance of the patient to treatment. Clues to that context can be as obvious, or as subtle, as the signs of respiratory distress.
Lets examine the same clinical scenario and see what we can learn from parental engagement.
You are working a long shift in ED. An outbreak of gastroenteritis and a late bronchiolitis season means the waiting room is full of miserable children with a variety of complaints. You are tired and hungry. The next patient is an 8 week old accompanied by both parents.
They have been waiting around 90 minutes which is short compared to many in the waiting room. It is reported to you that the parents are ‘demanding’ and have come to the desk on a couple of occasions to enquire about the waiting time. Normally patients less than 3 months old are prioritised in your department but there were no concerns on initial triage and there has been a run of sick patients brought in by ambulance which have tied up staff. You brace yourself for a challenging consultation.
At triage the nurse has noted the baby to be afebrile and had had only one small posit typical for an infant that age. The baby has not been observed to be irritable but has been crying in the waiting room. Observations, both objective and subjective were normal.
In the following scenarios the infant is clinically well and there is no evidence of a serious bacterial illness, cardiac or metabolic problem. The mother has been concerned about the child’s feeding and some intermittent vomiting during the day.
As you enter the cubicle a man and women are huddled around the baby. They both look very anxious, are hypervigilant and have numerous questions. Mum is continually crying and not speaking very much at all. Dad has obviously been crying and is very emotional when he speaks; regularly having to pause to be able to speak. You observe that they hold onto each other as much as they are holding on to their baby, they look incredibly vulnerable.
They are clearly uncomfortable in the hospital setting although despite not being medically trained, appear to have some medical language. Both parents are quite insistent that they would like the baby admitted for observation despite no real symptomology
The nurse-in-charge needs the cubicle for a child with breathing difficulty and bed capacity in the hospital is tight. You are being leant on to discharge the ED as soon as possible. What is going on? What is your duty of care to this family?
As you walk into the cubicle the infant is being cradled by a woman. She appears very anxious. She seeks lots of assurance from you in relation to the baby and speaks in quite a timid voice. She is so quiet you have to ask her to repeat herself several times. Each time she speaks she glances to the man in the corner of the room who has accompanied her and the baby into the room. He is identified as the father of the baby. Dad appears completely benign and disinterested. He is checking his mobile phone as you talk to the woman. Then suddenly he is very sharp with the woman, completely contradicting what she has to say. Suddenly the atmosphere in the examining bay has changed. Dad is agitated and disgruntled and starts to dominate the interaction. Mum cradles the infant tightly and looks to the floor. Mum asks if the baby will be admitted. Repeats how worried she is for the infant. Dad looks at her and reproaches her, “Will you just calm down. The kid’s fine” ”.
As you walk into the cubicle the infant is being held by its mother. A man sits beside her, and identifies himself as dad. He keeps saying he feels things aren’t “quite right at home”. While the baby is in mum’s arms you note there is little interaction or engagement between the two of them. The mother does not look at the baby, or touch the baby when she speaks, when the baby starts to cry it is dad who touches the child. Mum’s affect is flat at best and you note she does appear teary. Mum constantly apologises for not being able to answer the questions. Dad appears helpful and supportive and answers the questions about feeding, weight and sleeping. Dad constantly rubs mum’s shoulders and is reassuring. Dad mentions a couple of times in the consultation the like need for an admission to observe the baby.
Have a think about how you would approach these cases? What further information would you like and what might be the cause of the observed behaviours? What realistically is your responsibility in a busy ED?
Potential background to Scenario One
- Parents lost their first born infant to Sudden and Unexplained Death in Infancy, this is their next baby and now only child.
The early days/weeks for the family of a newborn are an emotional time especially for first time parents. This is clearly exacerbated for families who have previously lost a child. Death will be a traumatic loss for any child however unexplained death will leave even very calm and rational bereaved patients anxious, concerned and hypervigilant about the baby for even the most minor ailment. Particularly until the infant is older that the timeframe when their sibling died. Bereaved Parents will be highly anxious about the smallest deviation from normal and will have difficulty placing simple symptoms in context. Empathy is vital here, and remember empathy is not sympathy.
Without empathy it will be difficult to hear the parental distress and communicate that you care. An appropriate management plan needs to be formulated before this family is discharged otherwise they will simply represent in several hours.
It is not simply a case of admitting for observation – the parents may be looking for authoritative reassurance. It is not simply a case of a consultant review – the parents may need time and space to be re-assured their child is well and safe.
Parents may find it to distressing to disclose the death of their first child, often bereaved parents have a huge sense of guilt and shame. Being asked “how many children do you have?” is the most dreaded question of bereaved parents. If they share their loss it can make everything awkward and risk them being emotional with strangers. If they deny their dead child it remains this painful lie. If you are suspicious that there is an underlying grief ask questions such as “was this your first baby/pregnancy?” Taking a little time with a bereaved couple may save you a lot of time in the future.
Potential background to Scenario Two
- Mother in an abusive relationship. Potential child protection risk.
Domestic violence rates escalate during pregnancy and when children are infants.
At times of stress such as when there is a sick infant and parents are tired and have been waiting a long time to be seen conflict and agitation between parents and family members is common and can be quite public. For most families in ED conflict between parents is a normal representation of fatigue and/or the fear a family member may have for their child and is a result of acute stress. However health care professionals must be constantly vigilant for interactions between family members which are not within normal variants and are indications of underlying abusive relationships.
The Royal College of Emergency Medicine FOAMed Network have a collection of resources on domestic violence which are worth reviewing. Evidence suggests that there may be up to 20 assaults before any disclosure is made and 30% of domestic abuse commences in pregnancy. There is no clear guidance on how to stop domestic abuse especially in the context of a child being the presenting feature but if you do not consider the possibility then we may be sending a mother and potentially a baby home at risk. There is also no one best way to approach the situation. Try to get mum on her own and ask her if she is safe. If she says no find out exactly the level of risk to her and to her children. If mum is reluctant to engage you may even discreetly slip her a small piece of paper with the number of a refuge or a similar community organization to assist women such as herself. If mum is too scared or disinterested in receiving care we have a duty of care to ensure the baby is not at risk. Children exposed to domestic violence are at risk of not only injury,
Potential background to Scenario Three
- Mother has post-natal depression
Bringing a new born baby into the world produces a range of emotions. There is elation, excitement and joy. It is also a challenging time, one in which you are sleep deprived and sometimes uncertain what to do. This is all wrapped up in the context of a slightly changed relationship with your partner as you bring a new ‘loved’ one into your life. On top of all of this nature deals mothers (and fathers) a cruel blow with the possibility of developing a severe depressive illness in the post-natal period. There are no absolutes to post natal depression, it is a spectrum, requiring different types of interventions and treatments. It is important to recognise though as it may be very difficult for the affected mother to recognise what they are feeling is outside the normal sphere of emotions. For this reason it can be difficult to intervene but there is a great deal of support available and direct contact with mother’s General Practitioner (Family Doctor) and Health Visitor would be important. Self scoring scales are available but this puts the onus on follow up on the family which might not be acted on. Supporting the partner is also important and they may need their concerns validated, especially if they are a first time parent.
Please be very mindful however that not every sad or weeping mother in ED has post natal depression. Lots of new parents will be teary and anxious and this is a normal adjustment to parenthood.
Presenting the cases in this way makes it obvious that a huge amount of information is available to health care professionals from the attitudes and appearances of parents and family members. The source of these emotions will not always be clear and there might not be time in Emergency settings to obtain a full picture of events. But if we don’t take some sort of history and visual examination of parents and families we are missing vital clues that will help us mange children and young people more effectively and potentially put parents and children at risk.
The other part of the teaching session is on communication and illness recognition. I’ve recorded a short summary of this: