Unspoken stories: Going beyond the paediatric history

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.

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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.

Scenario One

 

Scenario Two

 

Scenario Three

 

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

 

Potential background to Scenario Two

 

Potential background to Scenario Three

 

Conclusion

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:

 

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