Posts Tagged pediatrics
A physician acquaintance of mine is on a mission to promote awareness, especially amongst emergency physicians, of the potential for post-traumatic stress disorder in children who have been attacked and/or bitten by dogs. Thus this blog post. As a practicing psychiatrist, he has treated a number of such children, and he believes that it is very important for physicians who are treating these children for their bite wounds to inform parents to actively watch for signs of PTSD and to obtain evaluation and treatment if indicated. Dr. Schmitt has lectured and published on this topic (Larry Schmitt, MD, Dog bites in children: Focus on posttraumatic stress disorder, Contemporary Pediatrics, Jul 1, 2011). He makes a good case for the need for parents and pediatricians to monitor these children closely after their injury, and for incorporating information about PTSD into post-treatment ED and inpatient discharge instructions.
One may not readily consider the diagnosis of PTSD in children, but after dog bites it appears that children pick up on the guilt and sadness in their parents’ faces, and tend to bury their feelings and avoid discussion of the attack. This of course may precipitate PTSD, and make it more difficult to identify this pathology unless one recognizes the symptoms (excessive anxiety, irritability, decreased school performance, sleep disturbance, reduced creativity, withdrawal, altered appetite, depression, physical complaints, pronounced startle responses, and behavior problems), and relates them back to the attack. Parents need to know not only how to recognize PTSD, but also what to do to mitigate the potential for their child to develop PTSD. Preemptive psychological management is likely to be helpful, and parents need to participate in helping their children cope with this trauma and its psychological impact.
Dr. Stanley Goodman published a pdf on the web which provides an extensive outline of this issue; and he suggests that ‘children need to be helped to understand the following, in order to lessen their feelings of vulnerability and helplessness:
1. that many children become fearful whenever they have reminders of the incident, such as seeing other dogs or even watching movies/TV shows with dogs.
2. that they may feel more nervous when they leave their house, fearing they may be attacked and bitten again by a dog.
3. that they may experience depressive symptoms, such as feelings of helplessness, frustration, and diminished social and/or educational functioning; but these feelings are not a sign of weakness. Rather, they are a foreseeable reaction to having been bitten.’
Emergency physicians treat a lot of children with dog bites, and they have an important role to play beyond caring for the injuries themselves. Making parents aware of the potential for PTSD, providing information about the signs and symptoms of PTSD in written dog-bite discharge instructions, and suggesting referrals for preemptive psychological counseling can all make a significant contribution to the child’s successful recovery from this kind of trauma.
This post also appears in The Fickle Finger
In my short Pediatric Emergency Medicine career, I have successfully:
- burrito-wrapped my fair share of pediatric laceration patients;
- debrided 3rd degree burns with IM ketamine;
- removed cockroaches from ears, and
- sutured a sleeping child.
But never, ever in my career have I sutured a child without them screaming bloody murder. Until today, ladies and gents.
God bless you, Spongebob Distractionpants. For the low price of $1.99 (and your iPhone service plan, of course) you can download an episode from iTunes and totally distract a kid — without any respiratory depression or squirming!
It did absolutely nothing when I tried to distract the kid during the lidocaine injection, but once he was numb, I was suturing up his lip, dragging suture material along his face and waving suture instruments near his mouth and eyes without an ounce of fear — or even interest. He was totally, absolutely, completely fixated on my iPhone showing the SpongeBob episode. (And works faster and more reliably than PO versed.) Thank you, inherent distractability of the immature mind!
(The febrile 2 year-old tonight with otitis would have none of it, despite me going for a Yo Gabba Gabba episode, in case you’re wondering.)
We are certainly notorious for this “treat the fever” business. Most of my discharge instructions include “You may give motrin or tylenol for fever or pain.” But we treat fever in our patients for different reasons than parents do: we want to improve vital signs, and see if the kid’s heart rate and respiratory rate improve once the fever is controlled; we want the kid to perk up once the fever is improved. Otherwise, we start thinking badness. (It’ll also slow their metabolic rate, leading to less dehydration and, in really frail kids, less weight loss.)
Parents treat fever for several reasons:
- They think fever in and of itself is bad, and especially that a high fever is especially bad;
- Often kids feel better, eat and drink better, and are less cranky without a fever.
I’m certainly not going to blame parents for bringing in their febrile child. One could argue we ourselves as emergency physicians spent a good deal of our residency just learning “sick” from “not sick” (but the experienced parent on child two or three usually figures it out pretty quickly, too). Fever is one of the simple ways to say “Hey, there’s probably an infection going on,” and we doctors are Masters of Infections ™, so it makes logical sense. Often reassurance is the most important part of the pediatric visit: I think it’s a virus, the lungs are clear, the ears are normal, and the child is behaving normally, yada yada yada.
Too often I think people also equate fever with “needs antibiotics” or “needs medicine,” for which we’re to blame as professionals as well. I once had a well-appearing, happy, normal-looking 5 year-old with an otitis media whose mother could not believe I was going to send him home with pain medicines but without antibiotics. “I have never, ever heard of such a thing,” she said, storming out at 4 in the morning, only to return with a script from her pediatrician and several choice words about me. It’s so strange that people have so little faith or respect or belief in their own immune systems — that without antibiotics, the human race would die out. We’ve also created a subculture of patients on day 3 or 4 of their cough who get a Z-Pak and then believe that the Z-Pak cured their bronchitis or URI. These are the patients who now are dependent on antibiotics for their magical antiviral properties and demand them immediately, preferring not to listen to reason, logic, or risk-benefit discussions.
It shouldn’t be up to parents to decide “sick/not sick” before coming to the ED, and if we decrease our sensitivity we just end up with more false negatives. If we tell parents not to bring kids in unless they have a fever AND they “don’t look right,” we’re going to have fewer kids overall but sicker ones who eventually find their way in.
There’s no great solution besides educating people about signs and symptoms of a potentially sick child, but we can certainly try to educate people about fevers: they’re not dangerous, they’re probably the body’s way of trying to fight off infection by “making the body work harder and faster than whatever’s attacking it” (my usual spiel), and usually we worry about children becoming dehydrated from viral infections more than the viral infections themselves. What else can we do?