CluelessMedic

My current job has me working with children, which is kind of a weird shock after years in environments where a “young” patient is 40 years old.  Here’s my impressions so far:

Birth - 1 year: Essentially a small cute animal.  Handle accordingly; gently and affectionately, but relying heavily on the caregivers and with no real expectation of cooperation.

Age 1 - 2: Hates you.  Hates you so much.  You can smile, you can coo, you can attempt to soothe; they hate you anyway, because you’re a stranger and you’re scary and you’re touching them.  There’s no winning this so just get it over with as quickly and non-traumatically as possible.

Age 3 - 5: Nervous around medical things, but possible to soothe.  Easily upset, but also easily distracted from the thing that upset them.  Smartphone cartoons and “who wants a sticker?!!?!?” are key management techniques.

Age 6 - 10: Really cool, actually.  I did not realize kids were this cool.  Around this age they tend to be fairly outgoing, and super curious and eager to learn.  Absolutely do not babytalk; instead, flatter them with how grown-up they are, teach them some Fun Gross Medical Facts, and introduce potentially frightening experiences with “hey, you want to see something really cool?”

Age 11 - 14: Extremely variable.  Can be very childish or very mature, or rapidly switch from one mode to the other.  At this point you can almost treat them as an adult, just… a really sensitive and unpredictable adult.  Do not, under any circumstances, offer stickers.  (But they might grab one out of the bin anyway.)

Cranquis: … so this virus will probably stop causing fevers within the next 2 days, and as long as he keeps drinking liquids meanwhile, he’ll be just fine.

Mom: BUT YOU’RE GOING TO GIVE HIM ANTIBIOTICS FOR THE INFECTION RIGHT.

Cranquis: Well, if there were any signs of bacterial infection on his exam, I would definitely do that. But this is a viral infection, and viruses just giggle when they see antibiotics.

Mom: NO YOU GUYS HAVE STRONGER ANTIBIOTICS THAT KILL ALL THE VIRUSES TOO AND YOU’RE GOING TO GIVE HIM SOME BECAUSE I AM SICK AND TIRED OF HIM GETTING VIRUSES EVER SINCE HE STARTED DAYCARE 6 MONTHS AGO.

Cranquis: That’s the unfortunate nature of daycare – kids share all their viruses around a lot. On the plus side, he’ll have a much healthier immune system by the time he starts school and–

Mom: HE WON’T EVEN SURVIVE TO START SCHOOL AND WHEN HE DIES BECAUSE OF THIS VIRUS IT’S GOING TO BE YOUR FAULT FOR NOT GIVING HIM ANTIBIOTICS. THERE HAS TO BE SOMETHING YOU CAN DO TO KEEP HIM FROM GETTING VIRUSES.

Cranquis: Well, funny you should mention it, because I noticed he hasn’t had a flu shot yet, and the flu is a virus that could actually kill him, so a flu shot could help keep him from getting a deadly virus.

Mom: I’M NOT PUTTING THOSE CHEMICALS IN HIS BODY HE NEEDS TO FIGHT IT OFF ON HIS OWN.

Cranquis: … so this virus will probably stop causing fevers within the next 2 days, and as long as he keeps drinking liquids meanwhile, he’ll be just fine.

Mom: BUT YOU’RE GOING TO GIVE HIM ANTIBIOTICS FOR THE INFECTION RIGHT.

Cranquis: Well, if there were any signs of bacterial infection on his exam, I would definitely do that. But this is a viral infection, and viruses just giggle when they see antibiotics.

Mom: NO YOU GUYS HAVE STRONGER ANTIBIOTICS THAT KILL ALL THE VIRUSES TOO AND YOU’RE GOING TO GIVE HIM SOME BECAUSE I AM SICK AND TIRED OF HIM GETTING VIRUSES EVER SINCE HE STARTED DAYCARE 6 MONTHS AGO.

Cranquis: That’s the unfortunate nature of daycare – kids share all their viruses around a lot. On the plus side, he’ll have a much healthier immune system by the time he starts school and–

Mom: HE WON’T EVEN SURVIVE TO START SCHOOL AND WHEN HE DIES BECAUSE OF THIS VIRUS IT’S GOING TO BE YOUR FAULT FOR NOT GIVING HIM ANTIBIOTICS. THERE HAS TO BE SOMETHING YOU CAN DO TO KEEP HIM FROM GETTING VIRUSES.

Cranquis: Well, funny you should mention it, because I noticed he hasn’t had a flu shot yet, and the flu is a virus that could actually kill him, so a flu shot could help keep him from getting a deadly virus.

Mom: I’M NOT PUTTING THOSE CHEMICALS IN HIS BODY HE NEEDS TO FIGHT IT OFF ON HIS OWN.

Should bisect carina, tip below the diaphragm and moving towards the patients left side.

When you see it…..

Emergency Criteria for Dialysis

refractory pulmonary oedema or fluid overload

persistent hyperkalaemia (>7)

severe metabolic acidosis (pH <7.2 or BE <10)

1 - no response

2 - extensor response to pain (decerebrate posture)

3 - abnormal flexor response to pain (decorticate posture) - to remember think it is “better” as the body is being covered/protected

4 - withdraws to pain

5- localises to pain

This diagram shows how the mechanics of the heart co-ordinate with the heart sounds and the ECG (EKG).

By keeping this diagram in mind, it can make identifying murmurs much easier, by taking the pulse whilst auscultating.  

Here’s some causes of murmur patterns:

Ejection Systolic Murmurs

AorticStenosis - Ejection systolic murmur, radiates to carotids (In Aortic Sclerosis, there is no carotid radiation)

Pulmonary Stenosis  - Ejection systolic murmur which radiates to back/left scapula (may obscure second heart sound)

Atrial Septal Defect - sounds like pulmonary stenosis

Hypertrophic Cardiomyopathy - Harsh Ejection systolic murmur, palpable

Pansystolic Murmurs

Mitral Regurgitation - Best heard at apex, radiates to axilla

Tricuspid Regurgitation - Best heard at left lower sternal edge (tricuspid region) 

Ventricular Septal Defect - Best heard at left sternal edge

Early Diastolic Murmurs

Aortic Regurgitation - best heart at left sternal edge, in expiration, with patient leaning forward

(Rarely) Pulmonary Regurgitation

Mid-Diastolic Murmurs

Usually Mitral Stenosis - Best heard with Bell of stethescope at apex, with patient rolled to left

Rarely Tricuspid stenosis - sounds simliar to Mitral Stenosis

Continuous Murmur - referred to as a ‘machinery murmur’, although I don’t think anyone knows what machine it sounds like.