Whoa Nurses!

The “Parent First” or “Watch [Parent] Do It” Strategy: employing the philosophy of having a taster for monarchs because if [parent] does not die after you look in their mouth then it must be okay.

The “Toy Checkup” Strategy: only useful if the kiddo brought their own toy, generally, but kind of fun to show them how you will listen to their chest or check their ROM or look in their ears… (can be combined with the “You Try” strategy–see below)

The “You Try” Strategy: Hand over your stethoscope or your otoscope or reflex hammer or tongue depressor or whatever. Let them touch it and understand it’s not threatening. (WARNING: Toddlers are gross and indiscriminate with their bodily fluids, so be prepared for an unexpected goober/booger/vomit and ALWAYS, ALWAYS clean/dispose between patients!). If going for combo of “Toy Checkup” + “You Try” or “You Try” + “Parent First”, show the kiddo how to do the maneuver for their turn, then it is your turn to check on them, etc.

The “Taking Advantage of Developmental Imagination” Strategy: Stethoscope = special heart, lung, and tummy telephone. Otoscope = lava checker/sucker; otoscopy = checking for [cute or silly thing] inside ears (I tend to accompany this with, “Hello? Are any [cute/silly thing(s)] home? Nope! No one is home. Maybe they’re on the other side?”). Abdo exam = “Did you eat [silly thing]? Maybe I can find it in your tummy!”, or “Did you know that your tummy is also a drum? Listen here! *proceed to percuss*”, or “Where are the [silly/cute thing(s)] hiding in your tummy? Let’s find them…”

The “FOMO” Strategy: Younger kiddos often want what their older siblings have… if you’ve got a cooperative older sibling, examine them first with the little one watching. They usually want what their older siblings have, so they might even be eager for their turn to have their ears checked…

The “Sound Effects” Strategy: Anything you need to palpate or make general contact with in the toddler’s sphere of personal space should have a sound effect. Personally, I’m a fan of “boop boop”. Other kids really like singing and music…

The “Kindasorta Bribing” Strategy: …this one I find is pretty hit-or-miss, but sometimes the thought of a reward will get a bit of cooperation. Always remember that our little friends love stickers.

The “Monkey See, Monkey Do” Strategy: Sometimes you kinda just walk in there, wave at the kiddo and make funny faces at them and get them to warm up to you, and then do the stuff you want them to do and they just… do it. I find it SUPER cute when I do this for MSK exams to check neurovascular status after an injury or for neuro exams, particularly finger-to-nose testing… it’s just so magical.

The “Smoke and Mirrors [and Additional Screentime]” Strategy: I cannot stress enough how powerful distraction is…

The “Yeah… You’re Just Not Having It So Let’s Get This Over With” Strategy: …you just do the thing and you do it as quickly as possible and GTFO. The kid’s already crying, screaming, and trying to get away from you by any means possible so you might as well make it short.

Before I could even answer, I got called to a patient’s bedside. I legit just opened up this page, said, “Sorry team, you can read this until I get back,” and abandoned them again for another 10 minutes.

me after lunch:

“I’m sorry that those other kids have said those scary things to you,” I told him. “Is it okay if we talk a bit more about appendicitis?”

He nodded hesitantly. I gently explained a bit about the pathophysiology of appendicitis–his posture loosened slightly with every passing moment, and with every question I answered for him. 

“So then, why did they say people die?”

“Unfortunately, not everyone gets to the doctors in time and they can get very sick if they don’t get the proper treatment,” I told him. “And some people are very unlucky and have problems happen after their treatments, like allergic reactions to their medicine. But around here we see lots of kids who get appendicitis, and they get better really fast. You’ve probably met other kids who have had appendicitis and you wouldn’t even know it unless you asked!”

“But I was okay after my treatment,” he said, perking up. His mother smiled at him and ‘boop’-ed his nose. “See? I told you they’d take good care of you at the hospital.”

Now much more at ease, we moved on to discuss the kiddo’s current complaints and that they could be in keeping with a recurrence of the appendicitis, which was still very treatable. My little friend got more apprehensive when we had to talk about next steps and investigations, including blood work and imaging.

“Blood? That’s a needle, right?” he asked, voice trembling.

“Unfortunately yes, bud,” I told him. His eyes almost immediately filled with tears. “I promise we will only do the blood tests if we need them to take care of you and get you healthy, okay?”

He nodded, mouth still pressed in a miserable flat line as he tried to hold in his tears.

“I can give you a choice here though, my friend. We can start with the [imaging test] first, and while we do that, we can put on some numbing cream to make the needle poke less pinchy. If the [imaging test] ends up being very reassuring, it’s possible that blood tests are not needed today.”

His eyes went big and round with hope as he looked at his mom.

“That does mean that you may be waiting here in the emergency department for a little longer though,” I told him. He had expressed multiple times that he wanted to go home as soon as possible. “This is because the blood tests take some time to come back, and we still have to wait your turn for the [imaging test]. So if we do the blood tests now then we can wait for both at the same time, and if everything looks good, it’s possible you could go home a bit sooner.”

“Okay,” he said.

“But if the tests all look good today and you’re still not a hundred percent better in a few more days, then the tests may need to be repeated later. Do you understand?”

The kiddo sighed. “To keep me safe and take care of me?”

I laughed. “Yep! You got it.”

He looked up at his mom.

“Can I… Can I get the blood test after the [imaging test]?”

“It’s your body and your choice, kiddo,” I told him. “But your mom also knows how to take care of you best, so is it okay if we ask for her thoughts, too?”

His mom smiled. “Yeah, of course! We’re here to take care of him, and if this is what he wants, the wait is fine. See, hon, you’re not gonna die.”

Her son rolled his eyes and pouted. “I know! I feel better since the two of you talked to me. See? Normally when I’m nervous you can hear the nervous in my voice, but there’s no nervous in my voice. There aren’t even any tears in my eyes!” He pointed to his eyes in an endearingly exaggerated way, and I hid my smile in my mask. “I’m not nervous.”

“I’m glad you’re not nervous, buddy,” I told him. “Do you have any more questions you want to ask me?”

“No,” he said. “I feel better now. I’m not even gonna cry with the needle.”

—–

Talking to your pediatric patients is so important. Where I practice, there’s no legal age for consent, and the process of obtaining consent for treatment requires us as practitioners to assess the capacity of our patients. Of course, in pediatrics, this is more complex when you factor in developmental stages.

I cannot stress enough how often kids will surprise you with the depth of their understanding. It may not always be in the way you expect them to understand something, but they are a lot more perceptive than grown ups tend to give them credit for. Please, if you work with kids in any healthcare capacity, remember:

Sometimes kids don’t know what’s best for them, and that’s developmentally normal. We have to keep their best interests in mind and at heart. So let them exercise their autonomy in other ways–give them choices where you can, e.g. which hand they would prefer their IV/bloodwork, what order they’d like their tests to be done. Even kids at the earliest points of their verbal development are able to participate in discussions like this.

Whatever you do, do NOT lie to kids about pain. Don’t tell them that something “won’t hurt a bit” if it will. And if something does hurt, please don’t tell them not to cry.

It’s so important to validate their feelings. Letting kids know they’re allowed to feel scared and that it’s normal is sometimes all they need to start calming down. I often tell them, “It’s okay to be scared, I’d be scared to do this, too. I’m sorry it’s scary for you. How can we make this less scary?” or “Some kids find it less scary if we ___. Would you like to try that?”

When you are answering kids’ questions, it’s true that there’s a lot of information that you or their family might feel uncomfortable with you telling them directly. Try to take cues from the kiddo’s caregivers to help with this–sometimes it may be helpful to ask a caregiver to step out of the room to chat with them separate from their child before discussing with your patient. These kinds of conversations will not always go gracefully or smoothly like in an example standardized patient encounter in medical school, but they will often be a lot less challenging if you’re receptive to cues from other stakeholders in the room. You won’t always be able to read reactions perfectly and, like me, you will probably still end up with your foot in your mouth every so often, but if you’ve got an eye out then at the very least you can react quickly and avoid inserting your second foot in your mouth alongside the first…

On Sunday, I finished my overnight shift late because I spent a little extra time explaining and re-explaining a management plan to a patient because I was just not confident they understood what was going on. Once they were able to “teach back” what I had told them and all their (many redundant) questions were answered, I ran to catch the train home because the connecting transit system that gets me to the train station doesn’t run until 8am on Sundays. Of course, I reached platform just as the train doors closed, leaving me to wait an hour to catch the next one.

Bottom line: Don’t ever let anyone minimize the personal sacrifice healthcare workers make just to show up every day. Sometimes it’s mustering up the physical and emotional energy to get out of bed after an exhausting run of draining shifts. Sometimes it’s pulling yourself out of a profound sense of grief and depression after having a devastating patient outcome. Sometimes it’s doing your best to shake off what’s going on outside of work so you can truly focus on patient care.

The world is a weird place right now. I’m really disappointed in my fellow Canadians who so steadfastly believe their own rights trump those of their fellow humans that they took to protesting outside hospitals. They have been actively threatening healthcare providers who had no hand in any of the political decisions/mandates and who are already incredibly burnt-out, exhausted, and honestly just trying to do their job and take care of others. They have obstructed their fellow Canadians’ access to healthcare services, including blocking ambulance roadways to multiple major hospitals, including our children’s hospital, that treats many patients who are either too young to be vaccinated, or otherwise extra vulnerable due to age or other health conditions. They have endangered passersby due to their needless gathering in a large group of unvaccinated people, their aggressive behaviours, and consequent traffic obstructions.

We get it–you’re tired of the pandemic. You’re frustrated. You want to get back to enjoying the things you enjoyed before COVID. So do we, and we want that for you. That’s why we encourage as many people as possible to get vaccinated.

Comic on having long-COVID as a young person. Sending love to others who may be similarly suffering.

Ko-Fi

(ID under the cut)