You can’t prepare for a rotation in the pediatric ER

Walking into Riley Pediatrics Hospital in Indianapolis, Indiana, and having just completed two prior rotations in emergency medicine at two different level 1 trauma centers, I thought I would be able to easily fit in with pediatric population here. I thought I would be able to slide fluidly from patient to patient, oral reports to consults, while staying connected with the rest of the team. I thought I would be able to resume as I had previously functioned in the adult world, and I thought I would enjoy seeing kids again, as it has been almost a full year since my outpatient pediatric rotation. I was entirely surprised by how differently I would feel in seeing truly sick kids.

The aspect of emergency medicine I love the most is being able to care for patients in the acute phase. I love being able to see the problem first in line, do what I can to help the patient, stabilize them, and then direct the care to where they need to go. I think emergency medicine is really quite fun in that regard. I enjoy seeing the patients and talking with them, and I doing some good for the patients.

When my patients are kids, though, an entirely different feel encompasses the encounter. Previously, my experience in a pediatrics office was where the “sick” kids would have runny noses, coughs, or ear infections. Everyone else was largely healthy and happy. (Well, maybe not happy, but definitely healthy!)

Entering the room of my first patient on my first shift, I met a two 2-month-old girl who could no longer feed due to an enlarging aneurysm in her cheek. Her oral intake had declined of the last few days, and the number of wet diapers had been steadily dropping. She was scheduled for surgery in the next three days, but her parents were worried that she wasn’t going to feed enough in the interim. She looked entirely uncomfortable.

Her enlarged, heavy cheek forced her head to the side whenever she lay down, and despite her best efforts to toss around like a typical 2-month-old baby, the awkward positioning of her head inevitably pushed the rest of her body into a slightly twisted, contorted, and uncomfortable positioning. Her distressed parents were anxious for their girl, and helplessly watched as their daughter’s cheek painfully prevented her from latching. We had a good discussion, decided to place an NG tube and consult with ENT, then admitted the girl until the surgery could be performed. Simple case, simple admission, simple fix — but the memory of the enlarging buccal aneurysm, fully one-third the size of her small head, continued to follow me.

A few shifts later, I met a teenage boy with metastatic cancer coming in for abdominal pain. In reviewing his chart, I saw that he met with palliative care about five months previously, when he declined further chemotherapy and anticipated living only for the next six months. For several minutes, I sat looking at the screen, my mind racing. Certainly, I had read about these cases, learned the pathophysiology, could talk about the genetic markers, and recite the biochemistry behind the chemotherapy drugs. I have also met and cared for many adult cancer patients before as well.

But, I had never met someone younger than me with cancer. I had never met a kid in his final stages who was looking at his last remaining weeks. In my mind, I kept asking myself, “What can I do here? How do I even begin the assessment and plan?” As the minutes stretched on and I dawdled at the computer, I realized that there wasn’t anything medically-speaking that I was searching for. I knew how to take a history and perform a physical exam. I knew we would likely provide pain medications, fluids, and include an empiric antibiotic in an immunosuppressed, tachycardic patient with a soft blood pressure. This wasn’t a cognitive preparation, but an emotional one. I was steeling myself to face this patient. I was reaching down in the alcoves of emotional reserve before I met this boy, almost as if I were preparing myself to grieve for the pending death of the boy I had yet to meet. I also realized that over the past few shifts, the encounters with sick, young patients had left me drained.

In my encounters with sick, adult patients, I had certainly felt empathy for their conditions as well. I strove for compassionate care, dutifully performing the tasks of a medical student to my best ability, and appropriately making recommendations for their management. I had even connected with many patients who were likewise in bleak prospects, facing days of life left due to their condition. I have run many, many codes, and worked on traumas of all sorts — from horse-and-buggy accidents to motor vehicle accidents to gunshot wounds and stabbings. I had never felt depleted, though, like I have while taking care of sick kids.

The mental model for pathophysiology has, up to this point, only theoretically been applied to those in their younger years. I’ve been able to apply a generalized, incorrect model that “kids bounce back,” while older adults are the ones who crash. In coming face-to-face with this model, I know that in general, kids do indeed “bounce back” — but some don’t. And even for the ones that do, seeing a young kid before the “bounce back” can be difficult, emotionally.

As my month wore on, I found that I became less and less shocked at the initial exposure to a sick child, and more and more I saw them as just kids – kids who still giggled when I tested their reflexes and laughed at the funny faces we made during the cranial nerve exam. It was these little reminders that made me feel that, like all other patients, sick kids are kids, too.

Austin Beck is a medical student.

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