On a recent shift I had a 10-year-old who was very anxious and worried about coming to the hospital. When I asked him more about what was worrying him, he got very withdrawn; he eventually gave his mother a pleading look until she disclosed that he was scared he “was gonna die”. Surprised and a bit alarmed, I probed a bit further. Between my patient and his mom, they were able to explain that the poor kiddo had been admitted for acute appendicitis a few weeks ago that was managed non-operatively. Other kids at school told him that people died from appendicitis, making this poor kiddo terrified of coming back to a hospital because he thought he might die.
“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…
- Use your resources to help ease the process for kids. At children’s hospitals, we are so, so lucky to have wonderful Child Life Specialists to work with. Know what resources your centre has to help reduce pain, anxiety, and distress for children that you take care of.
Reblogging for the excellent advice
(via wayfaringmd)
