When Little Ones Get Hurt
With the specialized pediatric emergency care of the 90s,
they’re getting better care than ever before
Children are not little adults,” says Marie Lozon, M.D.
“My secret,” she adds, grinning, “is that adults
are just big children.”
Marie Lozon |
The comment bespeaks the cheerful earthiness of the medical
director of the Health System’s Emergency Department’s
pediatric area, but her point is nonetheless a serious one.
Just as the care of children is recognized as a specialty in
its own right, so the emergency care of children is sufficiently
different from other aspects of both fields to warrant its subspecialty
status.
“We have a whole different set of issues to be concerned
about,” says Lozon. “Injuries can affect children
differently than they do adults. Children are growing, their
bones are not completely fused. Their brains are not like adult
brains. If children suffer an injury, their little bodies may
react differently from those of adults. If you don’t have
a sensitivity for the different ways children react to illness
or injury, you can miss the boat, miss a serious injury or illness,
and then it’s too late to do well for the child.”
This sense of urgency rises a few notches with the knowledge
that trauma is the leading cause of death among children older
than nine months. “It’s more than all other diseases
combined,” says Lozon, “so expert care of injured
children is required to reduce morbidity and mortality. Children
have different patterns of head injury than adults do, and head
injury is what usually kills them, so being able to recognize
and manage serious head injury in children is very important.”
And there are procedural differences as well. “One of
the most important things to be able to do for an emergency
physician is to manage the airway, and the airway of a child
is very different from the airway of an adult,” she says.
“And the way that a child’s vascular system reacts
to shock is different from the way an adult’s does. Children
can compensate for hemorrhagic shock in such a way as to appear
generally stable or well until they’re very seriously in
danger.”
Physical separation of adult and pediatric patients is also
better for all concerned. “It’s often not reasonable
to house ill children next to ill adults, for both their sakes,”
says Dr. Lozon. “If you’re having a heart attack,
do you want to hear a nine-month-old baby screaming? If you
bring in a child with croup in the middle of the night, do you
want to hear a drunk cursing in the next room? That’s why
we feel having a special area to care for children, where there
are toys, distracting pictures, and a certain kind of nursing
staff is really very important. Children tend to do better in
that environment.”
Pediatric emergency physicians also must learn to recognize,
and act on, the symptoms of physical and sexual abuse. “It
can be a very tricky and subtle business,” says Dr. Lozon.
“The child may come into the emer-gency department with
an injury or a complaint that, on the face of it, seems very
innocent, but if the child is examined or the story does not
seem to match up with the pattern of injuries or pattern of
illness, this can be recognized and appropriate steps taken.”
She has her share of war stories, but prefers to focus on the
ones that represent successful teaching experiences. “A
resident saw a little girl who complained that it hurt when
she went to the bathroom,” she says. “He got a urine
specimen, which was the appropriate thing, and it indicated
she might have a urinary tract infection, and he wrote a pre-scription.
I said, ‘Did you examine the child’s bottom?’
He said, ‘No, she looked okay.’
“We went back to examine her genital area and it was clear
she had been sexually abused. When the family was questioned
more deeply about the child’s caregivers and any potential
for abuse, it was clear that the potential was high. The make-up
of the household revealed many suspects. The child was admitted
to the hospital and later found to indeed have been abused.
Possibly in another department, that child would have been dismissed
as simply having a UTI, which she indeed had, but I’ve
looked at so many little kids’ bottoms that I can tell
you what looks normal and what doesn’t.”
Perhaps equally important, she knows “what sounds like
a reasonable story and what doesn’t.” This is invaluable
from a pedagogical perspective. “The young training physicians
seeing patients in the emergency department do not have the
experience that the attending physicians have,” says Lozon.
“One of the important ways we can help them is to give
them the “Heads up” that says, ‘This doesn’t
look kosher, let’s contact the child protection authorities.’”
Reporting abuse to the proper authorities, though, can be the
least of it. “Sometimes you have to be willing to incur
the wrath of a parent when you say you have to take custody
of their child because you believe they’ve abused or neglected
them,” she says. “You have to do what’s best
for the child and not have fear, and that’s a scary thing.”
At such moments both the emergency physician’s self-confidence
and can-do attitude, and the pediatrician’s experience
in dealing with parents are both needed.
“In pediatrics, there is more than one patient in the
room,” Lozon says. “You’re also taking care of
the parents. The people making the decisions for children are
the adults. A huge part of pediatric practice is reassurance,
of parents and children.”
In addition to knowing how to provide reassurance, the pediatrician
in the emergency room has to know how to quickly change her
style or way of interacting with the child according to the
child’s developmental age, which may not always match chronological
age. “Learning to deal with a recalcitrant toddler to obtain
a proper physical exam is one thing,” Lozon says. “You
have to change your style in dealing with an adolescent, who
is basically still a child but feels an element of autonomy.
You have to go from room to room and instantaneously change
the way you relate to people.”
But people skills and being light on one’s feet are among
the hallmarks of emergency medicine. “Most people attracted
to emergency care enjoy the requirement to make decisions based
on a very limited set of data,” she says. “You have
one opportunity to address the patient’s illness, you have
a brief window, and you need to have a very good ability to
integrate information.
“There’s an element of self-confidence that’s
required. You have to be the leader of a team of people who
could be called upon at any moment to work on a patient with
what may be a limb- or life-threatening problem, and you have
to be able to do that instantly and keep in mind all the other
patients in the emergency department. And these patients are
very stressed; they can be quite annoyed with you, they may
have had long waits, they’re anxious, and when their most
unappealing characteristics come forward, you have to be a counselor,
a spiritual advisor, a friend, a fellow parent.”
And you also—as a bonus—get to practice procedural
skills. “Many people don’t want to do procedures all
day, so they don’t become surgeons,” says Lozon, “but
they would like the opportunity to do life-saving procedures
when necessary. I enjoy doing complex intravenous line placements,
managing airways. And I’m interested in pain relief in
injured children. That is a major mission of mine that has been
only recently addressed in the medical community. Children historically
have been vastly under-treated for their pain, and this is an
area where the pediatric emergency specialty has made great
strides.”
She cites, as an example, the evolution of treating a child
with a broken leg. “If you asked an orthopedic surgeon
who had been here for many years, ‘What kind of support
did you receive to care for a child with a broken leg in the
emergency department 20 years ago vs. now?’, he would tell
you he now receives expert pain control and sedation for children
when they have their fractures reduced,” she says. “That
means the child is better served, and the surgeon doesn’t
have to tie up an operating room or an anesthesiologist to put
the child to sleep to set the bones. The best thing is that
the child doesn’t have to endure undue pain and suffering,
and the orthopedist can do the job humanely and more effectively
because the child is asleep, and at much less cost than calling
in an anesthesiologist and an OR team. That is now the standard
practice—to put the child to sleep in the emergency department
and do their care there.”
Lozon and her team can enjoy such moments of triumph only briefly,
however, before they’re on to the next emergency. “I
think a lot of us have a short attention span,” she chuckles,
“and this is where I can put mine to good use.”
Also:
A Discipline
for the 90s: Emergency Medicine Comes of Age and Gains New Visibility
in the Medical School
25 Years
of Progress in Emergency Medicine.
Emergency
Medicine Research: The Goal is Always Fewer Emergencies
The Emergency
Medicine Delivered by Hawkeye and Hot Lips Was Always the Best—and
Walter Dishell Was There on the TV Battlefield to Make Sure
of It
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