By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate knowledge of child protection issues including identification and management of suspected and confirmed child abuse

Key Feature 12:  In children with traumatic injury, rule out abuse. (Carefully assess the reported mechanism of injury to ensure it corresponds with the actual injury.)
Skill: Clinical Reasoning, Selectivity
Phase: Diagnosis, Hypothesis generation

In my last post on trauma, I mentioned how it is important to consider abuse as being a reason patients may present with trauma. Depending on the trauma that has occurred, this may not be obvious, and when you see a loved one who seems legitimately worried about a patient at the bedside, it may seem downright counterintuitive. But victims of abuse are commonly brought in for medical care by the perpetrator, particularly when it comes to  children and their primary caregivers. Assessing for abuse in children can be particularly tricky when it comes to physical trauma: children are clumsy and take chances exploring in sometimes dangerous ways. Getting injured is one of the ways we learn that things can harm us. 

UpToDate offers up some signs and symptoms that may help you pick up on a child with trauma secondary to abuse:

Whenever you have more than a wisp of worry about abuse as a factor in a child's presentation for traumatic injuries, it warrants reporting the situation to the local child protection agency. Some physicians may hesitate to do this for fear of accusing caregivers who actually have not done any harm, which could have serious and unforgiving repercussions such as removing children from a home with caregivers who in fact provide good care. But reporting a situation that is questionable for child abuse does not mean you are charging the parents with abuse. It simply means the child protection agency will perform a thorough assessment to look for evidence that confirms or refutes child abuse. Given the prevalence of child abuse that is always too high (Statistics Canada), and the fact that, according to UpToDate, "Children returned to their families after an event of maltreatment have an 11 to nearly 50 percent chance of a second event," I think most people would agree that it is worth being overcautious at the risk of over-investigating cases and finding that many of them were in fact unintentional injuries.

Key Feature 5a: In a patient with signs and symptoms of shock: Recognize the shock.
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Diagnosis

Key Feature 5b: In a patient with signs and symptoms of shock: Define the severity and type (neurogenic, hypovolemic, septic).
Skill: Clinical Reasoning, Selectivity
Phase: Physical, Diagnosis

You would expect a patient with shock to appear unwell and activate that nerve in your stethoscope that tells you a patient seems unwell. Indeed, this may very well be the case, but on other occasions, it may absolutely not be. Some patients are very sneaky. What may start as one or two symptoms or signs of shock may rapidly progress to full on shockity shock and impending risk of full circulatory collapse, as any sign of shock signals that the body is no longer able to sufficiently compensate for the lack of oxygen reaching the end organs. When it comes to decompensation, it is a slippery slope, so heed any warning and respect its authoritah. 

"SHOCR" symptoms and signs of real-deal shock:

• Symptomatic tachycardia (aka chest pain and shortness of breath)
• Hypotension, H+ (metabolic acidosis or elevated lactate)
• Oliguria
• Cool, clammy, diaphoretic skin
• Restlessness, agitation, altered level of consciousness

Early signs of circulatory compromise (or pre-shock) for which the body may still be compensating  include: 

• Tachycardia
• Tachypnea
• Dry mucous membranes
• Poor skin turgor
• Weak peripheral pulses
• Delayed capillary refill >3 seconds

Note the above signs are generally asymptomatic, and require a clinician to look for them. Anytime a patient is at risk of circulatory compromise, because they appear unwell or because information on history suggests risk (ex: infection, excess vomiting, possible allergic reaction, post-operative, etc.), it is imperative to look for these signs. Intervening during pre-shock means a better chance of preventing deterioration and securing a better outcome for the patient. With decompensation, pre-shock can quickly turn into shock, which can then ultimately lead to end-stage organ dysfunction, characterized by irreversible organ damage, multiorgan failure, and death.

It is also important to know that there are different types of shock, and that not all types present with all of the above features. This is another reason to have a high index of suspicion for shock or at least circulatory impairment when noticing the presence of any of the above symptoms or signs. These signs are also not specific, and may indicate other disease processes (ex: tachycardia in the setting of fever without circulatory compromise per se), but it is important to consider shock or impending shock on the differential to be able to react sooner rather than later if indicated.

Shock is generally classified as being 1 of 4 types, and it helps to narrow down the type of shock based on clues from the primary examination (if possible, but it's important to know that more than one process can be co-occuring) to determine more quickly the underlying etiology and provide definite treatment ASAP.

1. Hypovolemia (This could be from blood loss, third spacing, or some other loss such as diarrhea or vomiting, among others)
   1. Hypovolemic shock may present with signs of dehydration, which are typically not part of the presentation of other types of shock (think dry mucous membranes and reduced skin turgor). A history of bleeding or other source of fluid loss such as from excess vomiting, urination, diarrhea, fever, or sweating can suggest hypovolemia. Shock in the setting of trauma is always suspected to be hypovolemic unless proven otherwise (ex: from internal bleeding).
2. Cardiogenic (This could be from cardiac myopathy such as secondary to infarction, as well as a dysrhythmia or valvular dysfunction)
   1. Cardiogenic shock generally presents as hypotension in association with clinical manifestations of pulmonary edema (ex: diffuse lung crackles, distended neck veins). The heart is not able to pump forward so the blood basically backs up in the lungs and large vessels that transport blood to the heart, such as the jugular vein in the neck.
      
3. Obstructive (This could be from a massive pulmonary embolus, tension pneumothorax, cardiac tamponade, pulmonary hypertension, aortic dissection, or venacaval obstruction)
   1. Similar to cardiogenic shock, obstructive shock usually presents as hypotension associated with distended neck veins, but it is different in that it usually presents without clinical signs of fluid overload (ex: lung crackles, peripheral edema). 
      
4. Distributive (This could be from sepsis, anaphylaxis, toxic shock, neurogenic dysfunction, spinal shock, or an Addisonian crisis)
   1. Distributive shock is also known as warm shock, characterized by loss of peripheral vascular resistance and therefore hypotension associated with warm as opposed to cool extremities more characteristic of the other 3 types of shock. There may be other clues on history that point to an underlying etiology as well, such as a possible allergic reaction (raises suspicion for anaphylactic shock), known preceding infection (raises suspicion for septic shock), or regular corticosteroid use (raises suspicion for adrenal crisis secondary to steroid withdrawal), among others.
      

Crisis

Key Feature 7: Ask your patient if there are others needing help as a consequence of the crisis.
Skill: Patient Centered 
Phase: Hypothesis generation, History

Trauma

Key Feature 3: When faced with several trauma patients, triage according to resources and treatment priorities.
Skills: Selectivity 
Phase: Treatment

Okay so mass casualty trauma is not my forte. To be honest, I had to try repeated search terms in UpToDate to find content in keeping with what I was searching for. But, as it turns out, UpToDate does know a thing or two about triaging in the face of mass casualty (and almost every other medical topic you could think of). From the script of the wizards:

"Appropriate prehospital triage of trauma victims depends on a number of variables, including the nature of the incident, the number of victims, available resources, transport time, and the judgment of prehospital caretakers. As an example, triage for a motor vehicle accident with multiple victims involves determining which patients are most severely injured and ensuring that they are immediately transported to a trauma center. Priorities change during a mass casualty incident capable of overwhelming local healthcare resources. In such a circumstance, priority is placed on providing care to victims most likely to survive; victims with such severe injuries that they are unlikely to survive are given low priority because they consume a disproportionate share of resources."

The article (Prehospital care of the adult trauma patient) then goes on to identify various scoring purposes, which is beyond the scope of my interest, but which could certainly be useful in the mass casualty trauma I hope I never have to deal with. In any case, I think the above paragraph summaries the gist of things, which is that when there are a number of patients who can all receive relatively timely treatment, expedite care first for those who are at greatest threat to life and limb. (And if a solitary patient presents with a history of serious trauma, confirm there were no others injured in the event.) On the other hand, if the mass casualty trauma is so extensive compared to available resources, it may be time to adopt a Saving Private Ryan approach and probably develop PTSD after it's all said and done.

Crisis

Key Feature 11b: When dealing with an unanticipated medical crisis (ex: seizure, shoulder dystocia): Be calm and methodical.
Skill: Professionalism
Phase: Treatment

Key Feature 11c: When dealing with an unanticipated medical crisis (ex: seizure, shoulder dystocia): Ask for the help you need.
Skill: Professionalism
Phase: Treatment

Suicide

Key Feature 5: In trauma patients, consider attempted suicide as the precipitating cause.
Skill: Clinical Reasoning
Phase: Hypothesis generation

Trauma

Key Feature 1: Assess and stabilize trauma patients with an organized approach, anticipating complications in a timely fashion, using the primary and secondary surveys.
Skill: Clinical Reasoning
Phase: Treatment, Physical

Key Feature 2: Suspect, identify, and immediately begin treating life-threatening complications (ex: tension pneumothorax, tamponade).
Skill: Selectivity
Phase: Treatment, Diagnosis

Key Feature 5c: In a patient with signs and symptoms of shock: Treat the shock. 
Skill: Clinical Reasoning, Selectivity
Phase: Treatment

Key Feature 6: In trauma patients, rule out hypothermia on arrival and subsequently (as it may develop during treatment).
Skill: Clinical Reasoning
​Phase: Hypothesis generation, Physical

Key Feature 7: Suspect certain medical problems (ex: seizure, drug intoxication, hypoglycemia, attempted suicide) as the precipitant of the trauma.
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 8: Do not move potentially unstable patients from treatment areas for investigations (ex: computed tomography, X-ray examination).
Skill: Clinical Reasoning
Phase: Treatment, Investigation

Key Feature 9: Determine when patient transfer is necessary (ex: central nervous system bleeds, when no specialty support is available).
Skill: Selectivity, Clinical Reasoning
Phase: Treatment, Referral 

Key Feature 10: Transfer patients in an appropriate manner (i.e., stabilize them before transfer and choose the method, such as ambulance or flight).
Skill: Clinical Reasoning
Phase: Treatment, Referral

I have not yet encountered a patient presenting with life-threatening trauma during my residency so far, but during my clerkship, I did see a handful of these, and I mostly watched and stayed out of the way as my preceptors proceeded to inspect and initiate life-saving measures. Fascinating.

Ironically, although I was getting more exposure to trauma in clerkship, in residency is when I may actually be called upon to direct the resuscitation of a patient with life-threatening trauma. Although it is extremely unlikely that a family medicine resident would be expected to do this in a tertiary hospital like St Paul's Hospital where I work in Vancouver, when I am posted rurally for 2 months next year, on the remote archipelago of Haida Gwaii, it is not unlikely that I may be the one needed to take charge. 

Advanced Trauma Life Support (ATLS) is an emergency response course to trauma (the equivalent of ACLS for cardiac arrest). While I have not taken ATLS, the design is infused into all educational teaching about how to respond to trauma, namely, by calmly and methodically first performing a rapid primary survey to assess and intervene immediately for signs of life-threatening compromise, and then by performing a history and complete secondary survey to not overlook any injuries not noticed on the rapid first-over.

My take on the rapid primary survey is as follows: (ABCDEF)

• Is there a chance this patient could have a c-spine injury (ex: history of blunt trauma)? If so, consider this in any intervention so as not to cause a secondary spinal cord injury. Place patient in c-spine collar or use in-line manual stabilisation when performing resuscitative maneuvers, as indicated.
• Is the patient unresponsive? If so, assess for a central pulse, and if indicated, begin CPR.
• Does the patient have an altered level of consciousness or altered mental status? This can be an ominous feature of global decompensation.
  • Altered level of consciousness can be communicated by the AVPU acronym, where A = alert, V = responsive to voice, P = responsive to pain, and U = unresponsive
  • Altered mental status may present as irritability, agitation, confusion, or lethargy. Often it is a patient's loved one who presents with the patient and raises this concern. It is wise to take this seriously, particularly in reference to young children and elderly patients with less functional reserve.
  • If a patient is getting your spidey senses tingling and making you uncomfortable, consider ordering a movie (starting continuous monitoring, having oxygen ready, obtaining a set of vital signs, starting at least one large bore IV, and considering ordering an ECG)
• Any cause for concern? Call for help immediately.
• Airway & Breathing assessment
  • Examine for signs of airway compromise or respiratory distress (look, listen, then feel)
    • Look for cyanosis, sounds (ex: stridor or silence), or signs of increased work of breathing (ex: accessory muscle use or indrawing). In the setting of trauma, look for flail chest, unequal air entry, and palpable crepitus.
    • Assess relevant vital signs (respiratory rate and oxygen saturation). If a patient is in significant respiratory distress, consider ordering an ABG or getting a portable xray if you think if may help you diagnose and treat a suspected life-threatening etiology.
  • If signs of airway or breathing compromise are found, your first step is to call for assistance, ideally from someone who is skilled in securing an emergency airway (ex: anesthesiologist) or a Respiratory Therapist to assist with ventilation and oxygenation. Note that in a rural setting, your inexperienced self may be the most experienced person fit to intubate it needed (which is why it is important for me to know how to perform emergency intubation, which I have previously posted about).
  • Perform airway resuscitation measures, as indicated:
    • Basic airway management maneuvers (if ventilation is thought to be compromised by possible oropharyngeal obstruction): head tilt (or jaw thrust if ?c-spine injury), sweep/suction oropharynx if foreign body or excess secretions are visualised, inserting an airway adjunct (an oropharyngeal or nasopharyngeal airway, as discussed in a previous blog post), and consider elevating the head of the bed slightly while awaiting definitive airway management 
    • Definitive airway management: Ideally this will be done by an experienced person, but if not, I may have to attempt emergency intubation with the help of a bougie if needed, or alternatively inserting an LMA (all reviewed in a previous post). Alternatively, the option to perform a cricothyrotomy can be life-saving if the other techniques of securing the airway cannot be done
  • Perform breathing resuscitation measures, as indicated:
    • Position the patient upright, or however is best clinically
    • Provide ventilatory support with a bag-valve-mask (unless patient is already intubated)
    • Provide supplemental oxygen, by whatever method is most suitable (ex: low flow nasal prongs, simple face mask, nonrebreather mask)
• Circulation assessment
  • Examine for signs of circulatory compromise
    • Feel for cool extremities, weak pulses, and a capillary refill of >3s
    • In young pediatric patients, look for the additional signs of a sunken anterior fontanelle, an absence of tears when crying, and dry mucous membranes
    • Check blood pressure and heart rate, and consider obtaining an ECG, monitoring urine output with a Foley catheter, and obtaining a FAST ultrasound scan
  • If there are signs of circulatory compromised, you will definitely need help from nursing right away if available to assist with inserting 2 large bore IVs and starting a bolus of normal saline. You may also need to enlist the help of a trauma surgeon, particularly if there is suspicion for active intra-abdominal bleeding.
  • Perform circulation resuscitation measures, as indicated:
    • Position patient supine with legs raised
    • Establish vascular access
    • Control any life-threatening hemorrhage with the principle of pressure
    • Give fluid +/- blood to resuscitate
    • Draw blood for investigations (consider type and crossmatch, beta-hCG, INR/PTT, CBC, metabolic panel, lactate, cardiac biomarkers if indicated, tox screen if relevant, CK if patient was found down, others as indicated)
    • Reverse anticoagulation if indicated
• Disability assessment 
  • Examine for signs of disability by assessing
    • Glasgow Coma Scale score
    • Pupils
    • Bedside blood glucose measurement
    • Perform a gross neuro exam
  • Resuscitation here really means to enlist the help of a neurosurgeon, as indicated
• Exposure/Environment assessment
  • Undress and examine the patient from head to toe for any gross abnormalities
  • In the setting of trauma, it is important to get help and logroll the patient so you can palpate the full length of the patient's spine and perform a DRE to assess rectal tone and for blood.
  • Assess patient's temperature to assess for fever, hyperthermia, or hypothermia.
    • Hypothermia (<35 C) can be a sign of prolonged or intense exposure to cold, or it can be a sign of advanced shock, most commonly because of hemorrhage in the trauma population. Attempt to correct hypothermia by warming the room, using external heaters and warmed blankets, and infusing IV and blood products that have been warmed. More aggressive central warming may be needed for more severe hypothermia (<32 C; warm the trunk before the extremities).
• Forget not to reassess (consider ordering repeat vital signs every 5-15 minutes) and consider the need to transfer the patient to a higher acuity assessment for complete management as needed. (Consider calling to arrange for transfer prior to completing the secondary survey as this is an urgent step to expedite and can take time. Other considerations here include still making sure a patient is vitally stable enough or has life-sustaining measures in place to survive transport, as much as is in your humanly power. Occasionally there are options to transport patients by ground or air, and there are a lot of resource-based decisions that go into selecting a choice that supercede the level of the physician. However, advocating for the option that is in your patient's best interest is always within the domain of the physician.)

After performing the rapid primary survey, perform a history and secondary survey.

The brief initial trauma history is best known as obtaining a SAMPLE history. 
S = Symptoms at present
A = Allergies
M = Medications
P = Past medical and surgical history
L = Last eaten when (important if considering need for surgery)
E = Events leading up to and surrounding trauma (This includes gathering information to determine precipitating factors such as substance use, mental illness, seizure, or domestic violence, the latter of which requires a high index of suspicion. In particular, it is important to think of this possibility with patients who may be vulnerable to repeat trauma if it is not picked up and they return to an abusive living situation. Consider intimate partner violence, consider child abuse, and consider elder abuse in terms of who may be a victim. Consider self-harm/attempted suicide. Does the mechanism of injury make sense? If your gut is twitching, pay attention.)

If the patient is not getting expedited to surgery and is stable enough to answer more questions, consider obtaining a more complete history as indicated.

The detailed secondary survey is essentially a complete head to toe examination that assesses as much as can be examined. Then you can consider if any additional investigations not yet ordered would be helpful (ex: CT scans may be quite helpful but are generally contraindicated if a patient is unstable; first-line imaging in the unstable patient includes portable xray and FAST scan). 

Note that in the approach above, I reviewed general resuscitation measures, but I didn't review the approach to addressing any rapidly reversible specific life-threatening etiologies that may be suspected during the assessment per se. If there was a life-threatening etiology of distress that was suspected on the primary or secondary survey, immediate correction of this is warranted. Two important complications of trauma to be on the lookout for when performing the rapid primary survey are tension pneumothorax and cardiac tamponade. These seriously life-threatening etiologies are as fatal as they are correctable, so the assessing physician needs to be on the lookout for them and correct them swiftly if detected.

Tension pneumothorax
A tension pneumothorax can be a complication of trauma, and should be suspected in the patient who has dyspnea, hypotension, and ipsilateral decreased breath sounds. It is basically the creation of a one-way valve, or a sucking chest wound, which causes air to fill up the thorax, compressing the lung and major blood vessels in the thorax. Confirmatory imaging in the setting of high suspicion for this should not be done, and the physician should proceed to decompression of the lung immediately with a large angiocatheter (ex: 14 gauge) or else by immediate tube thoracostomy. Needles may need to be as long as 7-8 cm to penetrate far enough into the chest wall of a large patient. Insert the needle into the second or third intercostal space in the midclavicular line, or alternatively into the 5th intercostal space in the anterior or midaxillary line (success is reportedly better at this latter site). If needle decompression is done, then tube thoracostomy will simply need to follow immediately after. This is because there is expected to be blood and fluid that will fill this space afterward and so is necessary to allow it to drain. The chest tube should be at least a  size 36 French.

Cardiac tamponade
Otherwise known as pericardial tamponade, this can occur as a complication of trauma and basically involves the sac around the heart filling with blood, constricting the heart and impairing it's ability to function as a pump. Unsurprisingly, this can lead to a triad of signs (known as Beck's triad) that are as follows: hypotension (from decreased cardiac output), jugular-venous distention (from impaired venous return to the heart), and muffled heart sounds (from decreased transmission of heart sounds as they are muffled by the surrounding fluid-filled sac). Nowadays, if and when rapid bedside FAST ultrasound scans are done in trauma, this is another way this can be picked up. However, it is unlikely I will have someone around to do a FAST scan when I am practicing rural medicine. The treatment for cardiac tamponade is drainage or pericardiocentesis and may need to be done at the beside if the patient's life is truly and emergently threatened. Yikes!

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate awareness of ethical and cultural considerations and legislation involved in men’s health (ex: contraceptive and pregnancy counselling for minors, childhood sexual abuse, effects of poverty, low self-esteem and marginalization on the health of men)
  

Contraception

Key Feature 1: With all patients, especially adolescents, young men, postpartum women, and perimenopausal women, advise about adequate contraception when opportunities arise.
Skill: Patient Centered, Communication
Phase: Treatment

Eating Disorders

Key Feature 1: Whenever teenagers present for care, include an assessment of their risk of eating disorders (ex: altered body image, binging, and type of activities, as dancers, gymnasts, models, etc., are at higher risk) as this may be the only opportunity to do an assessment.
Skill: Clinical Reasoning
Phase: History

Immigrants

Key Feature 4c: As part of the ongoing care of all immigrants (particularly those who appear not to be coping): Assess patients for availability of resources for support (ex: family, community organizations).
Skill: Clinical Reasoning, Patient Centered
Phase: History

In Children

Key Feature 2: As children, especially adolescents, generally present infrequently for medical care, take advantage of visits to ask about:

1. Unverbalised problems (ex: school performance)
2. Social well-being (ex: relationships, home, friends)
3. Modifiable risk factors (ex: exercise, diet)
4. Risk behaviours (ex: use of bike helmets and seatbelts)

Skill: Clinical Reasoning, Patient Centered 
Phase: History, Treatment

Key Feature 3: At every opportunity, directly ask questions about risk behaviours (ex: drug use, sex, smoking, driving) to promote harm reduction. 
Skill: Clinical Reasoning, Communication
Phase: History, Treatment

Key Feature 4: In adolescents, ensure the confidentiality of the visit, and, when appropriate, encourage open discussion with their caregivers about specific problems (ex: pregnancy, depression and suicide, bullying, drug abuse). 
Skill: Communication, Patient Centered
Phase: Treatment

Substance Abuse

Key Feature 4: Discuss substance use or abuse with adolescents and their caregivers when warning signs are present (ex: school failure, behaviour change).
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment, Diagnosis

Key Feature 6: Offer support to patients and family members affected by substance abuse. (The abuser may not be your patient.)
Skill: Patient Centered
Phase: Treatment

Trauma

Key Feature 11: Find opportunities to offer advice to prevent or minimize trauma (ex: do not drive drunk, use seatbelts and helmets).
Skill: Clinical Reasoning
Phase: Treatment

Being in the Pediatric Emergency Department for just over one week now, I've been getting much-needed exposure to sick kids. I need to know what they look like, how to recognise when they're at risk of decompensating, and how to intervene in this natural history. Being in the Pediatric ED has also reminded me that so many acute problems are really exacerbations of chronic issues with potential to be attenuated by strong primary care connections. This is because these problems are often significantly aggravated or alleviated by social issues that cannot be sufficiently addressed with fleeting relationships of care, as is the case with emergency department medicine. This is not to knock emergency medicine. It is a miraculous thing in a time of crisis. But it is not a solution (as it is not intended to be) to many problems grounded in and complicated by psychosocial factors, the rule rather than the exception when it comes to illness and wellness. 

The welfare of all people hinges on social determination. To have a significant positive impact on health and wellbeing it is necessary to modify the social factors that determine them. As a family doctor this means I must ask about patients' social factors to gain insight needed to modulate them, if possible. This is particularly important when it comes to managing the health of patients who are more vulnerable, having a reduced capacity to control the social factors that can seriously harm or help them. Children and adolescents make up a particularly vulnerable population for this reason, so although it is always important to gather any patient's social history, it is all the more critical when it comes to pediatric medicine. Furthermore, while the vulnerability of a child may decrease as they grow into adolescence with increased self-determination, this autonomy comes at a time when their capacity to manage emotions may be underdeveloped, increasing risk of harm by impulsive behaviour.

People present for medical care for medical concerns. They typically do not present to address social determinants that may create or contribute to medical problems before they have arisen. So when it comes to primary care and its priority for preventative health, it is necessary that the primary care practitioner suss out those social barriers and strengths. The classic acronym used to remember the important elements to always ask about when it comes to the adolescent social history is HEADS (with a variable number of trailing S's as people tack on more things to alliterate with the letter S to remember to include). This is my version, with the general categories laid out that need to be explored more in depth as indicated. I also use it to think about the important elements to ask when interviewing people of all ages, so certain questions listed here may not be all that relevant for pediatric patients specifically. It may in fact seem quite odd to think about applying parts of this acronym to a 5 year old (unlikely to be using illicit drugs, for example), but sometimes these can still be helpful to keep on the template because it prompts me to think about factors influencing their circumstances (ex: parental illicit drug use). In fact, this concept serves as a reminder to me to ask about problems with important relationships in general, when taking any complete medical history as any patient's family doctor: it is not uncommon for parents to have distress over the problems their children may have as well, such as may be the case in the setting of substance use as well.

HEADS

• Home (ex: who do they live with, where do they live, what is their housing situation, does the household have difficulty making ends meet at the end of the month, can they afford any medications they may need, assessment of function +/- Advance Care Planning)
• Education/Employment (ex: what have they done as far as obtaining education, how they are doing if currently studying and if they able to meet their goals, employment history and any concerns +/- screen for worksite exposures and counsel about injury prevention as indicated)
• Activities (ex: how do they spend their time outside of school, what do they do for fun, counsel about injury prevention as indicated, what do they do to take care of their health and wellbeing, any associated risk factors for infectious disease such as traveling or camping or being around others who have been ill)
• Drugs/Dieting
  • Do they use alcohol/smoke/other drugs
  • Do they have poor body self-image +/- any restrictive or binging behaviour, especially with teens who engage in certain types of activities, such as dancers, gymnasts, models, etc. that makes them at higher risk of developing an eating disorder
• Social/Safety (ex: experiencing any forms of abuse [ex: child abuse, bullying, intimate partner violence, elder abuse], time spent using screens/social media, what social supports do they have, any intimate relationships, consider obtaining a sexual history as well, including inquiring about contraception use)

Gathering a history that includes the above elements, as tailored to the patient, +/- obtaining collateral history, can provide insight into salient social issues that may be impacting on - and that may be impacted by - the patient's health. I can then attempt to work with the teenager or parents of a child to address factors that may be the underlying reason they presented for medical care in the first place. 

One last comment I will make here is the importance of opening the process of gathering a social history from adolescents with a confidentiality statement. Adolescents are in a unique transitional period during which many aspects of their life are still being managed by parents or other guardians, but gradually they are assuming more responsibility. If the adolescent patient presents for care with a parent - after the parent has had opportunity to provide collateral information on the presenting concern - I have the parent leave the examining room so I can gather a social history from the adolescent in privacy. It goes without saying that many teenagers may not want to disclose sexual activity or substance use with a parent present, so this presumably increases my ability to gather accurate information. In the same vein, I always start this sans parents portion of the visit with a confidentiality statement, to ensure the adolescent understands that whatever they tell me at this point is confidential, and that unless they tell me something would warrant an exception to the rule of confidentiality (that they are hurting themselves or others, or that someone is hurting them), then whatever they disclose to me is just between the two of us. When the adolescent patient does disclose information that indicates they are having a hard time coping, and considering my HEADS assessment as it pertains to social supports, if the adolescent has trust in their parents then I do encourage patients to share their concerns with their parents or other supportive allies. I do leave it up to them to decide what exactly and how much they wish to disclose, and say that if they chose not to that is completely okay. I also let them know regardless that they can always return to the clinic for further support with their ongoing issues. And last but not least, I often end my adolescent visits with a recommendation to check out the Sex & U website, a wonderful resource for all adolescents to learn about sexual health and a plethora of related topics, all organized on an aesthetically-appealing interface that is easy to navigate and understand.