Key Feature 1: When evaluating children, generate a differential diagnosis that accounts for common medical problems, which may present differently in children (ex: urinary tract infections, pneumonia, appendicitis, depression).
Skill: Clinical Reasoning
Phase: Hypothesis generation
Key Feature 7: When investigation is appropriate, do not limit it because it may be unpleasant for those involved (the child, parents, or health care providers).
Skill: Clinical Reasoning, Selectivity
Phase: Treatment, Investigation
I haven't posted in quite a few days now, but it was not for lack of reflection or knowledge-building. In fact, the exact opposite was happening. But it's time to whip myself into blog action.
I started my Pediatric Emergency Medicine this week at BC Children's Hospital. I went into it feeling nervous about my ability to save a child's life. I didn't feel this way because I thought I would be responsible for not saving a child's life on this one-month rotation. Rather, it was because I know that one day in the not-too-distant-future I will not unlikely be the most responsible physician who needs to manage a pediatric emergency. Stressful. So I began my rotation and in almost all of my minimal free time I studied hard on the ABCs of pediatric emergency response, with a focus on respiratory distress, as this is a common life-threatening emergency in pediatrics. After a handful of days of focusing my energy on this, I awoke this morning at 4:05 AM, imagining a parent running up to me with their child in arms with an impending airway obstruction. Jolt of adrenaline! Would I know what to do to save their life? What if it was from a foreign body? How about anaphylaxis? What is the dose of epinephrine to give and what are my next steps? My mind raced through the possibilities, and it quickly uncovered emergencies to which I hadn't yet developed an approach.
Suddenly an inertia-stopping metacognitive thought arose: I am fixated on learning about respiratory distress, necessarily to the exclusion of other things. It's a big topic, and it will take time to sort through all the ins and outs, and there is still so much I have yet to learn. But I have to take it in stride or I'm going to go fruitlessly crazy. I don't need to know how to treat a patient with respiratory distress from a terrorist anthrax attack right now. And at this exact time, I don't need to know all the steps in a rapid sequence intubation of the pediatric patient. Time to get grounded. I absolutely love learning, and I like to follow all the thought rabbit holes, testing my ability to follow the maze of a presenting complaint through to all of the steps I would need to do to address the underlying disease process. I love it so much, and there are endless possibilities such that I will surely spend the rest of my life exploring that infinity. But for now, I need to be able to take care of common and not-so-rare serious problems. I need to learn the basics of family medicine before I try to master how to be an emergency responder.
To be honest, the learning objective that is the feature of this post was what started me on this pediatric respiratory distress fixation. The endless possibilities of addressing the vast differential of which pneumonia could be a part of got me recognising pungent knowledge gaps and motivated (burdened) me to rectify them. This morning, I realised just how preoccupied, perfectionistic, and not productive this was getting to be. While I have not at all mastered an approach to pediatric respiratory distress yet, I have, during this first week on my peds emerg rotation, diagnosed a pneumonia, investigated for a possible UTI in a febrile infant*, and I explored depression in a teenager with suicidal ideation. I have not yet encountered a patient with abdominal pain on this rotation, but when I assessed a pediatric patient in my family medicine clinic earlier this year, the possibility of appendicitis was something I actively looked for, examining the abdomen for signs to rule it out. Besides, I don't think the point of this learning objective is to know everything about managing all of the possible alternative explanations that could result in a similar presentation as, for example, a UTI or a pneumonia. Instead, I think the point is to remember to keep the common and possibly serious reasons for a disease presentation in mind when evaluating a pediatric patient with an undifferentiated presentation. As I mentioned in a previous blog post, pediatric patients - like elderly or immunocompromised patients, or any other patients who have features that make their case not otherwise equal - may have a disease process that presents atypically, and as a generalist I need to first keep the common and worrisome but not-so-rare disease processes on the top of my DDx. Once I've gotten a basic mastery of this, along with all of the other major competencies I will need to attain as a family doctor, then I can get back to developing my approach to mass casualty respiratory distress from chemical terrorism.
*The infant was a 4 month old female with Trisomy 18 and only one functional kidney. Her parents brought her to the children's ED for fever as measured by thermometer earlier that day. Her parents were also concerned about the fact that she hadn't urinated much that day, and they reported that she had presented similarly earlier in life with a urinary tract infection. At the time of my assessment, she was afebrile, but in this patient who was not otherwise a well 4 month old child, I felt her presentation warranted a preliminary workup as she had predisposing conditions that could impair her ability to mount an effective immune response and its telling sign of fever. In the otherwise well febrile child without a localising source of infection, my approach is to start with a complete blood count with differential and a urinalysis. In this child in particular, catching an occult urinary tract infection would be prudent given the importance of preserving her kidney function. So I started by requesting bloodwork (CBCd, along with electrolytes, creatinine, and urea - the latter three tests being ordered given her baseline reduced kidney function and possible dehydration) and a urinalysis and urine C&S. In a child who is not toilet-trained, urine microbial studies unfortunately must be done on a sample of catheterised urine - clean catch is not feasible and bagged urine samples are too often too contaminated to be useful. I have never experienced what I imagine to be the seriously serious discomfort of having a urinary catheter inserted from my urethra to bladder, but I don't wish it on anyone, let alone an infant or child. But the harm of missing a urinary tract infection can be life-threatening, and so obtaining a catheterised urine sample in an infant or child without a localising source of fever must be done. The infant was not found to have signs of a UTI on urinalysis (urine culture pending), and she was sent home without further workup, but I was relieved - as were her parents - that we did the urine test to evaluate for that possibility.