Kids test my emotions as well as their own and their parent’s. Treating them puts me through all sorts of emotions. Immense satisfaction after fixing a pulled elbow; profound sadness and disgust with the realisation that a child’s injuries are the result of abuse – sexual or otherwise; anxiety when it is obvious the child will need an injection; remorse when the treatment inevitably causes the child pain or discomfort; humour with children using laughing gas for temporary pain relief; worry when a parent refuses permission to immunise the child against tetanus; happiness when children thank me for “fixing” them and I offer a brightly coloured T-shirt sticker pronouncing “I was brave today” or “Perfect Patient” . I am glad I am not a paediatrician because I don’t think I could properly manage seriously ill or dying children. That all began when a six year old boy died in my arms, from cerebral malaria, on Manus Island in 1965. ** I also worried every minute of every day about my own children and grandchildren – and still do.
We do see many children of all age groups in ED. Probably, the majority are brought in with relatively minor illnesses by worried parents who cannot get an appointment with their GP. They are usually a pleasure and relatively easy to manage - except when accompanied by an aggressive or particularly demanding parent. Some parents, for example, will demand x-rays when x-rays are not appropriate. On the other hand, some will strenuously object to x-rays when they really are necessary. Others refuse tetanus vaccination following tetanus prone wounds. Over the years it has become less common for parents to inappropriately demand antibiotics but many still do and, of course, there are those who refuse to let us use them. These are challenges we must deal with as best we can. Most times the problem is obvious and routinely sorted out and the patients cause no angst and parent are grateful for our efforts.
“Pulled elbows” are fairly common and usually easy to diagnose and treat. Managing them is immensely satisfying. The condition occurs most commonly in children aged 1 – 4 years. In 50% there is no known trauma – the child suddenly refuses to use the affected arm and lets it hang, limply by the side of the body. Many have a history of the affected arm being pulled or jerked – often by a parent swinging the child by either or both arms sometimes maliciously but usually in fun.
Characteristically the child stands with the arm hanging limply with the hand facing backwards. There is no distress unless the arm is moved. There is no obvious deformity, swelling or significant tenderness as would be present with a broken bone. Characteristically, the parents are very anxious, distressed and guilt-ridden - especially if they have pulled the elbow.
These children are best examined sitting on the parent’s lap. The arm can be very gently felt and examined. If there is no indication of fracture or dislocation it is easy to gently flex the elbow and hold it with one hand while gently twisting the forearm so that the palm faces upward. Usually a click will be felt by patient, doctor and - often - parent. The child will experience a brief pain and cry for a few minutes then relax. After about a half hour of trepidation it will then start to use the arm. The problem is fixed. The mother usually cries with relief, dad is abashed and both are embarrassingly grateful. It remains only to warn the parents that it can happen again and pulling the elbow must be avoided. Rarely, a child will have repeated episodes and require surgery to correct the torn annular ligament that is the root cause of the problem.
The Toddler’s fracture occurs in the same age group as the pulled elbow but is a real fracture in the lower leg. That is, it really is a broken leg. It can be caused by physical abuse but most commonly is a result of the child falling forward with the foot turning outward causing a twisting action to be transmitted through the lower leg. If the fall is witnessed then the description can help with diagnosis. Often, the fall is not witnessed but the child suddenly will not stand on the affected leg.
Examining these children often reveals only that it will not use the leg. There is no swelling and no obvious deformity. No matter how much effort is put into trying to establish a rapport with the child and gain its confidence they will be apprehensive of any contact with the leg. This is a good sign something really is amiss. They may indicate that the pain is coming from the knee or hip. Repeated examinations may give conflicting responses. The trap young players fall into is to conclude that there is really nothing wrong with the child and send it home. The leg must be x-rayed from hip to foot.
Even then, the x-rays may appear normal or, as in one such recent case, show a fracture in only one of several views. Usually, however, a spiral fracture of the far end of the tibia, (shin bone), will be easily seen. The problem is then solved. The treatment is simply to apply a plaster of paris back slab or a full cast for six weeks. (This is simple to do but the consequences are difficult for the parents to manage for six weeks.)
Sometimes the x-rays do not reveal the fracture. The experienced doctor will then treat the child as if there is a fracture, apply the cast and repeat the x-rays in two weeks. The healing process will become visible and the fracture revealed. If it doesn’t and the child still has symptoms then it may be time to involve a specialist.
The child who has been the subject of physical abuse is pitiful but it is critical that the doctor maintains an objective view. Western Australian law mandates the reporting to authorities of such cases or even if abuse is suspected. That removes a significant issue for the doctor who may be in conflict with his or her patient confidentiality ethics. Once reported the doctor can manage the treatment or arrange transfer to a children’s hospital and the responsible authorities handle the unsavoury business of the abuse.
Suspected abuse can be a more difficult issue. For instance, I recently saw a two-year-old who had a fractured collar bone and she screamed when I picked her up to place on the examination couch. (It subsequently transpired she also had fracture ribs.) The mother explained that the child had complained of a sore shoulder for two days but denied witnessing trauma of any type. Examination revealed the fractured collar bone.
There were clear warning signs of abuse here. Delayed presentation is a common feature of abuse. Fractured clavicle is very uncommon in toddlers given the flexibility of the bones at this age and very significant force must be applied to break this bone. I discussed the case with the senior people on the shift and handed the case over to them. The notification of suspected abuse was initiated but I do not know the outcome.
A sleepless night followed. Had the child, indeed been abused? Were the mother and her partner guilty of such repugnant behaviour? Had I unnecessarily initiated a process that would cause them a great deal of stress even if they were innocent? Would it result in the child being taken from its mother? In the end one can only hoped the child’s best interests would be looked after.
Genital injuries in children, of course, also raise the same issues. One only feels confident that sexual abuse has not occurred when there is an independent witness to the incident. And that is uncommon. Girls falling astride monkey bars or the edge of a bath or bicycle frame are relatively common events. Delayed presentation of those injuries starts the alarm bells ringing. I have, thankfully, been spared having to deal with a child sexual abuse case in the acute phase and, with the grace of God, that will not change in the few years left to me in medical practice.
Most children are terrified of needles. I know I always was but, as one matures, one develops enough courage to overcome the fear and permits the cold steel to be thrust into the skin. (There can be no courage without fear!) Enlisting in the navy, as a sick berth attendant, erased my irrational fears given I was first subject to the usual battery of vaccinations and immunisations then, subsequently, found myself on the other end of the needles vaccinating sailors. Even so, I remain softhearted about injecting children but, of necessity, perform the task. Having done that it behooves me to attempt to erase the memory with a couple of bright stickers and a whole lot of sympathy laced with humour.
There are times when it is not possible to avoid causing some children pain during the process of assessment, investigation and treatment. Broken bones are a god example. The child arrives with the limb bandaged or ensconced in bandages or a splint – often makeshift. Usually, this must be removed in order to make a clinical diagnosis and the removal and examination can sometimes be painful. Similarly with burns and lacerations– the bandage must be removed to examine the wound. We often give the child oral medication to relieve pain before we do this but sometimes, if the available information suggests a general anaesthetic will be required, we must forgo it to ensure the child has an empty stomach for the anaesthetic. In such cases one does what must be done as gently and quickly as possible.
Entonox – a mixture of oxygen and laughing gas remains a handy tool. It is great when suturing lacerations in children aged about four and upwards as an adjunct to local anaesthetic. It is difficult not to laugh along with the kids – they really do laugh and giggle – as we get about the procedure. In younger children we tend to use Ketamine or Midazolam (which are required to be injected). These drugs put the child into a trance-like state under which sutures can be inserted, foreign bodies removed, minor fractures put back into place and plaster of paris splints applied painlessly.
If a toddler finds an interesting small object such as a piece of bean bag stuffing or a bead or such like it is London to a brick the toddler will want to insert it into a bodily orifice. The nose and ear are most common and frequently present us with the challenge of removing them. Often as not the child must be anaesthetised with Ketamine or Midazolam. Sometimes we can get away without that especially with foreign bodies in the nose. One very old fashioned method of removing a foreign body from the nose of toddlers is to get Mother or Father to hold the opposite nostril closed, place their mouth over the child’s and give one forceful puff into the child’s mouth. Sometimes this results in the foreign body being ejected from the nostril. I have seen it work – and I have seen it fail. With very cooperative toddlers we can sometimes convince them to let us insert the tip of a sucker into the nostril. This will pull out things like lumps of sponge rubber or bean bag packing but not peanuts, glass beads or similar solid objects.
Parents who refuse to have their children vaccinated are a real worry. There is no point in arguing with them – their beliefs are usually set in concrete – and, of course, we have no authority to act against their wishes. For whatever reason, they have decided that vaccination is not necessary and/or is dangerous to their children. It cannot be denied that there is a risk, albeit very low, of severe reactions to vaccination. It would be a dreadful situation to persuade a reluctant parent to allow us to vaccinate a child then have it suffer a serious reaction. It would be worse to deal with a child with tetanus as a consequence of parental refusal to allow vaccination following a tetanus prone wound.
Adolescents are an interesting group. They most commonly present to ED with injuries sustained in sport or play but occasionally with appendicitis or torsion of the testis or serious infections. With increasing frequency we are seeing them with conditions such as tonsillitis, glandular fever, gastroenteritis and other such common ailments. They present to us because they cannot get in to see their GP. Most of these kids are very pleasant and I enjoy chatting with them about their sports or school or what ambitions they may have. Now and then there will be one, quite young, who already has a realistic, set goal, in life and knows what must be done to reach the goal. I envy them – I didn’t seriously decide on medicine until I was about 21 and locked into nine years service in the navy. Most, though, don’t have or don’t want to divulge an ambition. Yet it is still interesting to listen to their impressions of school, society and life in general. Some even ask about being a doctor. If they express interest I encourage them but don’t pull my punches about what is involved in reaching the goal. I certainly do not glorify the profession for it certainly not glorious.
Occasionally an obnoxious child presents with bad manners or arrogance or demanding. They test one’s patience. Often they are accompanied by parents with similar personalities or with obviously inadequate personalities and the child treats them with as much contempt as they treat us.
However, it is one of the great pleasures of the game to receive a hug, a high five, a shake from a tiny hand or even just a shy smile from a happy child I have had the honour of helping.
** you can find out more about this at https://www.kenhaywriteimages.com/navy
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