Parental Guidance in the Pediatric ED

Parental Guidance

Certainly saving lives is an exciting and rewarding aspect of our roles in the Pediatric ED; however, not all encounters need Chest Compressions and Epinephrine.  I do believe that we are uniquely positioned and trained to discover what each patient is in need of and to provide that to them.  Sometimes that need is antibiotics for an Acute Otitis Media. Other times, that need is ondansetron, an ice-popsicle, and reassurance. Still, other times, the perceived parental need is in need of being adjusted to what is reasonable. That can require a fair amount of education.  In fact, the educational aspect is as important as the final medical plan. With this being the last Morsel of 2018, please indulge me as I offer up a few of my perspectives on Anticipatory and Parental Guidance in the Peds ED:

What follows is a few of my perspectives… based on “extensive personal clinical research and application.” It is not from case-control trials and is only blinded when I close my eyes tightly and hope for the best. Put simply, what follows is based on my clinical experience. Feel free to share yours in the comment section below.

Sean M. Fox, MD, FACEP, FAAP

We Are on the Same Team

  • Medicine was once practiced from a maternal/paternal perspective. 
    • The balance of “power” was with the physician
    • “I see your problem. I know best. Do what I say and it’ll get better.
    • This was bad for patient autonomy.
  • Medicine has evolve to focused on patient autonomy.
    • This is good, but can lead to physicians treating their roles as that of “health care consultant.”
    • “Here’s what I know. This is what I think you should do, but you have options and one of those options is to ignore me.”
    • Physicians can easily abdicate responsibility for educating and re-educating the patient/family in this relationship.
  • I prefer a Team Approach. 
    • Families, patients, and phsyicians are on the same team with the primarily objective of caring for the patient.
    • Physicians are the leader of the health care education… the head health coach (if you like sports analogies).
      • We coordinate the strategy, but still need to whole team to cooperate in unison.
      • This requires education… to ensure the entire team working in an orchestrated fashion toward the same goal.
    • Families and patients are the important teammates who actualize the plan.
      • If they don’t understand the plan accurately, the goals won’t be achievable.
      • Occasionally, the teammates may disagree with the coach’s strategy, but often there is a reason for that too… one the coach should attempt to discern rather than taking offense (which is the difference between “poor adherence” and “non-compliance” to the medical plan).
    • When there is a disagreement between teammates, refocus on the primary goal.

Anticipatory Guidance vs Return Precautions

  • My Pediatric training taught me to give “anticipatory guidance” to all of my families coming to clinic for well child visits.
    • Educate the families about what to expect in the coming months as their child grows.
    • It helps them know what is normal and help detect what is not.
  • My Emergency Medicine training taught me the importance of “return precautions.”
    • Educate the patients / families about the warning signs of impending doom.
    • Essentially, “come back if things get worse.”
  • In the Pediatric ED (or during acute care related complaints), I find that the combination fo the two is helpful.
    • In the ED, we are seeing only a brief period of time of the illness process. 
      • At the time you are seeing the kid, there may be no obvious emergent danger or urgent condition warranting therapy… but… 
      • Anticipate the potential trajectories that may exist and educate about them.
        • This may be an uncomplicated viral illness now… but, it is still wise to note that otitis media and pneumonia can develop and discuss what that may look like.
          • This not only helps families know what to look for, it also protects you from looking like you “missed” the ear infection when the child is diagnosed with one in 2 days.
        • The child with vague periumbilical pain and vomiting may appear exceptionally well now… but…
          • Describing the possible paths before the family will help them detect which one they are on tomorrow:
            • Completely resolved symptoms – wonderful
            • Development of diarrhea and fevers – encourage fluids and monitor
            • Development of worse pain that now is in the RLQ – come on back as we need to reconsider the possibility of appendicitis.
    • Be concrete and specific.
      • Remember, humans don’t retain much from verbal education (how much did you actually learn in that conference?).
      • Don’t overwhelm with excessive details. 
      • Using “teach back” to ensure what you taught was received is always a good idea.

Parents aren’t Crazy… They are Worried.

  • Mant times I will hear that physicians prefer not to see children, because “they can’t ‘deal’ with the parents.”
  • This point of view places parents in an adversarial role… avoid this by keeping them on your team!
  • Parents are the best advocates for the patients
    • It is much harder to convince a 22 year old to take care of her/himself than it is to convince a parent to change behavior to help their child.
    • Having a concerned parent actually improves your options for outpatient management – “I know it you will keep a close eye on your kid, and this is why I feel comfortable sending you home.”
  • It is helpful to anticipate some common parental worries:
    • These concerns often need to be addressed up front and directly.
    • FEVER:
      • Media and Families have perpetuated the myth that “high” fevers are dangerous.
      • We know that there are certain conditions associated with high fever (ex, Heat Stroke, Vehicular Heat) that are dangerous, but the common viral illness causing a temp of 104F is not generally one of them.
      • With fevers, the number is not as important as the child’s behavior.
    • NOT EATING:
      • Parents spend the majority of the child’s infancy focusing on ensuring that she/he is growing well… and this, obviously, revolves around eating.
      • Anytime the child doesn’t eat, this sends off alarms in a parent’s brain.
      • Poor po intake can lead to problems (ex, dehydration, hypoglycemia), but missing a few meals is usually not a problem for most Americans.
      • I’ll point out that many people actually choose to Fast (some for religious reasons, some are just doing a “juice cleanse”), and they do just fine… provided that they stay hydrated.
      • Refocus attention on fluids and adequate sugar/calorie intake.
    • “Just a Virus.”
      • Do yourself a favor… don’t say “it’s just a virus.”
      • For one thing… viruses can be deadly!
      • Additionally, parents perceive that you did not appreciate their concerns.
      • They are concerned about pneumonia, ear infection, meningitis, etc.
      • Announce that you have evaluated for these conditions and haven’t found any evidence of them at this time…
        • and here is where you can discuss the appropriate anticipatory guidance for those entities.

References

Simon TD1, Phibbs S, Dickinson LM, Kempe A, Steiner JF, Davidson AJ, Hambidge SJ. Less anticipatory guidance is associated with more subsequent injury visits among infants. Ambul Pediatr. 2006 Nov-Dec;6(6):318-25. PMID: 17116604. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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