I’ve been busy, as you might imagine, with work, study, and applying for medical residency. However, I thought it was about time to get people up to date with some of the clerkships I’ve finished in the meantime before letting you guys in on some of the decision-making processes involved in choosing a residency.
So, time to talk about pediatrics. Pediatrics, despite a reputation for warmth and fuzziness, is a challenging field. Kids aren’t just little adults, and the treatment and diseases of infants are different than those of toddlers, which are different from pre-adolescents, which are different from the problems of teenagers and young adults. It’s an intense mixture of preventative medicine, diagnostics, and a lot of the intangible skills involved in getting the necessary information out of uncooperative patients and distressed parents. One also has to remember that a pediatrician has to spot the rare very sick kid in a field of sniffles, coughs, and possibly malingering youngsters who just want out of school. It’s a helluva a field of medicine, and if anything it has made me more passionate about educating against anti-vaxxers and quacks. For one pediatrics is critically dependent on prevention – which the anti-vax movement seeks to undermine with potentially dangerous consequences. For another, many of the diseases of childhood when they do occur are serious – but imminently treatable if recognized. The idea of a quack tinkering in this field without proper respect for the enormous amount of medicine involved, and potential for harm, is terrifying.
So let’s talk about a set of pediatric cases and just to piss off the gun nuts, why it’s a good thing that pediatricians screen for guns in homes.
Let’s emphasize the differences between medicine in different age groups. Because it’s pediatrics the past medical history is easy – they have none. Here are two cases, details altered, but both real patients I saw almost at the exact same time.
Patient #1: A 2.5-year-old male presents to the ED because her mom is concerned he is “puffy”. She sought care in a PCP’s office 6 days ago who initially treated him for a potential allergic reaction with Benadryl and advised her to return if he did not get better. The child has had no illnesses except for a cold 2 weeks ago, has met developmental milestones and is fully immunized. Mom has lost confidence in her PCP and now presents to UVA, very worried. On physical exam the child appears to be alert, awake, in no acute distress, with completely normal physical exam except for puffiness – non-pitting edema in the extremities and face.
Should we be concerned? What tests would you order in this patient?
Patient #2: A 14.5 year old male presents to the ED with a camp counselor with complaint of fainting during band practice (it’s summer and it’s hot). For the last week he has felt unwell, but has been continuing to go to practice and participating in activities. He has had no other illnesses, is fully vaccinated and has a normal physical exam. He has no other complaints except his eyes are “puffy”.
Should we be concerned? What tests would you order in this patient?
First let’s talk about what the majority of pediatrics is about – prevention. And the main thing you have to remember is that, thanks to vaccines, the majority of serious threats to health in children involve trauma and accidents. Starting from the first day of life, pediatrics begins with parent education about child safety. No parent should leave the hospital these days without being advised about the SIDS back to sleep campaign (kids sleep on their backs, in a crib, without soft bedding pillows or toys, always), and car seats which should be in the back seat, and rear-facing for the first year of life and until the child is at least 20 lbs. There are about 40 or 50 other items of importance that we usually go over and send the parents home with in a small book. Every kid also gets set up with a pediatrician who will continue the process of screening, marking developmental and growth milestones, and making sure every kid is up to date with immunizations.
With each well-child visit, new risks are screened for, and trauma and accidents are always at the top of the list – although the potential risks are different at different ages. Starting from avoiding dangerous items within reach of cruising youngsters, to proper safety equipment for bikes and sports, prevention of avoidable accidents is one of the primary responsibilities of the pediatrician. And yes, this includes, and should include, screening for guns in the home. In a landmark study in 2001, Jackman et. al found that of 8-12 year old kids who found a gun most will handle it and about half will pick it up and pull the trigger. Most parents underestimate the stupidity of children in their response to guns.
This is exactly why prevention is important, and gun nut paranoia about the grand pediatrician conspiracy against guns is misplaced. Your job as a parent raising a kid is to protect them from danger, and that includes locking up poisons, medicines, and guns. Kids are dumb, and accidents represent the greatest threat to their health. Car accidents, bike accidents, accidents in the home, accidental poisonings, gun accidents etc. Pediatricians screen for safety practices for all of these things and guns should be no exception. If you are the parent of a child with guns in the home, they should be made inaccessible to your child/locked up or preferably removed from the home as statistically they are a greater danger to your children than some imaginary criminal. Child use of guns – hunting trips, sharpshooting, whatever – should be age appropriate and always with close adult supervision – if only to avoid being shot in the ass by your own son. Granted, many pediatricians would love to see guns banned forever, they tend to be a liberal bunch, but don’t fear the gun safety screening. It is sensible and necessary because parents just don’t get how stupid kids are about guns. This really should be non-controversial.
Now, back to our cases. What causes fluid to leave the intravascular space and go into peripheral tissues? Or more appropriately, what keeps all that water in the bloodstream and not in the cells? In the first case puffiness all over is very concerning because it indicates that the child doesn’t have adequate amounts of protein in his blood to keep the fluid where it belongs. This case is serious because there tends to be three causes for inadequate protein in a kid this age. Inadequate production (liver failure, nutrition), loss through the kidneys, or loss through the gut. All three indicate a potentially dangerous pathology and needs to be worked up. Be concerned for the young child with generalized puffiness, it may be a simple allergic reaction but it also could be glomerulonephritis of several origins, Henoch-Schonlein Purpura, protein-losing enteropathy, severe malnutrition (Kwashiokor, liver disease etc. It gets a huge work up, and pretty much any test you named would have been a good choice. In this case it was loss through the gut – a post-infectious wasting of protein through the digestive tract that will likely resolve with supportive treatment. This is one of those cases that I would be terrified would land in the hands of an quack (and hopefully most quacks wouldn’t touch with a ten foot pole since they only really want to treat healthy people or stable illness).
Now for case number two, this one is actually pretty simple. Two or three tests would work in this case and you only really need to order one. Give me your suggestions in the comments.