9 ways to piss off your paediatrician: A disgruntled A&E Manifesto

-->

Most people think that paediatricians are all fluffy bunnies and stickers. Well, we are… sort of… I find that as a group of doctors, we are generally nice. We tolerate a lot of things that the other subspecialties don’t see, at least, not en mass: Screaming patients, patients trying to kick us or bite us, patients vomiting on us, patients peeing on us, patients who stick things up their noses, patients that can’t/won’t talk to us, parents/families controlling the care (I know Psych and Med El know some of these feels). That being said, it is possible to upset your paediatrician. If that’s what you’re looking to do, look no further; I’ve compiled a list of ways to make your paediatrician cringe… Consider it something of a manifesto.

9 things that parents say in the ED that are likely to piss off the Paediatrician… (or at least, they really grind my gears) and the reasons why I stand my ground:

1.     I thought we were going to see a doctor.

Not to eschew gender stereotypes, but in spite of my size (yeah, I’m less than 5 and a half feet tall), and my gender (I am female), and my apparent age (I’m actually older than I look), I am, in fact, a doctor. I’m a paediatrician; I’m not going to pull out my diplomas to prove it. Let’s get past the fact that I’ve introduced myself as a doctor. I have worked my butt off to get to this point in my career.

I have, more than once, been asked if a patient could be seen by, “that nice male doctor.” Short answer: no. Long answer: more than likely, there is no male doctor working this fine day in the A&E. Furthermore, if you want to shop around for a doctor, go to your GP (or find some new GPs for every time your child gets the sniffles). An emergency department doesn’t work like that.

While this is one of the things that makes my blood boil, let me just say something small here. I have been a customer of many different A&Es (I was a bit injury prone). I’ve found a lovely group of doctors in each one. And to the kind, albeit nervous, ED doc that did my LP when I was SO sick, I feel your pain now. And you were fantastic.

2.     What do you think is wrong with him?

Now, I do understand this question. I actually don’t mind it (if you’re going to listen to what I say). But please don’t plop your kid down on the examining table and sweep your hand in a fed up gesture and demand an answer. I am not a psychic. I need to ask you some questions. I generally start off a history with, “What’s the story? What’s going on with ?” I don’t find it amusing or appropriate to respond with, “That.” Or, “See for yourself.”

Further, what I express as an answer to this question is my medical opinion. You can take it or leave it. But it is based upon my (or the other physician’s) clinical opinion as to how your child is medically managed. We studied hard and work harder (I’m not going to go into the hours and pay thing) to get to our place in this profession. We treat each patient individually. Yes, we occasionally make mistakes. But, not pulling rank here, we are the doctors. To the parents that respond with a roll of the eyes and, “That’s what my GP said too.” … I think there’s a special place in hell for you.

3.     I want my child scanned.

Generally, these are the first words out of the parent’s mouth. I find that they are often accompanied by a chronic (6 months or longer) complaint for which they are already seeing a general paediatrician. And frequently, it’s Saturday or Sunday at 8pm. Shockingly, most of the complaints are not ones that can or should be investigated by a scan.  Also, I don’t care if your GP suggested you come in to us for a scan [Dear GPs, don’t do that, cheers.].

CT scans carry a very high burden of radiation. This is why every child in the door isn’t passed through one on the way to triage. There is research that demonstrates lifelong increased cancer risk and mortality is linked to childhood CTs, and leukaemia and brain tumours are similarly linked (triple the risk!!!). Down the road, I may have to stand up in court and explain why I requested (nay required) a CT scan knowing this risk. Saying the parents bullied me into it won’t stand in court, nor would it stand in my conscience.

X-rays carry a small burden of radiation; that is why the nurses and techs that hold your child for an x-ray wear protective lead shields. I realize that it is a quick test, but it is not without risk. I don’t x-ray children without indication. And x-rays are crap for diagnosing bowel problems…

MRIs are really pretty. I love them. They’re great for certain soft tissue windows. They make nice brain pictures. They’re time consuming. Your child needs to sit, unmoving, in a loud banging tube for thirty minutes to an hour… So, at times (such as in the A&E) I find them a little unpractical.

4.     I need an antibiotic.

No, that’s not a typo. “I” need an antibiotic. My brain instantly responds with, well then why are you here, clearly you need an adult physician, you’re far too old to be treated by a paediatrician. And yes, I know what they mean… They mean that they think their child needs an antibiotic. These too are often the first words out of the parent’s mouth, prior to the history, prior to the exam, often accompanied by the phrase, “The D-doc said it was viral, but I know my child and they’ll only get better with an antibiotic.”

Small news flash: If your child has vomiting and/or diarrhea, there is an incredibly slim chance that an antibiotic is the right answer and an even slimmer chance that the antibiotic will do anything but make the vomiting and/or diarrhea worse.

We are no longer living in a time where it is acceptable to give an antibiotic without a source. If a child has a UTI, there needs to be a culture and sensitivities. If it’s a bacterial tonsillitis, a swab should be taken. If it’s OM… don’t get me started. People are all up in arms about super bugs and MRSA, yet won’t bat an eye to demand an unnecessary antibiotic from the GP or Paediatrician. Yes, my responsibility is to look out for children, so I’m doing my best not to breed super bugs. You tell me that every time your child gets a head cold, it becomes a bacterial pneumonia, fine. I’ll give you an antibiotic when there’s a pneumonia. It sounds harsh, but trust me, you’d rather the standard penicillin actually treat tonsillitis than just give your kid the trots.

That being said, I do, on occasion, prescribe antibiotics. Which brings us to the next point…

5.     My child won’t take that medicine.

I assume you mean that you’re not willing to make your child take that medicine? Let me be frank for a moment. You have brought your child to an emergency department. They have been diagnosed with something that requires medicine. Now you’re telling me that they will be dying of overwhelming sepsis, because you don’t know how to give them medicine?! Ok, that was a bit over the top. But think about it. What wouldn’t you do for your child? Apparently force them to take medicine…

I’m not trying to be glib. I know it isn’t easy to be a parent. I know it isn’t easy to do things that your child disagrees with. But you HAVE to do them every day. If it’s not medicine, it’s brushing their teeth, eating their vegetables, going to bed at night, NOT PLAYING IN TRAFFIC! As a parent, you are going to have to do things your child does not like. And no… I don’t think it’s appropriate for me to stab your child, break the skin and introduce a foreign body into their vascular system, and give them IV antibiotics so that you can be the good guy… That does not make you the good guy… Nor does that make you a parent. Stop trying to be their friend, be an adult.

On occasion, the objection to a medication is one of allergy… That I do understand. But just going back to my previous point, vomiting and/or diarrhea is not an allergy, that’s a normal side effect of antibiotics. Swelling up so you can’t breathe or breaking out in a rash and having your skin peel off… Now that’s an allergy.

6.     But… We’re going on holiday tomorrow…

Look, I know how much we treasure our holidays. I’m happy that you are one of the few families that can afford flights and sun based holidays. I know how expensive they are. Do you know how expensive life long impairment is? I’m sorry that you wanted to swim with the dolphins. But your child has a) a serious infection requiring hospitalization or b) broken their arm/leg/head and require treatment.

I am not unsympathetic to the need to change holiday plans. However, looking at me with puppy-dog eyes will not make this problem go away, nor will it change the way the system works. For example, we do not put full fiberglass casts on in the A&E, because there is a good chance that a fresh fracture will continue to swell. You end up with one of two outcomes; either the cast is too tight and it cuts off circulation to the extremity, or the swelling recedes and the cast is too loose and the fracture is not stabilized. There is a reason we do things this way.

More aggravating to me, is the idea that some amount of negotiating is going to make me laugh and say, “Just kidding, there’s nothing wrong. Your child was screaming for no reason and that massive deformity in their forearm is just a joke.”

7.     This wait is too long. I’m leaving.

Sometimes, there are no words. Sometimes, there is only an expression of exasperation. Let me be clear on this: the reason there is a wait time in the emergency department is because there are a lot of sick children; and if you’re waiting, it’s because the other children are sicker than yours. I don’t like the days when the wait times brush 4 hours. I think it’s terrible. But frankly, if your child is sick, and you’ve been concerned enough to come to the A&E, you should be concerned enough to wait. Leaving before being seen by a doctor is normally a sign that you didn’t need to be there in the first place.

One of the reasons the A&Es are overrun is that we don’t have the space, the equipment, the staffing numbers that are needed. Another reason is that people just don’t go to the GP… Most of the kids (and shamefully, I’m going to estimate about 50% of them) don’t need to be in the A&E… There is neither an accident nor an emergency in some of the attendances. And yes, it’s summer, kids are out doing silly things, there are a lot of injuries. This means that certain things get pushed back on the timeline. Wounds that need suturing in the ED, sometimes we have to leave them until we can sit down and give them the appropriate attention. This isn’t because we don’t care; this is because we have to work as efficiently and effectively as possible. And not all lacerations need sutures, and not all lacerations that need sutures need to be seen by a plastic surgeon.

8.     We have a safety net on the trampoline; it just wasn’t closed…

I file statements like this under the same category as, “My child doesn’t like wearing helmets,” “I always let them swim by themselves,” and “My child’s friends drink, but they don’t.” … And I know, there are some kids who can have that peer group that drinks when they themselves don’t partake (I was one of them). There are some things you cannot prevent. Kids will fall down (or off of things). Kids will push boundaries and challenge you. Kids will strive for independence. But there should be a safety net where possible. Don’t buy a safety device that you don’t plan to use. Don’t let your kids swim in a pool/ocean/river/pond without supervision. Don’t leave your kids to fend for themselves without preparing them for the pressures they will face.

Also, trampolines and bouncy castles should be banned… Or you should be required to sign a waiver before letting a kid on it, accepting all consequences, including broken bones.

9.     I don’t believe in vaccination.

To me, that’s like saying, “I don’t believe in gravity,” or “I don’t believe in the moon.” It not only makes you sound foolish, it makes you sound dangerous. I’ve talked to many parents that don’t wish to vaccinate their children. I’ve also listened to them plead for a solution when their child is ill with measles.

We see some pretty horrible things in paediatrics. One of the worst is something preventable. I don’t like watching children suffer. Measles is horrible. But worse than measles is slowly dying of encephalitis years later. I have, thankfully, only seen one such case. I’ve seen epiglottitis, where a child struggles to breathe as the airway swells. I’ve seen little babies cough so hard they cannot catch a breath due to pertussis. I’ve seen a child need multiple infusions to prevent infection following a dog bite. And that horrible discomfort you see with chickenpox… Yeah, that too is preventable (though not on the national immunization scheme). There was an 8 month measles outbreak in Wales that was just declared over which saw more than 1200 notifications, 88 hospitalizations, and one death (you can read more about it here).

My largest concern is that opting not to vaccinate your child puts other children (even the ones that are vaccinated) at risk. I’m going to be super controversial here and say that not vaccinating is like drunk driving: you put more than yourself at risk (single story here). There are buckets of research in favour of vaccination. There’s only anecdotal stories to the contrary. A couple in New Zealand went through a horrible experience as their son nearly died of tetanus; they’ve been telling their story (here) in hopes of keeping others from suffering the same. Maybe only 4 out of 5 dentists recommend a certain tooth paste, but 95% of paediatricians are all for vaccines (and of the remaining 5%, there are some objections to the schedule, not the vaccinations). In the US, paediatricians now have the right to “fire” patients whose parents are vaccine refusers. Still have doubts, this is one of best responses to arguments against vaccination I’ve read (here).