Dear readers, this is my EM News column for July.  Or at least, what it’s supposed to be.  Apparently when I submitted it to my gracious and excellent editor, Lisa Hoffman, I only attached half of the piece.  So if you read it in the magazine and it looks a bit silly, this is why.  Here’s the full text.  (And the link to the unfortunately truncated version).

http://journals.lww.com/em-news/Fulltext/2013/07000/Second_Opinion__The_Road_Runner_Theory_of.5.aspx

 

I’ve learned a few things about children over the years.  While most have come from raising children, the rest have come from caring for them as patients.  Knowing children, knowing their hearts and their ways, gives me great joy.  I like to think that as I know them better, I become more like them, and while my time on earth may not be any longer for it, it may be richer.  Or perhaps one day I will simply wake in Narnia and find that I was always a child, dreaming dark dreams that will suddenly end.

So, in light of what I know, here are my tips for taking care of children when they are your patients. They are not given in order of preference or importance; and only generally in sequence.

First, walk into the room, look at them and smile.  Don’t give them that condescending smile you learned in medical school interviews.  Smile.  Watch them, because sometimes they’ll smile back.  Learn to wink.  Winking is very useful.  It conveys the idea that you are paying attention, even as you listen to the boring adults.

Move purposefully, but slowly.  No barging in, slamming down charts, jerking open cabinets or yanking things off the wall.  Modulate your voice.  If you need the nurse to get something, don’t yell.  Say it softly.  Give children at least the concern and demeanor you would give to a wounded stray cat or dog.  The children deserve it even more.

Sit down and talk, both to the child and to the parents.  Let your attention be a pendulum that moves between them.  They both have things to tell you. But first, complement the child.  Tell them you like their name, or the stuffed hedgehog they are clutching.  See what they are watching on the television.  (It is useful to have at least a passing knowledge of cartoons, so that you can tell them what your favorite is.  Or at least, what it used to be.  The Road-Runner will likely always be with us.)  At the right age, video games or sports (or in certain locales deer season) make great conversational topics to put the child at ease and show that you are not, actually, a monster.

At some point, complement the parents. Tell them what a strong, or beautiful, cute or brilliant child they have.  It suggests you noticed that their child is special.  Indeed, what child isn’t?

Ask your wee patient, ‘can I check you out?’ If they say no, ask mom or dad to help.  But again, move gently and carefully.  Put your stethoscope on their knee first.  Use the otoscope on mom, dad or older sister. Or on yourself! Odds are, things will go alright.  If you aren’t kind, the child will scream and the screaming and kicking and fighting will get squarely in the way of your exam and assessment. And hurt your ears.

If screaming and fighting persist, be firm and have parents and/or nurse hold child in something reminiscent of WWF, but allowing plenty of air to pass in and out of lungs.  Children, like small animals, are not always rational and must sometimes be told and shown that they aren’t in charge  despite endless empowerment talk from experts.  You are smarter and bigger. And they need your to take charge.  Sometimes to save their little lives.

As you assess them, cultivate that thing we don’t discuss in medical school but the thing that makes for the best medicine.  Practice loving them.  Imagine them at home playing, in the yard running, in bed snuggling, in school learning. Imagine them well and pray that you can return them to that state as quickly as possible.  Unlike many adult patients, the children have no desire to be in the hospital.  To a child, disability means nothing except sitting in bed while other kids play.

Practice thinking also about how much their parents love them.  About how they were anticipated and how they are treasured.  If you sense that their parents could not possibly care less, then project love onto the child.  Show them that at least with you, an adult finds them to be of inestimable worth. Give them crayons, give them stickers.  Give them snacks if the situation allows.  Shower them with concern.  Occasionally, an infant or small child will climb into your arms and want to stay there. Or will hold out their arms, as if to say, ‘please take me away from these crazy people!’  You cannot do that. But you can still look at them with love, treat them with skill and try to discern if they are in danger.

If you must hurt them a little, try to explain why.  And tell them you’re sorry, and that you wish there was some other way to do it.  Talk to them endlessly, so that they know you are not a robot in white.  Learn what you need to know to save them, or ease their pain.  And if you find something terribly, terribly wrong, talk to their parents first.  If, G-d forbid, one of them dies, remember that for the child’s family, the universe suddenly collapsed and all good things ceased to be bright.  Either way, with grave illness or death, remember that the parents will suddenly be wounded children themselves.  Follow the above steps and be gentle.  It’s acceptable to cry with them.

Now, bear this in mind.  For all our knowledge and skill, all our education and cool professionalism, we were all children once. And because of dementia, strokes, accidents and illnesses, we may yet be like children.  Everyone you treat was a child.  Everyone you treat is afraid, and mortal, and suffering some unique wound of the heart or soul.  Don’t forget the child in everyone.

So, when you walk into the exam room of an adult patient, don’t forget to smile.  Make no sudden moves. Sit and talk.  Ask them about the things they love…And learn to love everyone, if you can, with the love that should be showered on every child on earth.  For on some level, we are all children still.