Compared to child rearing, treating patients in the emergency department is simple.
When our daughter Florence was born, we were shocked that a tiny, seven-pound beauty could turn our household (and our entire lives) upside down. Why was it so difficult to deal with one human being, when we often took care of a department full of ill patients? How could someone so cute induce a state of perpetual anxiety, forcing us to question every single action we took?
It was disconcerting to find that while we had a combined clinical experience of over twenty years as emergency physicians, after having treated over 100,000 patients (including at least 20,000 pediatric patients), when our baby cried and we couldn’t figure out why, we instantly went into panic mode. We couldn’t figure out why we were getting so overwhelmed, so upset, so frustrated, so angry with each other, given our experiences in the medical field.
As parents working in the emergency department, we often related our baby’s crying back to our training. Our approach in dealing with Florence’s excessive, paroxysmal crying was similar to our approach dealing with any patient who presents to the emergency department, which consists of a simple three-step approach:
- Is the patient sick?
- What are the patient’s vitals?
- What is the differential diagnosis (i.e. the possible causes) of the patient’s chief complaint?
Answering the first question requires gestalt. Although many people show up to the ER with heart attacks and strokes, appendicitis and shoulder dislocations, most people end up using the ER for routine complaints: cough and sniffles, sore throat and cuts, sprains and mosquito bites. Teasing out which patient is emergently ill may seem difficult, but it is often straightforward, especially for the seasoned physician. If the patient is complaining of crushing chest pain but he’s eating a Big Mac and taking a selfie, chances are he’s not having a myocardial infarction.
The second step requires a little more preparation. Vital signs for an ER patient are critical because they give you important clues to help you decide whether a patient is sick and what the diagnosis is for a patient’s chief complaint. For example, if a patient shows up with an elevated heart rate, you need to consider if the patient’s tachycardia is simply due to pain or anxiety, or if it’s secondary to an underlying disease like a cardiac arrhythmia (atrial fibrillation or flutter), fever, pulmonary embolism (lung clot), myocardial infarction (heart attack), thyroid storm (abnormal elevation of thyroid hormone), or infection.
The third step, figuring out the causes for a patient’s complaint, will distinguish a good doctor from a great one, and will ultimately decide the fate of a patient in the ER. Clinicians are taught that there is a list of potential diseases associated with every complaint; it’s up to us to sleuth out the cause. For example, every year, over three million people present to the ER with a headache. As clinicians, we need to figure out which of those patients’ headaches have potentially life-threatening causes. If you assume everyone showing up to the ER has a primary headache (i.e. tension, migraine, or a cluster headache), you are going to miss the less common life-threatening causes. Therefore, coming up with a list of emergency causes of headaches becomes extremely important (intracranial hemorrhage, meningitis, tumor).
Having a differential list in mind, knowing the vital signs, and observing whether the patient is sick or not, will determine what questions you ask, what you pay attention to in the physical exam, what laboratory and imaging studies you order, what medications you give, and ultimately what the diagnosis and disposition of the patient are.
As seasoned emergency physicians, we get very comfortable with this process. However, dealing with a fussy newborn consistently left us stumped. Was our daughter’s crying due to a life-threatening pathology like meningitis or intussusception? Or was it just gas?
We knew that our self-doubt wasn’t solely due to sleep deprivation. We had both survived the long hours of residency training. Once our daughter turned four weeks, we had a sudden realization. We needed to approach our daughter with the same protocols and calculations as we would any other patient. As silly as this may seem, the awareness that there was a step-wise approach to dealing with the constant crying suddenly put our minds at ease.
Chief Complaint: Crying
Vital Signs: Normal
Differential Diagnosis: There are life-threating causes and non-life-threatening for the crying neonate. Since we’re both emergency physicians, we looked at the life-threatening causes first.
The common potentially life-threatening causes of fussiness in the neonate are infections like sepsis, meningitis, pneumonia, and UTI. These are usually accompanied by a fever, which our daughter lacked. We quickly ran through the other serious causes of inconsolable crying (e.g. strangulated hernia, intussusception, hair tourniquet, corneal abrasion, bronchiolitis, GERD) and found those unlikely. Since we live in Las Vegas, we also considered a scorpion sting, but our daughter was consolable, had no signs of trauma, and did not have the excessive salivation, vomiting, shortness of breath, nystagmus, or agitation associated with severe envenomation.
Having excluded these, we then moved to the non-life-threatening causes of a crying baby and asked ourselves the following questions:
- Does our baby need to eat?
- Does she need to be burped?
- Does she need to be changed?
- Does she want to be held or swaddled?
It was a relief to approach crying spells in this way, ruling out life-threatening causes, then systematically running through the list of non-life threatening causes, and then attempting the above potential ways to solve the crying. Of course, there were other things that we noticed in the course of that month that helped our baby: being in a stroller and going for a walk or in the car seat and going out for a drive, having the white noise of the beach waves in the background, or listening to the sweet tunes of Jack Johnson and David Berkeley all helped.
Although having a protocol put our mind at ease at first, we quickly realized why our parenting experience was more stressful than that of our nonmedical friends. Whereas most parents consider the common causes of the inconsolable baby first (mainly, they make sure the baby is fed, burped, changed, and cuddled) before even thinking about any other cause, we were constantly running through our differential of life-threatening causes every time our daughter whimpered.
Sometimes an emergency physician’s approach to the crying baby isn’t necessarily the most effective one. Now we take each crying fit in stride. Our daughter still cries, but we don’t rush to the assumption that she’s come down with meningitis or that a scorpion has stung her.