Cuts, Scrapes, and Anxious Parents: A Tuesday Night in the UNC Pediatric Emergency Department

By Sara Holmes • Health Humanities, Special Issue: ER Observations, 2019
 

 

 

CHAPEL HILL, N.C. –– The University of North Carolina Hospitals Emergency Department serves to treat patients with urgent medical conditions. Ambulances fill the road in front of the looming concrete building. People come and go through the automatic door of the main entrance. Inside the door, an overworked security guard sits beside a metal detector. The main waiting room of the E.D. is chaotic. Televisions play, people murmur, doors open, and stretchers move. People fill every chair, and the occupants of the room express varying levels of stress and fatigue. Patients awaiting available beds lay on stretchers strewn about the room and nearby hallways.

The Pediatric Emergency Medicine Department requires authorized access. Upon entry, the mood shifts away from the stressful chaos of the waiting room. The walls are covered with murals of children playing basketball, swinging on a tire swing, and playing tag in a grassy field. Exam rooms are painted bright, mood-warming colors, and medical staff members approach the rooms with smiles.

Here are the patterns of a typical Tuesday evening.

7:00 P.M.

At the beginning of a new shift, half a dozen doctors and nurses fill the cramped nurses’ station. All ten rooms of the Pediatric E.D. are occupied, and each case must be reviewed with the attending physician – Dr. Tammy Romas. Currently, three cases are psychiatric. Several children are suffering from lacerations or head injuries. One child has a broken arm. Another has a respiratory condition.

A resident approaches Dr. Romas and states a patient’s case: “Room 5, A ten-year-old girl with a history of depression and ADHD. Admitted by her mother for aggressive behavior.” This is not the young girl’s first time being admitted, and the mother is becoming impatient with both her daughter and the doctors. A psychiatric doctor recommends that she be held overnight for further monitoring. As the resident speaks, Dr. Romas types into the electronic chart and asks questions throughout the description. She inquires if the patient is prescribed any medications, and the resident assures Dr. Romas that the patient takes all of her prescriptions.

The patient is bawling under a table in her room for unknown reasons. Raised voices fill the hallway. The mother states that she must go home to watch her son. She wants to leave her daughter in the hospital overnight alone. Dr. Romas warns against this abandonment and declares that the patient must be moved to the Psychiatric Ward before the mother can leave. Dr. Romas expects the patient to throw a tantrum in her mother’s absence. Two police officers arrive to escort the young patient to her new room after the mother leaves.

7:45 P.M.

The melody of “Baby Shark”, a children’s song, can be heard from exam room five. Inside, a two-year-old boy sits in his mother’s lap watching a video on her phone. He was referred to the UNC E.D. by a local primary care doctor for his respiratory distress.

Dr. Romas enters and greets the patient and mother with a smile. She recognizes the song playing and engages the patient by singing and performing the coordinating dance. The boy begins to smile.

Dr. Romas asks about the patient, and the anxious mother gives a long-winded answer. She worries that her child cannot properly breathe. Using her stethoscope, Dr. Romas performs a routine breathing examination. She determines that the sound is harmless, and the child merely has croup—an infection in the upper airway that results in a distinctive barking cough.

The patient’s mother begins asking questions in rapid fire. Dr. Romas assures the mother that within two to four days her son will be healthy. The mother continues to worry. She considers sleeping on the floor beside her son’s crib. Following each question and expression of concern, Dr. Romas smiles and provides reassurance. Once the mother is comforted, Dr. Romas says, “You’re good to go!”

8:40 P.M.

A nurse distributes a trayful of coffee. A resident begins explaining a new patient’s case to Dr. Romas: a five-year-old is suffering from a head injury. She slammed her head into a metal bar on the jungle gym at her school’s playground. One of her pupils, relative to the other, is over dilated. This presents an immediate concern.

The condition of one pupil being more dilated than the other is known as anisocoria. This can be a normal, physiological occurrence, or it can signal an underlying medical condition. Because the anisocoria developed after the accident, it could indicate a critical internal medical issue. The resident recommends an MRI to check for a specific condition. Dr. Romas argues that the results of the scan will not impact treatment, so it is unnecessary to acquire the expense.

Dr. Romas enters the exam room of the anisocoria patient and is met with anxious looks from stressed parents. Before Dr. Romas can even say a word, the father, with a voice full of worry, asks, “Will she be okay?” Dr. Romas introduces herself and maintains a calm demeanor. She smiles at the young girl laying on the exam table and asks about what happened on the playground. The mother jumps in and tells the story of the jungle gym. Dr. Romas politely acknowledges this, but then she turns to the young girl again and asks about how she felt and if she cried, giving the young girl an opportunity to answer for herself.

Dr. Romas performs an eye and head exam on the young girl. This includes testing her balance, reflexes, and vision. Dr. Romas clears the girl from a concussion, and she does not detect any pressing internal medical issues. A wave of relief flows over the child’s parents, and they relax in their chairs. Dr. Romas instructs the parents to take their daughter to her eye doctor the following morning to inquire about the anisocoria. After ensuring the parents do not have any further questions, Dr. Romas discharges the patient.

9:25 P.M.

Sympathetic expressions fall over the faces of the doctors and nurses when the triage screen lights up with a familiar name. A few years ago, the fourteen-year-old patient was diagnosed with leukemia. Now, she is forced to come into the E.D. regularly. Leukemia weakens her immune system, so she must be checked out by a doctor for every minor symptom or issue that arises.

A resident approaches Dr. Romas in the nurses’ station and begins to report the patient’s case information. Even though Dr. Romas is saddened to see the leukemia patient forced to come into the E.D., all emotions must be set aside when discussing a patient’s case; they cannot impact the treatment and medical decisions. The patient is in the E.D. tonight for a fever. This common symptom could mean immense issues for the fourteen-year-old.

Dr. Romas enters the exam room with a soft smile. The patient lays on the bed facing the wall. Her mother sits in a chair beside her. A forced, weary smile spreads across the mother’s face. The exhaustion is evident in both of them. Dr. Romas approaches the patient and asks how she is, and the mother responds for her after a few moments of silence. She had a 101-degree fever when they checked it at home, but no other symptoms are apparent.

In a soft voice, Dr. Romas asks the patient if she can perform a short exam. The patient silently rolls over onto her back as an indication of consent. Dr. Romas listens to her breathe and feels the patient’s stomach area. She feels a tender spot and asks the patient if it hurts. The girl replies, “It hurts as much as it always does. I’m used to it now.” An expression of sympathy flashes across Dr. Romas’s face.

Dr. Romas’s actions and attitude are different in this room than with other patients. Rather than taking extra time to cheer up the patient and calm down the parents, Dr. Romas gets straight to the point and helps the family go home as quickly as possible because she knows that although they are used to frequent visits, the trips to the E.D. never get any less tiring.

Dr. Romas debriefs the patient and her mother about the current situation. Her fever is decreasing, and she should return to her average temperature soon; However, her platelets count dropped by fifty percent since her visit last month. Dr. Romas prescribes an additional medication for the patient to take each evening that should help her count increase. Before exiting, the mother thanks Dr. Romas with a gracious smile.

9:55 P.M.

Nurses and doctors enter and exit the nurses’ station frequently as they alternate between checking on patients and charting. A nursing student describes the E.D. in two simple words: “It’s chaotic.” There is rarely a dull moment. As soon as Dr. Romas returns to the nurses’ station, a resident approaches with a new patient’s case: a three-year-old boy fell while running on a concrete sidewalk during daycare, cutting open his bottom lip. The mother could not bring her son in until she got off work a couple of hours after the incident, which is a typical scenario for many working parents. No head injury other than the laceration is observed.

Dr. Romas enters exam room two with an enthusiastic smile and greeting. The little boy stares back in bewilderment. Dr. Romas approaches to examine the child’s mouth, but he refuses to let her and tries to crawl away. The mother apologizes for his lack of cooperation. Her tone indicates her exhaustion.

Dr. Romas opens a cabinet and pulls out a light blue exam glove. She blows into it until it forms a balloon. She shows it to the little boy as she pulls out a black marker. She draws a smiley face on the balloon glove and asks the little boy, “Can you smile like the balloon?” This makes the little boy laugh as he plays with the balloon, and Dr. Romas quickly utilizes this opportunity to examine his teeth.

The front teeth are pushed back further than normal; this is likely due to the impact of the child’s fall. Dr. Romas notices that the laceration on the child’s lip extends beyond the lip and crosses into the child’s chin. With a smile, Dr. Romas tells the mother that a dental team will be in shortly to examine the child’s teeth and evaluate if treatment is necessary.

Dr. Romas’s demeanor shifts immediately after exiting the exam room. Her lively attitude in the room with the little boy becomes serious as she explains to a nurse that the boy needs stitches. The lip may heal misaligned without them. Light sedation will be required because it is likely that he will need his front teeth removed.

10:30 P.M.

Dr. Romas checks her watch and realizes that her shift ends in thirty minutes. She must prepare the department for the new attending physician. She spends several minutes updating each current patient’s case in the electronic charts so the new doctor will understand the situations. She then goes into several exam rooms to check on cases – a broken arm, depression, constipation, respiratory infection – and ensures they do not need anything urgently. She prepares the suture cart with the proper tools for the little boy’s stitches and places it outside of the exam room.

She hands off the patients to the night shift’s attending physician. One needs stitches. Several are ready to be discharged. An ambulance is currently on the way with a new patient.