Indexing Title: CLEYSONs Medical Anecdotal Report [05-08]

MAR Title:  COMPLEXITY

Date of Medical Observation: SEPTEMBER 2005

Narration:

 This is a case if a four-year-old male, who underwent exploratory laparotomy and ileostomy secondary to a gangrenous ileum due to adhesions secondary to a meckel’s diverticulitis. He went through the procedure well, and on the fifth post-operative day he was able to eat rice for lunch. The family was very enthusiastic in feeding the child; he was given as much food as he desired. That afternoon, nonetheless, the patient grew weary; he complained of abdominal pain, colicky in character. The relatives also noted distention of the child’s abdomen. He was put on non per os, then, nasogastric tube was instated. Part of our management was to start intravenous fluid support. My colleagues had difficulty inserting the intravenous line, so I went to the patient myself; and upon seeing him weeping up a storm, I had chitchat with him to calm his fears as I was preparing the items needed for venoclysis. Then his mother said “Sana last na yan, Doktora!” I contemplated it as a warning that I should be successful in locating the venous access that time. Luckily, I was able to insert the cannula with one attempt, I was so thankful. On the following day, the same scenario happened. The next day, as I entered the room, his mother was talking to him quite animatedly; she then asked him why he suddenly fell silent when I walked in. I asked him if his tummy still hurts and he said yes. Although on physical examination, his abdomen was soft and non-tender. From that day onwards, every time he saw me or heard my voice, he complained of abdominal pain and he would start crying. The medical clerks informed me that prior to my rounds, the patient was all right, and he walks, laughs, and talks a lot. But the moment I’m around, he displays a different him. I told myself, what a talented child! He’s still so young, and yet, you can already see the actor in him. In reality, I was a little upset by the way the boy was acting; it seems that he was frightened of me. I know that it wasn’t me in particular that he was scared of, but the association of pain that he experienced and my causing the sensation during our previous encounters with intravenous insertions.

Even though I’m the only person who was able to insert his line, he associated all the failed attempts to me. On the first day of my leave, I wasn’t able to make the usual rounds with my colleagues, so when I came in that afternoon they informed me that the boy was looking for me, and asking why I’m not with them. My heart swelled up, and I was in high spirits when I went to his room and happily talked to him.

Insights (Physical, Psychosocial, Ethical) (Discovery, Stimulus, Reinforcements)

 Pediatric patient is one of the most difficult of all patients. The primary problem that we encounter where they are concerned is focused on communication, because most of these patients convey everything through crying. They cannot tell you what is aching or where is the pain. It is quite annoying really, so doctors should stretch their patience in dealing with them.

 Children associate pain to the medical personnel or to their white uniform, so every time a nurse or a doctor enters their room, they bursts into non-stop crying until the medical personnel disappears from their view. This particular patient though has a different kind of reaction. He particularly demonstrates a child in pain every time he sees me. This shows that pediatric patient have thousands of ways to express themselves. We, as their doctors, should find ways to identify whether the patient is only acting out or when he is really in pain. We should be familiar with their mannerisms or traits. We can achieve this familiarity in doing our daily rounds and simultaneously gain their trust.

 Intravenous insertion is another problem. The veins of the young patient  is not that visible to the naked eye, and often times, the imagination is greatly being put into action in order to succeed in the task. During insertion, these children will not willingly give you their hands, or they will not be able control their movements.

In addition to this, the parents are usually around while you do the insertion, which gives one an added pressure. In situations like these, we should keep our cool and remember the things we have learned in the past years and to execute the procedure without hesitation. We should not forget to let the parents know and feel that we are doing the best we can for their loved ones.