Emergency General Surgery

When Dwarves’ Doctors are not Small Doctors

…There were two undeniable truths in the Realms: it was very easy to overestimate a drow and even easier to underestimate a dwarf.

R.A. Salvatore

It’s 3 p.m. on a sunny spring Sunday and, as usual, you’re on call!

The phone rings. It’s the pediatric A&E… They call for a 6 yo boy with unclear abdominal pain. Blood tests are pending, but they would like you to discard acute appendicitis. 

With all your strength and fear (especially fears), you walk into the ambulatory where the boy is with his mother. 

Your first try is to talk to both at the same time, but the boy doesn’t answer and starts crying at every question. 

The mother tells you the boy has a 2 days history of abdominal pain associated with fever. His stools are normal, but he has a bit of anorexia. 

The boy is already leaning on the bed. You try again getting closer to evaluate him but he kicks you away!

This is going to be very hard…

The children are small adults… Children’s surgical conditions are similar to adult conditions… Common conditions always manifest in the same way…

These often used phrases erase with a few words the many differences between a pediatric and an adult patient.

Introduction

Fully understanding the multifaceted pediatric patient requires a thorough knowledge of the possible surgical pathologies that may be encountered, as well as detailed knowledge of pediatric physiology and some socio-psychological aspects. In fact, we have specialties for it (pediatricians and pediatric surgeons), but sometimes they are not in the hospital or they are waiting in a referring one, so you may have to do their work sometimes… Here’s some help!

First of all, not all “little patients” are the same: in the first 15-20 years of life, the patient changes radically! We can speak of newborns, infants, toddlers, children, and adolescents. They have extremely different physiological and psychosocial features.

The neonatal physiology and neonatal surgical condition (e.g. duodenal atresia, necrotizing enterocolitis, anorectal malformations, and so on) are unique of the first 30 days of life, those days are also influenced by the prenatal period. 

Infancy (i.e. 30 days to 1 year of life) is characterized by a period of rapid growth and change. Even in this period, unique surgical conditions may be encountered, for example, pyloric stenosis.

Toddler (i.e. 1-3 years) and childhood (i.e. 4-12 years) reflects continued development in communication and psychological aspects. Adolescents have more adult-type conditions, but unique psychosocial aspects.

After that, good basic knowledge is acquired, and a fundamental step is to establish a healthy and trusting relationship between the doctor and the patient, and between the doctor and the patient’s parents or guardians.

The parents have a fundamental role, both in small patients (who do not yet have the capacity for autonomous expression) and in older ones. It is well known that the fact of having a sick child increases the parents’ anxiety and worries which directly exacerbates the anxieties of the child.

The pediatric surgeon has the task and responsibility to dispel these fears. Fostering a good relationship with the family can be achieved with clear and qualified communication. Don’t forget that the surgeon must always explain the child’s problem simply and thoroughly (as when we speak to families of ICU patients).

Clinical Examination

As doctors who are not used to dealing with pediatric patients, it is essential to firstly win the trust of the child (and of the parents). This will let us evaluate the patient with less difficulties. Therefore, it is fundamental to try to make the baby feel comfortable and safe.

Physical examination in an older child or adolescent can be done in the same way as in adults. However, during the collection of the medical history and the physical examination in younger and less cooperative children, we can implement some tricks to obtain the most information and maybe even making a (little) friend in the meantime. 

Firstly, we have to remember that the child has conscience and knowledge, so we have to interact with him/her…. Talk to the children, explain what you’ll do, and explain your thinking in a way he/she can understand to gain their trust and not be seen as an unknown white-coated ghost!!

It is indeed a good idea to remove the white coat!

In many cases, the physical exploration can be carried out by distracting the patient with toys or other topics of conversation (depending on age). Examining a newborn or an infant in the arms of a parent, or a child while watching a cartoon or playing on a cell phone can be of great help to the surgeon. From 5 or 6 years old, in the case of cooperating patients, it can also be very useful to explain to the child what is being done during the examination. We start by asking the patient to jump to get off or on the couch: if he/she moves without difficulty and any facies of pain, we are not dealing with a child with an acute abdomen!

It is not necessary, during the examination, to follow a predefined and fixed pattern. We must be able to change the order of things, also based on what is most tolerated at that moment by the patient. Let him/her understand that we will not hurt him: we can first examine a puppet or our colleague or the parent, especially before using “new tools” on him, such as a stethoscope. 

During palpation of the abdomen, if the little patient is frightened by the hand touch, we can use the stethoscope instead of our fingertips to understand if the pain or the defense contracture is real.

Remember to always perform a genital examination in boys with abdominal pain, shame is often the cause of omission of information on genital or testicular pain in many children. Just as we must never forget to open the diaper when we evaluate a newborn or infant: more than 10% of inguinal hernias in infants under 6 months of age firstly appear as incarcerated hernias!

In some cases, however, creating a connection is impossible (think about children with neurocognitive impairment or with autism). Therefore, the physical examination must be quick and concise in order to highlight the signs of possible surgical pathology as soon as possible.

In other rare cases, adequate evaluation requires patient sedation: typical is the case of a patient with genital trauma who cannot safely be explored.

In short, when we are on call and we have to evaluate a child in the emergency room, it is not so impossible! You can proceed as in an adult examination, but taking into account all these small details that will allow us to carry out an effective and efficient evaluation.

Clinical Scenarios

Let’s analyze now what can be the warning signs for which it is worth worrying and alert the pediatric surgeon as soon as possible.

If we are asked for an urgent consult in the neonatology or neonatal ICU, we must take into account various surgical pathologies, some of which are life-threatening.

We may find ourselves evaluating a premature infant who was tolerating feeding, but who begins to develop abdominal distention, increased gastric retention, and who has pneumatosis on abdominal x-rays. This is a case of necrotizing enterocolitis, the initial treatment of which is conservative. The only two absolute indications that require urgent surgical intervention are evidence of perforation on abdominal x-ray (i.e. pneumoperitoneum) and a positive abdominal paracentesis (which is rarely practiced in newborns).

Idiopathic bowel perforation, which is a rarer condition, may also require emergency surgery, especially in premature infants, who are the most fragile and have the least stable conditions.

In neonatal and pediatric surgery, biliary vomiting is always a warning sign; in particular, an intestinal volvulus must always be excluded!

In the pediatric age, the cause is often intestinal malrotation, which in the neonatal period can give pictures of recurrent acute or incomplete intestinal obstruction, or intestinal volvulus, with the classic symptoms of shock, biliary vomiting, abdominal distention, bloody stool, erythema, and skin edema. There may also be an intermittent volvulus. Always keep an eye on these patients, close monitoring with frequent visits and serious abdominal X-rays help in the diagnosis… Always remember that volvulus is the grave of the pediatric surgeon… The diagnosis is complicated! Sometimes a newborn or an unstable pediatric patient, just with the abdominal palpation may become hypotensive and deteriorate clinically. In these cases, it is not possible to transfer the patient to radiology for an urgent abdominal CT as in adults!

Another emergency that we have already mentioned is the incarcerated inguinal hernia. In these cases, you have always to proceed step by step: reduction by cabs with an awake patient, then under sedation with the help of the emergency department pediatricians. Urgent surgery is the last option (if OR is needed, don’t even think about using a mesh!!!). 

Another condition to be considered is intestinal invagination. It occurs in an otherwise healthy infant with poor oral intake, abdominal distention, and vomiting. The patient usually looks well, chubby, and lethargic. The mom reports a history of intermittent severe abdominal pain with reddish, thick-mucous stool. The diagnosis is ultrasonographic and the treatment is nonoperative management (radiologic reduction of the invagination with air or with liquids), but with a pediatric surgeon present for possible complications (e.g. perforation or failure of the procedure).

If, on the other hand, a child presents with painless rectorrhagia, you have to think of a complicated Meckel’s diverticulum. Bleeding is the most common presentation in children with peptic ulceration at the base of the diverticulum. In newborns and infants, the Meckel’s diverticulum may present as a bowel obstruction (i.e. volvulus or intussusception). If the patient is unstable, profusely bleeding or a complicated Meckel’s diverticulum is suspected, an exploratory laparoscopy is indicated.

Last note on a congenital thoracic malformation: the congenital lobar emphysema. If during one of your calls, you have to manage an infant with this already known malformation (typically at 4 weeks of life) and who manifests respiratory symptoms, don’t wait to call the pediatric surgeon: you don’t want to find yourself having to perform an emergency thoracotomy alone!

Back to our little boy…

You decide to forget for one minute of being on call on a sunny spring Sunday and start playing with the child dinosaur puppet. Your history classes at primary school are still there and thanks to them you explain to the child that some dinosaurs may have stomach aches. He finally gets a bit more relaxed and confident with you… that’s the way!

A few moments later you are finally able to touch the boy’s abdomen… It is tender with positive McBurney and Blumberg signs in the right iliac fossa!

Your clinical suspicion is supported by the blood tests: high white cell count with neutrophilia and elevated CRP. 

The pediatric surgeon’s number is already on the desk…

References
  1. Ziegler MM, et al. Operative Pediatric Surgery. 2nd Ed. New York, NY: McGraw-Hill Education; 2014.
  2. Lacher M, et al. Pearls and Tricks in Pediatric Surgery. 1st Ed. Berlin, Germany: Springer Nature; 2021.
How to Cite This Post

Bianchi F, Marrano E, Bellio G. Dwarves’ Doctors are not Small Doctors. Surgical Pizza. Published on May 29, 2022. Accessed on September 24, 2022. Available at [https://surgicalpizza.org/emergency-surgery/when-dwarves-doctors-are-not-small-doctors/].

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