Making emergency departments less scary for children

Hospitals are scary places for children, with the emergency department probably representing the darkest chasm of despair. Emergency clinicians have a special responsibility to guide our patients safely and humanely through this environment. As outlined in the post on pediatric pain management, we have many options available to control pain in emergency medicine. However, our responsibility goes well beyond pain. As I mentioned in that post, we really need to address the many sources of a child’s distress. This post aims at starting a discussion about techniques for making emergency departments less scary.

I cannot pretend to have all the answers. I am no expert. There is no definitive paper. My plan is to outline some of the tips and tricks I have picked up, but my real hope is to inspire a conversation. I know there are many clinicians out there that do this much better than I do, so please share your tips and tricks for making the emergency department a friendlier place in the comments below. 

Setting the tone

First impressions matter. This is true for all our patients, but is particularly important when trying to allay the anxiety inherent in being a child in an emergency department. Although I tend to walk and talk pretty quickly in the emergency department, I try to consciously slow myself down when entering a child’s room. I want to give them time to warm up to me, so instead of immediately approaching the bedside, I will start the conversation from across the room, crouching down so I am at the child’s eye level.

I introduce myself to the child first, usually with some kind of silly banter:

“Hi, my name is Dr. Justin. You must be Katie. Katie, who did you bring with you today? Is this the Taxi driver who drove you here? No – oh, it’s your teacher from school? No – your sister? Your friend? No?! Oh my goodness, are you just sitting in the room with a stranger??” At some point during this spiel the child will inevitably tell the silly doctor that of course it is mommy whose lap she is sitting on.

I tend to continue the silly doctor routine with some more overly cheesy banter:

“OK, Katie. Let me see if I can guess why you are here today. It says here you are 6 years old. That must mean you are the girl from the news. You were at the zoo today, and a lion escaped, and you got bit by a lion. That’s why you are at the hospital, right? A lion bite? No? Oh, you must have been riding a unicorn, and you fell off and hurt your arm? No? Oh, you got hit by a bus? Mom sat on you by accident? Your skin is turning green? No? OK – I give up, you better tell me why you are here.”

Usually that is enough to break the ice, and let me close the gap and come sit on the edge of the stretcher without causing too much anxiety. (One of the most important skills in pediatrics is watching the child closely for signs of anxiety and picking the right time to approach).

Obviously, this overly cheesy spiel needs to be adapted depending on the age and maturity of the child. For most adolescents, I find speaking to them directly as I would an adult gets the best results. 

Physical Exam

For most pediatric encounters, the physical exam will be the scariest part of the visit. If possible, I try to demonstrate most of the exam before actually doing it. Sometimes this means checking the ears of a sick teddy bear. Sometimes it means listening dad’s heart before bringing the stethoscope anywhere close to the patient.

A “confused doctor” routine also works pretty well. I will look at the end of my stethoscope and pretend to forget where it goes. I usually start my trying to listen to my own head. Then a parent’s knee. Then moving to the child, but somewhere non-threatening like a knee or an elbow. The goal is to slowly work towards the more scary chest exam. (Often the child will just laugh and grab the stethoscope from my hands, putting on their chest to show the silly doctor how it is supposed to work.)

Specific exams

Vital signs

When putting on an oxygen saturation probe, I tell the patient that it is a special machine that measures magical powers. (And that I have never seen a score higher than 90 before, but let’s see how high their score is).

The blood pressure cuff can be a machine for measuring how strong your muscles are. Or it can be for giving really tight hugs and making sure you are safe.

Abdominal exam

I might listen to make sure they didn’t swallow a frog. (And then usually, I forget what sound a frog makes, and go through a series of noises: Is it “moo”? Is it “neigh”? Is it “roar”? Usually ended with, “your tummy makes a lot of strange animal noises – do you eat a lot of animal crackers?” Or, if age appropriate, “nope, I can’t hear any frogs – just a lot of toots”.)

When doing abdominal palpation, I might claim to be magic, with the ability to know what the child ate for breakfast just by feeling. (And either I end up being magic, which is amazing, or I am not, and the kids are very happy to prove me wrong.)

The other approach to palpation is just a search for where the tickles live: “no, they dont seem to be here…  not here.. not here… but.. there they are!”

If a child is really fearful of abdominal palpation, I will usually just do the palpation with my stethoscope while pretending to be totally focused on listening

Head and neck

Throats can be seen while children demonstrate the loudest “roar” they can make, or while singing their favourite song.

The otoscope can be a scary piece of equipment, and just giving the child some time to get used to it can help. Doing the exam on a teddy bear or mom sometimes helps. I will also show them my “magic flashlight”. If you hold the otoscope up to your finger tip, you can make the whole finger glow. Then, I blow on my finger tip and turn the light off at the same time (which they never seem to notice), so it looks like I am blowing out my glowing finger.

I also spend a lot of time searching for objects in children’s ears. Just make sure it isn’t scary. I tend to find frogs, but you will find the occasional child who is afraid of having frogs in his ear. Treasure or gold work. I found a radioactive spider in a child wearing a Spider-Man costume just yesterday, but I would generally avoid insects.

Procedures and treatments

Procedures are obviously scary. Clearly, we should focus on making them as pain free as possible. I spend a lot of time talking up my magic potions (EMLA or LET) that protect from pain. 

Make believe plays a big role here. An oxygen mask can be a “space mask” and the noise from the oxygen is the spaceship taking off. A nebulizer can be “unicorn farts” with magic powers to make them feel better. IVs can become spiderman web shooters or Iron Man blasters. Let your imagination run free.

Preparation and familiarity with equipment is also important. I show older kids IVs with the needle removed, so they know that it is just soft plastic and not a sharp needle left in their arm. Pictures of CT scanners and X ray machines can help. I have never had the opportunity to try it, but I know that Sick Children’s hospital in Toronto even has a virtual reality app, so children can experience going into a CT scanner or MRI virtually before having to do it in real life.

And obviously, distraction is a huge part of any pediatric emergency department. Blowing bubbles is fun for children and staff alike, and nothing is as powerful as a good movie or video game on a smartphone.

Other stuff

The best emergency departments I have worked in have stocks of toys or teddy bears to keep kids occupied. Some have also had video consoles, so children can watch Sponge Bob Square Pants (and yes, I really did need the full 22 minutes to finish that child’s exam.) A large supply of stickers definitely helps. So does the age old trick of blowing up gloves into makeshift balloons, especially when you draw funny faces on them. I won’t admit to teaching children how to use syringes as water guns, as that has got me in trouble too many times, but you have to admit it is pretty fun.

What are your favourite tricks?

I wrote this post with the primary goal of learning. I have a few tricks, and they have served me well, but I am no master. I would really like to hear your tips and tricks. What do you do to make the emergency department a less scary place for children? Please share in the comments section below.

Other Resources / References

Krauss BA, Krauss BS. Managing the Frightened Child Annals of Emergency Medicine. 2019; 74(1):30-35. Open access article with video examples. 

The art of distraction – Don’t Forget the Bubbles