He Fell Out Of Bed and Bumped His Head

This week’s guest columnist is Dr. Rachel Kumar, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

Three year-olds sit on barstools.  Three year-olds get the wiggles.  And when you’re in the kitchen making dinner, she does both at the same time.  Then she drops out of sight and you hear a smack and a scream.  You abandon the spaghetti and rush around to find her flat on her back, shrieking at the top of her lungs.

All parents have had this nightmare.  Your child hits his head, screams bloody murder or acts odd in some other way, and you think “do I need to call 911?”  Parents often feel that an immediate assessment is a must.  However, most head injuries don’t require an Emergency Department visit.  Knowing the signs and symptoms of severe head injuries, versus those that can stay home, can save you lots of anxiety, and moolah, on medical bills.

You can simply ask yourself three main questions: What was the mechanism of injury, how was the child immediately after, and how is the child now?  The bad mechanisms- high speed car crashes, getting hit by baseball bats- they’re easy. Get seen!  Likewise, the toddler bonks his head on the coffee table, the car’s rear-ended in a parking lot- stay home!  It’s those in-between patients, like the toddler on the barstool or the baby rolling off the bed, that require some thought.

Here’s the mechanism rules, plain and simple.  If your kid is over two year’s old, it takes a fall from 5 feet or more to generate enough energy for bad head injuries.  Under two years-old: a 3 foot fall.  Use a measuring tape; sometimes we do, to show a parent what three feet looks like.  Is that how high your bed is, we ask?

High energy impacts, like thrown baseballs, swinging bats and golf clubs, also need checking.  Getting hit by a car, whether your kid’s walking or on a bike without a helmet, warrants an ER visit.  Getting hit by a thrown plastic toy- not so much.

Children jump from one couch to another- it’s what they do.  We all, you and me, did it as kids.  Who needs trampoline parks when we all have one at home, whether it’s couches or a room with two beds?  But then the inevitable- young Mary Lou Retton doesn’t stick the landing, stopping the fall with her scalp instead of her feet.

Let’s answer that second question from above: immediately after a head injury, how’s your kid acting?  There’s red flags at this stage that tell us a kid needs medical attention.  Of course, if the child is unconscious, he needs to be seen.  If the child isn’t knocked out, but is acting dazed and talking in a confused manner, that’s worrisome too.  This is the scenario with many football players- they aren’t knocked out, but are staggering around after the blow, can’t remember their plays or what just happened, or  even where they are.

For babies and toddlers, the immediate assessment is more vague.  Of course if after stopping crying, they go back to themselves, walking about and smiling and babbling, you can stay home.  But if they’re acting sleepy, seem more unsteady than usual, or are “just not acting right,” then you should call your doctor, or get seen.

The third question is: how is your child acting now, some time after the injury.  Of course if he goes back to playing and running,it’s cool.  But what if he goes to sleep?  Many kids tend to want to lie down and nap after a traumatic experience and some hard crying, but what’s the line between a normal nap and somnolence from head injury?  If it’s the child’s normal nap time, she takes her usual 30 minute nap and then wakes up, then cool.  But if after a half hour she’s harder-than-usual to wake up, it’s check time.

Other red flags are vomiting after a head injury, or severe headaches.  Children who are squinting and holding their heads hours after a head injury need to get seen.  What about lumps?  Many kids get them, just like characters on Bugs Bunny cartoons, rising from their scalps.  We only worry about lumps on kids under two years-old.  And even then, lumps on foreheads are okay.  Lumps on the sides or back of the head- come on in! 

Is Chapped Lips An Emergency?

One of last year’s fun news stories was a 911 call from a man whose cat wouldn’t let him in his house.  After a three hour stand off, and after the police and 911 operator finished laughing themselves silly, an officer was dispatched and apparently talked the cat down.

Similar absurdities happen in Emergency Medicine.  Once when I worked in Baltimore, a mom brought her child in for chapped lips.  Thinking that no one would come to the ED for such a minor thing, I searched for the “hidden agenda,” some underlying worry explaining mom’s thinking.  Like if her Uncle Frim had lip cancer and she feared her son had it too. However, after an exhaustive history, there was no such issue: her son simply had chapped lips.

It’s sometimes difficult telling the public when to call 911 or not, and when to bring kids to the Emergency Department or not.  We want to encourage people to get emergency help so they don’t blow off potentially serious issues.  On the other hand, we don’t want the Emergency Department and EMS systems clogged with non-emergencies.

Most pediatric ED visits are not emergencies, but families come for many reasons. First, parents get scared for their kids.  They love their kids and when they get sick or hurt, parents sometimes rush for help rather than call their doctor for advice or wait for an appointment.

Often parents can’t get their kid seen in the office that day.  An appointment for next week doesn’t help when your child won’t stop vomiting, or needs x-rays.  Sometimes when the parent does call for advice, the mom is told to go to the ED, rather than office staff taking time to talk the situation through, giving advice that could keep the child home.

Sometimes when a child gets sick or hurt, a doctor’s office or school is worried about caring for a potential emergency.  They aren’t used to emergencies and don’t want to miss something, or get sued.

Almost daily we see kids in the Emergency Department who were in car crashes, seem fine, but the parents want them “checked out.”  You can’t fault this reasoning; they care about their kids and are worried.  However, when the “crash” involves cars backing into each other in a parking lot, and the child was strapped into a car seat, maybe an ED visit is overkill.  Unless the lot has cars speeding into their slots like the Indy 500 pit stop.

Too often the ED is used as a walk-in clinic, rather than for true emergencies.  The point of this blog is to inform you about what real emergencies are, what can wait to see the doctor, and what you can take care of at home.  So let’s review common issues appropriate for the ED, and things that are not emergencies.

Kids who are short of breath, tugging to breathe, belong in the ED.  Of course bring any children with possible broken bones, cuts that need stitches or won’t stop bleeding, or severe pain. When kids get lethargic (difficult to arouse), they need to get seen.  However, there are gradations of cuts and limb injuries, and lethargy: kids with fever get lethargic, but recover with anti-fever medicines.  If it isn’t obvious if it’s an emergency or not, call the doctor’s office.  If they can’t help, go to the column in this blog to the immediate right side of the page.  Click on your issue to read specifics about what is an emergency, and what can be handled at home.

Things that are commonly not emergencies: fever, coughing, rashes.  Fever doesn’t hurt kids- it doesn’t cook their brains and is rarely associated with seizures.  The height of the fever doesn’t correlate with how sick the kid is either: a child with a 104 temperature isn’t sicker than a child with 101.  Coughing also isn’t an emergency- kids cough when they get colds and if they aren’t otherwise short of breath, it can wait.  Again, see the column to the right.

This is a busy time of year for the Pediatric Emergency Departments, so use common sense when deciding to visit.  Use your doctor’s call line, or this blog when in doubt.  But if you still can’t decide, bring your child in. Better safe than sorry, but you can leave the chapped lips at home.

If You Call 911, Shouldn’t you Listen to your Paramedic?

The following is not an unusual situation:  The paramedics pull up on the scene of an injury.  They assess the patient, and let’s say the patient is a seven year-old girl with a broken leg. 

Mom: “Can you take her to Regional Medical Center?”

Paramedic: “Well ma’am, Regional does not typically take care of kids, and they do not have an orthopedic doctor on call for their Emergency Department today.”

Mom: “I want her to go to Regional!”

 

When you call 911, you are calling “help!” in an emergency.  Someone is having bad chest pain, or trouble breathing, or is hurt so bad that they cannot be moved without expert help.  Of course, you should not call 911 when the situation is clearly NOT an emergency-fever, baby who briefly gagged on mucus, fainting spells (and getting an ambulance ride to the hospital does NOT get you ahead of the line for waiting at the Emergency Department- non-emergencies go to the waiting room like everyone else).  When the paramedics show up, the question then arises, where to go?

In many towns in Louisiana, there are several choices for hospitals.  What many people don’t know is that each hospital has some capabilities, but not ALL capabilities.  Some hospitals are best for broken legs in children, but those hospitals may not be best if grandma is having a stroke.  Some people choose the hospital they want to go to by preference- they had a good experience at one hospital, they have a relative who works there, they liked the hospital’s ad on TV.

In an emergency though, you need to take your paramedic’s advice about where to go.  The participating ambulance services in Louisiana (including Acadian and Med Express) are tied into a state system called LERN-Louisiana Emergency Response Network.  LERN is a separate system from 911.  It is a set of dispatch/call centers that keeps tabs on all participating hospitals’ available surgical services, ICU bed capacities, and CT scan services.  The purpose of LERN is to quickly tell paramedics which hospital nearest to them can handle that patient’s needs, and save the patient precious time that might be needed for survival.  Before LERN, paramedics had to sometimes make two or three time-consuming calls to find a hospital that could manage their patient.  Now, one quick call and the ambulance knows where to go and the receiving hospital knows they are coming.

So when you call 911, you need to listen to your paramedic.  He or she knows, from LERN, that maybe Lafayette General is closed to orthopedic injuries because their operating rooms are at full capacity; or that Lourdes’ ICU is full and Uncle Joe should go to the Heart Hospital for his chest pain. 

If you would like more information about the LERN system, visit them on the web at LERN.La.Gov.  And in an emergency, call 911.  If it is not an emergency, don’t.