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Little Patients: More Than Just Small Adults

By: Catherine Matusow - Houstonia Magazine

It was 6 A.M. on a summer morning when it happened: 3-year-old Max Mullervy, asleep next to his mother, Laura, rolled off the bed. This was something he’d done before, which is why she’d put cushions on the floor, but he missed those entirely, and on the way down, hit his eye on the side table. Max’s scream woke his mom with a start.

“It was a scary moment when I first saw him,” she says. “I thought, ‘Oh my goodness we have lost an eye.’ I couldn’t see much, because there was so much blood.” Mullervy put a cold compress to his face, carried him to the car, and headed for the Texas Medical Center and Children’s Memorial Hermann Hospital. Fearing he had had a concussion, she tried to chat with him the whole way there. For his part, Max was eerily quiet. “I think he was in shock,” she says.

Did You Know?
Once you’ve had a concussion, you are at increased risk of having another concussion.

On the way to the ER, Mullervy placed a phone call to the hospital, and when mother and son arrived, there was a team waiting for them. Immediately, she remembers, Max was made to feel comfortable and she herself felt relief. “He wasn’t put in a panic. As well as speaking to me, they spoke to him. They were sweet to him and told him what was going on. The fact that they are specifically geared toward dealing with children in these situations—and ours was thankfully in no way a big emergency at the end of the day—was really unique.”

“Part of what attracts people to work in a pediatric emergency department—they want to take care of kids, and they like it,” says James McCarthy, Chief of Emergency Medical Services, Memorial Hermann-Texas Medical Center and Chair of Emergency Medicine at McGovern Medical School at UTHealth. “They connect with kids. They like to get down and talk to kids on their level.” He adds, “There’s never just one patient. The parents are really involved. There’s usually two or three patients in the room, and you have to work with all of them.”

As a mom, Mullervy concurs. “You’re managing the fear of a child and the fear of an adult,” she says. “The adult’s going to want to know about ongoing treatment and any lasting repercussions, and the child is in the moment—what’s happening to me now?”

Max’s fall turned out to have missed his eyeball altogether—it was a cut to the eyebrow and the area right beneath it, requiring only a few stitches—but doctors in the pediatric ER at Children’s Memorial Hermann see severe injuries too. And while communicating with multiple audiences on multiple levels is important, it’s not the only consideration unique to children’s medicine.

In the days before there was a field of children’s medicine, doctors treated young patients like small adults; in fact, it was out of recognition of the differences between treating children and adults that the field was created. In the ER, for instance, “the equipment is very important; it must be appropriately-sized,” says Dr. McCarthy. “And from a medical perspective,” he says, “kids get different kinds of illnesses, bugs less commonly seen in adults.” Doctors have to pay acute attention. “Kids have tremendous reserve, so children look pretty good until they look awful. They don’t have a slow decline like adults do.”

Did You Know?
Placing an IV in a child is much more difficult than placing one in an adult. Children have smaller peripheral veins, more subcutaneous fat, and are less likely to sit still during the procedure.

Then there’s the fact that basic procedures in an adult ER can be anything but basic in the children’s unit. “For a 2-year-old kid, blood work is sort of an ordeal,” says Dr. Samuel J. Prater, the hospital’s Medical Director of Emergency Services. “A nurse has to hold the child down, because it’s something no child would willingly consent to. Their extremities might be a little pudgy. Now you have to stick the child a second time.” Distraction helps, he says: “There are Child Life Specialists there with toys and coloring books to play with the children.”

Pain management poses a special challenge when it comes to kids. “One of the things we do a terrible job of nationally is pain control,” says Dr. McCarthy. “They think kids are just crying because they’re scared.” Doctors affiliated with Children’s Memorial Hermann try to alleviate the pain without causing more of it, using numbing patches and nose sprays before putting in IVs. “Twenty minutes later and the kid is calm, willing to let us place the IV,” says Dr. Prater.

Meanwhile, dosages of medication must be determined individually for every single child in close collaboration with a pharmacist, because when it comes to children, the potential for dosing errors goes way up. “While we just give adults 500 milligrams of X,” says Dr. McCarthy, “it’s 250 for one kid and the next kid gets 375.”

Max Mullervy was one of 18,000 children seen last year in the Children’s Memorial Hermann Hospital ER, one of only two Level I pediatric trauma centers on the Texas Gulf Coast, with seven beds dedicated to pediatrics and separate waiting and triage areas. Because Max was so young, and his eyebrow—where the stitches were to be placed—required such careful attention, he had to be sedated.

“He hadn’t been under sedation before, so they were very good when they put him under,” remembers Laura Mullervy. “They talked him through it, how he needed to breathe through this tube and breathe normally, and don’t worry, he was going to go to sleep for a little bit.” Just in case, she continues, “they warned me that when children come around from anesthetics, they can be quite aggressive, maybe because they don’t know where they are, or because of an after-effect of the drug.” Lucky for her, when Max came to, says Mullervy, “he wasn’t aggressive, he was laughing.”

Today Max, now 4, can’t quite describe the experience himself, but he’s very enthusiastic about showing off Topper, the stuffed giraffe he got out of the ordeal, to a visitor. His mom meanwhile pulls out her cell phone and scrolls to a photo of Max in the ER after stitches. Above his bruised eye, he’s wearing a yellow bandana, and Topper, sitting next to him on the bed, has one to match.

“Our experience at the ER was incredible, full stop,” says his mom, shutting off her cell phone and looking over at her son, before adding dryly, “I don’t expect that this will be our last visit.”