WAITING ROOM

Parents of pediatric patients often arrive at the reception desk feeling anxious. They may be worried about what is involved in a procedure because they have not had the specifics explained to them or because they did not hear all that was explained to them. They also may be worried about the amount of time the care of their child will take, not to mention the outcome.

Feelings of anxiousness and tension are often transferred from parent to child—the child senses a parent’s tension through the parent’s tone of voice or actions. A well-equipped waiting room (this does not have to be expensive) can reduce this tension. Children are attracted to and amused by the toys, leaving the parents free to check in or register and ask pertinent questions.

Gender-neutral toys or activities such as a small table and chairs with crayons and coloring pages are most appropriate. (Children should be supervised to prevent them from putting the crayons in their mouths.) Books or magazines for older children are also good investments. The child life department of the hospital can provide advice and the most appropriate recommendations (Fig. 26-2).

IMAGING ROOM

Time can pass quickly for lengthy procedures if age-appropriate music or videos are available. A child who is absorbed in a video often requires little or no immobilization (other than the usual safety precautions designed to prevent the child from rolling off the table). Charitable and fund-raising organizations often donate televisions, DVD players, and computer games for this purpose.

Experience has shown that children are less likely to become upset or agitated if they are brought into a room that has been prepared before they enter. This preparation should include placement of the image receptor (IR), approximate centering of the tube to the IR, and placement of all immobilization tools likely to be needed at one end of the table and moving the x-ray tube in proximity to where the patient will be positioned.

Young children are often afraid of the dark. They dislike having the lights turned out but are often comfortable with low levels of illumination. Dimming the lights enough to see the collimator light before the child enters can prevent the need to explain why the lights have to be dimmed. Busy radiographers often turn the lights down without explanation, causing unnecessary anxiety.

After the procedure is complete, the radiographer or other imaging professional should take a moment to emphasize, even overemphasize, how helpful the child was and to explain where the child should wait or what the child should do next, ensuring that the parent is comprehending the instructions.

APPROACHING THE PARENT

No discussion of dealing with children is complete without mentioning ways to approach the parent. Although children are sometimes brought for medical care by someone other than the parents, in this discussion, the caregiver is referred to as the parent.

In many cases, radiographers find that they are dealing with two patients—the child and the parent. They may wonder to whom they should primarily speak. The answer, however, is easy:

APPROACHING THE CHILD

Naturally, good communication is essential to obtaining maximum cooperation. Children should be spoken to at their level in words that they can understand. This is not as difficult as learning a new language, and it can be made even easier if the radiographer keeps a few strategies in mind, as follows:

The child’s age should greatly influence the approach. Children are unique individuals with unique social styles, but the following guidelines may still prove helpful.

APPROACHING PATIENTS WITH SPECIAL NEEDS

EMERGENCY PATIENT

When an accident happens, emotions run high, thought processes are clouded, and the ability to rationalize is often lost. For the parents of a child who has been injured, another powerful factor is often involved—guilt. As parents try to absorb information about the child’s condition, they also ask themselves how they could have let the accident happen. Dealing with these questions often prevents parents from hearing or understanding all that is being explained. In addition, fearing that permanent damage has been done, the child can feel extremely traumatized by a relatively minor injury. The radiographer should observe the following guidelines in dealing with emergency patients and their parents:

OUTPATIENT

Generally, outpatients and their parents are easier to approach than inpatients. For a radiographer who has had little experience with children, these are among the best patients with whom to begin. Outpatient visits are frequently a form of progress report, and patients are usually ambulatory and relatively healthy. For the most part, parents are calm because they are not dealing with the emotions of an emergency situation or perhaps the tension or fear that the parents of inpatients can experience. They can become agitated, however, if kept waiting too long, which happens often in the outpatient clinical setting.

INPATIENT

A child usually must be very sick to be admitted to a hospital. Children often become acutely ill in a much shorter period than adults. They generally heal more quickly than an adult, however, which decreases the length of the hospital stay. The stresses the child experiences involve fear and separation from parents, family, and friends. It also is a stressful time for the parents who, while worrying about their child’s health, must often juggle time for work and for taking care of other family members. By understanding that these responsibilities weigh heavily on parents’ minds and by remembering to provide reassurance and simple explanations, the radiographer can make the child’s visit to the imaging department easier.

GENERAL MEASURES

Depending on the level of care being provided, children may arrive in the imaging department with chest tubes, intravenous (IV) infusions (including central venous lines), colostomies, ileostomies, or urine collection systems. Usually these children are inpatients, but in many instances outpatients (particularly in interventional cases) arrive in the department with various tubes in situ (e.g., gastrostomy or gastrojejunostomy tube placements). The radiographer must be aware of the purpose and significance of these medical adjuncts and know the ways to care for a patient with them (see Figs. 26-46 and 26-47).

A competent and caring radiographer takes note of the following:

Many inpatients are on a 24-hour urine and stool collection routine. Medical personnel who change diapers on these patients should save the old diaper for the ward or floor personnel to weigh or assess.

Hospital policy and the availability of nursing staff within the imaging department determine the amount of involvement the radiographer has with the management of IV lines. The radiographer must be able to assess the integrity of the line and must know the measures to take in the event of problems.¹

ISOLATION PROTOCOLS AND STANDARD BLOOD AND BODY FLUID PRECAUTIONS

Prevention of the spread of contagious disease is of primary importance in a health care facility for children. Microorganisms are most commonly spread from one person to another by human hands. Careful handwashing is the most important precaution, but it is often the most neglected. In addition, all equipment that comes in contact with the radiographer and patient during isolation cases must be washed with an appropriate cleanser.

The premise of standard blood and body fluid precautions is that all blood and body fluids are to be considered infected. The U.S. Centers for Disease Control and Prevention recommend that health care workers practice blood and body fluid precautions when caring for all patients. These precautions are designed to protect patients and medical personnel from the diseases spread by infected blood and body fluids. All blood and body fluids, including secretions and excretions, must be treated as if they contain infective microorganisms. Working under this assumption, personnel can protect themselves not only from patients in whom a known infective organism is present but also from the unknown. The management of patients in isolation varies according to the type of organism or preexisting condition, the procedure itself (some can alternatively be performed with a mobile unit), and hospital or departmental policies. Decisions regarding when to bring an infectious patient to the department also often depend on the condition of other patients who may be in the vicinity. Patients with multiresistant organisms should not be close to immunocompromised patients.

The radiographer should follow all precautions outlined by the physician and nursing unit responsible for the child. Respiratory, enteric, or wound precautions for handling a patient are usually instituted to protect staff members and other patients. Isolation procedures are instituted to protect a patient from infection. Protective isolation is used with burn victims and patients with immunologic disorders. The protective clothing worn by staff members may be the same in either situation, but the method of discarding the clothing would be different.¹

PREMATURE INFANT

One of the greatest dangers facing a premature and sometimes a full-term neonate is hypothermia (below normal body temperature). Thermoregulation, the balance of heat losses and gains, is crucial to the care and survival of a premature infant. The sources of heat loss—evaporation, convection, conduction, and radiation—are greater in the preterm infant. Premature infants have a greater surface area compared with body mass. They are incapable of storing the fat needed for warmth, and they have increased metabolic rates.

To avoid hypothermia, premature infants should be examined within the infant warmer or isolette whenever possible. General radiography must be performed with a portable or mobile unit. (See Chapter 28 for a discussion of mobile radiography.) The radiographer should take great care to prevent the infant’s skin from coming in contact with IRs. Covering the IR with one or two layers of a cloth diaper (or equivalent) works well; however, the material should be free of creases because these produce significant artifacts on neonatal radiographs.

When a premature infant is brought to the imaging department for gastrointestinal (GI) procedures or various types of scans, the radiographer should observe the following guidelines:

Because of the risk of infection to infants in the neonatal intensive care unit (NICU), most units insist on adherence to isolation protocols such as gowning and handwashing.

NOTE: Neonatal refers to newborn. Although premature infants constitute the highest percentage of patients in NICUs, all of the infants in these units are not premature. Full-term infants experiencing distress are also cared for in NICUs.

The radiographer must take care when positioning an infant from the NICU. Many of these infants can tolerate only minimal handling without their heart rates becoming irregular.

MYELOMENINGOCELE

A myelomeningocele is a congenital defect characterized by a cystic protrusion of the meninges and the spinal cord tissue and fluid. It occurs as a result of spina bifida, a cleft in the neural arches of a vertebra. It can be recognized by fetal ultrasonography at the 17th or 18th week of gestation. Myelomeningoceles may cause varying degrees of paralysis and hydrocephalus. The higher the location of the myelomeningocele, the worse the neurologic symptoms.

Patients with myelomeningoceles are cared for in the prone position. Whenever possible, radiographic examinations of these patients should be performed using the prone position until the defect has been surgically repaired and the wound healed. The primary imaging modalities used in the investigation and follow-up care of myelomeningoceles include ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) (Fig. 26-5).

OMPHALOCELE AND GASTROSCHISIS

An omphalocele is a congenital defect that resembles an enormous umbilical hernia. Omphaloceles are covered in a thin, translucent, membranous sac of peritoneum, and their contents include bowel and perhaps liver. Gastroschisis is a similar condition in which a portion of bowel herniates through a defect near the naval. The difference is that in gastroschisis the bowel is not included within a sac.

In omphalocele and gastroschisis, the herniated abdominal contents must be kept warm and moist. This is especially important with gastroschisis. A responsible physician or nurse should be present when patients with these conditions are examined radiographically because such patients become rapidly hypothermic.

EPIGLOTTITIS

Epiglottitis is one of the most dangerous causes of acute upper airway obstruction in children and must be treated as an emergency. Its peak incidence occurs in children 3 to 6 years old. Epiglottitis is usually caused by Haemophilus influenzae, and the symptoms include acute respiratory obstruction, high temperature, and dysphasia (inability to swallow or difficulty in swallowing). When epiglottitis is clinically suspected, the radiographer observes the following steps:

OSTEOGENESIS IMPERFECTA

Osteogenesis imperfecta (OI) is a disease characterized by brittle bones. The approach and management need to be altered significantly in the imaging department to accommodate patients with OI. Children with OI are prone to spontaneous fractures or fractures that occur with minimal trauma. Although OI can vary in severity, patients with this disease need to be handled with extreme care by an experienced radiographer (Fig. 26-7).

Children with OI are almost always accompanied by a key caregiver—usually a parent. Experience has shown that these patients are best handled with a team approach in an unhurried atmosphere. The team comprises the patient, parent (caregiver), and radiographer, with the radiographer observing the following guidelines:

SUSPECTED CHILD ABUSE

Although no universal agreement exists on the definition of child abuse, the radiographer should have an appreciation of the all-encompassing nature of this problem. Child abuse has been described as “the involvement of physical injury, sexual abuse or deprivation of nutrition, care or affection in circumstances, which indicate that injury or deprivation may not be accidental or may have occurred through neglect.”¹ Although diagnostic imaging staff members are usually involved only in cases in which physical abuse is a possibility, they should realize that sexual abuse and nutritional neglect are also prevalent.

It is mandatory in all states and provinces in North America for health care professionals to report suspected cases of abuse or neglect. The radiographer, while preparing or positioning the patient, may be the first person to suspect abuse or neglect (Fig. 26-8). The first course of action for the radiographer should be to consult a radiologist (when available) or the attending physician. After this consultation, the radiographer may no longer have cause for suspicion because some naturally occurring skin markings mimic bruising. If the radiographer’s doubts persist, the suspicions must be reported to the proper authority, regardless of the physician’s opinion. Recognizing the complexity of child abuse issues, many health care facilities have developed a multidisciplinary team of health care workers to respond to these issues. Radiographers working in hospitals have access to this team of physicians, social workers, and psychologists for the purposes of reporting their concerns; others are advised to work through their local Children’s Aid Society or appropriate organization.

Plain image radiography, often the initial imaging tool, can reveal characteristic radiologic patterns of skeletal injury. Clear evidence of posterior rib fractures, corner fractures, and bucket-handle fractures of limbs are considered classic indicators of physical abuse (Fig. 26-9). All imaging modalities play a role in the investigation of suspected child abuse. After plain radiography, nuclear medicine is often the next investigative tool of choice (Fig. 26-10). CT with three-dimensional reconstruction has contributed to differentiating cases of actual abuse from accidental trauma (Fig. 26-11). The presence of numerous fracture sites at varied or multiple stages of healing can also indicate long-term or ongoing abuse. These cases are often viewed by nonradiologic staff members (e.g., lawyers) and imaging professionals. Evidence of injury must be readily apparent, especially because pediatric fractures at an early age can remodel totally over time, providing no clear evidence of earlier fractures.

The radiographer’s role is to provide physicians with diagnostic radiographs that show bone and soft tissue equally well. Referring physicians depend on the expertise of the diagnostic imaging service for the detection of physical abuse, and radiologists are able to estimate the date of the injury based on the degree of callus formation or the amount of healing.

The radiographer observes the following guidelines when dealing with a case of possible child abuse:

• Give careful attention to exposure factors and the recorded detail shown for limb radiography. Imaging systems yielding high detail are recommended for cases of suspected child abuse because the associated skeletal injuries are often very subtle (Fig. 26-12).

Fig. 26-12 Chest radiograph showing different stages of healing posterior rib fractures (arrows).

• Performing a babygram

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