James Cave provides a good comment on the articles about management of acutely ill children.1
It seems barely credible that British GPs fail to use basic, simple tests such as pulse, respiration, capillary return, and temperature in assessing acutely ill children. Perhaps they see so few really ill children in a year that they can get away with it.
I wonder what they do in the 15 or 20 minute consultations after making the general observation that the child is either well or ill!
A 1960s film was titled The Knack … and How to Get It. I believe it referred to chat up lines by young men. If being a careful family doctor is just to do with a acquiring the knack for safe diagnosis all well and good, but without a systematic approach, ‘general impression’ is bound to fail some children.
In my practice I do not have the luxury of a paediatrician at a referral centre or an ambulance service to rescue the cases that I miss. Here in rural Gambia our locally-trained (school grade 9) nurses are taught the four observations (as stated above and by Cave) which should be used with any ill child, supplemented by a simplified coma score (Blantyre coma score). Results are reproducible from observer to observer and an urgent request for the doctor to see the sick child is the result. I tend to repeat the same observations to confirm the severity of the case, en route to a diagnosis and treatment.
The proviso is that WHO Integrated Management of Childhood Illness guidelines suggest actually counting respiratory rate for a full, timed minute. Perhaps a minute is too long for highly trained doctors to sit still and count, but I would suggest that this can be a quiet interlude in which to allow parents and the child to watch you take a careful, objective view. Following that, most doctors can listen to the family while counting the (usually regular) pulse.
Brandishing a stethoscope is not likely to help any further and anyway stops the clinician from hearing the family while his/her ears are blocked!
Poor overall appearance of the child is also important, but parents with their own children are just as likely to tell you this without the benefit of any medical training, particularly for a child who you have not seen recently.
As a junior anaesthetist I learned that risks drop to rarities when you do things systematically. GPs could do well to take the same line.
- © British Journal of General Practice, 2008.
