Teaching Points for Hearing Impairment and Medication Storage Case
I. Patient Physician Interaction
a. Always introduce yourself to the patient and their family upon entering the room. Clarify your role in the team.
b. Be respectful of your patient and their family. Use Mr./Ms./Mrs. when addressing adults.
c. In general, it is best to sit at eye level with the person you are interviewing.
d. Try to maintain eye contact as much as possible during your interview.
II. Data Gathering skills
a. Always turn the TV off if one is on in the room at the beginning of the interaction.
b. If there are a lot of people in the exam room, you may want to ask some of the people to step out during the history in order to decrease distractions.
c. Try to not sit with a window/bright light to your back. If the person you are speaking to read lips, it is more difficult to do so if the speaker is back lit.
d. Do not chew gum or eat while gathering the history, and try to not cover your mouth.
e. Allow your historian to finish their opening statement without interrupting.
f. If the historian asks you to repeat a question, try to rephrase the question rather than repeating back the same phrase.
g. Instead of raising the volume of your voice when speaking with someone with hearing impairment, try lowering the tone of your voice. Presbycusis, or age related hearing loss, reduces the ability to hear higher frequencies, so people with higher voices (women) are harder to hear. It is also helpful to speak more slowly and to take care to clearly enunciate.
III. Information Giving/Counseling
a. The caregivers may feel guilty when children in their care present for medical care, especially in the case of ingestion. As the physician, you can ease these feelings of guilt by sharing empathy and offering supportive and encouraging statements. For example, to a grandmother guilty that her grandson got into her medication you could say, “I know you would not ever do anything on purpose to harm Johnny. Children are naturally curious and like to explore. Let’s see if we can work together to make a plan to keep Johnny safe in the future.”
b. While gathering the history and providing guidance, it is important to let the caregiver know that you are attentively listening to their concerns. While a caregiver is talking, you can use cues such as nodding your head, injections such as “yes or OK” to signal that you are following the conversation. You can also provide a summary at the end of their statements in order to make sure you heard the story correctly. For example, “Let me make sure I understood this correctly. You found Johnny asleep a couple of hours ago and noticed an open bottle of medication on the floor. You suspect he may have taken some of those pills.”
c. If you suspect a historian is hearing impaired it can be difficult to inquire about impairment if the historian is embarrassed or unaware of the problem. You can always ask the historian in a manner which places the onus on yourself such as, “I have been told I can talk too fast/quietly. Are you able to understand me ok?” This might make the historian feel more comfortable asking you to speak more slowly or repeat statements.
d. In any medical setting, it is a good idea to use the repeat back technique when gathering the history or when giving instructions, but it is an especially good idea in cases where you suspect hearing impairment. In this case you might say, “Just to make sure I explained everything clearly, tell me how you are going to store your medications when you get home.”
e. It is always a good idea to assess the storage of medications in a house as a part of your anticipatory guidance. The largest factor influencing accidental ingestions of medications in the pediatric population is storage of medication, not child proof caps. Medications should be stored out of reach, and hidden. Child proof medication storage boxes are also available to be purchased, and the use of child proof caps should be encouraged.
f. Remind families to never keep medications in purses, or out in plastic daily medication storage containers.
g. All homes should have the Poison Control number easily accessible in case of accidental ingestion.
IV. Clonidine Ingestion
a. Toxic effects are typically seen within 30 minutes to 4 hours after ingestion
b. Can see central adrenergic inhibitory effects such as impaired consciousness, hypotonia, hyporeflexia, miosis, bradycardia, hypotension, respiratory depression, apnea, and hypothermia.
c. If symptoms are mild, patients are admitted for observation.
d. May consider using activated charcoal if within 1-2 hours of ingestion.
e. In the case of severe symptoms, the use of naloxone may be considered, although it has been found that some people will not respond.
f. Provide needed support in the case of hypotension
g. In the case of significant respiratory depression ventilatory support may be needed.