Case Scenario: Foreign Body Ingestion in a Child (Button in Esophagus)

Summary:

A four-year-old child was brought to the emergency department after swallowing a button. An X-ray was initially reported as normal, and the child was sent home without intervention. Two days later, a radiologist reviewing the X-ray identified the foreign body in the esophagus. The consultation involved informing the mother, ensuring safe management, and facilitating hospital admission.

Key Points:

Data Gathering Issues:

The candidate did not sufficiently explore the history of the event, including:
- How and when the child swallowed the button.
- Any symptoms at the time of the incident.
- Parental understanding of the situation.
Current status assessment was lacking, which is crucial in determining urgency:
- Any breathing difficulties, pain, or trouble swallowing?
- Is the child eating and drinking normally?
Missed opportunity to clarify past medical history, medication history, allergies, and social history.

Complications of a Foreign Body in the Esophagus:

Immediate risks: Perforation, aspiration, airway compromise.
Delayed risks: Esophageal stricture, erosion, infection.
Specific concerns for button batteries: Severe risk of tissue necrosis and perforation due to electrical discharge.

Telephone Consultation Etiquette:

Always confirm full name, age, and address.
Check if this is a good time to talk.
Confirm if the number can be used to call back if the line is cut.
Ensure clear audio/video connection if applicable.

Diagnostic Approach:

History-taking:
- Open-ended questions: "Can you tell me more about what happened?"
- Current symptoms: breathing issues, pain, vomiting, drooling.
- Previous interventions or similar incidents.
Clinical Assessment:
- Ask about any new symptoms that could indicate obstruction or complications.
- Ensure no immediate red flags (e.g., difficulty breathing, cyanosis).
Investigation Plan:
- Repeat X-ray to confirm foreign body location.
- Further imaging (CT/MRI) if needed to assess complications.

Management Plan:

Emergency Referral:
- Immediate hospital admission required.
- Ensure the mother understands the urgency of the situation.
Explain the Next Steps Clearly:
- X-ray reassessment to confirm button location.
- If still lodged: Endoscopic retrieval may be needed.
- If it has passed into the stomach: Observation and stool monitoring.
Safety Netting & Follow-up:
- Signs of deterioration: increased pain, difficulty breathing, vomiting.
- Return to hospital immediately if symptoms worsen.
- Offer written information on foreign body ingestion management.

Communication Skills:

Empathy & Validation: Acknowledge maternal anxiety:
- "I understand this must be very worrying for you. I’m here to ensure we do the best for your child."
Breaking Bad News Using the SPIKES Protocol:
- Setting: Ensure privacy, calm tone.
- Perception: Ask the mother what she knows so far.
- Invitation: Prepare her for the unexpected findings.
- Knowledge: Explain the new radiology report.
- Emotions: Validate distress, offer reassurance.
- Strategy: Explain the next steps and why they are urgent.
Addressing Barriers:
- If the mother cannot leave work, offer an excuse letter.
- If childcare is an issue, suggest social services for support.
- Transport issues? Offer ambulance services if necessary.

Ethical Considerations:

Duty of Candour: Clearly acknowledge the medical error (missed diagnosis).
Child Protection: If repeated incidents suggest neglect, safeguarding concerns should be raised.
Parental Autonomy vs. Best Interests: If the mother refuses to bring the child in, escalation may be required.

Final Notes for PLAB 2 Success:

Prioritize Data Gathering: Always establish what is happening now before delivering any news.
Follow a Structured Approach: Use open-ended questions, explore history, and confirm understanding.
Manage Time Efficiently: 8-minute stations require focus—don't skip steps.
Show Confidence: Speak clearly and assertively, but always remain empathetic.