This is a fantastic concurrent, isn’t it? My colleagues here are going to take your through the nightmares of every clinician. But I’m here because actually, those nightmare scenarios represent a tiny proportion of the children we see.
I have a huge list of tweetable clinical tips I’m going to share over the next couple of weeks using the #paedstips hashtag, but we don’t have time to cover all of that today, so I’ve boiled this talk down to the essentials of understanding the approach to paediatric patients.
So this is the purpose of this talk: the majority of paediatrics is common sense medicine. This is certainly true in the developed world. In fact, many of the children we see in the paediatric ED and rural GP aren’t presenting with life threatening illness/injury and most will get better despite what we do to them. But that doesn’t mean it’s easy, but it’s not hard.
Kids are supposed to thrive, grow up, make everyone proud, have their own kids and die at a ripe old age. They are not supposed to be critically unwell or critically injured, let alone die. When bad things happen there is a huge emotional burden.
A major aid to coping with seeing tragedy in childhood is being able to take refuge in knowing that you did everything possible. We know we’ve done everything we can because we know in advance how we are going to approach life threatening illness and injury. Cliff Reid says “How we train is how we fight”. Don’t be a cowboy; if you routinely see sick/injured kids, get good at managing them.
APLS and similar courses provide great starting points but APLS is a three day course and brilliant as I am, I can’t condense it into 20mins. SO: here are some thoughts from the paediatric ED which will help you look after your paediatric patients and get you off on the right foot
It might not feel like it but serious illness and injury in children are rare. And what’s more, unlike adults kids rarely fake it. They have much better places to be than in the ED (although playing in the WR is awesome fun).
However, assessment of paediatric patients is made more difficult because of pain, emotional immaturity, fatigue and fear. If you can recognise and properly address these factors, your job will be easier. Sick, injured and scared kids regress developmentally. Even adult-sized rugby-playing teenagers are not emotionally adult and may not behave in the way you expect them to.
But PEM is a team sport and the most important part is the pre-match huddle. Choose your team carefully and get everyone on the same page and playing in the same direction before you start: pay particular attention to getting mum and dad on your side if you can. Allocate roles and explain responsibilities in all PEM situations whether a resuscitation or a routine examination. Invest time in preparation for non-emergency procedures. Play to your team’s strengths; get your best players (the paeds nurses) up front; for goodness’ sake don’t try to play without them.
Much of medicine is actually performance and pretending to be something you are not - which is good, because it means you can practice. Have and learn a pep talk script you can perform to parents. It is in your interest to make things run smoothly. You are investing in future ED attendances, not just in your patient’s childhood but in their experiences into adulthood too.
The most important skills in Paediatric EM are communication skills. You have to know how to talk to kids and their families, to instil confidence in them. A child who trusts you will believe you and it’s your job to bring calm and reassurance to the consultation. Do not lie to children; this will backfire and the child’s mistrust of you will carry over into future consultations.
You need to understand the world children live in. The best prep for paeds is to hang out with kids; learn how to play with them, learn what they like to talk about, learn the name of Peppa Pig’s best friend. If a child recognises you in the context of the world they know and understand, you will become less threatening. Know about popular television shows, compliment children on their spiderman t-shirt; show an interest in who they are.
Children need to be the focus of the consultation. Give all but the very sickest children an opportunity to tell you about their illness story. We can treat our patients better, whatever their age, when we understand their priorities; ask the child about the problem that has brought them to the ED - and make sure you address it.
Hospitals and healthcare settings are scary in their own right, even to adults. Try to see children in a designated paediatric area. Toddlers are the most difficult age group because they transition from fear of strangers to fear of being separated from their parents. The worst thing you can do is combine these fears into a single event. Parents know this; google separation anxiety and you’ll find discussion boards of parents asking how they can make medical and dental attendances less stressful for their terrified offspring. Parents find this emotionally challenging too.
At the other end of the spectrum, being a teenager is complicated. There are lots of opportunities to make a difference to young people; offer to see them alone, state “it’s part of my practice”
Recognise that the patient is not always the child in front of you. Being a parent is tough. It’s REALLY tough. Parents selflessly sacrifice for their children in ways we can barely imagine. Sometimes the most important thing is to allow mum & dad to share their concerns, worries, anxieties and frustrations. This is especially true of new parents. I would strongly advise that whenever you see a neonate you take the time to ask the parents how things are going. Validate feelings of helplessness and exhaustion in parents and carers of children of all ages. You have a vital role in providing support here.
Situational awareness is crucial in PEM. One of the best examples of this is obtaining IV access in the septic, clapped out, shut down LLS kids. Sick kids need treatment so make this your mantra; two strikes and you’re out - in a sick kid MAXIMUM two attempts at IV before IO access. If you are someone who knows they might be tempted to break your own rules in this situation, take the EZ-IO out, give it to the nurse and tell them to give it to you after the second failed attempt. Share your mental model to get your team on the same page and give them permission to hold you to account.
If things are going badly, make early an decision to phone a friend. Sometimes when we see adults and ask for help, we get resistance from specialties and other services. One of the best things about PEM is that this is rarely the case. Two heads are better than one; make the most of the expertise and skill sets available to you.
Babies - neonates in particular - deserve a special mention because they are special. They are different from all other human beings; they do very unique things and deserve careful consideration. And now the good news; it’s your professional responsibility to hug babies. It’s an important part of the assessment of their tone. It also makes them stop crying when they’re held by someone calm and well slept :-) You need to get used to hugging babies. Practice!
Children of all ages feel pain. Treating it is not only necessary, it also helps assessment. Pain in the neonatal period alters clinical outcomes, brain development and subsequent behaviour. There’s evidence that neonates who experience pain develop increased pain sensitivity and hyperalgesia, and is associated with changes in behavioural stress responses, ultimately leading to psychosomatic pain and psychiatric disorders in later life. However, inflicting pain to relieve pain - if you want to give IV/IM meds - is not something that most children can rationalise. Therefore, consider alternatives; femoral nerve blocks for femoral shaft fractures.
Make use of the intranasal route for severe pain: in Manchester we primarily use intranasal diamorphine, other options include fentanyl and ketamine
In babies who are too young for topical anaesthetic, sucrose has been shown to reduce distress associated with the pain of venepuncture and cannulation in babies; breast milk is an alternative. Be kind!
LAT gel is a wonderful thing: combination of lidocaine, adrenaline, tetracaine for open wounds (alternative TAC). Rule of Jenner - if kid allows you to put it on, they will usually allow you to clean/suture the wound.
You need to be systematic and think critically. There will be times when things don’t quite add up and it is the way we approach these situations that not only makes EM challenging and interesting but it also defines us as EM clinicians.
If things don’t make sense, check a blood sugar: hypo and hyperglycaemia present in all sorts of weird and wonderful ways. Easy to treat, easy to miss.
Beware the child with unexplained tachycardia There may be badness there
If in doubt, get an ECG. Monitors lie. The heart rate here is not 164/min despite what the analysis says.
Be on the ball: examine the scrotum and testes in male kids and adolescents with abdo pain (vomiting?). As Ross Fisher, paediatric surgeon, advises; “Play gently with scrotum for best results” Tortion hurts like being kicked in the nuts. In an emergency, untort like opening cupboard doors: nothing to lose by trying this if in middle of nowhere
Be thorough, be systematic; avoid anchoring and be aware of the influence of heuristics and bias. E.g. non-specific abdo pain localises to T10 (the umbilicus). This does not mean the umbilical hernia is obstructed/incarcerated! They almost never need surgery and virtually always resolve in kids <4. E.g. rectal prolapses do not make children ill. Rectal prolapse plus sick kid = colonic intussusception
All kids who cannot give a history must be examined from head to toe. You MUST take off ALL clothes and the nappy and look carefully front and back. If you don’t do this you will miss purpuric rashes. You WILL miss non-accidental injury.
Lots of PEM involves drug calculations. Check and double check and ask if it makes sense. If it is more than you would give an adult, it’s probably wrong.
Babies are nice. Sometimes teenagers have them. Think pregnancy test!
Never, ever, ever forget NAI. Strip the child off. Have a look for other injuries. Ask yourself if what you are being told makes sense. Ask yourself if that mechanism would cause the injuries you are seeing. If a child discloses abuse, you cannot promise to keep it secret BUT you can promise to help them and reassure them that they are not in trouble.
Time is one of our greatest tools. Things can change quickly. Utilise opportunities to observe children for evolving pathology in ED and create an extension of this at home by explaining to mum and dad what to look for.
Don’t get burned Safety net well Things change, kids get sick, you need the parents to know it’s ok to come back. Use your script here too: “we know that things change. We don’t need to do anything else at the moment, but if you are concerned - any time, about anything, even if it’s just when you get to the car park - come back. We won’t tell you off. We would rather see you and everything be fine than not see you when actually we really need to.”
Team game and performance
Communication and empathy
Knowing your enemy.
Paediatric Tips You Won't Find In Books - @_NMay at SMACC Gold
Tips for Kids You Won’t Find in Books