The Sweet Spot – Meredith Borland, part 1

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The Paediatric Emergency Department is a relatively unique area in medicine as the registrar workforce usually comes from one of two backgrounds: Emergency or Paediatrics. Consequently, we strive to have the optimal combination of both specialties – The Sweet Spot.

The two groups come with a very different skillset and approach to medical care. In some cases, the Emergency trainee may not have cared for children previously, or the Paediatric trainee not have worked in the ED since their intern year.

In this edition of the Sweet Spot, we’re hearing from Dr Meredith Borland, Director of Emergency Medicine at Princess Margaret Hospital for Children in Perth, Australia. She has previously featured on the empem series of podcasts. In her own words;

“I came to Paediatric emergency medicine after working as a GP for 8 years and realising my passion was paediatrics and emergency medicine. It seemed logical to return to training through the ACEM. This was when the JTC PEM was still being negotiated and I was lucky to complete training in WA and Vic and commence full time as a PEM consultant position in 2004. Since then I have enjoyed developing the field of PEM for both paediatric and emergency trainees.”

Part 1 : For Paediatric doctors new to the ED setting:

What are some common stumbling blocks & how can these be avoided/fixed?

Minor trauma (fractures, lacerations etc) – don’t avoid seeing these patients – actively seek them out and use local resources to get familiar with the procedures you need to develop – nurse practitioners, consultants or ED trainees are valuable resources – just don’t hand the patient over though … do it yourself.

Getting bogged down chasing rare conditions  – most children in ED need no or very few investigations – take a good history, perform a focused and appropriate examination and develop rapport with the child and their family. Then you can educate and discharge without unnecessary tests or treatments and you’ll be more efficient.

How does their mindset need to change evolve?

Working in tertiary hospitals during training you see lots of uncommon things such as children with brain tumors or leukaemia but not every child with a bruise or a headache have cancer. You need to recognise the flags to be worried about and put in place appropriate investigations. Over investigating is not a substitute to a good assessment to reassure parents

What are some knowledge deficits that can be ameliorated...

– quickly and easily?

Getting up to date with latest resuscitation protocols

– with concerted study and experience?

Understand the adult clinical decision rules for ordering CTs in head and neck trauma and how to apply them to paediatrics.

Recognition of early sepsis

The skill/attribute that differentiates an average Registrar from an exceptional one is…?

Capacity to recognize the need put the foot down – to churn through the workload while still keeping the quality of the assessments

Uses current evidence to question practice and challenge dogma and learning how to incorporate this into practice.

What is the most under-used feature in the History/Examination/Investigation?

History – the social history

Examination – the heart rate

Investigation – avoid ordering unnecessary tests

How is the communication different...

– with parents? Should be inclusive – work as a team for the child, respectful instructive and knowledgeable

– with medical & nursing colleagues? Supportive, knowledgeable – encourage to think rather than follow protocols without rationale

– with senior staff? Respectful, ask questions to help inform practice.

A strength that this group might be surprised they have is…?

Friendly, supportive and capable group of junior doctors.

My top five tips for this group:

  1. Don’t be scared of being in resus
  2. Your input is valuable
  3. Read up on resuscitation protocols
  4. Take up any simulation or airway sessions offered
  5. Learn to recognize serious illness in a child 

The most important piece of advice for Paeds Reg new to ED is:

 The opportunity to work in ED develops your capacity to differentiate the worried well from the seriously ill – immerse yourself in all that is offered and your confidence in managing acute illness throughout your career will be enhanced.

Thanks Dr Borland! We’ll be back soon with the rest of the interview in Part 2 : For Emergency registrars new to Paediatrics.

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About 

A Paediatric Trainee based in Queensland, Australia, Henry is passionate about Adolescent Medicine & General Paediatrics, with a strong interest in Medical Education & Clinical Teaching. An admitted nerd & ironman with a penchant for Rubik's Cubes & 'Dad jokes'.

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