The Sweet Spot – Natalie May, 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.

This edition of the Sweet Spot is brought to us by Dr Natalie May, Dr Natalie May is a Consultant Emergency Physician with speciality training in Paediatric Emergency Medicine. She is currently working at the famous Sydney HEMS in Prehospital & Retrieval Medicine.

In addition to liking tea, running and singing at FOAMed conferences, Nat has been instrumental in editing and contributing to StEmlynsBlog.org and PEMLit.org and tweets prolifically as @_NMay. She is one of the eminent contributors to #FOAMped worldwide and is a member of the SMACC organising committee.

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

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

The biggest stumbling block I’ve seen is a tendency to migrate towards your comfort zone. You guys are amazing at dealing with sick kids (and not so sick kids), particularly neonates. But that doesn’t challenge you and you won’t get the most from the department. Paediatric EDs are usually very well supported by senior staff, especially consultants. We would rather you challenged yourself and got the most from our learning environment.

Please also respect that, whatever your existing opinion of government set targets (like the 4-hour target in the UK), our service depends on our ability to perform within them and we expect you to understand their importance to the department’s function. You’ll get a far greater appreciation of the importance of ED flow from working within the department so hopefully that will persist if you return to paediatric practice.

How does their mindset need to change/evolve?

The key to successful Emergency Department working is teamwork – once you come to join us in our department we consider you one of ours – we will support you and back you up. We just ask in return that you try to believe it and wholeheartedly join us! There will be great opportunities to impart your knowledge onto junior colleagues and medical students and we will welcome that.

Remember that the cohort of patients we see is typically a few hours earlier into the clinical course of their illness than you might be used to seeing; signs and symptoms may not be so obvious and you will have to rely on subtle concerning features and a shorter observation period than you might have in a child already referred for admission. This is part of the skill and the nuance of the job (and the reason we love it). It also makes safety netting even more important when children are discharged and finally it makes us humble – we have all seen patients come back significantly more unwell. It happens and it doesn’t mean you have missed something or done something wrong – but there will always be something to learn. Be open and honest and we can all learn from one another.

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

– quickly and easily?

Traditionally paediatric trainees have been really comfortable with all things illness and less so with trauma, particularly minor injuries. Major trauma is pretty straightforward – familiarity with local and national guidance is key.

– with concerted study and experience?

Minor injuries, particularly in kids, are not as straightforward as their name implies. If there is radiology teaching available to you in the ED setting, take that opportunity! Knowing when – and what – to x-ray is a skill that improves with experience.

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

Understanding and respecting the ED staff. Many nurses are exceptionally skilled; most have good instincts for seriously ill and injured children. If they ask you to do something there’s usually a good reason. They have great instincts for wound management and often bring the voice of common sense. Similarly our allied professionals, porters and receptionists are key to the department’s function and developing and maintaining good working relationships is key.

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

ECG – there’s an intrinsic fear of the paediatric ECG because it looks so different; there are all sorts of different numbers and ranges to remember. But in truth you don’t really need to have that knowledge wedged in your brain to find a paediatric ECG useful. Familiarity grows with exposure; some things will just jump out at you and the rest you can work through with a good resource (like http://lifeinthefastlane.com/ecg-library/paediatric-ecg-interpretation/). I’ve been caught out with relying on a monitor to read heart rate and nearly missed an SVT. If the child is tachycardic without explanation (or has had a collapse under any circumstances), get an ECG. And take your time to look at it carefully, with a friend if you want to!

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

Chest x-rays – I very infrequently order them for children with respiratory complaints because they rarely change my management. Neonates are an exception to this rule (as the x-ray can give useful cardiac information too), as well as those kids with fever, slightly lower SpO2 than normal on air, increased respiratory rate and just a little extra work of breathing – they are usually the ones with a lobar pneumonia. That said, I’m not sure the x-ray changes anything as I’d almost certainly be giving that group of children antibiotics in any case. It’s a nuanced approach though, and a conversation I’m happy to have with juniors.

How is the communication different...

– with parents? Parents are almost always anxious and looking for reassurance. Being a parent is a complex interplay of fear that something awful will happen to your child and societal pressure telling you that you’re inadequate if you’re not hugely concerned about a minor bump on the head. We have to try to understand these influences and give them the airtime they need so that when the child gets worse (it will happen one day!), they aren’t afraid or angry to bring the child back to you.

– with medical & nursing colleagues? One of the things I love most about paediatric EM is how smoothly things often seem to work in comparison with adult practice. Your colleagues seem genuinely interested in helping patients – it feels a lot more like you are on the same page and that can be really refreshing when the adult side has been feeling like an uphill struggle. It isn’t always that way, though – so your politeness, respect and good temper are just as important.

– with senior staff? I am always interested to know what is happening in the ED when it’s my responsibility. As the named consultant, I am responsible for the care delivered – being oncall is what I get paid for! When I leave the department in the evening I try to impress upon the junior doctors AND nursing staff that they are welcome to call me, for anything they want to call me for – if they even think it’s something I might want to know about, I want to know about it! I am sure that my ED colleagues would agree with this mindset. I hope my colleagues in other specialties do too. Generally, if a consultant from another specialty is in the ED seeing a sick patient, I want to know about it.

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

Comfort with newborns. Many non-paediatricians have inverse fear: the smaller the child, the more terrifying they are. Having worked in neonates is a huge advantage in knowing what matters in history and examination, having amazing procedural skills and even just knowing how to pick up a baby.

My top five tips for this group:

  1. Work outside your comfort zone
  2. Be willing to share your knowledge and skills: the ED is a place where everyone is learning, every day
  3. Ask for help!
  4. Involve the consultant for sick patients – that’s what we are paid for
  5. Enjoy the diversity – every day is different and ED is a great place to learn and work.

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

It will feel uncomfortable – relax! You are well supported and appreciated. This is a great opportunity to stretch yourself and then when your friends’ kids fall over and they expect you to know what to do you’ll feel far more confident (and know who to speak to in the ED if you think they need to attend).

Stand by for more of Nat’s wisdom in Part 2 : For Emergency Registrars new to Paediatric Emergency. Thanks Nat!

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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'.

@henrygoldstein | + Henry Goldstein | Henry's DFTB posts