Natalie May, Part 2

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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 2 : For Emergency registrars new to Paediatric Emergency:

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

Just like the paediatricians, ED docs tend to migrate to their comfort zone – it’s just a different comfort zone! Take the opportunity to get good at looking after sick kids (not just minor injuries) – as much as it might be soul destroying to spend a whole shift seeing snotty nose after snotty nose, somewhere in there might be a child who is really unwell. This is the time and place to learn how you can identify them and what to do with them when you do. That said, if you do have a shift like that – spend the last hour seeing minor injuries and give yourself a break! 

How does their mindset need to change/evolve?

You need to be totally flexible in paediatric consultations. Getting the confidence of the child and their parent or carer is paramount. Examinations rarely follow the same pattern – you need to learn to rapidly identify the child who is about to cry (and listen to their lungs before they do). Sometimes a little time/food/paracetamol/sleep will make your assessment of a child a lot easier – you’ll come to learn which situations those are and when it’s safe to let those things happen (it usually is)!

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

– quickly and easily?

There are key components of the paediatric history we don’t think about in adult practice – birth history, immunisations, family and social history, school – you’ll get into the swing of that rapidly but it does matter.

– with concerted study and experience?

Paediatric fractures are tricky – I spend a lot of time in the paediatric ED reviewing x-rays both at the time with our junior doctors and afterwards (with our missed fracture reports). I’d prefer the former, so if you’re not sure – ask! You’ll get to know what sort of injuries you might see and how they are subtly different.

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

Willingness to listen to parental concerns. We can get frustrated in the adult ED when there are lots of people in the cubicle, all trying to contribute to the story, but it’s essential in paediatrics and often the reason the patient is there in the first place. Be patient, ask specifically about concerns and remember to ask if there’s anything else you can help with while the family is present in the ED.

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

Asking the child to give the history first. This is a great way to build rapport in children who are able to try (realistically, children from about 2yrs can point to the bit that hurts or nod and shake their head; older children might give you a more comprehensive story of injury or illness). Don’t be dismissive of the child, even if the parent tells you that it’s total nonsense! You’ll find that taking time to make the child part of the consultation (including asking them which ear to look into first) makes things go much more smoothly.

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

Blood tests in general. Most children don’t need any and considering the amount of distress involved for everyone in obtaining bloods, it’s probably worth just running any plan involving venipuncture past a senior doctor before you start poking kids with needles.

How is the communication different...

– with parents? New parents deserve a special mention – they are often spectacularly overwhelmed and not having nearly as much fun as they feel they should be having. Give them the time and space to tell you how they are going. Your care responsibility doesn’t start and end with the child.

– with medical & nursing colleagues? You’ll generally find referrals a little easier (but not always). In many EDs there will be nursing staff who can perform venipuncture but do not expect this: you’ll need to be willing to perform procedures your patient needs (arguably this is also the case in the adult ED…) That said, paediatric nurses are highly skilled; never attempt procedures on children without a nurse. A doctor is no substitute!

– with senior staff? You’ll often find senior staff beyond the ED more involved with patient care than in adult specialties. It certainly isn’t unusual to speak to registrars about referrals and consultants in tertiary specialties will usually want to know that their patients are in the ED (especially in-hours).

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

An ability to know when something isn’t right. Don’t ignore those feelings; talk to a senior doctor. We are there to help, and even if it turns out there’s nothing serious going on it’s an ideal time to fine tune your spidey senses with some wisdom from someone senior.

My top five tips for this group:

  1. Don’t be scared – most kids will respond cooperatively if you smile!
  2. Learn the basics of the language of children – know the name of Peppa pig’s little brother, for example. This helps children see you as part of their world and less threatening
  3. Never attempt procedures without a nurse. Just don’t.
  4. Invest pre-procedure time in planning, preparation and communication. You want things to go smoothly and this time is never wasted.
  5. Know some basic important drugs doses (think APLS) and keep other important doses stored somewhere easy-to-access under pressure (?mobile phone)

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

Safety netting really matters. Take the time to provide adequate reassurance, a clear explanation of what you expect to happen to the child and when to return. When the first kid returns because you told the parents to look out for something and it actually happened, you’ll find it much easier to sleep at night.

Be sure to read more of Nat’s advice in Part 1 : For Paediatric registrars new to Paediatric Emergency. Thanks Nat for taking the time to be interviewed!

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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

Author: Henry Goldstein

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