The Sweet Spot – Sean M. Fox, 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.

In this edition of the Sweet Spot, we’re excited to interview Dr Sean M. Fox; the energy, brains and action behind Pediatric EM Morsels, as well as working as an Associate Professor in Paediatric Emergency Medicine at the Carolinas Medical Center in Charlotte, North Carolina, USA. Why “Morsels?” He likes dessert more than jewelry (also known as pearls).

http://pedemmorsels.com/home/

Sean was a resident in training for 5 years as both a Pediatric trainee and an EM trainee. So, he actually knows what it is like to be a Pediatric doctor covering the random pediatric hospital floor emergencies in the middle of the night with limited resources as well as what is like to be a junior EM resident trying to not look completely overmatched in a trauma code.

Part 2 : For Emergency registrars new to Paediatrics:

What are some common stumbling blocks & how can these be avoided/fixed? How does your mindset need to change?

The biggest challenge working in both the adult and pediatric ED is that your perception of illness can become distorted. Adult patients are more often critically ill than children (which is good for kids!). This makes it easy to learn that we need to assume adult patients are ill until proven well (i.e., rule out the worst first). Conversely, the fact that children are generally well, can make it easiest for novice clinicians to assume kids are well until proven to be sick, because their experience has reinforced that, generally, kids do well. This approach can be very detrimental, especially when we consider that children are able to compensate for illness extremely well — until they suddenly decompensate!

It requires an active and vigilant mind to continue to be alert for the covert and subtle signs of significant illness in children. Assuming children are well, however, is often not actually detrimental, because, the odds are in favor of the child actually being relatively healthy. This playing of the odds can encourage complacency. It is complacency that kills!

I also find that it is the complacency, and the notion that kids usually “just have a virus,” makes the role of the Emergency provider “boring.” This further dissociates the provider from the task at hand and reinforces sloppiness. Obviously, a “bored” EM provider is a “bad” EM provider.

So, then, the question is how to remain vigilant, yet reasonable. We don’t want or need every kid with chest pain to get a troponin level. Equally, we need to be vigilant for myocarditis. Essentially, the task of working in the Ped ED is like looking for grenades in large haystacks. {Why grenades instead of needles? Needles might inflict a little bit of pain if you miss it and it pokes someone. Lost grenades, like missed significant pediatric illness, causes death and destruction for all who are near it… potentially, even to the providers.}

I have found that one of the best strategies to remain vigilant is simply by training your brain to actively search for illness (what was that kid’s cap refill?) and use your history and exam skills to help weed through the big, bad, and ugly conditions. Then, instead of telling the family that “it’s just a virus” (Please remove this phrase from your lexicon as it does not actually reassure families and can actually harm their opinion of you – there is literature to support this), tell the family all of the terrible things that it is not. “Well, I am super glad to be able to tell you that your daughter/son does not have meningitis or pneumonia. Right now we are seeing a lot of viral illness in the community causing many of your child’s symptoms, so I believe that is actually what is going on. Importantly, I don’t see any signs of complications of typical viral illness, but please continue to watch for X, Y, and Z.”

Additionally, appreciate and anticipate the parental concerns (they are not coming to the ED because they are worried about a “virus.”) and address them up front clearly. Spending 3 more minutes discussing their concerns for appendicitis, etc, will save countless minutes and hours later trying to either convince them that you did a thorough job or responding to complaint emails/letters.

What are some knowledge deficits that can be ameliorated.

A lot of what gets covered and cared for in the Ped ED is in the realm of “primary care topics.” I don’t think that you need to do a fellowship in Primary Care to work in an ED, but knowledge about typical growth and development really assist in finding subtle signs of illness. Pyloric Stenosis? Not likely in the kid who is growing in the 98 percentile and consuming a gallon of formula a day. Knowing how much a young child should eat is a topic that always proves to be useful in the Ped ED.

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

Stop reiterating “Kids aren’t little adults.”

I know, that seems counter to what I should support; however, I believe that clinicians are prone to use this statement as justification for “opting out” of taking care of children. “Kids aren’t little adults! I am comfortable with adults. I don’t take care of kids.”

Let’s be honest, the statement was meant to reinforce the fact that children have different anatomy and physiology that must be accounted for, but this does not make them an alien population. Kids aren’t aliens. They are special population of little humans that require some special considerations for their specific anatomic and physiologic differences.

I believe approaching children as a special population rather than aliens one empowers EM providers and promotes becoming more comfortable with caring for them. This approach is vital to ensuring that kids are afforded excellent care EVERYWHERE, not just in large cities with giant pediatric specialty care centers, which are not numerous enough to care for all of the children who need it.

Thanks again for the wise advice Dr Fox!

Read Part 1 : For Paediatric registrars new to the Emergency Department.

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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

One Response to "The Sweet Spot – Sean M. Fox, part 2"

  1. Ben Symon
    Ben Symon 12 months ago .Reply

    Maintaining vigilance in a sea of URTIs can be difficult indeed. I couldn’t agree more that being exposed to a high number of likely well, viral kids who don’t need bloods or investigation can really switch your gestalt to ‘chill out’ mode. Learning from the adult reg’s to actively create a differential list and ‘check off’ important, life threatening differentials using your Type 2 critical thinking is a really important skill that we don’t talk about enough in PEM.

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