COVID and RSV HEADER

COVID and RSV

Cite this article as:
Laura Riddick, Damian Roland and Andrew Tagg. COVID and RSV, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33694

There was a time, perhaps a century ago, when the only virus we really worried about was RSV. Children, snot dripping from their noses, would come in coughing, and struggling to breath and, as days grew shorter and nights grew longer we knew that bronchiolitis season was upon us once more.

But things have changed. We worry about a different virus now and there is plenty of evidence to show that the usual seasonal variations in RSV have flattened. It was heartening to see the data showing that the mid-winter peak was no more as we kept ourselves to ourselves. Non-pharmacological interventions – physical distancing, respiratory hygiene and restricted movements – meant that the scourge of the paediatric emergemcy department was held at bay. Until…

Half a world away…

Bronchiolitis presentations peaks in June – July in Australia (remember it is our winter in the Southern hemisphere). Last season there was a 98% reduction in RSV (and a 99.4% reduction in cases of influenza (Yeoh et al., 2020). But let’s take a look at the surveillance data from Western Australia to see what has been going on of late.

Western Australia RSV incidence- Based on Foley et al. 2021

McNab et al. (2021) looked to see what had been going on in Victoria, a state that had much stricter lockdown measures than WA. Whilst there was clear suppression of the winter cases of bronchiolitis, these began to increase by the beginning of the year, coinciding with the return to school after the long Christmas break Normally, in February, the Royal Children’s Hospital would return 5.6% positive RSV swabs. In 2021, they returned 32.8%. More worryingly, this peak is higher than the pre-COVID winter peak (30.4%)

RSV incidence in Victoria
Victorian Australia RSV incidence- Based on McNab et al. 2021

But this snapshot doesn’t give you the whole picture. Let’s just slide the data along a few short weeks…

Victorian Australia RSV incidence- Based on McNab et al. 2021

These data have been echoed all over Australia and New Zealand with a ramping up of out of season RSV positive cases. What is most concerning is that numbers appear to be higher than the usual peak and the patients older (mean 18.2 months compared to 7.3 – 12.5 months). Why could this be? It could be, as Foley et al. (2021) suggests due to an increase in RSV-naïve babies born during that first wave coupled with waning herd immunity.

What does this mean for paediatricians in the Northern hemisphere who are about to face this surge in cases?

Getting started?

Paediatricians at the frontline need to be able to see what is going on and so PERUKI will shortly be launching BronchSTART. The aim of this prospective observational study is to both track the potential surge so that health policy is informed as much as possible but also to describe its epidemiology. As highlighted above the data suggests a potentially wider age range and steeper spike but these are from retrospective studies By reporting potential cases (in children under two years of age) presenting to over 50 Emergency Department across the UK, in real-time, clinicians and researchers will be able to really understand the impact and outcomes of this respiratory disease.

Given the challenges of identifying and managing children who may have RSV, COVID-19, or both, some guidelines have been produced by the RCPCH.

What do the guidelines say?

The RCPCH guidelines focus on THREE key areas:-

  • Reducing hospital attendances with mild cases
  • Pathways and guidance for testing and cohorting
  • Minimising patient time on High flow and reducing the exposures to AGPs

The guidelines are designed to reduce potential unnecessary referrals from primary care to the emergency department. Hopefully, reducing the number of children presenting (and then mixing with each other in the waiting room) will lessen the burden on paediatric emergency departments. It offers a traffic light system for reviewing patients, with suggestions of how to manage some borderline cases in the community with secondary care input.

NHS bronchiolitis pathway

When it comes to testing, the aim is to be able to minimise the spread of COVID-19 and protect clinically vulnerable children.  As with what is happening in most hospitals, the recommendation is to only test patients being admitted to the hospital. Any further testing is then influenced by the patient’s condition and the prevalence of COVID in the hospital, as well as cubicle availability.  

Using Point-of-Care-Testing (POCT)/rapid testing for patients going to PICU and HDU may limit cubicle occupancy, and improve cohorting of patients. Additional COVID testing then should be considered in cases where respiratory panels are negative (or suggest low-risk causative organisms such as bocavirus or rhinovirus). Additional testing should also be considered if aerosol-generating procedures (AGPs) are required or parents are displaying symptoms. 

Given that AGPs provide a high risk for transmission, the recommendation is for rapid but weaning of high-flow with guidance provided by north and south Thames retrieval service protocol used.

For those of us in clinical practice, the guidelines remain largely unchanged. Non-pharmacological measures- physical distancing, good respiratory hygiene and use of appropriate PPE are key. Cohorting patients into red and blue, hot and cold or low/high-risk zones may add some value unless physical distancing can be maintained.

As case numbers rise, and cubicle capacity becomes an issue then departments need to come up with a risk mitigation strategy to protect the vulnerable.

  • Weekly testing for all prolonged stays 
  • Test if there are new symptoms 
  • More emphasis on risk assessment for use of RPEs (respiratory protective equipment) 
  • If single room capacity is exceeded, patient may be risk assessed for cohorting 
  • If respiratory virus +ve and COVID –ve patients can be cohorted even if requiring an AGP  
  • We still need to advise those DC’d from CAT/ED with respiratory symptoms of the need for COVID testing via track and trace
  • Parents should not be in hospital if symptomatic. Do not test asymptomatic parents
COVID and RSV flow chart

Bottom line

  • Support community services to reduce strain on hospital services
  • Use testing to help cohort and plan patient care
  • Wean or reduce AGPs where safe to do so
Infographic depicting RSV and COVID guidelines

Selected references

Foley, D.A., Yeoh, D.K., Minney-Smith, C.A., Martin, A.C., Mace, A.O., Sikazwe, C.T., Le, H., Levy, A., Moore, H.C. and Blyth, C.C., 2021. The Interseasonal Resurgence of Respiratory Syncytial Virus in Australian Children Following the Reduction of Coronavirus Disease 2019–Related Public Health Measures. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America.

Huang QS, Wood T, Jelley L, et al. Impact of the COVID-19 nonpharmaceutical interventions on influenza and other respiratory viral infections in New Zealand. Nat Commun. 2021;12:1001. https://doi.org/10.1038/s41467-021-21157-9

McNab, S., Do, L.A.H., Clifford, V., Crawford, N.W., Daley, A., Mulholland, K., Cheng, D., South, M., Waller, G., Barr, I. and Wurzel, D., 2021. Changing Epidemiology of Respiratory Syncytial Virus in Australia-delayed re-emergence in Victoria compared to WA/NSW after prolonged lock-down for COVID-19. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America.

Oh, D.Y., Buda, S., Biere, B., Reiche, J., Schlosser, F., Duwe, S., Wedde, M., von Kleist, M., Mielke, M., Wolff, T. and Dürrwald, R., 2021. Trends in respiratory virus circulation following COVID-19-targeted nonpharmaceutical interventions in Germany, January-September 2020: Analysis of national surveillance data. The Lancet Regional Health-Europe6, p.100112.

Public Health England. Weekly national Influenza and COVID19 surveillance report: Week 49 report (up to week 48 data) 3 December 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/940878/Weekly_Flu_and_COVID-19_report_w49.pdf. Accessed July 20, 2021.

Tang, J.W., Bialasiewicz, S., Dwyer, D.E., Dilcher, M., Tellier, R., Taylor, J., Hua, H., Jennings, L., Kok, J., Levy, A. and Smith, D., 2021. Where have all the viruses gone? Disappearance of seasonal respiratory viruses during the COVID-19 pandemic. _Journal of Medical Virology

Waterlow, N.R., Flasche, S., Minter, A. and Eggo, R.M., 2021. Competition between RSV and influenza: Limits of modelling inference from surveillance data. Epidemics35, p.100460.

Williams, T.C., Lyttle, M.D., Cunningham, S., Sinha, I., Swann, O.V., Maxwell-Hodkinson, A. and Roland, D., 2021. Study Pre-protocol for “BronchStart-The Impact of the COVID-19 Pandemic on the Timing, Age and Severity of Respiratory Syncytial Virus (RSV) Emergency Presentations; a Multi-Centre Prospective Observational Cohort Study”. Wellcome Open Research, 6(120), p.120.

Yeoh DK, Foley DA, Minney-Smith CA, et al. The impact of COVID-19 public health measures on detections of influenza and respiratory syncytial virus in children during the 2020 Australian winter. Clin Infect Dis 2020.

Paediatric Chest Drains

Cite this article as:
Andrew Tagg. Paediatric Chest Drains, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.18913

We know that critical procedures are rare in clinical practice but that when they do need to be done they need to be done right. Whether for relieving a haemo-pneumothorax or a large empyema it is incumbent upon us to know what to do when the need arises. With the exception of our South African colleagues, most of us may only ever insert a chest drain every other year. So let’s take a look at what you need to know with the help of this paper from the trauma team at the Royal Children’s Hospital in Melbourne.

Teague WJ, Amarakone KV, Quinn N. Rule of 4s: Safe and effective pleural decompression and chest drain insertion in severely injured children. Emergency Medicine Australasia. 2019 Apr 30.

Why do a chest drain?

When blood, pus or air fill the pleural space they disrupt the normal negative intrathoracic pressure leading to unopposed elastic recoil of the lung and thus collapse. When a chest drain is inserted blood, pus or air can drain to the outside world allowing re-expansion of the lung.

Reasons for putting in a chest drain

Blood

Although, as a whole, penetrating chest injuries are rare in children, the rising incidence of knife crime means that that the management of penetrating chest injuries is something that we are gaining more experience with. Blunt thoracic injuries are uncommon in children with 204 cases reported in Victoria over a 5 year period. These were overwhelmingly as a result of motor vehicle accidents.

Massive empyema

In my part of the world, there has been an increase in the number of cases of massive empyema. These often seem to develop as a simple parapneumonic effusion (from Staph. pneumoniae), before developing interleaving septae and then becoming a loculated collection of lung custard. As the lung fills respiratory embarrassment becomes outright failure and cardiovascular instability. These children benefit from early drainage, prior to transfer if PICU is not available on-site, although whether this is best achieved via thoracocentesis or formal chest drain is still up for debate.

Air

The pleural space is a virtual space until it becomes filled with either fluid or air. Whilst most pneumothoraces can be managed with either a conservative watch-and-wait approach, simple aspiration or insertion of a pigtail drain they do occasionally need insertion of a more formal intercostal drain.

How often do we do them?

When Nguyen and Craig looked at how often emergency paediatricians performed critical procedures across their network they found that only three were placed over the entire year. I’m sure our colleagues in South Africa have much more experience than I ever will ever get in this area of practice.

Rule of 4s

The paper describes an aide-memoire for the time-poor clinician – handily titled the “The Rule of 4s“.

  • 4 steps in a good plan
  • 4th (or 5th) intercostal space as the basis for a ‘good’ hole
  • 4 x uncuffed ET tube size as a guide to a good sized chest tube
  • 4cm mark for a good stop

As big fans of using infographics to get complex points across it is great to see Teague et al. take that on board. It is well worth taking the time to read through the whole article as it discusses some of the finer points of inserting an intrapleural drain.

Infographic for safe insertion of chest drains

How to secure them

Perhaps you have been taught that a purse-string is the way to go (it’s not) or perhaps you have spent some time in South Africa and have become a fan of the Jo’Burg knot as demonstrated by Neel Bhanderi.

One thing remains true – chest drains must be securely fastened before they get the chance to ‘fall’ out. That means sutures, an appropriate sandwich dressing and a mesentery of tape to take the strain in case someone pulls at the drainage tube.

What can possibly go wrong?

Sticking a needle in somebodies chest is not without risk. Even when I qualified from medical school the trocar method of inserting a drain was falling out of favour. Many a surgeon took them home to use in the garden rather than relegate them to the recycling bin.

Immediate complications include the following:-

  • damage to underlying structures e.g. thoracic duct, lung, oesophagus, stomach (rare unless there is an undiagnosed diaphragmatic injury)
  • bronchopleural fistula formation
  • recurrent pneumothorax
  • intercostal artery haemorrhage
  • chylothorax
  • re-expansion pulmonary oedema

Delayed adverse events include:-

  • infection
  • empyema
  • Horner’s syndrome

What should you do if…

…it stops swinging?

If that spirit level like bubble stops swinging it may mean that the tube is kinked or compressed in some way. I’ve seen it happen as the tubing has been passed through the cot sides and been squashed as the side has been put down so be mindful.

…the drain stops bubbling?

Generally, this is a good thing as it means the air has drained out of the pleural space and the lung has re-expanded. You want to be more concerned when it continues to bubble and bubble and bubble as that would suggest a persistent air leak. If it seems to bubble more than a hookah pipe then you need to get out your trusty clamps to figure out where the leak is. If, when you clamp near the point of insertion, the bubbling stops then the problem must be either in the lung or at the insertion site (perhaps one of the eyelets has migrated outside?). If that fails to isolate the cause then you can work your way down to the collection chamber until the bubbling stops and you have found your leak/disconnect.

…it falls out?

If it’s just the connection between the drain and the tubing connecting to the underwater seal it is time to clamp the tube to prevent air going the wrong way, i.e. back into the chest, and causing a pneumothorax before fixing the problem.

If the whole drain falls out then cover up the hole with an occlusive dressing and decide if you actually need one in the first place. If another one is required it should go through a new incision.

Selected References

Balfour-Lynn IM, Abrahamson E, Cohen G, Hartley J, King S, Parikh D, Spencer D, Thomson AH, Urquhart D. BTS guidelines for the management of pleural infection in children. Thorax. 2005 Feb 1;60(suppl 1):i1-21.

Brandt, M.L., Luks, F.I., Lacroix, J., Guay, J., Collin, P.P. and Dilorenzo, M., 1994. The paediatric chest tube. Clinical intensive care: international journal of critical & coronary care medicine5(3), pp.123-129.

Course CW, Hanks R, Doull I. Question 1 What is the best treatment option for empyema requiring drainage in children?. Archives of disease in childhood. 2017 Jun 1;102(6):588-90.

Kwiatt M, Tarbox A, Seamon MJ, Swaroop M, Cipolla J, Allen C, Hallenbeck S, Davido HT, Lindsey DE, Doraiswamy VA, Galwankar S. Thoracostomy tubes: a comprehensive review of complications and related topics. International journal of critical illness and injury science. 2014 Apr;4(2):143.

Laws D, Neville E, Duffy J. Pleural Diseases Group SoCCBTS. BTS guidelines for the insertion of a chest drain. Thorax. 2003;58(Suppl 2):i53-9.

Mehrabani D, Kopelman AE. Chest tube insertion: a simplified technique. Pediatrics. 1989 May 1;83(5):784-5.

Playfair GE. Case of empyema treated by aspiration and subsequently by drainage: recovery. Br Med J 1875;1:45.

Porcel JM. Chest tube drainage of the pleural space: A concise review for pulmonologists. Tuberculosis and respiratory diseases. 2018 Apr 1;81(2):106-15.

Samarasekera SP, Mikocka-Walus A, Butt W, Cameron P.  Epidemiology of major paediatric chest trauma.  J of Paediatrics and Child Health.  2009; 45: 676-680

Shoseyov D, Bibi H, Shatzberg G, Klar A, Akerman J, Hurvitz H, Maayan C. Short-term course and outcome of treatments of pleural empyema in pediatric patients: repeated ultrasound-guided needle thoracocentesis vs chest tube drainage. Chest. 2002 Mar 1;121(3):836-40.

Stather P, Cheshire H, Bogwandas H, Peek G. Pneumothorax post paediatric chest drain removal. The Thoracic and cardiovascular surgeon. 2011 Aug;59(05):302-4.

Strachan R, Jaffé A. Assessment of the burden of paediatric empyema in Australia. Journal of paediatrics and child health. 2009 Jul;45(7‐8):431-6.

Strutt J, Kharbanda A. Pediatric Chest Tubes And Pigtails: An Evidence-Based Approach To The Management Of Pleural Space Diseases. Pediatric emergency medicine practice. 2015 Nov;12(11):1-24.

Tovar JA, Vazquez JJ. Management of chest trauma in children. Paediatric respiratory reviews. 2013 Jun 1;14(2):86-91.

Walcott-Sapp S. A history of thoracic drainage: from ancient Greeks to wound sucking drummers to digital monitoring.

Book review

Love, Learning Disabilities and Pockets of Brilliance by Sara Ryan

Cite this article as:
Liz Herrieven. Love, Learning Disabilities and Pockets of Brilliance by Sara Ryan, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33746

I’d been looking forward to reading this book and it absolutely did not disappoint. Professor Ryan is a social scientist whose son, Connor, had autism, learning disabilities and epilepsy. He died in 2013 whilst an inpatient at a specialist NHS assessment and treatment centre. Her campaign for justice, #JusticeforLB (Connor was known as Laughing Boy), raised awareness and eyebrows around the inequalities and injustices faced by people with learning disability or autism.

Cover of book

“…It is back to parenting without a map and with some of the (few) signposts kicked over in the ditch or pointing the wrong way.”

This book describes some of the issues faced by people with a learning disability (LD) or autism and their families, from birth to end-of-life. It describes the horrendous moments in history that are still all too familiar to us as lived experience today. Yet, it also describes some of the very meaningful and wonderful acts that can make such a positive difference. Some magnificent quotes from people with LD and their families remind the reader that this is not an abstract text, but an account of real lives. The good, the bad, the heartbreaking and the brilliant are shown, along with some great myth-busting.

Some of the pockets of brilliance may surprise readers. They are fairly mundane or, at least, expected as a good standard of care. The fact that parent-carers describe them as brilliant speaks volumes about the inequalities we face on a daily basis. One example is particularly moving – a speech and language therapist writres a letter to parents with a comment detailing what a pleasure it was to work with their son.

“Out-of-hours home visits, alternatives to the main waiting room, positioning on the consultation list, additional time, talking carefully through what was going to happen, all contributed to positive encounters.”

Ryan challenges readers to consider a viewpoint a little different to the one commonly taken – disability as a social construct, with services set up to mould individuals to fit societal expectations, rather than communities adjusting to accommodate all individuals whatever their needs. A focus on deficit fails to highlight people’s abilities. Society suffers from ‘inclusion phobia‘ and is disablist, often due to ignorance. The first step to overcoming this, she suggests, is recognising that we are all human.

“Parents are constantly trying to prevent the downgrading of children to bundles of burden and toil rather than fully fledged little people.”

She writes with authority, vulnerability and humour. This book made me smile, nod in recognition and, at times, cry. As Mum to a young lady with Down syndrome and autism there was much that resonated – both good experiences and bad. As a clinician, there was also much for me to learn and build into my practice. I particularly liked the “What can you do?” sections, and would have liked more of these although, to be fair, the whole book acts as a guide to professionals in health and social care, whether they regularly work with people with LD or autism, or not. There are many stark truths in this book, which professionals would do well to acknowledge. We need to do better and Ryan not only explains why, but also gives us tools to start on the “how”.

Bystander awareness header

Bystander Awareness

Cite this article as:
Emily Fowler. Bystander Awareness, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33482
Elie Wiesel on bystander awareness - "What hurts the victim the most is not the cruelty of the oppressor, but the silence of the bystander

You look too young to be a doctor,’ would be a flattering phrase now (and one I haven’t heard in a while!). But when I qualified back in 2011 I’d hear it every week.

I didn’t translate this as a compliment, but as, You look too young to be competent to look after me/this patient/my relative’. It was never a welcome comment. I had never identified it as anything more than a throwaway line until I learnt about bystander awareness and micro-aggressions.

Bystander awareness- What is it?

As a GP registrar, I recently attended a session on bystander awareness. I will admit, I’d never heard the phrase before and had no idea what to expect from the session. It’s a concept much more commonplace in schools, universities and the military, but one I now think we should be very aware of in healthcare.

During the teaching session I realised I knew exactly what bystander awareness was. Here’s my explanation:

It’s that uncomfortable feeling of being a witness to a conversation you feel is discriminatory on some level.

Sometimes we witness obvious discrimination and bullying in the workplace. This session was more focused on being aware of subtle acts of discrimination, or micro-aggressions, as I now know to call them. These may relate to age, race, sex, gender identity, sexuality, disability… the list goes on.

Ashamedly, I now have to admit that I have been a passive bystander and I have witnessed these micro-aggressions without choosing to act. The incidents I remember have nearly all been at work. Following discussion with peers at this teaching session I realise I’m not alone.

I think the example I’ve most witnessed and the one which came up repeatedly in our teaching session is this one…

Person 1: Where are you from?

Person 2: *UK place name inserted*

Person 1: No, I mean originally?

…and so on.

This could be rephrased as you don’t belong here particularly if it’s asked often and out of context. People don’t like to be asked this. It is uncomfortable and this was reflected in our session. In fact, why would people ask that question? How is it relevant to the situation in the workplace? It’s (almost always) not. This is a micro-aggression.

Other examples of these micro-aggressions mentioned by colleagues included subtle discriminatory remarks/questions about size or height, as well as sex and sexual orientation. It was hard to imagine how most of these topics would ever be part of a relevant discussion at work. Once we got started it was really quite easy to identify that these were examples of micro-aggressions.

Solutions

Micro-aggressions can lead to a toxic culture in the workplace, and these behaviours become normalised over time. They can build up and really affect an individual’s confidence and enjoyment of their job and workplace. Some colleagues expressed how challenging and upsetting they found this sort of dialogue.

Some of the skills needed to tackle these micro-aggressions are very simple, and might just slowly start to shift the boundaries of what behaviour is considered to be acceptable.

So what can we, as individuals, do about it?

Bystander awareness infographic

1. Call it out

This is the obvious one, but it’s often incredibly tricky. For example; you’re in a group on a ward round where there is a clear hierarchy, and a patient says something inappropriate to a colleague which your seniors don’t react to.

It can be really hard to be the one to say I don’t think you should say/ask that when no one else is acknowledging it. In fact, this bystander effect is well recognised by psychologists as one reason people in a group don’t act. You could just make a simple statement such as I don’t see the relevance of that’ or ‘That is not appropriate’.

2. Provide a distraction

Change the topic of conversation, interrupt the conversation, ask an unrelated question.

3. Use body language

If you don’t feel able to speak up or it doesn’t feel appropriate, then try some disapproving body language. This can be highly effective. It can be as simple as not laughing at the racist joke, if that was the expected reaction, or providing a silent stare, followed by the statement “Can you explain how that was funny?” Nothing makes people more uncomfortable than having to explain their behaviour. Other options include moving next to the person being targeted as a silent show of support or simply changing your position by sitting/standing unexpectedly.

4. Discuss after the event

If you feel unable to react at the time, all is not lost. Approach the perpetrator directly afterwards to discuss your feelings. Or try a discussion with the targeted person afterwards to confirm if they see the situation as you did and ask how you could help. A discussion with other bystanders could help to work out a group strategy for further episodes.

To Conclude

In healthcare, we can only benefit from being aware of micro-aggressions towards others. Unfortunately, most of us (with a new understanding of what a micro-aggression is) will recognise situations where we were passive bystanders and did not act.

Having better awareness of what micro-aggressions are, and how detrimental they can be to an individual will help us to make the transition from passive to active bystander with the aim, in time, to have a positive impact on our workplace environment.

Selected references on bystander awareness

The Art of Saying No

Cite this article as:
Andrew Tagg. The Art of Saying No, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33214

I have been a consultant for almost six years now. I love putting on my black DFTB scrubs, waving hello to the comms clerks as I walk past triage, and doing what I think is a good job. I am no longer a new FACEM, despite what I think, and I’ve reached that point when advanced trainees are starting to ask me for career advice. I think back to what I had been told.

Join lots of committees,” they said.

Say yes to everything.”

Looking back, I am not so sure that this is the best advice. Has it done me any good? It has certainly helped my career. But there is much more to life than your job. Perhaps, just perhaps, it is better to learn to say no?

The first no

You may not remember your first time, but I’m pretty sure your parents do. Were you snuggly strapped into your highchair trying to figure out why you needed to open your mouth for that limp, overboiled, spear of broccoli? No, here doesn’t come the aeroplane. Were you dragging your heels around Woolworths, clad in an embarrassing mismatch of brown corduroy and mustard yellow polyester when it was time to leave the plastic heaven of the toy aisle? No, you scream as you fall to the floor in the perfect imitation of premier league midfielder. Or were you just lying there, minding your own business, enjoying the warmth of freshly laid poo in your nappy, when some do-gooder decided you needed to be naked and cold (and clean)*?


Those two letters hold such power. They are often our first show of defiance so why don’t we want to use them more as we get older? Maybe, it is the sense of embarrassment? We feel for the harassed parent as they leave their wailing child to their tantrum on the filthy linoleum. Do we then display negativity bias, our brains recalling in exquisite detail, these confronting turns? As we grow older, programmed to please, rather than upset, we choose to say yes instead.

Why? – E – S spells YES

We crave approval. Our sense of self-worth is inherently tied in with our need for acceptance by the tribe. By pleasing people, and saying yes, we then avoid conflict. It is easier to answer in the affirmative than feel the social tension of a request denied so there is this innate sense that we should conform to the norm of saying yes. If we say no they might turn their burning gaze of approval away from us and we will no longer belong. Making the active decision to say no means you are turning away from the tribe and deliberately turning down the emotional reward offered.

But, we are not responsible for other peoples feelings. If we can learn to say no, graciously, then our lives might be a little easier.

Perhaps, we say yes because it is easier than thinking through all of the options? Paralyzed by choice we answer a request on autopilot. At that exact moment in time, with your director standing in front of you, you don’t want to hesitate and so you blurt out the first thing that comes to mind.

But by saying yes, what are you saying no to? Are you saying no to playing in the park with your children? Are you saying no to catching up with a friend that you haven’t seen for ages because they have been self-isolating? How comfortable are you with saying no to your own self-care? In the same way that we rehearse hard conversations, in our head or with friends, we can practice our new script until it becomes a new auto-response.

Let me get back to you later about that. I need to check my other commitments.

You may, indeed, want to take up the opportunity offered. But only do so after carefully weighing up the costs and benefits.

There may be a deeper, darker reason for saying yes, too. Being busy can be a way to avoid being. Living a distracted life makes it easy not to think about the hard things. I know I have been guilty of this. It is much easier to get on and write another blog post, or join that committee, or pick up that extra shift than think about where your life is heading. It is not sustainable. It is also not good self-care.

The myth of the perfect life and FOMO

In this never-off world, we are exposed to a heavily curated alternate reality – one where all of our friends are writing papers, presenting at conferences and transporting critically ill patients around the country in helicopters, all the while maintaining elegantly coiffed hair. With greasy thumbs swiping up and down our timelines, we compare ourselves to that Finsta-life and wonder why we have less. We wonder why don’t have what they are having and we feel a sense of sadness.

Patrick McGinnis called this FOMO – the Fear of Missing Out. This is a form of loss aversion and so we say yes to things because we worry that we are going to miss out on some remarkable opportunity that will catapult us into that perfect life. We worry that the opportunity will never again present itself, in part, because we find it hard to see our own merits. We think that good things only ever happen to us on account of luck or serendipity. Because we cannot always see our own goodness we rely on the validation of others. And how do we gain that validation? We say yes.

The problem with saying yes (to everything)

It is easy to say yes. It is far easier to say yes, than no. But what does it lead to? If you say yes to everything, then nothing is important.

Tsundoku

We all have them – on the bedside cabinet, in the office, on our electronic devices – that pile of unread books, spines unbroken, stories unread. They sit there, tempting us with their bright and colourful covers. “Read me,” whisper untouched pages, knowing that once you have picked them up, you will become lost in the strange flow of time that only books can create. There is a Japanese term for this memorial of words and lost worlds – tsundoku. And, like your boss asking you to do that one extra shift, you might find it is time to say no too. Instead of saying yes to all of the books, it might be time to create what Umberto Eco would call a library of the unread. When you can find out the answer to almost any question with a click of a button, isn’t it better to know where to find things rather than to have them lodged in your own private memory palace?

While I am not denying the value of a perfect piece of fiction, it is easy to say yes to every colourful cover in the bookshop. We need to place more value on our time and learn to say no. We need to set boundaries and focus on what actually is important. What projects are sitting on your bedside table of ideas? What requests have you said yes to that are left unfinished, or perhaps not even yet started? Every time we add a new book to our tsundoku we are reminded of our failure to complete that thing we started. By saying no, you are actually committing to being able to say yes to something else.

On boundaries

When the COVID pandemic began and work shifted, from office to home, boundaries became blurred. It was easier to ‘just send a quick email‘ before closing the laptop for the night. Before you knew it, you were ensnared in a reply-all thread regarding which dressing you should stock for paediatric cannulation (Editor’s note – Tegaderm teddies, obviously) and your children were scratching at the door like extras from a George A. Romero movie. It has been hard to switch off when working from home but until someone pays me to look after my own children they cannot dictate what I do when I am not at work. Firm boundaries need to be set.

Have you ever checked your e-mail at 8pm on a school night and been tempted to respond? It’s easy, especially if you only need to dash out a couple of lines. What you are doing is eroding the boundary between work and not-work. You are setting an expectation that you will respond, even if you are not at work. I used to be that person – the one that would respond to enquiries at 10 o’clock at night. Achieving Inbox Zero would give me a teenty tiny dopamine hit. But I never considered the cost. I never considered what I could have been doing instead. I’m a huge fan of Greg McKeown’s Essentialism and responding to an e-mail late at night is just not essential. It does not need to be done.

And the funny thing is if you leave a problem for a day or two it often seems to sort itself out. Someone else volunteers for the job. The lost vein-finder shows up. Management changes their mind on PPE requirements (again). It has been a long time coming but now I say no to checking my email obsessively and just wait.

So, having considered the importance of saying NO, here is some guidance on the how.

1. Focus on the request not the feelings

You are saying no to the ask not the asker. Don’t worry that you will hurt your bosses feelings because you are saying no to something. This is a refusal, not a rejection. All you are doing is setting boundaries. If you already have a lot on your plate ask what task they want you to de-prioritize in order to take on a new project. That way you are asking them to make the choice, not you.

Thanks for thinking of me. I’ve already got a lot a other projects on the go at the moment for you. Which one would you like me to drop?

2. What’s the alternative?

Perhaps you have been asked to give a talk and your digital diary is full? This is an opportunity to practice allyship and show your support for a colleague that might be better placed to take on the task. We know that, despite women being in the majority in paediatrics, they are much less likely to be invited to speak at an event, or be listed as first author. This is the perfect opportunity to suggest that a colleague who is much more qualified than you take the (virtual) stage.

I’m sorry but I have a lot on next month so the answer will have to be NO. But let me give you the name fo three amazing women that would do a far better job than I ever could.

3. NO is a complete sentence

You don’t have to say why. You do not have to over-explain. “I cannot do the extra shift because I am spending time with my family.” That is enough. You don’t need to over-explain and go into details about what you are going to do. You are setting the boundary between work and home. You just need to say no with confidence. It’s too easy to bargain with someone that over-explains.

If you do feel the need so say something after the no then make sure you use the word because. In one of those classic social psychology studies that could only be performed before the dawn of the internet a group of experimenters would approach people lining up to use a rigged photocopier. An actor, weighed down with a pile of textbooks (pre-internet, remember) would struggle to the front of the queue and ask to skip the line. Langer et al. (1978) found that just by adding the word because, the actor was much more likely to be allowed in, even if the excuse made no sense. It was the word because that seemed to work wonders.

No, because I would like to spend some time with my children.

4. Sorry is NOT the hardest word

I’m sorry, I can’t” seems like the polite way of turning someone down but you do not need to express regret. You are not sorry. Reframe it. You are saying yes to other important commitments, to the things you want to do. Just because you ran the medical student teaching program last year, it does not mean that you have to say yes again this year.

No.

5. Just say NO

Those of you who grew up in mid-80’s Thatcher-ite Britain will recognise the song. There are some requests where the answer is obvious. Channel your inner Zammo and just say no.

NO.

What are your real priorities? Is this important? Will it actually matter in a years time? Five years? If you had to give the talk that you have asked to give tomorrow would you say yes? Perhaps, if it is not a ‘Hell Yeah‘, then it should be a no?

*No was definitely the first word out of my middle daughters mouth in exactly the circumstances described. The other two managed shoe and more.

Selected references

Guadagno, R.E., Asher, T., Demaine, L.J. and Cialdini, R.B., 2001. When saying yes leads to saying no: Preference for consistency and the reverse foot-in-the-door effect. Personality and Social Psychology Bulletin27(7), pp.859-867.

Kline, S.L. and Floyd, C.H., 1990. On the art of saying no: The influence of social cognitive development on messages of refusal. Western Journal of Speech Communication54(4), pp.454-472.

Izraeli, D.M. and Jick, T.D., 1986. The art of saying no: Linking power to culture. Organization studies7(2), pp.171-192.

Langer, E., Blank, A., & Chanowitz, B. (1978). The mindlessness of Ostensibly Thoughtful Action: The Role of “Placebic” Information in Interpersonal Interaction. Journal of Personality and Social Psychology, 36(6), 635-642.

Patrick, V.M. and Hagtvedt, H., 2012. “I don’t” versus “I can’t”: When empowered refusal motivates goal-directed behavior. Journal of Consumer Research39(2), pp.371-381.

All paediatricians are complicit in delivering a racist healthcare service

Cite this article as:
Zeshan Qureshi and Anna Rose. All paediatricians are complicit in delivering a racist healthcare service, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33938

We’re supposed to be the nice ones. The friendly, fun, caring and supportive speciality – right? We’re the ones who have teddies on our stethoscopes and know all the words to Disney songs. In the hospital, we’d like to think we’re the Good Guys – but maybe we’re not when it comes to race. 

The COVID-19 pandemic has been a monumental challenge to the NHS and has, undoubtedly, showcased the everyday heroism of our staff. It has also thrown a sharp light onto the ongoing racial inequalities in our society and healthcare systems. Racial disparities in the pandemic have been widely documented – and make for sobering reading. Analysis of national hospital data suggests that people of black and other minority backgrounds are up to twice as likely to die from the virus, as compared to white Britons – with some groups, such as black African-born men living in Britain, having an even higher risk [1]. Despite this, we have little doubt that the major impetus for the unprecedented emergency measures, national lockdowns, and political obsession was not the deaths of the poor, the ethnic minorities, or those in low and middle-income countries – but the perceived threat to wealthy, predominantly white, Westerners.

In an eerie parallel to the racial inequalities highlighted by the pandemic, the past year has also seen racial tensions in the USA reach boiling point. Following several high-profile incidents of police brutality, there was an eruption of social unrest and protest in America and around the world. The systemic disregard of black lives is not just written in blood on American pavements. It is written into the systems that surround us in our everyday working lives. As a speciality, and in the NHS as a whole, we must confront these engrained systemic inequalities, if we are to provide truly equitable care to all of our patients. 

In this blog series, we will examine how clinical outcomes for common paediatric conditions are worse for children from minority ethnic backgrounds. Stillbirth, low birth weight and preterm birth are all more common in minority groups as compared to white northern European populations [2,3,4 ]. Outcomes for common chronic conditions, such as asthma and type 2 diabetes, are also worse for children within minority groups [5,6]. This could be because care received by children with chronic conditions is worse. Non-white children with renal failure are less likely to pre-emptively receive a renal transplant, for example [7]. There are also complex social and environmental roots to these adverse health outcomes – such as increased poverty in non-White groups [8] — and we will try to investigate these issues in more detail. 

We will also explore how paediatrics has normalized white Northern European genetics, physiology and behaviour, leading to biased clinical decision making. Normalization of one ethnic group has lead to the classification of other normal values (in both the laboratory and social sense) as pathological or inappropriate. In other words – you are only normal if you are white and normal. Neutrophil counts are often lower in black babies [9]. Rather than reporting ethnically normal ranges babies often end up having multiple blood tests due to a lack of awareness of the variation. Parents get told that their neutrophil count is low, but it’s acceptable for a black baby (rather than categorically stating that their count is normal). Worst still, it might be classified as a disease – benign ethnic neutropenia – despite not being associated with increased morbidity or mortality.

Within medical education, we are guilty of peddling irrelevant and outdated racial and religious stereotypes. These hold little educational value, but risk enforcing dangerous bias within our future doctors. Any paediatrician would be able to tell you about the association between Tay-Sachs disease and Ashkenazi heritage, or sickle cell disease and sub-Saharan Black Africans. Such associations are often over-simplified and over-emphasized, to the point of creating a disease-ridden caricature, particularly in exam questions. Most of these stereotyped conditions are very rare, and over-emphasis during medical school risks blinkering us to more common diagnoses. We’ll explore how racial bias is ingrained in medical education in the UK, and try to come up with some ideas on how we can improve MedEd to be more diverse and inclusive in the future. 

There also seems to be a disproportionate concern that those from Muslim backgrounds might be consanguineous, and that we need to ask about this even when it is not relevant to the presenting complaint. Conversely, when genetic testing is being sent off, a detailed family tree needs to be drawn. It should include details of any consanguinity – yet it seems that a white family is less likely to be asked. As first or second cousin marriages are no longer a social norm in the UK, they have become defined by pathological associations with genetic conditions, such as inborn errors of metabolism. And whilst there are, of course, differences in the prevalence of disease alleles in different populations, and an increased risk of recessive disorders in families with intergenerational consanguinity, it does not automatically follow that a child from a Muslim background has a recessive disorder, or that a white British child does not. The same considerations need to be given to other cultural practices that might be different to the social norms of Northern and Western Europe. Putting children on a vegetarian diet is often classed as a ‘restrictive diet’ – despite the fact that it is only restrictive based on traditional Western standards – and might, in fact, hold health benefits [10]. 

Finally, in our series, we will examine how systemic racism within the health service tolerates – and sometimes even facilitates –  the unacceptable behaviours demonstrated by some parents. One thing that sets paediatrics apart from adult medicine is that patients are almost never seen alone, and a parent is often required to deliver care. This can present a dilemma to staff when confronted with a racist parent. Any punishment directed towards the parents might directly harm their child. We will explore how guidelines should be developed to help clinicians handle racist parents, whilst minimizing the effect on the clinical care of our patients. 

It can be painful for us – as individuals and as a speciality – to consider that we might be complicit in a racist system that ultimately leads to poorer health outcomes for some children. Just because something is painful, does not mean we shouldn’t do it. We hope that you’ll join us for this series of short articles, as we try to explore how we can begin to move from a white-centric healthcare system to a child-centred one.

James Baldwin quote on racism

Selected references

1) The IFS Deaton Review. Are some ethnic groups more vulnerable to COVID-19 than others? 

2) Gardosi J, et al. (2013). Maternal and fetal risk factors for stillbirth: population-based study. BMJ 346:f108.

3) Kelly Y, et al. (2008). Why does birthweight vary among ethnic groups in the UK? Findings from the Millenium Cohort Study. Journal of Public Health, 31:131–137.

4) Aveyard P, et al (2002). The risk of preterm delivery in women of different ethnic groups. British Journal of Obstetrics and Gynaecology 109:894-899.

5) Asthma UK (2018) On the Edge: How inequality affects people with asthma. Available at www.asthma.org.uk

6) RCPCH (2020) State of Child Health: Diabetes. Available at www.rcpch.ac.uk

7) Plumb LA et al. (2021) Associations between Deprivation, Geographic Location, and Access to Pediatric Kidney Care in the United Kingdom. CJASN. 16:194-203.

8) Office for National Statistics (2020) Child poverty and education outcomes by ethnicity. Available at www.ons.gov.uk.

9) Haddy TB, Rana SR, Castro O. (1999) Benign ethnic neutropenia: what is a normal absolute neutrophil count? J Lab Clin Med. 133:15-22.

10) Kalhoff H. et al (2021) Vegetarian Diets in Children—Some Thoughts on Restricted Diets and Allergy. International Journal of Clinical Medicine. 12:43-60.

An Evidence-Based Cookbook for the Treatment of Adolescent Acne Vulgaris

Cite this article as:
Kate Hensley. An Evidence-Based Cookbook for the Treatment of Adolescent Acne Vulgaris, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33815

A 14-year-old patient named Shannon presents to their primary care physician for a sports clearance physical. During the visit, the patient’s parent mentions that they are concerned about Shannon’s acne. Shannon is being teased by other students at school. They make comments like, “why don’t you wash your face? You look disgusting.” Shannon appears embarrassed and admits that these comments are very upsetting. The parent reports that they have “tried everything” and when asked for specifics, they cannot name ingredients or brands, but they have tried numerous over-the-counter washes and topical preparations. Shannon reports they have never used any one product for more than about a week because “nothing works”. On physical exam, the patient is noted to have significant comedonal acne over the forehead, nose and chin with a pustular and nodular lesions on their cheeks. There is some mild scarring on the cheeks as well.

Acne vulgaris is extremely common, affecting about 85% of adolescent patients across ethnicities and nationalities.  Some 36% of adolescents experience moderate to severe acne. Adolescents with acne have increased social impairment and mental health problems. Those with severe acne are up to twice as likely to experience suicidal ideation compared to their clear-skinned counterparts.

Many effective treatment options are available over-the-counter, but patients, and their parents, may lack knowledge around which agents will work best for them. It is also important to educate them both about just how long treatment takes.  Most patients can expect to see a difference in their acne after 2-3 weeks of persistent use. Often, patients will cease using effective products too soon because they do not have realistic expectations of the treatment.

Etiology

  • Increased androgen levels in adolescence lead to sebaceous hyperplasia.
  • Alterations in follicular growth and differentiation affected by genetic factors.
  • Colonisation by Propionibacterium acnes (P. acnes).
  • Individual immune system response and inflammation.
  • NOT poor personal hygiene or too much junk food (education about this is important!).
Aetiology of adolescent acne

Types of Acne

Comedonal Acne

This results from increased cell division and cohesiveness of cells within the follicular lumen. These cells mix with sebum (production is increased in response to increasing androgens) and obstruct the follicular opening.

If the follicular opening is closed, comedones appear as whiteheads. If the follicular opening is larger, the keratin build-up is exposed to the air and will thus oxidize and darken. These lesions appear as blackheads.

Acne vulgaris

It is a common misconception among laypersons that the dark colour of blackheads is caused by dirt, reinforcing the myth that adolescents with acne are unclean.

Inflammatory Acne

This is caused by colonization by P. acnes. and leads to inflammation and formation of pus collections within the follicles. These then coalesce to form nodules or pseudocysts.

They may cause scarring and permanent disfigurement.

The type of acne and the presence of scarring determines the severity. It may be classified as mild, moderate, or severe. The severity does not necessarily correlate with the level of distress for the patient. Adolescents may be significantly affected by even mild acne.

Treatment

Choice of treatment should be tailored to the underlying etiology and level of severity.

Different active ingredients address different underlying problems. Ingredients all fall into one of four major categories:

  • antibiotic agents.
  • agents that reduce production of sebum.
  • agents that reduce desquamation of the follicular epithelium.
  • chemical exfoliants (i.e. keratinolytics).

Benzoyl peroxide

  • Acts as an antibiotic and eradicates P. acnes.
  • Advantageous over other topical antibiotics as there is no development of resistance.
  • Useful as a spot treatment for inflammatory lesions. Continued generalised use prevents their formation.`
  • May be used in combination with topical clindamycin to increase efficacy. It is important to note that topical clindamycin ALONE has not been shown to be effective for most inflammatory acne. 
  • Adverse effects – may cause irritation in some patients but this can be mitigated with use of a moisturiser, may cause bleaching of clothing and towels – recommend that patients wash hands after application. May cause a temporary orange discoloration of the skin when used in combination with topical dapsone.

Salicylic acid

  • Topical antibiotic, also has some mild exfoliant effects.
  • Can be used as spot treatment for inflammatory lesions.
  • When tested head-to-head, less efficacious than benzoyl peroxide.

Tea Tree Oil

  • Topical antibiotic.
  • Spot treatment.
  • Less efficacious than benzoyl peroxide.
  • May have estrogenic effects in males.
  • Strong and distinctive odour.

Minocycline

  • Systemic antibiotic, effective for moderate to severe inflammatory acne that is NOT predominantly nodular.
  • Dosing is 50-100mg given once or twice daily (i.e. 50-200mg per day total).
  • Can cause GI upset, sun-sensitivity.
  • Very rarely can cause Stephens-Johnson syndrome.
  • Should not be used in children under 8 years.
  • Most effective when used in combination with a topical antibiotic.
  • Should be discontinued 1-2 months after new lesions have stopped emerging. After cessation, plan to maintain control with a combination of topical antibiotic and retinoid.

Topical Dapsone

  • Effective for combination type acne.
  • Most effective when used in combination with a topical retinoid or BP.
  • Can cause skin dryness, mitigate with daily moisturiser use.

Topical Retinoids

  • Work by normalising desquamation of the follicular epithelium.
  • Most effective for comedonal acne.
  • Also have some anti-inflammatory activity.
  • Can cause dryness, irritation, and sun sensitivity. Patients should be advised to apply a pea-size amount all over the face (i.e. do not spot treat) at bedtime and use a moisturiser with SPF during the day.

Chemical exfoliants (hyaluronic acid, glycolic acid, uric acid)

  • Decrease build-up of keratin.
  • Can be an effective adjunct agent for comedonal acne but not very effective on its own.

Niacinamide

  • Decreases oil production.
  • Adjunct treatment for comedonal acne.

Oral Isotretinoin

  • Effective for very severe nodular inflammatory acne.
  • Can cause severe dry skin and myalgias.
  • Requires special licensing to prescribe because of teratogenicity. Patients who can become pregnant must also use hormonal contraception and have regular pregnancy tests.
  • Generally prescribed only by dermatologists.

Hormone therapy (oral contraceptives)

  • Combination oestrogen/progestin with spironolactone are most effective as they block the production of androgens as well as block the effects of androgens on sebaceous glands.
  • Using a lower dose of oestrogen can decrease risk of thromboembolism.
  • Should not be used in patients who smoke due to increased risk of blood clots.
  • Only an option in patients who have achieved menarche and who have no other complicating factors that would make contraindicate use of oestrogen.
  • Can be advantageous over oral isotretinoin due to fewer unpleasant side effects and no requirement for monthly follow-up visits.
  • Also of note, if a patient has significant acne with other signs or symptoms of hormone access dysfunction (oligomenorrhea, obesity, hirsutism), they should be screened for polycystic ovarian syndrome and congenital adrenal hyperplasia.

Shannon was prescribed a 30-day course of minocycline, along with low-potency topical tretinoin. The paediatrician recommended an over-the-counter benzoyl peroxide preparation to be used as a spot treatment for the inflammatory lesions. She also recommended her favourite moisturiser – an oil-free lotion containing niacinamide with an SPF of 30. The paediatrician also recommended using an alarm app on Shannon’s smartphone to help her remember to use all treatments daily. At follow-up, four weeks after the initial visit, Shannon’s acne had improved. Thus, minocycline was discontinued but the topical retinoid and benzoyl peroxide were continued. Both patient and parent were happy and grateful.