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.

Receiving negative feedback

Cite this article as:
Team DFTB. Receiving negative feedback, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.34295

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The 52nd Bubble Wrap

Cite this article as:
Currie, V. The 52nd Bubble Wrap, Don't Forget the Bubbles, 2021. Available at:
https://dontforgetthebubbles.com/the-52nd-bubble-wrap/

With millions upon millions of journal articles being published every year, it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Article 1: Does Rapid Respiratory Virus Testing Influenza Care?

Rao S, Lamb MM, Moss A, et al. Effect of rapid respiratory virus testing on antibiotic prescribing among children presenting to the emergency department with acute respiratory illness: a randomized clinical trial. JAMA Netw Open. 2021;4(6):e2111836.

What’s it about? 

This was a single-centre randomized clinical trial of paediatric patients aged one month to 18 years presenting with influenza-like illness (ILI) presenting to a large paediatric emergency department in Colorado. Presentations from December 1, 2018, to November 30, 2019 (pre-COVID-19) were reviewed to determine if rapid respiratory panel (RRP) tests could decrease antibiotic prescribing. ILI was defined as a temperature ≥ 37.8°C and at least one of the following symptoms: cough,sore throat, rhinorrhea, or nasal congestion. Children were excluded if they had an Emergency Severity Index of ≥2, had respiratory symptoms for more than two weeks or were seen in nurse-only visits. The BioFire FilmArray RP2 Panel was performed on 908 children. Just over 8 in 10 of the children were positive with enterovirus/rhinovirus, influenza, and respiratory syncytial virus, with adenovirus being the most common. They were randomized into two groups. The intervention group had RRP results provided to the ED clinician and family. The control group was not given RRP results. However, this randomization was complicated by the issue that some patients from the intervention group left prior to RRP results (just under 4 in 10 children), and some patients in the control group had alternative respiratory viral testing that resulted (around 1 in 10). 

The primary outcome was an antibiotic prescription. Secondary outcomes included antiviral prescription, ED length of stay, hospital admission, and recurrent health visits. They lost roughly one-third of patients from the intervention and control group during follow-up. 

Authors analyzed results in multiple ways: intention-to-treat (ITT) analysis, modified ITT analysis, and per-protocol analysis. 

ITT analyses

With ITT analyses, patients in the intervention group were more likely to receive antibiotics than the control group (relative risk 1.31; 95% CI 1.03-1.68), and no significant difference in secondary outcomes. With adjusted ITT analysis, there was no significant difference in an antibiotic prescription. Children in the intervention group were more likely to receive antivirals (relative risk 2.5; 95% CI 1.5-4.2) but had longer ED length of stay and hospitalization rates.

With modified ITT analyses, there was no significant difference between groups. Children for whom RRP results were known were more likely to receive antivirals (relative risk 2.6; 95% CI 1.6-4.5), have longer ED length of stay, and be hospitalized.

Clinicians changed their clinical decisions based on RRP results 17% of the time.

There are many limitations in this study. They did not include patients with very low acuity. There seemed to be an imbalance between control and intervention groups that resulted in patients more likely to have diagnoses with an indication for antibiotic therapy (sepsis, shock, pneumonia, pharyngitis, otitis media) in the intervention group. ⅓ of patients were lost to follow up from each group. Intervention group patients left prior to RRP results, and control group patients received alternative RRP tests. This study was conducted within a single healthcare system and should be investigated at other institutions.

Why does it matter? 

Coughs, colds, and sniffles are common complaints in paediatric patients. Most are due to viruses and require only supportive care. Rapid respiratory panels may reveal the viral aetiology 85% of the time but often does not change management or decrease antibiotic therapy in this study.

Clinically Relevant Bottom Line:

RRPs are sensitive and expensive tests that may provide the family and provider with an aetiology for an ILI, but the results do not often impact clinical care. Personally, I would stick with the more cost-effective rapid influenza test during flu season for a result you might actually act on.

Reviewed by: Dennis Ren

Article 2: Is lung US any use for patients going to PICU?

Sachdev A, Khatri A, Saxena K, et al. Chest sonography versus chest radiograph in children admitted to paediatric intensive care. Tropical Medicine 2021; 0(0):1-5

What’s it about? 

This prospective, double-blinded observational Indian study planned to compare and correlate the performance of point of care lung ultrasound (POCUS) versus routine bedside chest radiograph (CXR) in the paediatric intensive care unit (PICU) setting. Children between the ages of 1 month and 18 years were included in the study. Those with morbid obesity, chest wall oedema or burns and inability to turn were excluded due to the physical barrier to ultrasound technique (n=18).

CXR’s were conducted according to PICU protocol and subsequently reported by a radiologist, who was unaware of any previous ultrasonography findings. The same patients would then undergo a chest US by an off duty paediatric intensivist with at least 5 years of POCUS experience, within 3 hours of the CXR being taken. The intensivists did not have access to the patients’ clinical details or CXR report.

From October 2018 to May 2019, 413 patients were enrolled and 1002 CXRs were compared with corresponding chest US. The US findings were immediately available, and the average time of CXR requisition and reporting was 4.5 hours +/- 3.5hours. Of the 1002 episodes, 451 (just under 1in 2 patients) had a normal chest US and 512 (just over 1 out of 2) had a normal CXR. Pulmonary oedema, pneumothorax and pleural effusion were diagnosed in a significantly higher number of patients using US compared to CXR (p=0.001). Both modalities demonstrated equal efficacy in detecting consolidation and atelectasis.

Why does it matter? 

Chest US was shown to be as reliable a diagnostic modality, if not better with certain pathologies, compared to the standard CXR, and with the provision of immediate results. This is particularly beneficial in the context of pneumothoraces, where delayed diagnosis could be fatal. With pleural effusions, it has the additional benefit of deciphering optimal placement of drains and or thoracentesis. Chest US also obviates the need to expose children to unnecessary radiation and can be easily repeated.

This does not currently form part of the general paediatric curriculum as a required skill- there are courses available that focus on paediatric POCUS but work is required to increase the numbers of clinicians who can perform this skill. For more on POCUS in paedaitrics why not look at Cian McDermott and Pete Snelling’s post on it: https://dontforgetthebubbles.com/focus-pocus/

Clinically Relevant Bottom Line:

If paediatricians were to receive lung US training as part of standard training this skill could be used to diagnose pleural and parenchymal lung abnormalities. This can be done quickly, reliably and with reduced risk to the patient and with increased sensitivity in certain conditions compared to CXR. However, US can have limited use in the presence of emphysema, obesity, and bandages.

Reviewed by: Melanie Ranaweera

Article 3: Should you use mannitol or hypertonic saline for children with raised ICP?

Kumar N and Jaiswal A Comparative Assessment of Hypertonic Saline versus Mannitol in the treatment of raised intracranial tension in children. European Journal of Molecular and Clinical Medicine. 2020; 10 (7) : 3968-3974

What’s it all about?

This observational, prospective, Indian study compared the use of mannitol with 3% hypertonic saline in paediatric patients with clinical signs and symptoms of raised intracranial pressure (ICP). 220 children between the ages of 2 and 18 were included in this study and randomly allocated to the mannitol arm (Group A n=110) or the 3% hypertonic saline arm (Group B n=110). Patients with compromised renal function, diabetic ketoacidosis and cerebral malaria were excluded from the study.

In both groups, loading dose (5ml/kg) of either mannitol or 3% hypertonic saline was followed by a maintenance dose (2ml/kg) every 6 hours for two days. Mean arterial pressure (MAP) was measured at admission and then 6 hourly after the intervention. Serum electrolytes and osmolality were measured every 12 hours post treatment initiation. CT scans or MRI heads were conducted 6 hourly to indirectly assess intracranial pressure.

The decrease in MAP was highly significant ( p<0.001) at 0 hours in males and 0, 6 hours in females in the hypertonic saline group. Moderate significance in MAP reduction was noted at 12,36 hours in females and 6,24,42 hours in males in the hypertonic saline group. Serum chloride and sodium levels were significantly incremented in the hypertonic saline group but within acceptable levels. A decrease in coma hours was a highly significant finding in the 3% hypertonic saline arm ( p<0.001). There was no difference in overall mortality between both groups.

Why does it matter?

3% hypertonic saline and mannitol are both still used in clinical practice to treat intracranial hypertension, with no universal consensus which is the definitive treatment choice. This study adds to the growing evidence of the benefits of 3% hypertonic saline compared to mannitol, in its ability to significantly reduce mean arterial pressure and coma hours.

This study does not discuss any limitations- and there is limited information on the criteria by which CT/ MRI head were performed. The wording of when CT/ MRI scans were completed is unclear- and could be read as multiple CT head scans were completed- without any mention of long term effects of this.

The Bottom Line:

3% hypertonic saline demonstrates more effective immediate and longer-term benefits for raised ICP compared to mannitol and has a good safety profile. Further studies that offer direct methods of measuring ICP are required to fully substantiate these findings.  More research is also required to determine when to initiate treatment and how long to continue it.

Reviewed by: Melanie Ranaweera

Article 4: The burden of rheumatic heart disease

Wyber, R, Wade, V, Anderson, A, Schreiber, Y, Saginur, R, Brown, A, & Carapetis, J. (2021). Rheumatic heart disease in Indigenous young peoples. The Lancet Child & Adolescent Health, 5(6), 437–446. https://doi.org/10.1016/S2352-4642(20)30308-4

What’s it about?

We briefly discussed how reduced rheumatic fever incidence has led to reduced invasive URTIs in our 51st Bubblewrap; https://dontforgetthebubbles.com/the-51st-bubble-wrap/

However, there remains an inequitable burden of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in Indigenous populations. The authors review the key information in the epidemiological burden of RHD, the lived experience, causes and contributors, preventative techniques and national disease control initiatives for Indigenous young people in Australia, New Zealand and Canada.

Key facts were highlighted. From 2015 to 2017, newly diagnosed ARF occurred 89% of the time in Aboriginal and Torres Strait Islander peoples and 79% were in peoples younger than 25 years. With the highest-burden in the states of Northern and Central Australia. In New Zealand, up to 93% of people admitted to hospital with ARF were Maori or Pacific people. Major determinants in how RHD affected lives are strongly intertwined with access to health systems (such as timeliness to primary care, poor medical communication, cultural inappropriateness, and institutionalised racism within systems) and socioeconomic and environmental circumstances (such as housing inequity, crowding and inadequate plumbing). While national research and government initiatives have been signalled in Australia and New Zealand, there are no comprehensive disease control initiatives in Canada, and funding to implement long term plans are yet to be finalised.

Why does it matter?

It is well known that the RHD burden reflects biological aetiology, such as group A streptococcus skin infections, as well as socio-political contexts. The burden is most clearly documented in Australia, New Zealand and Canada where more research resources are readily available.

The bottom line

Reducing the burden of RHD for Indigenous peoples requires not only clinical best practice, but also a societal commitment to addressing prevention and tertiary care for RHD in a manner that is acceptable, accessible, and culturally responsive. Political support and leadership to advocate action on indirect determinants of the disease such as the disempowerment and separation of land and family to accelerate the reduction in disease burden.

Available data does suggest a disproportionate burden of rheumatic heart disease. However, the exclusion of marginalised indigenous communities even with available studies may underestimate the true rheumatic heart disease burden. Furthermore, research in low to middle-income countries where fewer research resources and a larger number of competing health priorities may help us in further understanding the true burden and drivers of RHD elsewhere.

Reviewed by: Ivy Wei-Jiang

Article 5: Can melatonin be used for non-procedural sedation?

 Ahmed J, et al. Melatonin for non-operating room sedation in paediatric population: a systematic review and meta-analysis Arch Dis Child 2021;0:1–8. doi:10.1136/archdischild-2020-320592

What’s it about?

 

This was a systematic review and meta-analysis with a comprehensive systematic search. Randomised and non-randomized studies were included that looked into one of the prespecified outcomes in the review. Children from birth to 18 years requiring melatonin for non-operating room sedation or diagnostic procedures such as EEG, BERA (Brainstem Evoked Response Audiometry), MRI, nuclear scan and electrophysiological studies.

Twenty-five studies (5587 subjects) in which melatonin was used for procedural (e.g. MRI, EEG) sedation met the inclusion criteria. Primary outcome: successful procedure. Secondary outcomes were: sedation failure, sleep latency period (time taken to fall asleep), duration of sedation, the yield of procedure, supplemental sedation required and adverse events. With regards to sedation for EEG there was no significant difference in procedural success between melatonin and sleep deprivation (RR 1.06 CCI 0.99-1.12), chloral hydrate (RR 0.97 CI 0.89-1.05) or combined melatonin and sleep deprivation (RR1.03 CI 0.97-1.10). Failure rates were significantly higher (RR 1.55 CI 1.02-2.33) for melatonin alone compared to sleep deprivation and melatonin combined.  No serious adverse events were reported. The authors were unable to perform meta-analysis on studies relating to brainstem evoked potential or MRI.

Why does it matter?

Safe yet adequate procedural sedation is an ongoing challenge in paediatrics with commonly used agents such as chloral hydrate having limited efficacy. Inadequate sedation can cause a delay in getting the investigation required – therefore a delay in diagnosis and management in addition to increasing costs.

Melatonin is a sleep hormone secreted by the pineal gland and used in patients with sleep disorders owing to its sedative properties. However, data on its use for procedural sedation is limited but it lacks the major side effects (e.g. respiratory depression, slow onset and unpredictable duration of action) of chloral hydrate or benzodiazepines so has potential as an alternative agent.

Clinically Relevant Bottom Line:

 Melatonin is safe but not particularly effective so sadly we are going to have to keep using chloral hydrate.

Reviewed by: Sarah Reynolds

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!

That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.

All articles reviewed and edited by Vicki Currie

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.