EMS Feedback

Cite this article as:
Andrew Patton and Andy O'Toole. EMS Feedback, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29849

Prehospital practitioners have an ever expanding role in managing the acutely unwell and injured patient. Despite this large contribution to patient care, the majority of practitioners find it very challenging to followup or get feedback on their management of the patient.

The recent publication of the NEMSMA position paper regarding bi-directional information sharing between hospitals and EMS agencies sparked debate on Twitter about the challenges of EMS Feedback.

Gunderson, M.R., Florin, A., Price, M. and Reed, J., 2020. NEMSMA Position Statement and White Paper: Process and Outcomes Data Sharing between EMS and Receiving Hospitals. Prehospital Emergency Care, pp.1-7.

What was the paper about?

The NEMSMA Position statement and White Paper focuses on the bi-directional sharing of data between EMS agencies and receiving hospitals. The authors looked at the challenges EMS agencies face getting feedback data regarding patient outcomes, propose best practices for bi-directional data sharing and explore the current barriers to data exchange. 

The paper highlights the importance of receiving feedback and patient outcome data for quality assurance and improvement (QA/QI). Among other things, feedback is necessary for EMS providers to determine if clinical diagnoses in the field were correct, if pre-arrival notifications were effective and if the destination choice was appropriate. 

The authors surmise that with confusing and complicated healthcare law, hospitals can be reluctant to “share information due to consequences of unintentional violations” of healthcare law, and fears of liability, many of which are misconceptions.

They report that…

“Many of the commonly held legal concerns preventing data exchange are misunderstandings and unfounded fears. While all regulations and laws need to be adequately addressed, legal issues should not preclude properly conducted sharing of electronic health records for quality improvement.”

Technology also creates a number of barriers to data sharing, in particular poor interoperability between EMS electronic patient care records (ePCR) and hospital electronic healthcare records (EHR). The absence of a universal patient identification value is another significant obstacle.   

The authors reference information blocking and market competition between hospitals as two of the big political and economic barriers which can be among the most challenging to overcome. 

They conclude by recommending a collaborative effort between EMS agencies and hospitals to develop and implement bilateral data exchange policies which would benefit all stakeholders. 

This paper focuses mainly on data sharing at an organisational level, it is very relevant to the difficulties faced by individual pre-hospital practitioners trying to follow-up on patients they treat at a local level. 

Why is this so important?

As discussed in the paper, feedback is an important part of quality improvement. For individual practitioners, feedback is a vital part of the learning cycle. Feedback is essential for us to learn from our mistakes, and to improve our practice.  To improve any performance, it is necessary to measure it. A practitioner that never follows up on a patient’s outcome will be left assuming that their treatment for the presenting complaint was accurate and warranted. They will likely continue to treat the same presentation in the same way in the future because their experience has never been challenged by facts that could have been discovered during patient follow up. 

Without feedback we could be unconsciously incompetent… We don’t know what we don’t know!

What’s the difficulty?

On an individual level, obtaining feedback and patient follow-up is challenging for EMS crews for a variety of reasons. In a local survey of 98 prehospital practitioners in Dublin, Ireland, only 21% of practitioners reported being able to follow-up interesting cases.

With dynamic deployment of EMS Resources, crews might transport a patient to a hospital and not return to that same hospital during their shift. If a crew does manage to find an opportunity to call back to the hospital, frequently the diagnostic work-up may be incomplete, and a working diagnosis still unclear. EDs are busy environments and, understandably, some practitioners may feel uncomfortable stopping a doctor or nurse to follow-up on a previous patient.

Calling back a few days later has its own complications; often there will be different staff working in the department who may not have been involved in the patient’s care. This method may work for the high-acuity resus presentations, but that ‘child with shortness of breath’ whose physical exam you were unsure of, or the child with a seizure who had a subtle weakness… the chances of the Emergency Department (ED) staff remembering their diagnosis or outcome is slim! 

Phoning the ED or ward is a route explored by many practitioners, but is fraught with increasing difficulty due to reluctance of staff to give out patient information over the phone fearing confidentiality issues. 

So how do we address this challenge?

Focusing specifically on providing feedback to individual pre-hospital practitioners, there are multiple potential ways to provide prehospital practitioners with follow-up information and feedback,  but you need to consider what system will work best for your individual department, ensuring patient confidentiality and data security.

The pre-hospital postbox

St. Vincent’s University Hospital is a tertiary referral hospital in Dublin, Ireland with approximately 60,000 annual attendances. Inspired by Linda Dykes and her team’s PHEM postbox at Ysbyty Gwynedd Emergency Department in Bangor, Wales, we set-up the Pre-Hospital Post Box in St. Vincent’s University Hospital Emergency Department in August 2017. 

We engaged local prehospital clinicians and ED consultants to develop an SOP. A postbox was built and mounted by the carpentry department. Using a template from Bangor, a feedback request form was developed.  Finally, the service was advertised in the emergency department, local Ambulance and Fire Stations and we were open for business. 

Prehospital clinicians seeking feedback on a case complete a form and place it in the post-box. The case notes are reviewed by an EM doctor and feedback is provided by phone call. 

To ensure patient confidentiality, feedback is only provided to practitioners directly involved with the patient care. A triple-check procedure is used to confirm this. The practitioner’s pin number on the request form is verified on the Pre-Hospital Emergency Care Council (PHECC) register and against the patient care record. The listed phone number is also verified through practitioners known to us or the local Ambulance Officer. 

Other hospitals use systems providing feedback via encrypted email accounts or posted letters.We elected to use a phone call system, the primary reason was the anecdotal reports that many of our pre-hospital staff don’t have easy access to work email accounts. We also anticipated that a phone call would be more likely to facilitate a case discussion and allow paramedics to ask questions that might arise during the discussion. 

Challenges with this system?

Providing feedback to prehospital practitioners is a very time-consuming and labour intensive job, particularly in hospital systems where the majority of clinical documentation is still paper-based. In our own system, where handwritten ED notes are scanned, radiology, labs and discharge letters are available on-line, and in-patient notes are handwritten physical charts – we’ve found the average time required to collate details for the feedback request is just 9 minutes, with a feedback phone call averaging 5 minutes per call.

To successfully upscale this would require a team of doctors or a rota based system with allocated non-clinical time to answer requests. Alternatively a digital solution allowing paramedics to access the data themselves, or facilitating the physician managing the case to reply directly would make it more feasible but may generate further challenges. 

The ideal, as discussed in the NEMSMA paper, would be an organisational process, with the automatic provision of discharge summaries and test results by hospitals to EMS agencies which would provide useful organisational data, and subsequent feedback to individual EMS practitioners.

GDPR / Data Protection Considerations

Patient confidentiality and data protection are of utmost importance in an EMS Feedback System. The system implemented needs to have robust mechanisms, such as our triple-check, to ensure that feedback is only provided to healthcare professionals directly involved in the patient’s care. 

It is also important that it is compliant with data protection legislation in your locality, such as General Data Protection Regulations (GDPR) introduced in Europe in 2018.  Our EMS feedback system is an important mechanism for us to review the care and treatment provided to patients and allows us to assist pre-hospital practitioners in evaluating and improving the safety of our pre-hospital services, which is provided for in the “HSE Privacy Notice – Patients & Service Users”

Providing EMS Feedback, in its current form, is a labour intensive process but we believe it is a worthwhile initiative. It is greatly appreciated by Pre-Hospital Practitioners and it enables them to enhance their diagnostic performance and develop their clinical practice.

If you’d like to find out more about how to set up a Pre-Hospital Post Box in your ED, have a look at these resources…

Attachments

References

Patton A, Menzies D. Feedback for pre-hospital practitioners: is there an appetite? Poster session presented at: 2017 Annual Scientific Meeting of the Irish Association for Emergency Medicine; 2017 Oct 19-20; Galway, Ireland.  

Gunderson MR ,Florin A , Price M & Reed J.(2020): NEMSMA Position Statement and White Paper: Process and Outcomes DataSharing between EMS and Receiving Hospitals, Prehospital Emergency Care, https://doi.org/10.1080/10903127.2020.1792017 

Croskerry P. The feedback sanction. Acad Emerg Med. 2000;7:1232-8.

Jenkinson E, Hayman T, Bleetman A. Clinical feedback to ambulance crews: supporting professional development. Emerg Med J. 2009;26:309.

Patton A, Menzies D. Case feedback requests from pre-hospital practitioners – what do they want to know? Meeting Abstracts: London Trauma Conference, London Cardiac Arrest Symposium, London Pre-hospital Care Conference 2018. Scand J Trauma Resusc Emerg Med 27, 66 (2019). https://doi.org/10.1186/s13049-019-0639-x  

Patton A, Menzies D. Feedback for pre-hospital practitioners – a quality improvement initiative. Meeting Abstracts: London Trauma Conference, London Cardiac Arrest Symposium, London Pre-hospital Care Conference 2018. Scand J Trauma Resusc Emerg Med 27, 66 (2019). https://doi.org/10.1186/s13049-019-0639-x   

O’Sullivan J. HSE Privacy Notice – Patients & Service Users v1.2.  2020 Feb, Accessed on-line: https://www.hse.ie/eng/gdpr/hse-data-protection-policy/hse-privacynotice-service-users.pdf 


Telehealth vs Traditional Medicine

Telemedicine vs Traditional Medicine

Cite this article as:
Caroline Ponmari, Kausik Bannerjee and Tony Hulse. Telemedicine vs Traditional Medicine, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28966

The COVID – 19 pandemic has resulted in significant changes in the healthcare system. In the early stages adult services were overwhelmed with sick patients, whereas it seems that there has been an unprecedented (and rather dramatic) decline in pediatric attendances. Lockdown and advice from the government urged people to stay at home to prevent the spread of the virus. In response we, as paediatricians, were forced to consider making changes in our style of delivering care and clinic services to support children and families.  

Telemedicine was not new before COVID-19 but it has now become a legitimate means of allowing medical professionals and patients to communicate in a virtual clinic setting. We aim to provide high-quality safe care to every patient but it has taken a global pandemic for us to start at scale to harness modern technology so that we can deliver care closer to home and provide a seamless service for our patients and their families. To make the most from advances in technology we must understand the benefits and problems.

Let’s start with the pros

Telemedicine is a game-changer in paediatric asthma. Take the example of a district general hospital with 3300 paediatric attendances with asthma/ viral-induced wheeze in a year, 780 admissions and sees a cohort of 120 re-attenders in paediatric ED. During the pandemic, there were concerns that children would present late for emergency care, and be sicker as a result of this delayed presentation. To addressing this, virtual asthma clinics were started seven days a week.

Then the unexpected happened.

Paediatric asthma attendances to ED reduced by 90%, the chronic attendees, some who were on a high dose of steroids and who would attend ED up to 10 times in a year, also needing PICU, on occasions were nowhere to be seen.

Several factors such as lockdown, change in air pollution levels and handwashing were probably the main contributors.

Virtual asthma clinics also reported a high level of engagement and increased compliance with medications, especially from repeat attenders and teenagers who previously had shown poor compliance. Parents were reported to be very appreciative of the virtual clinics at a time when they felt that getting GP appointments was not easy.

Clinicians and asthma nurses were able to suggest modifications in medications through the virtual clinics, treat exacerbations at home and liaise with primary care for repeat prescriptions. Compliance improved to an extent that a shortage of preventors was reported in the trust. Change in patient and parent specific behaviour due to fears of contacting COVID-19 was thought to have led to increased compliance with medication and contributed to better management of paediatric asthma. 

One frequent ED attender is a four-year old with recurrent wheezy episodes, who normally presents in respiratory distress needing nebulisation and IV medications. After many months, he arrives back to ED in May 2020 and recieves a rapturous welcome from staff. The triage nurse took him straight in, and the doctors and nurses got ready to write up medication. The patient and family were highly gratified with the welcome, but hastened to report that he had come in with a pulled elbow. “So how was the asthma then?”, the ED staff asked all puzzled. “Great”, said the mum, so well controlled, he has not had wheeze for ages, he is taking his preventors every day. The lad made everyone’s day in ED, even the pulled elbow reduced spontaneously.

COVID-19 seemed to be able to address the compliance issue in ways that clinicians and asthma nurses could only dream of. 

Similar experiences were reported from the virtual clinics for paediatric diabetes. Paediatric diabetes consultation is focused on data interpretation, behaviour modification and tweaking of the dosage of medication.

All of this can be done remotely.

Furthermore, children, as it turned out, proved to be a dab hand at uploading data from their glucometers and insulin pumps. This in turn led to greater engagement as children showed their parents and doctors the ropes around tech, giving a sense of ownership and empowerment. The did-not-attend rate became minimal and the compliance improved dramatically.

The virtual endocrine clinic is also working well. Children who present for their initial appointment are best seen in a traditional clinic setting. Subsequently, a vast majority can be followed up virtually with an annual physical assessment. This includes children with problems with growth, thyroid and CAH. However, there will always be a small number of patients who need more frequent physical assessment.

The cons

The inability to examine patients in a teleconsultation has risks. For example, a child with a longstanding goitre can become neoplastic. Physical examination allows the experienced clinician to construct the differential diagnosis based on palpation of the thyroid gland which guides further investigation. This is not possible in a virtual clinic setting.

This is where good old-fashioned traditional medicine comes up trumps. Every consultation and physical examination give clinicians an unique opportunity to address existing clinical issues whilst providing an insight into additional psychological issues that may be lurking beneath the surface, especially in children with diabetes.

The consultation effectively starts as the child walks in, the gait, the facial expression there is clue in every step. Vital signs, which often provide clues to the diagnosis, cannot be recorded in telemedicine. Language barriers add a third dimension to telemedicine, using a third party to add to the mix. There is the risk that the equipment related to telemedicine can fail resulting in interruption or cancellation of the virtual clinic. 

Complaints received in the NHS often relate to the perceived behavioural aspect of clinicians toward patients sometimes even more than medical management. Bedside manner is of importance, body language clues from the clinicians that reinforces that they are actively listening to children and their families thus making the consultation a positive experience. This results in better patient experience and job satisfaction for clinicians. Compassion and empathy are a vital part of the clinician and patient experience, how this would translate in a virtual clinic needs further investigation.

The disparity between equity of access also emerged during the pandemic when virtual clinics became mandatory. Some children only had access to the internet at school and the local library. This caused some logistical difficulty in managing data remotely. A request to social services was made to fund the upgrading of one family’s phone so they could access the digital platform for diabetes education and data transfer. Fortunately, these cases seemed uncommon. 

The UK’s General Medical Council (GMC) provides ethical guidance to help clinicians manage patient safety and risks and decide when it’s usually safe to treat patients remotely. Consent and continuity issues are addressed, additionally, choosing the right patient who is suitable for the virtual clinic is addressed. However, the issues of liability and responsibility are not clear. The UK Care Quality Commission and other national regulators do not provide specific telemedicine polices for healthcare providers.

Some clinicians believe that use of teleconsultation threatens the basics of medicine. Excessive reliance on tech goes against the traditional clinician-patient relationship. We enter an unchartered territory were risks and responsibilities are both unclear and unknown.

The bottom line

The pandemic has given a snapshot on how we can change the way we deliver healthcare. Expectations have changed. We need a system that allows flexibility between telemedicine and traditional medicine and is responsive to clinical needs. It is important not to forget the basics – observing the patient, review of nursing observations, clinical examination, reaching a differential which will then guide the necessary investigations. However, for the right patient, telemedicine can be a safe and cost-effective option.

Caroline Ponmani (Barking, Havering, and Redbridge University Hospitals NHS Trust) 

Kausik Banerjee(Barking, Havering, and Redbridge University Hospitals NHS Trust) 

Tony Hulse  (Evelina Children’s Hospital) 

Emotional Contagion: Andrew Tagg at DFTB19

Cite this article as:
Andrew Tagg. Emotional Contagion: Andrew Tagg at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22095

I’ve always had an affinity for John Carter, as played by Noah Wyle, from the TV series ER. The night ER premiered on UK television happened to be my very first ED shift as a medical student at the Chelsea and Westminster Hospital.  I remember sneaking away to the lounge to watch it. My first ED experience was nothing like Carters but I was hooked.

I went to Chicago to do my elective and saw them filming in the snow in between shifts at Northwestern and when I returned to England to prepare for finals we would gather around the TV trying to make the diagnosis before the medicos on the television. We called it revising, but really it was escaping from the textbooks for a short time.

My interest wained nearer the end of the run. Carter had been through many trials, as had I, but one thing has stuck with me more than anything else. It was something passed down from David Morgenstern (William H. Macy) to Mark Greene (Anthony Edwards), and then more importantly from Greene to Carter. That is the basis for this talk. You can read the background here.

 

 

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

 

Safety Netting

Cite this article as:
Carl van Heyningen. Safety Netting, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28803

Safety netting is a cornerstone of paediatric practice. 

Children are a vulnerable group. Their condition can deteriorate and improve rapidly. Uncertainty is inherent in paediatric emergency medicine. From the child with a fever to the infant with vomiting, it is up to us to safeguard children from harm.  

Of course, we can’t admit every child to the hospital. Nor should we. The vast majority of patients in A&E return home with reassurance. Easy right? Reassure. Give advice. Send home. Simple?

You’re at the end of a busy shift and you have a train to catch. You’ve put in blood, sweat, and tears and feel happy your last patient has a simple throat infection. You advise fluids, paracetamol for symptoms of headache and neck pain and to come back if worried. The mother is anxious, you give them a leaflet on fever and rush out the door. 

Typically, our focus is on the front door of care not the exit. Discharge care is often overlooked. Even in the best of circumstances, we are under pressure to maintain patient flow especially as our emergency departments begin to become busy again. 

The next morning, coffee in hand, you walk in the department and hear the words that strike fear into the hearts of all that hear them… 

“Do you remember that child you saw yesterday? They’re being admitted to intensive care, it looks like meningitis.”

What could you have done differently? More tests? Not necessarily needed, no? More time? They had been observed and appeared well for several hours. Senior review? You’d seen them with the Consultant and agreed on the diagnosis. Then what? 

Safety netting

Why is it important? 

Acute illness remains one of the most important causes of childhood mortality in the UK. Early illness is notoriously non-specific. Take meningitis. In only half of cases, diagnosis is made at the first presentation. So what do we do? We must educate parents about uncertainty. Discuss the potential for deterioration. Explain the importance of seeking further help if necessary. We must safety net. 

What is it?

The term was first formally described in 1987. Today, it has come to mean “advice about what to do and what to look out for to empower parents and carers to seek help if the child’s condition deteriorates further or if they need more support.”  

What else should it cover? 

In addition to the above, it is critical to cover how they should seek help, what they should expect ahead (the disease course) and when to become worried.

How should it be done? 

Whilst verbal and written formats exemplify current practice, ranging from information leaflets to printed discharge letters, audiovisual and online resources are growing in abundance. Families report wanting this varied range of approaches.

Let’s consider the options. 

Face to Face – individualized, personal but highly variable and time-dependent

TOP TIP – be adaptable (don’t just simply recite the same information each time)

Social, educational, and cultural differences may all necessitate adapting your usual spiel in order to truly achieve understanding. Remember, the parents are in an unfamiliar, often noisy, and stressful environment in addition to feeling worried about their child. Expect them to be distracted a little. 

Leaflets – standardised, quality assured but not necessarily up to date and potentially bland and uninteresting. 

TOP TIP – use leaflets to re-enforce verbal information

When taken home written materials can often act as an aide memoire.  

Audio-visual – engaging and memorable with the potential to overcome literacy and language barriers if well designed, though resource intensive and expensive upfront   

Internet, social media, websites, apps – there are many innovative methods of connecting families with health information. Our responsibility is thus to navigate the clutter, signpost reliable resources, dispel myths and thus champion true evidence based materials. 

TOP TIP – keep the message simple, it can be easy to overwhelm parents with information. 

Remember, many parents may not wish to go on the internet. A few may even not have access to it. 

Why tailor the information? 

As ever, before talking we must first listen. For example, one interview based study found a mother worrying about “their child with cough dying at night through choking on phlegm.” If we do not listen to such fears how can we expect our own advice to be heard. 

Parental priorities

Parents priorities include… 

Emotional distress (addressing this)

Physical symptoms (addressing these)

Information (providing this, particularly reassurance, diagnosis and explanation)

Care (basic care, including food drink and friendliness)

Closure (finding out what’s wrong and, where possible, going home)

An awareness of these priorities can inform our conversations, helping us to better look after our patients from their perspective.

Ok, but what is the reality?

“You don’t actually know how much of that leaflet they’re gonna actually understand, take in, comprehend… going through things step by step, listening, understanding and explaining, I think is more beneficial” (Paediatric ED doctor). 

“It’s very difficult to know ‘cause often they’ll nod their heads and say “yes I understand everything you say” and walk off and they might have no idea what we’ve just said”  (ED staff nurse). 

“If you’ve got a sick child at home and they’re moaning at you, you haven’t got the time to go on the internet… you’ve got a child hanging off your leg going, “Mummy I feel poorly, mummy I want this, mummy I want that”” (Mother).

“My doctor did give like an information leaflet… and I did read through it, because when you’ve got a sheet at least you can find time to do that” (Mother).

So how can we do it best?

After reviewing the literature and FOAMed (see further resources) here are my top tips for giving the very best safety netting advice, enjoy! 

  • Sit down – it has been shown to increase the perception of empathy 
  • Verbalize back concerns – be explicit important conditions have been excluded 
  • Explain things – share reasoning, show your process 
  • Highlight red flags – signs that necessitate reattendance
  • Be specific – ‘If x happens, do y’
  • Reinforce – provide written leaflets
  • Avoid criticism, foster understanding – put yourself in their shoes 
  • Document advice – yes, write down what you said 

And as with all good communication, ensure a quiet, private area and avoid using jargon. 

Finally, directly ask if parents understand and are happy. Don’t assume they are. 

Here is one good example to get you started… 

“…your little guy is likely to continue to have vomiting and diarrhoea. If he remains well in himself, is drinking the amount of fluid we have discussed and is having wet nappies then he is unlikely to become dehydrated. If, however, he becomes drowsy, develops a fever or fails to stay hydrated please call this number and come back to us.” 

We must stop thinking of reattendance as a failure – patients do get worse and some need to return. 

Good quality safety netting means both you and your patients can get a better nights sleep. 

References

Gill P, Goldacre M, Mannt D, Heneghan C, Thomson A, Seagroatt V and Harnden A (2013) ‘Increase in emergency admissions to hospital for children aged under 15 in England, 1999–2010: national database analysis’, Archives of Disease in Childhood 98, 328–34.

Wolfe I, Cass H, Thompson MJ, Craft A, Peile E, Wiegersma PA, Janson S, Chambers T, McKee M: Improving child health services in the UK: insights from Europe and their implications for the NHS reforms. Bmj 2011, 342:d1277.2. 

Thompson MJ, Ninis N, Perera R, Mayon-White R, Phillips C, Bailey L, Harnden A, Mant D, Levin M: Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006, 367(9508):397–403.3. 

Neighbour R. The inner consultation. Lancaster: MTP Press, 1987.

NICE guideline [NG143], Fever in under 5s: assessment and initial management, November 2019

Available at https://www.nice.org.uk/Guidance/Ng143/evidence

Almond S, Mant D, Thompson M: Diagnostic safety-netting. The British journal of general practice: the journal of the Royal College of General Practitioners 2009, 59(568):872–874

Jones CH, Neill S, Lakhanpaul M, et al. Information needs of parents for acute childhood illness: determining what, how, where and when of safety netting using a qualitative exploration with parents and clinicians. BMJ Open 2014;4:e003874.

Neill SJ, Jones CH, Lakhanpaul M, et al. Parent’s information seeking in acute childhood illness: what helps and what hinders decision making? Health Expect 2015;18:3044–56. 

Austin PE, Matlack R, Dunn KA, et al. Discharge instructions: do illustrations help our patients understand them? Ann Emerg Med 1995;25:317–20.

Scullard P, Peacock C, Davies P. Googling children’s health: reliability of medical advice on the internet. Arch Dis Child 2010;95:580–2.

Mackert M, Kahlor L, Tyler D, et al. Designing e-health interventions for low-health-literate culturally diverse parents: addressing the obesity epidemic. Telemed J E Health 2009;15:672–7.

Knight K, van Leeuwen DM, Roland D, et al. YouTube: are parent-uploaded videos of their unwell children a useful source of medical information for other parents? Arch Dis Child 2017;102:910–4.

CS Cornford, M Morgan, L Risdale, Why do Mothers Consult when their Children Cough?, Family Practice, Volume 10, Issue 2, July 1993, Pages 193–196

Body R, Kaide E, Kendal S, et al. Not all suffering is pain: sources of patients’ suffering in the emergency department call for improvements in communication from practitioners, Emergency Medicine Journal 2015;32:15-20.

(15) Jones, C.H., Neill, S., Lakhanpaul, M. et al. The safety netting behaviour of first contact clinicians: a qualitative study. BMC Fam Pract 14, 140 (2013)

Jones, C.H.D., Neill, S., Lakhanpaul, M., Roland, D., Singlehurst-Mooney, H. and Thompson, M., (2014) Information needs of parents for acute childhood illness: determining ‘what, how, where and when’ of safety netting using a qualitative exploration with parents and clinicians. BMJ Open 4 (1). 

Further resources

RCPCH (2015) Facing the Future: Standards for acute general paediatric services. RCPCH.

RCPCH Safe System Framework, resources accessed 19th November 2019,  https://www.rcpch.ac.uk/resources/safe-system-framework-children-risk-deterioration

Dr. Natalie May, MBChB, MPHe, MSc, PGCert Medical Education, FRCEM, FACEM, #CommunicatED 1: Discharge & Safety Netting in ED, available at https://www.stemlynsblog.org/communicated-discharge-safety-netting/

Bruera, Eduardo & Palmer, J Lynn & Pace, Ellen & Zhang, Karen & Willey, Jie & Strasser, Florian & Bennett, Michael. (2007). A randomized, controlled trial of physician posture when breaking bad news to cancer patients. Palliative medicine. 21. 501-5.

Sarah Jarvis, Medico-legal adviser

BSc MBBS MRCGP, Playing it safe – safety netting advice, available at https://mdujournal.themdu.com/issue-archive/issue-4/playing-it-safe—safety-netting-advice

Damian Roland, BMedSci (Hons) MBBS MRCPCH, PhD, TIGHTEN UP YOUR SAFETY NET #WILTW, available at 

https://rolobotrambles.com/tightenyoursafetynet/

Safety netting – a guide for professionals and parents of sick kids from GP Paedtips

Shame. How it affects patients and their relationships with health care professionals. https://abetternhs.wordpress.com/2012/11/16/shame/ 

A beginners guide to remote learning

Cite this article as:
Edward Snelson. A beginners guide to remote learning, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.27341

Many of us are finding that we are being thrust into the world of remote medical education without the training or the experience to feel that we are likely to do this effectively.  There is a huge lack of adequate training for non-experts in this field that is designed to be pragmatic and useful for those of us who are more comfortable delivering face to face medical education.  I have looked for resources that might facilitate learning for a clinician who considers themselves a novice in remote or online medical education and have found none.

To help get people started, I’ve to put together some of the things I have learned about being an effective educator in the world of online and remote medical education.

Core Principles

You are the most important educational resource.  If you are delivering the education, your learners haven’t come to get a textbook or a list of facts.  They want to know what you know and what they don’t.  Forget some of the habits of traditional medical education.  Bring more of your experience and less of what you can find in a textbook.

Online and remote medical education has many advantages.  It is more accessible and has benefits for many people’s learning styles.  You can get a greater diversity of learners involved which can also be a powerful tool.  The educator can have more control of the virtual classroom.  

Online and remote medical education also carries many risks.  IT failures and audience disengagement are probably the greatest risks.  Preparation, planning and rehearsal are key elements in overcoming these challenges.

ProblemsSolutions
IT failure (connectivity, software limitations)Good signal (WiFi or mobile data) Educator’s device must be up to the task Choose the best software application for the job
Lack of connection from the audience to the educator.  Educator less able to read the audience.Where possible, have the audience visible (e.g. all on video) Maximise interactive content Have questions via audio as well as via chat
Audience disengagement and loss of attentionMaximal interactive content Chunks of delivered education should be brief and broken up by interactive elements Use of breakout rooms Polls Virtual flipcharts Injections of humour Changes of pace Music
Educator’s unfamiliarity with online teaching as a modalityRehearsal Visual aids (session map) Repetition of session to multiple audiences
Learner’s unfamiliarity with online learningPre-session briefing and joining instructions Start meeting with an explanation of what the session will involve and explain the functions
SecurityUse of required password for Zoom sessions Link to meeting sent with clear ground rules for whether it can be shared and with whom

A Step by Step Guide

Choosing a software application

There are various packages that are available.  The decision as to which to use will depend on various factors including ease of access, user friendliness, functions available, familiarity and permissions within an organisation.

ApplicationProsCons
ZoomGood range of functions including hand raising, chat, screen sharing, polling and breakout rooms User friendly Most people are familiar with Zoom Works well across a range of audience sizesBreakout rooms are only available in pro package (cost) Software is not permitted by some organisations, requiring users to access via personal devices People have to know how to use functions such as chat Basic and entry level package limit audience size to 100 but this can be increased at further cost Users need to set up Zoom on their device prior to the session (very straightforward)
Microsoft TeamsGood range of functions Permitted by organisationsFunctions are often clunky and poorly designed e.g. breakout rooms Less user friendly than many other packages Users need to set up Teams on their device prior to the session (more complicated)
Google MeetUse is possible within most organisations SimplicityVery limited functions – essentially it is a conferencing software package
Facebook roomsSimplicity Use is possible within most organisationsUsers may not have a Facebook account
SkypePermitted by organisationsLimited functions
YouTubeAble to reach an unlimited audienceUnable to see audience Interaction only possible via chat or third party applications (e.g. polling and virtual flipchart via mentimeter) Security and governance is more difficult to manage

There are many other software packages available.  It is worth trying the different packages to see what is the best fit for the teaching that you want to deliver.  I would recommend Zoom Pro for simplicity and functionality.

Every package will have settings that you should configure to your needs. For example, in Zoom, you can set defaults such as whether people are automatically muted when they join a meeting. Tutorials and guides for how to do configure settings are available online.

Hardware and connectivity

As the person delivering the session, you do not want to be let down by the tech on the day.  You need a device which is able to run the application smoothly.  Old or underpowered devices that let you down on the day need to be avoided.  You need to have a good broadband signal.  If you are using mobile data, you need a good signal.

The best way to make sure that it all works is to try out with the device you intend to use, in the place that you will be on the day, with the software that you will using.  Don’t assume that everything will work, make sure it will.

Time and Location

You should choose a time which is well protected.  You should have no other commitments that might encroach on the session.  You should be ready and set up about 30 minutes before the official start time so you need to build that into your schedule.

The space that you use for the session should be quiet and secure.  Think about what is in your background and aim to have nothing in view than yourself if possible.  Make sure that your lighting is in front of you and that you are not backlit.

The way that you intend to deliver the session will depend on the topic, the size of the audience and the teaching style.  A large audience lends itself to a webinar style.  A medium size group best suits a classroom style session and a small group session can be delivered more like a tutorial.

You should think about what resources and teaching aids you wish to use.  These are a really important part of your planning as they help with audience engagement. Many people will choose to use a PowerPoint presentation via the screen share facility in Zoom or Teams.  If you do use a PowerPoint, make sure that it is minimal.  The number of slides should be very few and the content very limited.  Remember that your audience may be viewing the session on a hand held device and thus wordy slides simply will not be easily readable.  If you have too many slides, this will lead you to talk too much and your audience will not be able to maintain interest.

There are a number of other ways to add dimensions and variety to your session.  Features within zoom and teams allow polling and breakout rooms (with zoom, breakout rooms is only available in the pro version).  It is also worth considering using external resources.

External resourcePossible uses
Mentimeter www.mentimeter.com Polling, Agenda setting, Idea sharing , Sharing learning outcomes
Fun Retro https://funretro.io/ Agenda setting, Idea sharing, Sharing learning outcomes
Google Docs https://drive.google.com Case studies, Handouts, Links


Using external resources is a great way of facilitating learning in a way that changes the pace and keeps the audience engaged.  For example, you could get your learners to go into a breakout room having first sent them a link to a google doc that has a case study and the tasks for that exercise.  You can also give them a link and code for the mentimeter that allows them to share what they think (virtual flipchart).  While they are in the breakout room, they are engaged in the learning in a different way and you get a few minutes to do whatever you need or want to do.

If you are using external resources, it is well worth putting together a list of links for your learners and sending these to your audience ahead of time.  Proactive learners will have those resources open and ready for the session.

If you deliver a really simple session, there is little risk that you will miss bits or find that elements get lost along the way.  If you have planned a more complicated session, giving yourself a visual aid-memoire in the form of a session map can be really useful.  Unless you are using a second device screen, you will need to have this on paper and placed just above your webcam for ease.  Even for simple sessions, having checklists can be really useful.  When you are thrown a curveball in an online session (someone having technical difficulties at the start) it can easily throw you and make you forget to do something essential such as introduce yourself.

You need to decide how you want your audience to be.  Will they have cameras on or off?  Will they be muted throughout and only use chat?  Will they be unmuting to speak and then muting themselves?  Will they be unmuted throughout because it’s a very small group?

It is essential that your learners know these parameters ahead of time.  If not you may find that they have assumed that they will be passive listeners and when you ask them to turn on video you see them five minutes later in a moderately damp dressing gown!

I would recommend that you send joining instructions which include the technical things like which platform and links will be needed, along with a few key bits of information such as the need to have video and audio for the session if that’s what you want.  You should ask if anyone has access or ability issues to let you know ahead of the session.

If your session is really high level, and particularly if you are doing complicated functions, consider having a second person supporting you.  This person does not have to be in the room with you but it does help if they are.  A second person can watch the session from another device and therefore sees what your audience sees.  They can therefore tell you when something isn’t going to plan.  The second person can also monitor chat, which can be difficult to do for the main facilitator when they are focused on delivering the session.

Rehearsal is really important.  You need to familiarise yourself with the software and by trying the different features, you will discover the potential glitches.  At the very least as preparation, have a meeting with friend or family using the platform that you intend to use and play with the different functions.

If your session is complicated or your audience is of high value in some way, you really want to run the whole session fully with a test audience.  This allows you to find out the time it takes and you are very likely to find that you need to crop something.  It also helps you to work out any practicalities that will make things run smoothly.

Setting up

Make sure that you are comfortable in every way.  Have some water available to drink.

Get everything set up and open the session before you expect people to join.  It is worth having a PowerPoint slide with some sort of greeting or session title so that people know that they are in the right place and that the video feed is working.  Your audience will also want to know that their audio is working.  A simple way of doing that is to play some music through your device and share that via the screen share function on the platform you are using.

You need to look at how you appear on video.  Check that you have optimal lighting.

Depending on the platform and settings that you have chosen, you may need to let people into the session.  If not, you can leave the session running and people can join and wait for the session to start.  If you have a second support person, brief them on what you want them to do.

About five minutes before the official start time, I recommend saying hello to your audience (so far) and letting them know that the session will start on time.  You can also remind them of any settings or preparation that they need to do.

Starting the session

At the beginning of the session it is important to cover some practical points.  Some of your audience may be unfamiliar with the software and despite having sent them specific instructions, people may not have read or understood these fully.

Things to tell your audience at the beginning of a session

  • Introduce yourself.
  • Tell people what you will be doing and how long the session will last.
  • Set ground rules as appropriate.
  • Tell people whether you want them to have video on or off.
  • Tell people how you want them to let you know when they have a question.  If you want them to use a “raise hand” function, tell them that you won’t always see their video feed so if they raise their hand on camera, you might not see that.
  • Explain any special functions that you want them to use.  That includes chat.
  • Tell your audience to let you know if something is wrong.

If you have any elements to your session other than your face and a PowerPoint, I find that it is good to start by giving the audience a low-level opportunity to practice using these features at the beginning so that they can try these out safely.  For example, if you plan to use breakout rooms with information on an online document and interactive software such as mentimeter you could do the following:

Explain these elements and ask them to open the menti.com site and the linked document.  The document could be instructions for a starter task such as “Find out what everyone wants to learn in this session” and the menti.com ideas board would be one where they will write their learning objectives for the session.  Then send them to breakout rooms to complete the task.

When they come back you can talk about their learning objectives but also deal with any user or technical difficulties encountered.

Even if you are delivering a bare-bones session, get your audience to use the simple features such as chat or hand raising right at the start.

The main event

Now go for it.  In order to be as effective as possible, you want to engage your audience and maintain their attention and enthusiasm.  There are lots of ways to help you achieve this.

  • Have your audience put their video feeds on. It can help you as a teacher to see people.  More importantly, it makes it less likely that they will be engaged in other tasks.  The classroom equivalent of an invisible online audience is a room full of people texting or checking emails while you talk.  
  • When your video feed is on, look at the webcam.  Eye contact is very important.  If you are looking anywhere else, your gaze is tangential which is subconsciously disengaging for your audience.  If you have a thumbnail of your own webcam feed on the screen, place this as close to the webcam as possible as your tendency will be to look at your own face much of the time.
  • Smile.
  • Be animated, including the use of hand gestures.
  • Use humour.
  • Limit the amount of time that you speak continually.  Even if you are going to continue speaking again, every few minutes ask the audience a question and leave time for them to think and answer.
  • Make your session about three quarters interactive in whatever way fits the modality.
  • Vary things as much as possible. You can switch from PowerPoint to webcam, then video.  Using interactive elements such as polling, breakout rooms or large group discussions are all possible ways to keep the session varied.

Managing the question and answer element

Q&A is one of the most basic yet effective means that is available for an educator to engage their audience and improve the depth of learning.  It helps the session facilitator to find the level needed for the teaching and meet the specific needs of the audience.  If you are delivering an online session with more than a few people, it is a very different experience from a face-to-face setting.

Q&A in a remote teaching session is often the element that requires the most management.  You should be prepared for the possibility that your audience has already become disengaged or distracted by other things.  It can be useful to give people a warning that a question is coming, “I hope you’re all paying close attention, because I’m going to ask you all a question in a moment.”  This might result in a few people putting away their phones (on which they were commenting on something on social media or answering an email) in time to be fully engaged when you need them to be interactive.

If your audience is muted when you ask a question, you can manage that in a number of ways.  Remember that regardless of audience size, it may be difficult to get your participants to answer, so encourage them as much as possible.

Method 1 – answer via chat

This is most likely to get responses as people won’t be worried about interrupting someone and they may feel safer in terms of constructing an answer when they can review and edit it before sending it.  The facilitator needs to allow enough time for people to do this, so don’t ask a question and assume that no-one is answering after a few seconds.

If you use chat as the means for answering questions, it can be a really good way of engaging people more if you invite individuals to expand their question verbally.  “Mohammed, you’ve put ‘what about POPs scores?’ in the chat.  Could you please unmute your mic and tell me what you’ve been told about POPs scores and how they are used?”

Method 2 – hand raising

Software such as Zoom allows participants to hit a button called “raise hand” which comes up as an alert to the host.  The facilitator can then invite that person to unmute their mic in order to ask their question.

Method 3 – Verbal free for all

Most platforms give the host the opportunity to unmute everyone’s microphones at once.  This can be used to create something closer to a classroom experience where people can just start talking.  There is a risk that more than one person will talk at once, which becomes greater with large groups.  There is also the risk that any background noise from other participants becomes audible.

It is worth trying different methods to see which works well.  Within any session, if you find that one method isn’t getting any or much response, you can see if a different method works better as all audiences are different.

Other Top Tips and Resources

Here’s a list of tips and tricks that may help:

  • Use headphones to avoid feedback and a microphone to reduce background noise.  A standard mobile phone microphone earpiece set works well.
  • If you have a second device logged into the same meeting in the same room, one of them must always be muted and have speakers off otherwise there will be an echo.
  • Remember that even when your video feed is off, people can hear you if you are not muted.
  • Remember to stop screen sharing when you have finished showing something to your audience.
  • Backgrounds are a fun way to inject humour into a session but you need to have a plain backdrop and there is a risk that it affects the applications function.
  • Your software may allow you to record the session which can then be used as a resource for you to review what went well and what could be improved.
  • Recordings of webinar or lecture-style sessions can be recorded and used as an educational resource.
  • Most conference software has multiple views to choose from.  Try using each view both in rehearsal and when delivering a session.
  • Each time you deliver a session, you will become more familiar with the technical and educational aspects of online learning.  Delivering the same session multiple times in a short period of time will help you to learn and improve.

DFTB are proud to share with you our first 15 remote education modules that you can pluck off the virtual shelf.

Finally, a short list of other resources that have explored the issue of becoming an effective educator in an online setting:

https://dontforgetthebubbles.com/teaching-virtually-anywhere/

https://www.aliem.com/teaching-age-covid19-real-time-video-conferencing/

https://icenetblog.royalcollege.ca/2020/03/17/teaching-remotely-in-response-to-covid-19-10-tips-to-improve-your-digital-classroom/

https://www.youtube.com/watch?v=HCK_1ydMhiE

COVID-19 + children – from leaders across Europe

Cite this article as:
Team DFTB. COVID-19 + children – from leaders across Europe, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.27021

From the European Academy of Paediatrics, Don’t Forget the Bubbles, and LOW

In April this year, the UN published a policy brief on the impact that COVID was having on children. It highlights key areas of concern, affecting the safety, education, and welfare of children around the world. In its conclusion, it calls for more information, more solidarity, and more action.

We, paediatric leaders from across Europe, urge European leaders and national governments to take urgent and unified action to follow that lead, helping to mitigate the risks identified, to ensure the best possible future for our most precious asset – our children.

The UN Convention of the Rights of the Child enshrined the principles that we should follow when making decisions about children and young people. In particular they state:

  • In all actions concerning children, the best interests of the child shall be a primary consideration (Article 3)
  • All children and young people have a voice and the right to participate in decisions that affect them (Article 12)
  • All children and young people should have access to information required to make informed decisions with respect to their health and well-being (Article 17).

We have addressed three areas of concern – PROTECTION, PLAY, and EDUCATION – where we believe intervention is most needed. For each area we have defined a number of specific issues, providing evidence of the problem, recommending what we believe should be done, and finally suggesting how progress might be measured.

Some evidence remains uncertain, nowhere more pertinent than in the simple questions about how susceptible and how contagious children are compared to adults. Trials of novel therapies need to include studies in children, as physiology and pharmacokinetics can vary substantially. Careful psychological studies need to assess the true impact of the disease on vulnerable groups.

Much research is needed, and that needs coordinated funding across Europe. Some analysis will take years before it can answer some of the key questions, and so the funding needs to be sustained. In this document however we look at the policies that need to be urgently put in place that will help define the questions and direct that research.


Protection

Vaccination rates have fallen during the pandemic with risk of infectious diseases increasing, vaccine delivery is compromised, the low levels of uptake before the pandemic multiply the risks that any further reduction in coverage has on outbreaks

We call for:

  • Pan-European cooperation on vaccine supply
  • Funding allocated to train health care providers to vaccinate
  • Active campaign across Europe to publish international vaccine strategies, to raise awareness about vaccines and to address vaccine hesitancy

What does success look like?

Increase of vaccine uptake on a European and worldwide level, with all European countries reaching measles free status.

The risk of death from COVID is extremely low in children. Isolation of households has increased the risk of violence and injury, presentation may be severe or late, Children with chronic disease may have suffered through this period. There is evidence of late presentation of medical emergencies to hospitals and routine surgery and clinic appointments have been postponed. Young carers have been exposed to greater risks during lockdown.

Depression and anxiety are more common, normal peer support groups are lost.  Those living in more violent households are more prone to depression. Other ‘guardians’ (teachers etc) are not seeing children with referral rates to protection agencies falling. Increased financial pressure on families may increase tensions.  For adolescents social distancing and lockdown can be especially difficult.

We call for:

  • Increased provision of psychological support for children (especially adolescents) and families
  • Funding for better training in recognition of family dysfunction from health care workers
  • Prioritised health care access for children with chronic conditions
  • Young people should be given power and leadership to decide for themselves how to make up for not being able to do these things in person.

What does success look like?

A reduction in the incidence and severity of abusive injuries
All children protected from harm, as set out in the UN Convention of the Rights of the Child
National registers of the incidence of neglect and emotional abuse
Reduced self-harm/suicide
Improved outcomes in chronic conditions

Financial impact of pandemic over a generation, loss of education and future employment possibilities (see below), vulnerable families (socio-economic, BAME, being in care, in youth justice systems) have fewer resources to cope with both with effects of illness and effects of lockdown; consequently all poor outcomes from the pandemic will affect them disproportionately. Deliberate exploitation (grooming, trafficking etc), including evidence of pamphlets showing how to target children during the pandemic.

We call for:

  • Poverty reduction targets in all countries for vulnerable children and poor families
  • A ‘child health in all policies’ approach to all policy development
  • Targeted resources for at risk families

What does success look like?

Improving social equality across Europe
Stable unemployment figures without increasing poverty


Play (and exercise)

Play is critical for early cognitive and social development, has been affected by COVID, and provides support networks for families, especially those in vulnerable groups. Obesity is likely to increase, social development affected.

We call for:

  • Improved education for families, encouraging explorative play
  • Focused funding for vulnerable families
  • Relax social distancing rules for children
  • Promote and facilitate exercise in children, with regular structured exercise at school
  • Increased provision of child friendly sport and leisure access

What does success look like?

Reducing levels of obesity
All schools open and functioning normally

Adolescents have distinct developmental needs compared to children and adults. They are very much invested in social connections and in separating from their parents. COVID social distancing requirements is particularly challenging for them.

We call for:

  • Involvement of young people in policy development
  • Specific policies developed for adolescents

What does success look like?

Direct involvement of adolescents and young adults in policy development.


Education

School closure affects families directly by requiring child care, and affecting the parents’ ability to work. It has a disproportionate effect on the underprivileged, including the loss of support such as free school meals. There is a significant effect on children regarding their well-being and (psychological) health due to the loss of interactions with peers.

We call for:

  • Open schools for all ages.
  • Support the development of internet access and online teaching resources
  • Training for teachers and parents to recognise psychological problems (mental health support teams)

What does success look like?

Optimal psychological, educational and health development of all children.

Many children do not work through lockdown and lose valuable education time. 11% European families have no access to the internet or to equipment and technology. There may be a long-term effect on children due to under-education and reduced opportunities for further education and training, with fewer job-possibilities, affecting low income families disproportionately.

We call for:

  • Provide resources and funding to allow catch up education
  • Ensure full internet coverage for all areas of Europe

What does success look like?

Full internet accessibility for children and schools

Young people lose daily structure and motivation for learning. Exam results are devalued. Motivation is reduced; loss of long-planned events such as graduation can be very depressive. Loss of daily structure affects their ability to schedule effectively, and work efficiently.

We call for:

  • Improve career guidance support in higher education establishments
  • Support with scheduling teaching and self-directed learning

What does success look like?

Increasing employment levels and job satisfaction


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Connecting Advanced Care Practitioners

Cite this article as:
Team DFTB. Connecting Advanced Care Practitioners, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.26520

Our last ACP teaching session was on Thursday 8th October 2020. It covered case-based discussion, head injuries that may not be head injuries, and neonatal emergencies. See the recording below.

Our ACP webinar series is an opportunity for Advanced Practitioners who see children to connect with each other and to share knowledge.The webinars are delivered by and aimed at ACPs from any background who would like to share and improve their knowledge about caring for children in acute settings. The sessions are free, and anyone is welcome to join. Each session will comprise three short talks followed by a panel discussion and time for questions. We will be covering clinical and non-clinical topics, from a range of presenters. We will hear from some experienced speakers, as well as giving less seasoned speakers the opportunity to have their voice heard. If you have an idea for a topic you’d like to present, or if there’s something you have a burning desire to find out more about, please get in touch.

October 2020 – case-based discussion, head injuries that may not be head injuries, and neonatal emergencies

July 2020 – antibiotics, lymph nodes, and team leading

Getting in to training – Australia / New Zealand

Cite this article as:
Claire Chandler. Getting in to training – Australia / New Zealand, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.26173

Finding and securing a training position is tough. Claire Chandler has done it. Whilst these lessons are related to the experience in Australia there are a lot of lessons that apply to any application.

Crucial things

  • Do your RESEARCH – Start with college websites then move to statewide training programs then to the specific hospitals and rotations. Different positions open, close and send offers at all different times of the year so it’s worth drawing up a little timeline.
  • Give yourself PLENTY OF TIME to write your application – some of the answers may be equally weighted with your CV – it’s worth investing your time here. Start prepping weeks out from the due date, not days.
  • PROOFREAD the application and your CV – or even better, get someone else to as well. Fresh eyes help.
  • Use your colleagues and consultants for support and ADVICE. Try seeking out trainees in their first few years of training as their knowledge of the application processes and requirements will be most helpful.
  • Only applicants get the job. Don’t psych yourself out. SEND IT.

If you know early that you want to do paediatrics

You can give yourself a head start by building your CV from medical school. Try to get as much contact with your proposed specialty as possible.

Check out what conferences are on and go to them! They’re inspiring, you will network with like-minded people and get valuable advice for the future. It can be expensive – but there are often early bird prices, student and junior doctor discounts, plus a few scholarships, particularly for rural students.

Consider getting involved in paediatric focused audits or research.

Leap into the fabulous worlds of Twitter and FOAMed. I cannot overemphasize how helpful it is in forming connections with health professionals from a huge variety of backgrounds, all over the world. If you are a bit nervous when introducing yourself to the superstars of paediatrics, it‘s a great help when you find out you are already Twitter friends.

Consider a postgraduate course like the Sydney Child Health Program.

What if you only decided on paeds more recently?

Hit the short courses! Find out what you could get to, including:

  • Paediatric Basic Program
  • APLS
  • Resus4kids
  • Neonatal Resus
  • Leadership courses
  • Teaching on the Run
  • US Guided Cannulation Workshops

Know the job

  • Read through the job description
  • Check you meet college and registration requirements
  • Research the hospital – its facilities, expertise, institutional values, geography.
  • Visit the physical location or check out their website. The extra effort of contacting or visiting the department in advance may be enough to score you an interview

Your resume

Your resume is your sales pitch. The key to getting your interview. You need to stand out but for the right reasons! You need to succinctly and clearly state why you should be given the job. Aim for an absolute maximum of 3 pages keeping all information relevant to the position.

Think about an opening statement that summarises who you are, why you want the job, and why the employer would want to employ you. Here’s an example of one of mine

I am a PGY4 doctor with the goal of becoming a General Paediatrician in rural and remote Australia. I have extensive experience working in Emergency and General Paediatrics in the Northern Territory. I have spent my extracurricular time building my skill set to be proficient in leadership and education and have completed my APLS, Paediatric Diploma, and Paediatric ICU Basic course. I have researched your hospital online and spoken to some Paediatricians in the department. I truly believe my enthusiasm, dedication, and intelligence would be an asset to your hospital. I have always wanted to improve the lives of kids out bush and see this position as the perfect way to start doing that. 

Formatting

  • Pay attention to the criteria: Is the institution dictating the format? If so you need to follow this.
  • Think about adding a small number of visual effects to help it stand out. You could make the title a colour or add a simple neutral coloured frame. Ensure that the font is large and simple.
  • Think about the order that you present information. It may be useful to put more pertinent information or experiences first rather than just presenting the lot in chronological order.
  • Number your pages. This will help make sure no pages go missing.
  • Edit your content to make sure it is all relevant. Highlight the most relevant parts – think larger or bold font to draw the employers’ eyes. You need to make this CV look like it has been specifically created for this particular position.
  • Let your personality shine through! Let the employers know you have a life outside of medicine and what makes you different from all the other applicants

Experience

  • Your relevant experience since you got your degree.
  • If there are any gaps it is best to explain them. The employer would rather know that you went on a gap year rather than assuming the worst i.e that you had your medical registration suspended for the year.
  • Think about what elements of your pre-medical life would make you more employable and why. Did you grow up in a rural location that would make you more suitable for a rural position? Did you do an elective rotation somewhere exciting? You’re looking for points of connection with the interviewers – things that will help you stand out from the other applicants.
  • Find experiences within your previous rotations that will demonstrate the attributes employees are looking for. Rostering, junior teaching and supervision, overnight decision making, neonatal resuscitation experience, paediatric cannulation and lumbar puncture experience, participation in education programs, junior doctor representation to hospital executive – all of these things help.
  • At high school did you do anything out of the ordinary? Include it.

Work history

  • What did your life look like before medicine? Think about what elements of those past jobs fits the application criteria or your chosen specialty
  • Medical: Here include any association with hospital, state, or national committees. Include any publications, research, courses, conference attendance, and presentation.
  • Non-medical: Hobbies, volunteer work, language skills (AUSLAN), IT systems.
  • SPELL CHECK!
  • Don’t undersell yourself. And don’t lie!

Referees

Think carefully about your referees. Ensure that they know you well, have worked in your most recent job, and, importantly, will give you a shining reference. Ideally pick someone who has given you end of rotation feedback, that way you have a very good idea of what they’re going to say to the prospective employers. Have a conversation with them and make sure that they too think you can do the job!

Send your referees your CV so that they have the same information that you are providing the employer. Finally, ensure you have the correct contact details for your referee.

Welcome to the jungle of copious links, PDF downloads, and painful IT systems. Check everything that is required and in what format with plenty of time to spare! A single wrong click in a box could exclude you from the entire process so read the instructions carefully.

In each application, you will be required to download various types of evidence. This will be very difficult if you decide to take an overseas holiday at the time as I did. It helps to have a cloud storage system or portable hard drive where you can keep:-

  • Proof of ID and medical registration
  • Scanned copies of medical and postgraduate degrees
  • Proof of immunization status
  • Certificates of attendance for courses or conferences
  • Statement of employment and rotations at past hospitals
  • Some applications will even ask the specific dates your past hospital rotations were and when you took leave!

Finally check the character count. A friend of mine typed 130-word replies only to find out it was 130 characters including spaces.

Find an experienced buddy to practice with you. Consider a formal interview where your dress up, have time limits etc. and record it then debrief.

  • Are you umming and ahhhing too much?
  • Do you sound confident?
  • Are you addressing the questions whilst also selling yourself?
  • Could you be more succinct?
  • How is your posture? Are you sitting straight, smiling, looking like someone you’d want to employ?

An approach to your answers

  • Ask yourself why the interview panel is asking the particular question? How does it relate to the position criteria?
  • If you don’t understand the question or can’t think of an appropriate answer, ask for the question to be reworded.
  • If you need some thinking time you could paraphrase the question or give a comment like “that’s an interesting question” or “Yes that’s a complex scenario, let me think about how I would approach it on the ward…

Keep you at the focus of the interview. How can you sell yourself in each answer?

Consider (and practice) the ‘STAR”  approach to structured question answering:

  • Prepare answers to some of the common questions so you can practice them.  Even if you don’t use the exact phrasing, it takes away the “I have to think of an example on the spot” part of the interview.  There are many questions that are SO common that it’s crazy to not have prepared.
  • Tell us about yourself
  • Why do you want this training position?
  • A time you made a mistake
  • How to deal with conflict
  • How to deal with a colleague that isn’t performing (showing up late, showing up drunk, not doing work etc.
  • A time you showed leadership
  • How you deal with a stressful situation

An approach to specific question types

Clinical questions

  • Use a structured approach to question answering. Don’t forget the basics of resuscitation and calling for senior help as required. DRABCDEFG, HoPC, relevant PMHx, pertinent exam findings, bedside investigations, initial treatment, more complex investigations, and treatment.
  • If you have absolutely no idea what to do, just go with a sensible approach. Resuscitate, seek help (hospital guidelines, online prescribing resources, senior nurse, and doctor assistance).
  • Know your limits. How comfortable are you dealing with this scenario? When will you seek support? Employers want to know that you are safe.

Conflict resolution

  • Employers are looking to see if you are respectful, a good listener, and will escalate concerns if it’s needed.

Communication

  • Employers are looking to see if you are a good communicator – empathetic, and sensible.
  • In regard to an under-performing colleague – do you know how to escalate concerns to senior colleges? Are you aware of mandatory reporting?

Weaknesses or mistakes

  • What did you learn from the mistake? How did you address your shortfalls?
  • Try and pick a simple error and potentially one with a happy ending. It helps to have thought of one or two in advance.

Do you have any questions?

  • Prepare a question that sells yourself. Here are some examples
Whilst speaking to one of the other registrars I found out that you run simulation training. I have experience in running simulations and am eager to be involved in your program. Who can I talk to about this?

I heard a presentation about your research program by Dr X at the DFTB19 conference I was moderating at. Are there any similar research programs that I could be involved with?

What will you do if you don’t get this job?

  • Employers are sussing out if you cope with failure? Do you have a plan B? Does this job actually mean anything to you? Will you be upset?

  • Get plenty of sleep the night before and ensure your phone is charged.
  • Ensure you know where to be and when. Have the contact details of the interviewer on hand in case you get lost.
  • Put some effort in to your appearance. If you have a suit, wear it.  No one will ever judge you for being too formal, but they will definitely judge you for being to casual. Don’t be afraid of a little splash of colour or fun – after all this is paediatrics.
  • Arrive at the hospital with plenty of time to find the interview room. Don’t be late.
  • Don’t forget to be kind and confident with everyone you meet on the day – you never know who will be watching.
  • Consider a mindfulness meditation.

In the interview

  • Try to exude confidence. Fake it till you make it.
  • You are likely to be surging with adrenaline. Take a breath and reflect on the question asked. Start with a smile.
  • After you’ve answered the question take a deep breath. See if the interviews have any questions for you. If there is silence you can add some additional detail.
  • Observe your interviewers and be aware of the cues they are giving.
  • If you tank a question, try to move on with a light heart – you’ll be showing the interviewers you can pull yourself together when things are tough.
  • Smile at the panel before you leave, say thank you.

This wait can feel excruciating at times. Ensure you are looking after yourself mentally and physically and have a buddy to support you. I don’t think I talked to one person who felt 100% confident with their performance in the application process so please don’t worry if you are suffering from low confidence or imposter syndrome.

If you got the job – WOOHOO! Get your paperwork done quickly and completely. Start off on the good side of the administrators. You’re likely to need to provide police checks, immunization status, copies of your graduation certificate, AHPRA registration, and some proof of identification. Some of this may need to be signed copies by a JP.

And if you didn’t get the job

This may not be the end. You may be in the running for some 2 and 3 round offers for various sites. Seek feedback from the employer. They will often be able to tell you where your short fallings were or how the other candidates outshone you. Use this information to build a better application or do a better interview next time.

Virtual simulation

Cite this article as:
Nick Peres + Tim Mason. Virtual simulation, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.26002

What do you think of when you hear the words Virtual Sim? If your mind goes to Neo (Editors note: Keanu was actually quite good in the first Matrix- feel free to argue) then we are of like mind. If you think of the stereotypes of mainstream media, you will likely think Ready Player One, Tron, or even Lawnmower Man!

COVID-19 has changed our world with “socially close” teaching universally banned. Simulation is no different and I, for one, miss it! We know sim has its benefits, in situ, and for hands-on practice. Can we get back to that reflective learning we know and love?

Medical simulation is a tactile, experiential teaching modality, however, as sim trainers, we are often told “the learning is in the debrief”. This leaves us to beg the question – can we re-create or port something like a debriefing session virtually? And if so, should we be pausing activity in our sim centres and giving all trainees a VR headset?

 

 Looking at the realm of Twitter and our practical experience, how have people tried to bridge this gap? What’s out there?

Remote sim

Passive: Watching a live simulation session streamed to a video conferencing application via the sim centre camera(s) (or mobile) whilst a team perform the sim. This is then followed by a facilitated debrief taking place remotely, again utilising a video conference platform.

Interactive: A simulation takes place but there may be some interactivity with a confederate in the room being directed via video by a learner as a team lead. The debrief then follows on the video conferencing platform. Pre-recorded video can be repeated as appropriate.

 

A quick note on cameras

We are investigating the types of camera that best convey a remote simulation scenario. These include fixed-angle cameras (such as utilising those cameras already within a simulation suite), handheld or accessible cameras, such as a body-worn GoPro or even utilising a 360-degree camera, which can then be explored by participants or debriefer using their mouse to navigate the 360 recorded space.


 

The advantage of the passive approach is that we do get to be involved in the process, however, there may only be one or two fixed-view cameras impacting on your impression of the scenario. It may recreate some of the visceral feelings we get in a resus but you are still physically and psychologically removed. The alternate scenario adds an element of interactivity but the action in the room won’t reflect reality as it won’t directly represent the real team. Both measures will need clear learning objectives that fit these new methods. One interesting thought is if this actually represents the way senior doctors view their department and “direct” their juniors remotely without the need to physically be present (i.e. overnight on calls)?

Others have tried methods such as Telesimbox where a video is played whilst a facilitator guides the learners (over video) through a pre-set scenario.

Other paid-for services include app-based 360° films which may have a degree of interactivity or higher-tech solutions using headsets.

 

360° Sim

We’ve been doing something a little bit different which is 360° Virtual sim. 360° video is filmed using a fancy camera that can record all the way around it with two fisheye lenses. The camera then stitches together the images into a sphere which you can then look around by swiping the screen on a tablet or moving your head around a VR headset. 360° video has been used as a debriefing tool in itself with some success. Medical students found it gave them a deeper appreciation of their communication skills during the simulation.

Two years ago I was helping run a Return to Paediatric Training Sim course in the south-west, We didn’t have any time to add in resus but felt that it was an area people worry about. With the expert help of Nick of the Torbay VR team, we made a Neonatal Life Support (NLS) and an Advanced Paediatric Life Support (APLS) simulation utilizing  360° video which participants could access at home. The learners on the course loved it, though some felt it was stressful or uncomfortable, The sights and sounds of the room meant everything soon felt familiar. For others, it inspired them or put them back in the zone.

 

When the world became socially distant, it gave us the opportunity to debrief these videos over a video conferencing platform. Using 360° videos, the viewer becomes an active observer right in the centre of the action.  Although they can’t truly interact with the scene, they are still placed in media res. This really helps to bring about discussion of non-technical skills, with associated feelings and humanistic considerations, in the debrief.

If you have content that is created and shared with you to use, it then essentially becomes an accessible and free setup with no need for manikins, faculty, or dealing with the frustrating lack of parking spaces. Here’s an example of a 360° sepsis sim we ran and debriefed remotely.

 

There is also the potential to teach larger groups than what would normally be run through an in-person simulation session.  

 

Making your own 360° content

  • Write your simulation with learning objectives appropriate to your learners – think, medical, technical and non-technical.
  • Think about which scenarios work. Emergencies with lots of different teams to follow may be fun, but think about the difficult communication scenarios (safeguarding, breaking bad news) as it may be a safe way to sharpen communication skills.
  • A 360° camera (roughly £400) and stand (grip/ microphone stand).
  • A computer capable of editing (it needs a good graphics card)
  • When filming, position your camera at eye height in the centre of the action (hanging from the curtain rail is good).
  • Take away all patient identifying info if in situ (the camera sees all).
  • Think if you are going to tell the sim participants the theme of the sim. It adds to psychological safety but you may not get the authentic simulation experience.
  • Film it again if things go wrong as it is harder to edit afterwards.
  • Editing- steep-ish learning curve but simple things can be done easily in free packages.

 

Running your remote or 360° virtual Sim teaching session

  • Planning is key- time and place are less of an issue but think of your learners. How is the session going to meet their learning needs? Is there something particular that you are going to focus on?
  • Pick your video conferencing application of choice – we all have our favourite/ the one our trust allows us to use. Are you sharing your screen? Are you using sim centre cameras or mobile phones?
  • Practice using the kit/ technology before you do it live – not once but a good few times.
  • Solid Pre brief/ ground rules for the session are important.
  • Beware of “Zoom Fatigue”- try not to run a session longer than 1 hour. Most of ours have been 45 minutes at most.
  • Is the Wifi good enough? Will the videos cut out?
  • During the sim think about allowing learners/ observers to type thoughts and feeling that come to mind that you can then cover in the debrief.

 

Some thoughts on the virtual debrief

In a study looking at debriefing after medical serious games, in-person and virtual debrief both rated highly (self was the lowest). Remote debriefing has been used to train teams and faculty  in countries that do not have access to resources or experience in simulation.

 Make sure someone is designated to lead the debrief. Use the standard sim structure- Defusing, Discovery and Deepening. This model is based on Kolb’s experiential learning theory. This has made its way into many different models including Diamond, Pearls and ITRUST.

Who’s watching the watchmen? We’ve had more consultants during our sessions than the usual weekly sim. This changes the dynamic of the discussion. It skipped the medicine and went straight to the communication and processes seen. This may not be a positive for the junior members who needed experiential medical learning.  If using pre-recorded 360° content that is not live make sure you make it personal exploring real-life experiences. Has anyone seen this before? How does this work in your ward? Where’s the protocol kept?

As with all forms of online facilitated tuition, it is important to set the ground rules at the offset. Do you have learners muted? This will depend on the numbers in the debrief considering microphone echo verus silence.  You may need to use a signal to talk (i.e. Zoom thumbs up!). Everyone should keep their cameras on so you can see everyone and try to “read the room” keeping all involved.

So what might the future hold? It may be live streaming 360° content (which a lot of 360 cameras can do), a virtual space we can easily watch 360° video together, or Mozilla hubs where our avatars we can meet to watch content together. I don’t see this a replacement for regular simulation. It is an adjunct, a complimentary tool for the SBE toolkit.le.

The power (and pain) of the EMR

Cite this article as:
Henry Goldstein. The power (and pain) of the EMR, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22306

My earliest years as a medical student and doctor were in a paper-based system, and over the last decade, I’ve been involved with a sequential introduction towards full EMR. For the last 16 months, I’ve had almost no use for a pen in my daily work. At the same time, the dynamics of medicine – and inpatient ward rounds, in particular – have changed.  How much of this change is just ‘societal’ or ‘generational’, and how much of it is due to the changing technology we use in our work?

 

(Editor’s note: This post was written before COVID-19. We’d love to hear of its impact on your use of technology)

I asked Twitter, and received some thought-provoking concepts, in addition to some things I’ve been observing over the last several years.

The more I thought things through, the changes occurred at many levels of the system, and I’ll try to dig into some of these changes within each part of our system.

 

Physicality

WoWs (Workstations on Wheels) are large and can be quite physically awkward to maneuver into a room or bed space whilst positioning the thing suitably to enter information, view the consult, make eye-contact with both patient & the doctor leading the review and still remaining socially acceptable. And, for that training doctor – they’re often looking at the screen instead of the clinical interaction. I’ve seen and heard of trainees writing notes from behind the curtain!

One hospital I’ve worked used, albeit infrequently, tablet computers in addition to the standard WoW. This provided a point of offset for results but was unsurprisingly unhelpful when it came to imaging or any data entry. I continue to advocate for their usage.

 

The challenge of wrangling a computer into the interaction with you patient is obvious, and with some strategies the affect can be reduced. But there’s more to the screen than doctor-patient blockade; the physicality of multiple handheld inputs (ie paper chart and bedside chart) usually meant that during a ward round there was some standing, well, around. Specifically, before entering a bed space, or in discussions afterwards, we stood in circles and looked at each other and listened.

Mobile computing requires that we stand side by side. This is either in order to read the screen, or because the computer is human-high, and we can’t pragmatically form a circle around it!

I think there’s something inherently powerful in this change – we no longer engage in routine confrontation. Standing in a circle means that you’re always opposite someone. The body dynamics are oppositional.

I acknowledge that these situations could, on occasion, be used negatively, but by the same token, standing opposite another human is not, in itself, shaming or humiliating. But these circles were the perfect opportunity to acknowledge all members of the team, to teach to level, to have a discussion. Micro-confrontations as a mode of education, learning, and accountability. Instead, mobile computing changes the dynamic – we stand next to each other, make eye contact less frequently, and can nod along to the words of the most powerful person in the group.

 

Because we are conflict and confrontation avoidant, and the text is there for all to see, we have nullified the ‘need’ to present a patient. Instead, we perch on one another’s elbows and read together.

Read what?! What does each doctor consider important? How do we know? What’s the framing? This is part of clinical reasoning. When we read in silence without the brief “Yes-no” questions like “Was there a trial of salbutamo?” or “Are they immunized?”, much more is lost in the thinking, learning and engagement of the ward round.

 

Infection control and accessibility of WoWs are inherently in tension. This was played out with medical charts not entering the bed space and the need to physically either put the notes into the chart afterwards or write on the move to the next patient.

The same pattern occurs with WoWs exists; either the machine is (appropriately) left outside the room and catching up occurs afterward, or if there’s a computer that remains at the patients’ bedside, then the operator must log in, invoking the Latency issue.

I have on occasion witnessed a mobile computer being wiped down, and not just because one of us has tipped over a cup of coffee! Folks, remember your 5 moments for hand hygiene!

 

But what other aspects of physicality of having a workstation the size of a small person on the round?

Rightly or wrongly, operating the mobile computer frequently falls to the most junior member of the team. Under a diffused system with multiple devices, or the classical paper charts for vital signs, medication charts and so on, much of the pressure was relieved from the person actually writing the notes.

Instead, a single operator system means that – latency notwithstanding – the rate-limiting step to all information and all documentation is through the same person. This can become quite stressful, quite quickly, and if not considered can exacerbate the load for junior staff.

 

Proximity

Sharing information via the same screen can lead to people almost standing on top of each other. Wanting to read the screen leads means that in the clamor to see, personal space is quickly eroded. My practice is now to show new staff how to MAKE THE TEXT BIGGER, so that I can see the information from a distance without the feeling of standing too close to their shoulder, especially as a male in a senior role.

Conversely, and also as a consequence of mobile computing, we spend less time in the immediate physical presence of our nursing and other medical colleagues. Proximity is part of forging a small professional community. It’s part of being in a team and if you spend your entire day behind shelves and screens rather than openly and effectively communicating with colleagues, well, I hope that’s not what being a doctor is.

 

Latency

When tech is slow, it can feel as though the entire ward round is covered in treacle. Time begins to stand still in response to simple questions. The clinicians believe the answer is contained in the machine, yet the machine is too stuttering, slow or confused to provide the information you need. Where and how you vent this frustration? Do your patients sense it? Do you look or feel incompetent? Almost all of the above pose a threat to professionalism.

 

Notes 

Copy+ paste digital vs analog. There’s something engaging with re-copying, by hand, text. That’s why monks spent many an hour laboriously lettering pages of Latin text. Many of us have even studied this way throughout our academic careers. The essential thoughts and actions required to process and idea leave, I suppose, a beautiful residual trace in our memories. We have the chance to identify and fix errors, lest we are blamed for recreating them with our own hand. Digital copy+paste is the opposite. It is unthinking, impersonal, disengaged. It can compound & perpetuate errors.

Diagrams and patient drawings were a feature of paper charts. A surgical note here or the old favourite of lungs and abdomen sketched side by side. In paediatrics, the ease of giving a child a page of clinical notes on which to draw has evaporated.

Demonstrate your reasoning. Clinical reasoning and the context in which we make decisions is what medicine is about. Whilst both EMR and written notes can use full sentences to articulate thinking, I have memories of marginalia, small diagrams, relational arrows of all different shapes, intensities, and directions. Variable intensities or shapes encircling words for emphasis help frame or direct clinical thinking that transcends written language as we know it. I miss seeing this in the work of others.

There is a litany of nuances in note-taking that are subsumed by electronic records. But I’ve never seen illegible or dangerous lookalike terms in the EMR; they’re always surrounded by logical context, be that medication chart or notes proper.

 

Boundaries 

Finally, mobile computing is a serious threat to professional boundaries. Many of us have work-related apps and email on our own devices. Beyond this, remote access to clinical information is growing. Ironically – and as I highlighted in this post  – we’ve all worked on MET teams. We know what critically urgent looks like, and yet, we are challenged by the need to step away from our work.

Mobile computing encourages us to just log in to find out how the patient went overnight, instead of reading the back of a cereal box or whatever you do in the morning. Likewise, reviewing results late at night – or whilst out to dinner – is a boundary failure.

We need to be better at defining the way we use our tech. Whilst at ACAH19, I thought of this framework: 

Using this diagram helps us to understand why it’s okay (awesome!!) to review the program for #DFTB20 during a loo break, but definitely not okay to reply to a parents’ email about their child’s asthma whilst in the toilet cubicle.

Here’s the larger point: We need to practice small scale, low risk confrontational clinical communication so that when we need to have big discussions, our discomfort is around the clinical challenge, not the awkwardness of professional communication.

 

In summary, mobile computing has profoundly changed the way we work. Everything from satisfying our impulses to know what is happening with a patient, to how we demonstrate clinical reasoning, to how we interact with each other & patients. I’m not saying it’s all good, nor all bad. Only that we must remain mindful and develop insight into how these changes influence our practice, our thinking and our relationship to patients and families.

I’m grateful to be able to work with some sophisticated, reliable technology on a daily basis. I want that tech to be able to bring out the best in doctors and medical care.

 

What kind of mobile computing does your hospital use? How does it improve care? How does it change it?

 

Culture Cataclysm in modern medicine: Helen Bevan at DFTB19

Cite this article as:
Team DFTB. Culture Cataclysm in modern medicine: Helen Bevan at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22588
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Helen Bevan is the Director of Service Transformation for the National Health Service Institute for Innovation and Improvement. The NHS is one of the biggest employers in the world. When it was established in 1948 the average life expectancy for men was 66 and 71 for women. As science has advanced and the population becomes more medically complex so the challenges of meeting increased demand have become more apparent.

As Chief Change Office Helen talks about the clash between old and new power and the ability of super-connectors to drive change.

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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COVID anxiety

Cite this article as:
Ana Waddington. COVID anxiety, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24478

Working in healthcare is never easy, but working through the COVID-19 pandemic takes all the usual stresses, strains, and anxieties, and amplifies them by a factor of ten.

The mood in my A&E department is very emotional. Above all, we’re worried about the impact of the coming (or already arrived) tsunami of COVID-19 patients, which feels like it’s been looming for months now. But we’re also affected by the uncertainty and the deferral of plans and hopes which had been the only things keeping us going in the ever-strained atmosphere of A&E. Two weeks ago, a nurse I’d never met before broke down in the changing room, after having a much-needed break canceled by an airline. “I really needed this holiday”, she said. “I’ve been saving up for a whole year”. All I could do was hug her, which didn’t feel like enough. Our most used methods of coping have been stripped from us, and we’re having to find different ways to manage.

Many people are worried about spreading the virus to others, and these fears are particularly acute for healthcare workers. A friend texted me to say that she’s so scared that she will kill people in her household. She’s constantly disinfecting surfaces and feels like she spends most of her free time cleaning. And she’s not the only one – I’m not looking forward to receiving my next water bill, given the amount of time I now spend washing my clothes and showering. There’s also the feeling that we should be constantly working, permanently manning the barricades. A colleague told me she feels “helpless” on her days off: she wants to come into the hospital to support. I feel the same way, but I know, if I’m able to think clearly about it, that preserving myself and taking the time to recharge is more important. We can’t afford to burn ourselves out. I’ve just canceled my bank shifts.

 

One positive thing that I hope comes out of this is a tightening of the bonds of solidarity that hold the NHS workforce together. Watching how the entire workforce is uniting to help patients during this time is inspiring. Every time I walk through our ‘clean area’ and see groups of people gathered together, teaching one another new skills, reminds me how much we are doing to ensure we are prepared for what is to come – or what has already come, depending on when you read this.

 

I’ve written in the past about the issue of night shift anxiety, and the sense of isolation and disconnect from the wider society that comes with working nights. Over the past few weeks, I’ve found these feelings are more acute than ever. And it’s not just night shifts that are causing this: as healthcare workers, we are now living totally different lives to most. The patterns of working life continue as normal for us, even as the world around us dramatically alters. The experience is jarring: it feels like I’m living in a different timezone to everybody else, or like I’m a ghost of the world we inhabited a couple of weeks ago. Some colleagues have even said that they feel guilty that they get to go to work, and that we should consider ourselves lucky that we’re able to get out of the house. And they’re right to an extent, we are lucky to be able to see our colleagues and friends face-to-face – but it’s small consolation for having to face this pandemic as frontline staff.

 

I have struggled with my own rollercoaster of emotions. Some of my non-healthcare friends haven’t been taking the precautions they should, insisting they have nothing to worry about. I know that I should be more understanding – the advice provided by the government has been confusing and ambiguous, so it’s no wonder that people have different opinions on what’s appropriate – but I find it hard to understand their mindset. A friend of mine feels the same way: “my ability to cope with other [non-NHS] people’s emotions is low”, she tells me, adding: “I feel extremely guilty about this”. For healthcare workers at present, it feels a bit like the world is a Rorschach test, and we’re seeing and experiencing things differently to everybody else.

 

Nevertheless, the generosity of others is extremely precious in these times – the organized clap last Thursday moved me to tears. But I feel guilty receiving such kindness: I don’t feel like I’ve earned it yet. The worst, we are constantly being told, is yet to come. The looming doom is hard to handle. Colleagues are also concerned that we’re letting our normal responsibilities slide, forgetting about our other duties as nurses and doctors. “What happens to everyone who doesn’t have COVID?”, a colleague asks, “I’m worried about all the social cases that are being missed”.

 

We also know that, as healthcare professionals, we’ll have to make difficult decisions that we haven’t had to make before. Horror stories from Italy, or from our own ITU wards, are spreading across hospitals. As recently discussed in the New York Times, we may be forced to take actions that go against our moral judgment, such as breaking bad news without present family or making agonizing calls on access to ventilators. As a result, we run the risk of ‘moral injury’ – harm to the conscience due to being forced to violate our own moral values. The kinds of decisions we’ll have to make are similar to those faced by soldiers/aid workers in warzones, and there are likely to be cases of post-traumatic stress when this is all over. I’m already all too aware of such scenarios playing out – just yesterday, faced with an adult COVID-19 patient crying because she was too scared to die alone, I could only smile behind my facemask and offer her a gloved hand to calm her down: giving her a hug was not an option, even though it felt like the right thing to do.

 

What can we do to keep ourselves functioning and healthy in these trying times? Many of the normal tricks, used to confront the usual anxieties associated with healthcare work, can’t be applied to COVID-related anxiety. Eating well, for instance: it’s hard to do when the only dried food left in the shop when you finish your shift is bulgur wheat. Seeing friends in anything but a virtual context is ruled out for now. And suddenly every film you watch has an unexpected pandemic-related subtext.

 

My sister Dr. Emma Waddington, a clinical psychologist, says that teaching your mind not to become preoccupied with “wandering” thoughts is important. She recommends making a concerted effort not to focus on the negatives, absences, and perceived failings: not to let your mind drift to the things you aren’t doing, the social bonds you aren’t able to maintain, the news and information you aren’t keeping up with. Instead, try to focus on what you are doing, which is, as she and many others insist, amazing. She has a simple message which she wants us to keep in mind: “You are doing enough. You are enough.

Of course, focusing on our achievements and positive contribution to the fight against COVID-19 is easier said than done. One mechanism that Emma recommends to help with this is “thought stopping techniques”. These techniques help us to “pause, reappraise, and reframe”, to stop our minds becoming preoccupied with negative thoughts.

 

At work, finding new methods of coping has become key. We now cover our faces with masks and mostly work in cubicles on our own. Ensuring we take time to ask each other if we are okay is crucial. With expressions obscured by masks, it’s become a vital new healthcare skill to be able to tell what emotions people are going through solely by looking at their eyes. I’ve found out that no one can tell if I am smiling or not, I’m trying to achieve more expressions with my eyebrows now. Checking up on each other has been really important, and I’m particularly enjoying the new ways of being affectionate at work – elbow tap here, toe tap there.

 

With the help of friends and colleagues, I’ve added a few other techniques to the toolkit I’m using to help deal with COVID-19 anxiety. Firstly, I’ve bought an alarm clock so that when I go to sleep, I can leave my phone in a different room. That way I’m more fully disconnected from the world when I’m resting, and less tempted to catch up on things if I wake up in the middle of the night. And when I do get up, I don’t open my eyes to a bombardment of push-up notifications, emails, and frenzied messages. Secondly, I make sure I do some form of exercise once a day – even if this means following a pre-recorded boxing class via a choppy video stream. And finally, I make sure to properly relax during my time off by penciling in some time for indulging in my greatest passion (besides nursing): sprawling on the sofa and watching rubbish TV. Just make sure that the new Netflix series doesn’t have a pandemic-related sub-plot before you get stuck into it.

For some extra resources:

Watch out Clinician Care webinar

Managing mental health injury during pandemic

Podcast on moral injury

Good Netflix binges (not sponsored) that aren’t pandemic related:

  • Stranger things
  • The Stranger
  • Sinner
  • Sex education
  • Good girls
  • Frankie and grace
  • Working moms
  • The Fyre festival
  • Russian Doll
  • Ozark
  • Call the midwife

Good Instagram workouts

  • kobox
  • The jab
  • Melissawoodhealth
  • Joewicks