The good old days

Cite this article as:
Andrew Tagg. The good old days, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11095

As I introduced the latest batch of interns to the department I thought back to my first few days as a doctor and how I have changed. I qualified in 1997 and I still remember lots of things about my first year. I remember the fear of being on-call, the physical and mental exhaustion that would result in me falling asleep on the toilet, and I remember the colleagues that helped me through it.

Never enough hours in the day

Cite this article as:
Andrew Tagg. Never enough hours in the day, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10228

How do you do it? How do you keep up with all this blogging, tweeting and writing whilst holding a job and keeping your family happy?” It’s a question I invariably get asked when I speak about the use of social media in medical education.  I can talk about podcasts, and keeping up to date with the literature and there will always be a voice of dissention that wants to know “How?

Ring-xiety and how to unplug

Cite this article as:
Henry Goldstein. Ring-xiety and how to unplug, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10236

Ever felt your phone buzz in your pocket, only to find it hadn’t? Do you have #FOMO when it comes to the latest @ketaminh tweet, an @EMTogether podcast, or even the latest DFTB post in your inbox (yep, you can subscribe)?

I bought my first smart-phone two days before I graduated Med School (and certainly my patients are almost exclusively younger than the iPod (15 years!)), and the device has been omniscient throughout my clinical practice. Unsurprisingly, I have at times become overly attached to my ‘screens’, be they phone, tablet, laptop or desktop. (I ditched my pager long ago.)

This post confronts some of the challenges of how to ameliorate or obliterate your technophilia and how to combat the distraction of hyper-connectivity. It offers some pragmatic ways to reduce the influence of the devices, social media and the internet intruding into your thought space.

Firstly, I challenge you to think about the relationship you have with your device. Where is it now? Are you using it to read this?  Perhaps as you stroll down one of Antwerp’s mobile phone lanes ? (Perhaps you’re doing an ‘internet poo’!)  Is it your pocket? Out in your eyeline? Chances are if you’re not using it, it’s within reach.

I would speculate that in the medical profession, we succumb to the idea of keeping our phones close as part of the ‘emergency delusion’. In truth, MET buzzers, Cat 1 Caesarian pages, Bat-phone calls and their ilk are NOT coming through on our mobile. And, unless you are on call for a resus area, or retrieval service, it is entirely possible to discount the notion that the buzz in your pocket is a life-threatening medical emergency.

Other reasons we are so attached to our phones might include ringxiety, FOMO or as a nervous habit, perhaps it’s just something to do with your hands. We might even postulate that many people use their phones as what our psychiatric colleagues call a “transitional object”; much like a toddler’s thumb, teddy or blanket. Consider Winnicott’s seminal 1953 summary of the special relationship of the “transitional object” 

Summary of Special Qualities in the Relationship

  • The infant assumes rights over the object, and we agree to this assumption. Nevertheless some abrogation of omnipotence is a feature from the start.
  • The object is affectionately cuddled as well as excitedly loved and mutilated.
  • It must never change, unless changed by the infant.
  • It must survive instinctual loving, and also hating, and, if it be a feature, pure aggression.
  • Yet it must seem to the infant to give warmth, or to move, or to have texture, or to do something that seems to show it has vitality or reality of its own.
  • Its fate is to be gradually allowed to be decathected, so that in the course of years it becomes not so much forgotten as relegated to limbo. By this I mean that in health the transitional object does not ‘go inside’ nor does the feeling about it necessarily undergo repression. It is not forgotten and it is not mourned. It loses meaning, and this is because the transitional phenomena have become diffused, have become spread out over the whole intermediate territory between ‘inner psychic reality’ and ‘the external world as perceived by two persons in common’, that is to say, over the whole cultural field.

If you’ve made it this far, I suspect you’re somewhere at or beyond the contemplation phase of behaviour change (turns out it’s not just for quitting cigarettes!)

stages-of-change

At work,

Mobiles can really muck with our work; they divert our attention from the patient in front of us with a mere (and often phantom) vibration, they cause awkward pauses as we “just finish the text” before talking to a colleague and occupy our wandering minds in a packed clinical handover room. Not to mention distracting us on the drive home or during another death by powerpoint teaching session.

A common rebuttal to the use of smartphones in the medical setting is that they have a wealth of information at your fingertips. I have no dispute with this fact; but other than a calculator, a stopwatch and Shann’s Drug dosing, I’m yet to come across an app that has genuinely, in the moment, augmented my clinical practice.

If you do the kind of work which involves serious conversations or giving bad news to people on what could be the worst day of their life, practice turning your phone off or giving it to a colleague.

Mobile phones are sometimes prohibited in the NICU environment for their hypothesised risk as a bacterial vector, however, a 2014 study by Mark et al identified no pathogenic bacteria in swabs from 50 phones from the members of a surgical unit in Belfast. 

What about away from work? It’s important to consider the influence of shift work and the sleep-wake cycle; we live on a 25-hour planet when you consider New Zealand (GMT -11) vs American Samoa (GMT+13)!

As the sun rises and sets in different parts of the world, different sectors of the social media landscape ebb and hum. When it comes to devices, and mobiles phones in particular, consider the negative aspects of device usage at particular times of the day.

During the daytime, our phones can distract us from the task at hand, including real-time person to person communication and being present in the world around us. At night, devices can stop us from sleeping.

On the run,

Exercising without your device can sometimes be a challenge, particularly if you like music or run/ride/?ski more than five minutes from home. The tradeoff can be listening to birdsong, traffic noises or the gym’s choice of playlist. Besides, would you answer your mobile phone on a bicycle? Listening to a plain-old music player allows space from the threatened buzz of the cell phone whilst working out.

At night,

Sleep hygiene is essential in the medical profession. There are many components of this including having a dark room, minimal caffeine in the six hours before bedtime, a sleep routine et cetera. Some of the device related parts of this are to keep (charge) your phone away from the bedside, preferably out of the bedroom. This distance also slows the instinctive email-check as a soon as your eyes open. Remember, you can always buy an alarm clock!

Many of the tips offered to teenagers can help too, such as no phones at the dinner table. Some households have a Wifi bed time and a mobile phone bowl. That means there’s no chance of pottering around on Reddit after the appointed “electronic lights out”.

Productivity,

Use the right screen for the right task, and get rid of the others; if you’re trying to dictate a letter, write a paper or plan a talk, your mobile phone probably isn’t the ideal instrument for this. Make the most of ‘clean screen’ apps, such as good-old word processors, Grammarly, or Drafts, and if you’re really trying to unplug, you can always use pen and paper!

 

The overall message for this part is to eliminate the unnecessary & non-beneficial intrusions of your mobile into your life. In particular, I’d say this applies to holidays and night time. In his book “The 4-hour Work Week”, Tim Ferris dedicates a large component to the ‘elimination phase’ of information overload. Sometimes, one of the best things we can do is take an actual, wifi-less, internet-free holiday without any phone service.

Device tips

 If you must have your device in your pocket or nearby, try some of the following;

Do Not Disturb – most smartphones can be set to “Do not disturb” mode, which automatically silences all calls, messages & notifications between the prescribed hours. If you’re worried about emergencies, two calls from the same number within a few minutes will override the silence function. I only turn this off when I’m on call.

Night Mode – is another form of blue-blocker, which reportedly helps you regulate your circadian rhythms; this can be set as automatic on the iPhone. Kristin Boyle via Life in the Fast Lane reviews some other methods for this in the shift work environment here.

Notifications can be turned off on an individual app basis. From a stimulus – response point of view, less is likely more. That is, only calls and messages elicit any sounds. You can also reduce banner-style interruptions to zero both locked and unlocked, as well as stopping individual apps from showing the number of badges/notifications awaiting your limited attention.

The challenge here is to make the phone a thoroughly uninteresting proposition for procrastination / distraction. Consequently, if one gets to the stage of dragging the phone out of the pocket, it’s on your chosen schedule, not exclusively as a reaction to ongoing noises or buzzing.

Next, aim for no banners/notifications on your lock screen (these can be turned off, as above), so once you look, you know the time, date and perhaps glance at that photo of your loved ones or favourite motivational quote, before returning the phone to pocket, bag or table.

img_5213

After an accidental but compulsive unlocking of the phone in a weaker moment, aim to see no badges ( “Ooh, shiny!”) or things to attend to. Continue to open your particular app of choice, until…

img_6915

Freedom is an app that blocks part or all of the internet. You can set particular periods, and with a subscription, you can schedule repeating blocks. Currently, I have the first four hours of my work day set to block “all social media” and a few sites I visit out of habit (think ABC news, sports apps and Notemaker.com.au) to waste brain space. When the block is on, they just won’t load. Thwarted, I return to the present!

Forest is another app, more the carrot than the stick kind. Forest allows you to set a timer, during which time a digital tree or bush grows. When the timer finishes, the plant is added to your forest. But, if you change apps or switch to the home screen, your plant dies immediately, and the dead tree sullies the landscape.

One last app that can be an interesting and objective way to become aware of excessive phone usage is to us the IFTTT ‘Do Button’ feature. You can create a ‘recipe’ which collects a time stamp every time you press the button. Leave the app open and each time you unlock the phone, the button says “Unnecessary phone use.”; you are are obliged to press it before continuing; usage is collected in a google sheet for you read at a later time.

Both Forest & Freedom are about “blocking” the internet or phone usage. But what about positive internet time? I mean, it’s good to have some connection to the hive mind. Ferris describes setting time aside to screen emails and respond. Pragmatically, rather than withdrawing entirely, you can set aside an hour or two a day of dedicated social media time to “get your fix” whilst fostering connections and even schedule tweets.

Another way to make the most of short periods of connected time is to set emails to ‘snooze’; Google’s inbox offers this feature, as does the Boomerang app. This kind of technique also works well with the philosophies of David Allen’s Getting Things Done.

The Apple ecosystem has a habit of installing apps on all your devices. Critically and selectively deleting apps that you don’t want on a particular device allows you to discriminate what will buzz when. For example, I have twitter on my iPad but not my mobile phone.

To help with this ‘feature creep’, some folks use particular private message apps for set groups. For example, family on viber, work on WhatsApp, sports team on FB messenger and so on. In concert with the use of selective notifications, you can filter the distractions to a manageable amount.

If you’re really struggling to unplug from social media, but can’t be rid of your phone, you can just uninstall it all. Sounds dramatic? Try limiting your device to a set number of social media apps. Which five do you want the most? Which three? Which one? The same goes for all kinds of network; which of twitter, Instagram, snapchat, facebook, Reddit, LinkedIn and the rest can you divest yourself from without feeling isolated or lonely?

Password managers can also be useful; sometimes the temptation to “just to see what’s happening” on a particular social network leads to the actual website (in lieu of the app). If you can’t remember the inordinately long password, it’s another cognitive block to log in.

Lastly, consider do you need a smartphone? In the USA, about 1 in 7 people still use a “feature” or dumbphone . The phones can send messages and make phone calls; what else do you need? A handful of my colleagues have tried the two-phone option – one number for work calls, one for the rest of the world. It allows discrimination between the two and, I’m told, helps people to stop hating & fearing their phone.

In summary, mobile phones and devices are omnipotent in clinical and personal life for most people. Many people feel that their devices intrude into their lives. Although a bit preachy, this post has considered some of the challenges attendant with being constantly connected, as well as some pragmatic ways to free our minds from our screens. We’d love to hear your suggestions in the comments below!

Disclosure:

I’ve tried almost everything mentioned in this post, some successfully. I paid for any of the apps or actions in this post by myself. I also killed at least 4 trees in the Forest app, glanced at my phone six times whilst driving home, browsed twitter for thirty-nine minutes, read extraneous PubMed (and DSM-V) material for twenty-eight minutes, glanced at my iPhone (it’s in reach) at least twelve times and looked at expensive fountain pens whilst researching & compiling this post. Uploading was also delayed because I stayed up too late at night and thus my internet was blocked.

Or Not…

Cite this article as:
Andrew Tagg. Or Not…, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10499

With an impending new arrival I was excited about the educational opportunities that would arise.  I’d read up my fetal physiology and was eagerly awaiting the chance to write a series of posts on what normal babies do.  I had planned to take pictures of meconium filled nappies and film normal neonatal reflexes. I’d made a little list of the things I really wanted to capture. But things don’t always turn out the way you expect them to.

Big Picture Paediatrics : Adverse Childhood Experiences

Cite this article as:
Henry Goldstein. Big Picture Paediatrics : Adverse Childhood Experiences, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10082

So much of paediatrics, and medicine in general, is focussed on small experimental or observational studies. This series of posts takes the wider view; we’re talking here about some of the biggest and longest running studies that help us frame, measure and understand childhood through time and across the world.

Who & what was studied?

Kaiser Permanente is a large Medical Insurer in the USA; they collected data in two waves in the primary care setting with a view to describing the long-term relationship of childhood experiences to important medical and public health problems. The study initially rolled out in 1996 & 1997.

Felitti, VJ, Anda RF, Nordenberg D et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults : The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998:14, 245–258.

The study aimed to assess – both retrospectively and prospectively – the long-term impact of abuse and household dysfunction during childhood on disease risk factors and incidence, quality of life, health care utilization, and mortality for adults.

Here is the actual questionnaire:

Answer yes or no; all ACE questions refer to the respondent’s first 18 years of life.

Abuse

  • Emotional abuse: A parent, stepparent, or adult living in your home swore at you, insulted you, put you down, or acted in a way that made you afraid that you might be physically hurt.
  • Physical abuse: A parent, stepparent, or adult living in your home pushed, grabbed, slapped, threw something at you, or hit you so hard that you had marks or were injured.
  • Sexual abuse: An adult, relative, family friend, or stranger who was at least 5 years older than you ever touched or fondled your body in a sexual way, made you touch his/her body in a sexual way, attempted to have any type of sexual intercourse with you.

Household Challenges

  • Mother treated violently: Your mother or stepmother was pushed, grabbed, slapped, had something thrown at her, kicked, bitten, hit with a fist, hit with something hard, repeatedly hit for over at least a few minutes, or ever threatened or hurt by a knife or gun by your father (or stepfather) or mother’s boyfriend.
  • Household substance abuse: A household member was a problem drinker or alcoholic or a household member used street drugs.
  • Mental illness in household: A household member was depressed or mentally ill or a household member attempted suicide.
  • Parental separation or divorce: Your parents were ever separated or divorced.
  • Criminal household member: A household member went to prison.

Neglect

  • Emotional neglect: Someone in your family helped you feel important or special, you felt loved, people in your family looked out for each other and felt close to each other, and your family was a source of strength and support.
  • Physical neglect: There was someone to take care of you, protect you, and take you to the doctor if you needed it, you didn’t have enough to eat, your parents were too drunk or too high to take care of you, and you had to wear dirty clothes.

What does this mean?

The ACEs questionnaire accumulates a score from zero to seven based on yes/no responses to the above questions. These results in conjunction with a “Health Appraisal Clinic’s questionnaire” allowed correlation with risk factors such as smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, any drug abuse, sexually transmitted diseases, parental drug abuse and a high lifetime number of sexual partners (>50), as well as the big swingers; mortality and overall morbidity.

The ACE score has been utilised to demonstrate a graded dose-response with more than 40 outcomes. You can see the entire list of publications here.

How good is this dataset?

Although there are almost all of the expected threats to validity from a questionnaire administered to people obtaining health insurance in the USA in the 1990s, the dataset is very good.

Of the 13,494 surveys, there was a 70.5% (9508) response rate, sent a week after standardised medical review. Respondents who did not respond to all questions were excluded from the final analysis. After non-responders and exclusions, a total dataset of 8056 responders was analysed. Alarmingly, more than half of the exclusions were for not answering the question about childhood sexual abuse. This certainly raises some concern for a risk of underreporting, particularly if this was the only question omitted! 

What meaning can be drawn from the results (so far)?

The dataset has lent itself to the associations between adverse childhood experiences and a veritable laundry list of medical, psychiatric pathology as well as social and public health problems.

This is data reports that 1 in 5 were sexually abused, nearly 1 in 4 lived with a “problem drinker or alcoholic” and that around 1 in 6 had a household member who was depressed or mentally ill.

It’s worth remembering that this study paints a picture of the adverse childhood experiences of the older generations in the USA – the mean age of respondents was 56.1 (19-92) years – in a study undertaken just over 20 years ago.

Rather than provide a snapshot of what childhood is like today, this data informs us about the childhood of parents of our patients. This gives us some understanding and frameworks by which to consider expectations of childhood from the parental & societal viewpoint – that most parents hope for a rosier childhood with fewer adverse experiences than their own.

With this in mind, and with a critical eye to some of the correlating outcomes, behaviours such as alcohol & drug abuse, smoking, over-eating, and sexual behaviours might alternatively be viewed as both coping strategies and symptoms of the anxiety, anger and depression that is likely co-morbid with high levels of adverse childhood experiences.

Primary prevention of adverse childhood experiences necessitates change at the societal level; with a focus on improving the quality of family and household environments through the childhood years.

Funding for the original study was combined between Kaiser Permanente (San Diego) and the US Center for Disease Control.

Where next?

The Centre for Disease in Childhood has taken over the study and, since 2009, transformed it into a national program across 32 states of the USA, called “Behavioral Risk Factor Surveillance System” (BRFSS). Data from the 2010 BRFSS has been published and includes more than 50,000 respondents. You can see more about the participating states, future timeline and previous data via the CDC website, here.

References:
Felitti, VJ, Anda RF, Nordenberg D et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults : The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998:14, 245–258. 

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention Adverse Childhood Experiences (ACEs)”.U.S. Department of Health & Human Services, Atlanta, USA. Accessed 27 September 2016. https://www.cdc.gov/violenceprevention/acestudy

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. “About Behavioral Risk Factor Surveillance System ACE Data”.U.S. Department of Health & Human Services, Atlanta, USA. Accessed 5 October 2016. https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html

Are you okay?

Cite this article as:
Andrew Tagg. Are you okay?, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9785

Today (8th September) in Australia is RUOK? day. It’s a time for people to come together and think about more than themselves and meaningfully connect with others. I wrote recently about the prevalence of bullying in medical society and some of it’s consequences. The 2013 Beyond Blue survey on depression in the medical workforce showed that one in five doctors suffer from depression and that a quarter  had thoughts of self-harm or suicidal ideation.

But today, I’d like you to remember that mental health concerns only remain hidden because of stigma.  By talking out loud we can help smash the stigma. It’s a topic I’m going to expand on at next year’s DFTB17 conference. If one in five Australian doctors suffer from depression and (if it’s not you then) there is a good chance that one of your friends or team members does.  Don’t be afraid to ask the question – and listen to the answer without judgement.

For more information on RUOK? day then take a look at their official website.

If you need help then contact:-

BeyondBlue

Trethewie on death in the acute setting

Cite this article as:
Davis, T. Trethewie on death in the acute setting, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/pac-trethewie/

We have teamed up with APLS to share the videos from their Paediatric Acute Care Conferences. These videos have never been open access before, so if you weren’t able to attend the conferences, then now’s your chance to catch up.

The PAC Conference is run each year by APLS and consists of presentations on a range of topics relevant to paediatric acute and critical care.

Personal Learning Networks

Cite this article as:
Andrew Tagg. Personal Learning Networks, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9228

What sort of health practitioner do you want to be? Nobody wants to be average, as Simon Carley tells us, so how do we go about growing? Professor C. offered us lots of great advice and there will be more to come when the #smaccDUB podcasts get released.
This week, I have once again sacrificed myself to the roster gods, and got a week off to attend the Teaching Course in Melbourne. Without wanting to sound like a shill for the course on day one, I wanted to reflect on something that really resonated with me.

DFTB in Dublin – the Second Day

Cite this article as:
Tagg, A. DFTB in Dublin – the Second Day, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-the-second-day/

Small children prevented Henry and I spending too much time out on the town enjoying what Dublin has to offer. One advantage of this was that we were both able to enjoy the mornings sessions without the hangovers that so many of our friends and colleagues had.

The theme for the morning plenary session was “Slaying Sacred Cows”. Four excellent speakers took the time to challenge long held beliefs and make us question some of our ingrained ideas.

Leadership: not (just) for men

Resa Lewiss began by talking about leadership. To some of us the word ‘leader’ conjures up images of old white men with power ties and masculine poses.  Res reminded us that over half the medical population are women and it is time for us to realise this. Just as we have seen #Ilooklikeasurgeon trend worldwide she wanted to trend #IIlooklikealeader. With many strong leaders in the world of paediatrics this is something that we at Don’t Forget The Bubbles support wholeheartedly.  SMACC has tried hard this year to ensure gender equity with the speaker panel and this is one of our core aims for #DFTB17.

Resa had the following tips for those that want to inspire and lead:-

Praise in public, criticise in private

Make decisions – don’t be indecisive

Concentrate on your strengths and let others cover your weaknesses

Make people feel good about themselves

If you don’t ask you don’t get

As someone who is an extreme introvert it was this final point that really made me reflect. Nat May has already written a superb post on impostor syndrome but it is worth remembering that there is power in breaking free of the self-imposed shackles of quietitude and putting yourself out there and just asking for help. 


Things that scare me

Paediatric surgeon and presentation skills guru Ross Fisher showed why he is so well respected as a speaker. Eschewing supportive media he took to the stage to speak about fear.  Over the course of twenty minutes he spoke about some of the times in his life in which he had been truly scared.  Not the sort of fear you get riding on an out of control roller-coaster but the sort of deep, visceral fear that makes your mouth dry up, your head pound and your legs shake. By the end of his talk there was barely a dry eye in the house (or on the stage).  This is a must watch talk when it comes out and is the one that really made me just stop and think.

Emergency management of the agitated patient

Reuben Strayer concentrated on something that we don’t see very often in the emergency department. We do occasionally have to deal with agitated teens and it’s worthwhile looking at this alternative take.

What's love got to do with it?

The morning was topped off by the fabulous Liz Crowe.  She reminded us that we obviously all love our jobs – most of us seem to spend over a third of our lives there – but like any relationship we can have good times and not-so good times.  Just as any marriage takes effort to make it work the same is true for our relationship with our job.  We need the support of our work husbands and wives when times are tough and to remind of us of those times when we basked in the afterglow of our first successful resuscitation.

And whilst we love our jobs Liz reminded us that we must also love our patients. We must treat them all with kindness and compassion. They did not, would never, choose to be in hospital.  We must always, always remember that.  A kind word, a cup of tea, a warm blanket go a long way.

Later that same day...

After coffee we broke for concurrent sessions. I went to the session entitled “Time to gas, time to cut”. Karim Brohi spoke about Zen and the Art of Trauma, again reinforcing the need for the leader to be the centre of calm.  That calmness is infectious. We’ve heard about tools we can use in the moment to help use regain calm but Karim reminded us that calmness is a learned behaviour. It is paying attention to the minor details, reducing errors and variance in the system. It is understanding when less is more, that some patients do not need every conceivable test but only the necessary tests to get them to theatre. And it is mentally rehearsing for every possible outcome.

And whilst some of the talks may seem heavy, the morning session was completed by the (not safe for work) Suman Biswas.  I’ll leave this here…

But the question on everyones mind was where would SMACC be in 2017?

DAS SMACC

So start asking for annual leave now if you want to travel to Berlin.

DFTB in Dublin – the Workshops

Cite this article as:
Tagg, A. DFTB in Dublin – the Workshops, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-the-workshops/

Having braved international flights half of the team from DFTB (Andy and Henry) have made it to SMACCDub. For those of you not in the know the Social Media And Critical Care conference is in it’s fourth year now and partly inspired us to start Don’t Forget The Bubbles.  Although the editors regularly chat online this was the first time Henry and I have met in person.

In order to make the most of our time abroad we had both booked into the #SMACCmini paediatric workshop.

SMACCMini

With a line of speakers encompassing the best and brightest from the world of paediatrics (apart from us) we were excited to see what they had to offer. With a variety of lightning 10 minute talks over the course of the morning topics ranged from communication to caring for the critically ill child.

Resuscitation update

Natalie May was our leatherette clad hostess and kicked off the proceedings with an update on the 2015 ILCOR guidelines.  Whilst little has changed in resuscitation of the infant it is the rare resuscitation of the newborn that scares us the most.  Whilst a precipitous delivery in the department may be a rare event, it does happen.  Babies may be born in less than ideal circumstances – on the leather back seat of their husband’s new car, in the toilet (literally) or in the lift up to the birthing suite – but thankfully the need to perform complex interventions is rare. We need to know what to do before help arrives. This short video may help those who are paralysed by fear.

PEM literature update

Tim Horeczko took to the stage next, disguised as an event organizer. Despite technical issues that were out of his control he took us on a whirlwind tour of some paediatric literature that most of us in the room were not aware of.

Approaches to spotting the sick child

The Wonder Woman of Leicester, Rachel Rowlands, then took to the stage (along with her constant companion, Norman the dinosaur) to remind us of the importance of gestalt in spotting the sick child, a theme that would echoed by many speakers throughout the morning.  She took us on a choose-your-own adventure style quest, not to find the treasure, but to save the life of a young boy that had swallowed a button battery.  If you want to know more about the dangers of these deadly discs then take a look at her video.

Spotting sepsis early

Adrian Plunkett talked eloquently on the the use of the NICE traffic light system and other early warning scores to predict sepsis. But really he gave us two key take home points to lock onto:-

  • Be worried if there is a change of state – they are not the same as they were yesterday
  • Be worried if this illness is like no other illness they have ever had

By using these two key questions in the history we might become more alert to the risk of potential deterioration and look for ways to validate our fears – order the extra blood tests, keep the child in for a period of further observation.

Sick neonates are simple

Trish Woods, a neonatologist from WA, reminded us that all neonates want is to be protected.  When they are threatened, be that in the form of imminent airway or breathing difficulty, their physiology wants to return to the womb.  By understanding the transition from safe, warm and comforting intra-uterine life to the harsh outside world we can guide our resuscitation.

Mistakes and pitfalls in critical care

Phil Hyde, who gave an excellent talk about the use of real children during simulation at last years conference urged us to use our fear, not because it leads to the dark side, but to help us step towards the stressful.  We have all been in a resuscitation when there is a palpable sense of half-repressed panic.  Voices are raised and critical instructions missed, mistakes are made. But just as the emotions of the team leader can have a negative impact on the team they can also act to stop the sweating.  By being the slow, smooth voice of calm the team leader can imbue all of the group with the same feeling.

This can be a challenge so there are things we can do to mitigate the internal stress. Cliff  Reid talks of using the high fidelity simulator that is our brain to visualize these high stress scenarios, before they happen.  That is all when and good if you are experienced and have seen a lot of sick kids. But what do you do if you haven’t.  Phil suggests visiting your local PICU and asking questions of doctors and families, stepping towards the fear.  He also suggested using www.spottingthesickchild.com, a free online resource (though you need to register) to make you more comfortable in your assessment of deteriorating infants.

Paediatric ultrasound

The southern hemispheres Wizard of the Wand, Giant of the Gel, Prince of Probes, himself – Casey Parker – demonstrated how easy it is for us all to perform lung ultrasound on children.  In just 8 minutes he reminded us that our clinical exam counts for very nought and that a normal appearing chest x-ray can be deceptive in a child that you think has pneumonia from the history.  Waving the magic wand is easy and can be taught in just four minutes.  It is certainly a skill that I am going to take home to my place of practice.(Ed. I’d just like to give a huge thanks to Casey for encouraging me to write after the first SMACC in Sydney and publishing my very first blog post.)

What paediatric surgeons wished you knew

The esteemed paediatric surgeon, Mr Ross Fisher of p cubed presentations, then took us through some of personal bugbears.  After learning that there is no such thing as a normal bowel habit in a child, a fact that most parents can attest to, to decrying the lack of  proper physical examination prior to imaging he put us in his shoes.  Surgeons have no special ability to rule out appendicitis, but often have the benefit of experience to help determine what else may be going on.

Paediatric toxicology

As we came towards the end of the first half of the morning Nat Thurtle reminded us that children like to put things in their mouths that no normal person would.  Eschewing the usual list of one pill kills she talked about some newer toxins that most of us would not find palatable – e-liquids, laundry detergent pods and synthetic cannabinoids’s. By using the powerful Resus RSI DEAD mnemonic we can have a framework with which to risk stratify and deal with any potential toxic ingestion.

Paediatric trauma

As we were getting ready for our morning coffee Nat May reminded us that paediatric trauma often presents to non-paediatric centres and that we should all be able to recognize and deal with it.  Mechanisms of trauma vary with age from the drunken horse riding antics of teenagers, to younger children who skateboard in front of cars.  Paediatric trauma can be very confronting and how we approach our parents and their families can have a great impact on their long-term outcomes.

The SMACCmini superheroes

Appropriately caffeinated we headed back to the hall for another round of talks.

Excellence in critical care

Adrian Plunkett started off the session on a positive note.  Whilst it is easy to criticise bad practice it is much harder to praise the good.  He urged us to learn from the things we do well.  By actively promoting best practice within your network a culture of positivity and a ‘can-do’ attitude arises.  If you visit the Learning from Excellence website you can learn from others peer-reported episodes of excellence in practice.    Similar to the ‘Awesome and Amazing’ antithesis to the monthly M&M conference we need to let others in the team know they are doing a great job.

Communication: Kids and families

We all have had occasions when we think we have done a great job with our young patients and their families. Roisin McNamara brought us down to earth with a tale of when things that she thought had gone well had been perceived very differently by the family involved.  When harsh words are spoken it is important to have the emotional intelligence not to snap back, not to get angry. Often parents are not angry at you but at the situation but the doctor in front of them is the visible face of a systemic problem.  Parents may feel they are being dismissed as time wasters if time is not spent taking a thorough history and appropriate physical exam before pronouncing that their darling daughter has no medical cause for their symptoms.

Communication: Adolescents

Most of us know how to talk to children but, via the power of video, Thom O’Neill, spoke passionately about an issue we should all know more about- dealing with LGBT adolescents and youths.

Most traditional textbooks of paediatrics have yet to cover the subject and Thom gave us a useful framework to hang a conversation on, starting with recognising the child or youths right to be called what they want and to identify themselves how they want.  We hope to get Thom to write more on this subject for Don’t Forget The Bubbles. 

Resource poor settings

Nat Thurtle returned to the limelight to talk about her time working in resource poor settings.  Those of us that work in the developed world are incredibly lucky to have access to the resources we have. As she told her moving story of almost insurmountable challenges we al stopped and reflected on how lucky we truly are.

Complex kids

After hearing about children that don’t have access to even supplemental oxygen when it is needed Tim Horeczko talked about technology dependent children and their complex needs.  Whilst we are unlikely to encounter a child with a ventricular assist device outside of a quaternary centre we may well be exposed to children with a VP shunt, or a child that suffers from an incurable neuromuscular or mitochondrial defect.  As is nearly always the case in paediatrics – the parents know best, so listen.

Surgical surprises

Ross Fisher then urged us to “Keep Calm and Carry On” when confronted with potential paediatric surgical nightmares. He reminded us time and again that we know how to do the basics – analgesia, fluid resuscitation, investigate – and that there is nothing that we should be afraid of.

Neonatal procedure tips

Having previous told us that looking after sick neonates was easy-peasy, Trish Woods then went n to teach us how. By focusing on the ABC’s of resuscitation she walked us through the neonatal airway and breathing before showing some great slides and giving us all the tools we need to insert an umbilical line. At the time of neonatal resuscitation early vascular access as a means of giving fluids and adrenaline can save a life.  

Intubation tips

This great procedural talk was followed by Tim Horeczko on his top three tips for intubating infants.  We know that critical procedures are rarely performed by paediatricians let alone general emergency physicians but by adding these three things to ones repertoire we should increase our chance of first pass success.

  • Use the shoulder bump
  • Use the jaw thrust
  • Change your position and look high

Ventilation tips

Once we have successfully intubated (and confirmed tube placement with waveform capnography) Phil Hyde talked about ventilation strategies. By using PEEP and low tidal volume breaths (6-8mls/kg) we can adequately ventilate most children titrating to a pH>7.2 and and an SpO2 >92%. Attention to the simple things such as sedation, paralysis and monitoring can make all the difference.

Phil Hyde on the basics of neonatal ventilation

Patient experience

The final session of the day brought home to all of us in the room why we do what we do.  We heard from Emer, a brave 11 year old girl, who had spent 5 days in ICU with tracheitis, of her experience, both in the emergency room and in the unit.  Her clinical care was excellent and could not be faulted but if there was one thing she wanted us all to take away it was ‘Don’t use long medical words’. We doctors assume a common tongue and use medical terminology as a technical shorthand with our colleagues.  We occasionally slip into this mode of talking with patients and their relatives. Emer reminded us to think before we speak.

The organizing committee and all of the faculty did an amazing job of fitting such a wide array of topics in such a short time frame. Never did the audience feel overwhelmed with knowledge and most of us just stopped tweeting and just listened, quietly reflected and were inspired to do better. If you came along to the workshop and took away something that will change the way you treat children (or their parents) then please feel free to comment below.

pablo

 

Brown on APLS instructor attributes

Cite this article as:
Tagg, A. Brown on APLS instructor attributes, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/pac-conference-brown-on-apls-instructor-attributes/

We have teamed up with APLS to share the videos from their Paediatric Acute Care Conferences. These videos have never been open access before, so if you weren’t able to attend the conferences, then now’s your chance to catch up.

The PAC Conference is run each year by APLS and consists of presentations on a range of topics relevant to paediatric acute and critical care.

DFTB in EMA #4 – Spoonful of sugar: Improving the palatability of emergency department visits for children and their families

Cite this article as:
Andrew Tagg. DFTB in EMA #4 – Spoonful of sugar: Improving the palatability of emergency department visits for children and their families, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8049

Whilst it has been available online for some time now the fourth EMA article from the DFTB team has just hit doormats across Australia.

“Pain, fever, fatigue and fear can all add to anxiety and distress for unwell children and their families, as well as making assessment of their clinical state even more difficult. This article aims to describe some ways of helping the medicine go down for your paediatric emergency patients.”

Click here for the link to the full article – ‘Spoonful of sugar’

Reference:

Lawton, B., Davis, T., Goldstein, H., and Tagg, A. (2015) Spoonful of sugar: Improving the palatability of emergency department visits for children and their families. Emergency Medicine Australasia, 27:504506. doi: 10.1111/1742-6723.12506.