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.

Spina bifida – what is spina bifida?

Cite this article as:
Lydia Garside. Spina bifida – what is spina bifida?, Don't Forget the Bubbles, 2015. Available at:
https://doi.org/10.31440/DFTB.6758

A couple come to see you following their 18 week ultrasound. They have been told that the ultrasound showed that their baby has spina bifida. The family wish to discuss the situation with a paediatrician.

How common is spina bifida?

The incidence at birth <1 in 200.

The number of cases of spina bifida is declining. This is likely due to earlier ultrasound diagnosis and the increasing use of folic acid supplements by women of child-bearing age.

80% are now diagnosed antenatally and many are terminated in the antenatal period. Blood screening for raised alpha fetoprotein is helpful if positive.

What is spina bifida?

Spina bifida is a congenital lesion of the spinal cord which results in some part of the spinal cord and meninges being exposed.

Spinal lesions are classified into:

  • Anencephaly – the natural history is 67% stillborn, 33% neonatal death.
  • Encephalocele – the natural history is 23% stillborn, 43% neonatal death. Many of the survivors have a significant disability – spastic quadriplegia, epilepsy, hydrocephalus, and intellectual disability.
  • Spina bifida.

..and where is the lesion?

Most spinal defects are in the lower lumbar to sacral region, but they can occur at any level. Most are located posteriorly.

Spina-bifida

Greater than 97% of cases of spina bifida are associated with Chiari II malformation in the brain. This causes displacement of the cerebellum, fourth ventricle and medulla through the cisterna magna resulting in a banana shaped cerebellum. There is also concavity of the frontal bones resulting in lemon shaped skull and ventriculomegaly.

The more severe lesions can be seen as early as 11-12 weeks, but most are diagnosed at the routine fetal anatomy scan at 18-20 weeks

How can we predict functional outcome?

Ascertainment of the level of the spinal lesion is the most important predictor of functional outcome. MRI may be used to aid in this – but a thorough high resolution US examination is more effective at determining the level of the lesion.

There can be associated deformities of the lower limbs such as club feet and hip dislocation. Most neural tube defects are isolated malformations, but up to 15% have an association with other abnormalities (VSD, renal, IUGR), and 3% have an association with chromosomal abnormalities.

A lipomyelomeningocele is the mildest form of spina bifida – usually there is no Chiari malformation. Mobility issues are harder to predict in these cases though, and they may be progressive. Patients often have incontinence/bowel issues.

The main questions to ask when considering the likely functional outcome are…

  • Is this spina bifida?
  • Where is the lesion? How big? What type?
  • Is there a Chiari malformation?
  • Is there hydrocephalus?
  • Is there bony deformity?
  • Are there leg movements?
  • Any other anomalies?

You can check out the rest of the series here:-

Communication: Drug error

Cite this article as:
Tessa Davis. Communication: Drug error, Don't Forget the Bubbles, 2014. Available at:
https://doi.org/10.31440/DFTB.4896

Scenario: you are the register on the General Paediatric Ward. As you are reviewing patients, you realise that one of your patients, 9 month old Kayleigh, has been prescribed and given the wrong dose of paracetamol. She received one dose that was 5 x the recommended dose.

You need to speak to the family and let them know – how do you approach this?

What is autism?

Cite this article as:
Tessa Davis. What is autism?, Don't Forget the Bubbles, 2014. Available at:
https://doi.org/10.31440/DFTB.5235

As paediatricians we may not be required to diagnose autism, but we should be able to understand and recognise the main features.

There are two main diagnostic areas under the new DSM V criteria

A. Persistent deficits in social communication and social interaction

B. Restricted, repetitive patterns of behaviour, interests, or activities

For a diagnosis of Autism Spectrum Disorder (ASD) children need to have A. and at least two of the criteria in section B.

What constitutes a persistent defect in social communication and social interaction?

This can be deficits in social-emotional reciprocity. A child with autism has difficulty engaging in normal conversation. That’s not to say that child wouldn’t be able to answer direct questions – some children can do this very well – but the normal flow of conversation isn’t the same. That might be that they don’t share things in the same way as other people and don’t feel the need to tell you how they are feeling or respond to social interaction in the same way as others.

It can also be deficits in nonverbal communication behaviours used for social interaction. This can show itself as unusual body language or difficulty with maintaining eye contact. Again, autism is a spectrum disorder so it’s not as black and white as eye contact or no eye contact. It’s the quality of the eye contact – is it meaningful? Is it fleeting? Is it appropriate? Does the child smile at you or are they smiling at a toy they like? Body language deficits might also be difficulty using gestures to explain and communicate – such as pointing or waving.

And finally it could be deficits in developing, maintaining and understanding relationships. This issue is around the nature of play and interaction with peers. The child may not engage in interactive or imaginative play. They may enjoy playing but it has to be on their own terms and the child may not be bothered if another child doesn’t like the game or wants to play something else.

What are the criteria for showing a restricted, repetitive pattern of behaviour, interests, or activities?

For the diagnostic criteria for ASD, a child also has to have at least two of:

Stereotyped or repetitive motor movements, use of objects or speech. Children with ASD can demonstrate echolalia or use odd or repetitive phrases. They might have certain movements like hand-flapping; or they demonstrate repetitive behaviours like lining all their action figures up in a row.

Insistence on sameness, inflexible adherence to routines, or ritualised patterns of verbal or nonverbal behaviour. Some children can show very rigid thinking where they are unwilling to budge on their viewpoint regardless of what they parents or peers are telling them. Sometimes a routine can be very strict and any deviation from this can cause distress. This may be that they have to eat from the same plate and cup and have the same mat to eat their breakfast off every day.

Highly restricted, fixated interests that are abnormal in intensity or focus. The classic is a child who loves spinning objects – wheels, hoops, anything that turns. The child might be fascinated by watching the wheels spin endlessly. Or, the child may have a specific toys that they love, for example trucks – where they are obsessed by trucks and cannot focus on other activities.

Hyper- or hyporeactivity to sensory input. Children with ASD can have an unusual interest in sensory objects – lights, sounds or textures. Sometimes this can be a positive experience – they may love feeling soft objects against their skin or be fascinated by toys with lights. Or it can cause distress – not liking particular food textures, or becoming very upset at the feel of sand on their hands or feet.

What does it mean to have ASD?

Autism simply means that the way the child thinks and sees the world is different to other people. Although it’s a spectrum disorder we don’t grade severity.

A child with autism may have poor language skills; or they may have particular difficulty with rigid thinking and routines; or they may have a particular problem with a fixation on one type of toy; or they may have difficult making friendships or relating to their family members.

Autism means something different for each child and they may be very severe in one area but mild in another.

So, how it is best managed?

Management of autism is geared towards helping the child lead a life that is meaningful and happy for them.

Any therapies will be geared around supporting the child and family in managing the aspects of autism that cause the child the most difficulty.

Speech Therapy, Occupational Therapy, ABI, behavioural intervention, positive parenting and support groups can all help; but the most useful therapy will be very much tailored to that child’s needs.

What was the fuss about the DSM V?

In May 2013, the DSM IV was replaced and there were new diagnostic criteria. The main changes are:

Asperger syndrome is no longer a diagnosis. Asperger syndrome, PDD-NOS, childhood disintegrative disorder and autistic disorder have all been unified to ASD.

For diagnosis, symptoms can be in the present or reported historically. And, any symptoms should be taken in the context of an underlying genetic, neurological condition, or intellectual disability.

There is also a new Social and Communication Disorder which has the social and communication elements of ASD but without the rigid thinking and repetetive patterns.

People previously diagnosed using DSM IV criteria can keep the diagnosis and do not need to be rediagnosed. Any funding they had previously will not change.

N.B. For toddlers, we are allowed to use the DSM IV criteria as toddlers with autism are unlikely to show the rigid thinking and routine dependence that older children do, and this is a requirement for diagnosis in the DSM V.

Understanding autism is not easy for paediatric trainees or parents. Getting a handle on what it means for the child and the child’s way of thinking helps parents to support the child and helps paediatricians to recommend therapies.

The over-arching aim is to recognise what autism means to that individual child and how help them manage their way of thinking to maximise their enjoyment and ability to lead an independent life.

 

Other Resources

Autism Speaks

DSM-V