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

Time for Telehealth

Cite this article as:
Alison Boast and Allison Hempenstall. Time for Telehealth, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24401

As the COVID19 pandemic continues to spread and utilize more of our health resources, many clinicians are being asked to minimize in–hospital clinic appointments. While it may seem simple to switch to telehealth for routine clinic appointments, there are a number of factors that need to be considered to make the process as smooth as possible for yourself and your patient and family.

This post will help you make the transition from face–to–face clinic appointments to telehealth. There are even more tips and tricks for assessing children with acute illnesses via telehealth, stay tuned!

 

Is your patient suitable for telehealth review?

If the answer is yes then continue on! There are some factors to consider though.

Need for clinical examination – if a clinical examination plays a key role in decision making telehealth may not be appropriate e.g. features of heart failure in a child requiring correction of a congenital heart defect

Multidisciplinary clinics e.g. cleft palate clinic – it may not be possible for clinics with multiple different providers to be shifted to telehealth

Need for procedures – in some clinics procedures are essential such as dressing changes or immunizations and therefore may not be possible via telehealth or community services

Some of the above barriers may be overcome by collaborating with your patients, their families, local general practitioner, and nurse practitioner; it is worth exploring this as an option.

 

Does your patient and their family have the right technology?

In general, the technology required for telehealth includes:

  • Reliable internet connection (remember that the weather, location and other users online at the time can impact your connection speed)
  • Computer, tablet or smartphone 
  • Web–camera (inbuilt in many computers, tablets, and smartphones)
  • Secure program to communicate through (e.g. Skype, Zoom, FaceTime)

 

Telehealth consultations are inherently different to face to face ones. It’s really important to acknowledge that your consultation has shifted to a two–dimensional format which poses unique challenges.

 

Voice or video – which should I choose?

Voice is more accessible, particularly for the elderly who may not have phones or computers with video capabilities. It requires lower bandwidth and is less susceptible to disruptions. Unfortunately, you can’t see the patient (duh!) which means you can’t use your ‘end–of–the–bed–o–gram’ to see if they are well or unwell.

Video provides visual information on whether your patient appears ‘well’ or ‘unwell’. It is ideal for those patients and families with hearing impairment as non–verbal communication is preserved, as is the option to lip–read. With the increased use of the internet during isolation, quarantine and social distancing,  connectivity can be slow at times. Some governments have been advocating for online streaming services to downgrade from HD format to help preserve bandwidth.

Irrespective of the method chosen it is important to ensure the lighting optimizes illumination of your face, and sound is adequate with minimal background noise.

 

How should I run the consultation?

Before you start make sure you have your information technology support team phone number in case issues arise that you can’t troubleshoot. Check the patient’s identity, sound, and vision (if using video) and consider having a set of earbuds/ headphones handy.

Ensure that your patient and their families are holding the consultation in a private, safe space. Clarify the amount of time available for the consultation. Non-verbal cues that the consult needs to come to an end are more challenging with telehealth.

Limit distractions – if the family has lots of children or pets, it is worth asking at the beginning of the consultation if they can play in another room (safely), or have a quiet activity to get on with. Communication with noisy siblings is even harder via telehealth than in real life

If you need an interpreter before to organize this in advance, either by phone or in-person

At the end of the consultation take a brief moment to ask your patient and their family for feedback about the telehealth consultation

  • Did your patient hear/ see you throughout the consultation?
  • Was your patient happy with the care they received?
  • Would your patient be happy to have another telehealth consultation in the future?

 

But how do I examine the patient?

A major barrier to telehealth is the inability to carry out a physical examination. You can, however, gather more from video telehealth than you realize.

General Inspection – probably the most important part of the paediatric examination :

  • Does the child look well or unwell?
  • Are they active and engaged, or quiet and withdrawn?
  • Do they look well-grown? (remember to review your patients’ growth charts!)
  • Do they look like their parent(s)? Do they have dysmorphic facial features?

Observations – In most teleconsultations you won’t have this information, some patients and their families may have:

  • A  thermometer to take their temperature (although generally not required for a routine clinic appointment unless the child is acutely unwell)
  • A smartwatch or app on their smartphone which can take their heart rate and or oxygen saturation for older children with comorbidities (e.g. chronic lung disease)
  • If a blood pressure is important for decision making (e.g. chronic kidney disease) it is vital that the cuff is fitting correctly; few families have at–home sphygmomanometers, so they may be able to visit the local practice nurse for an accurate measurement

RespiratoryA wise professor once said that most of the respiratory examination only requires your eyes

If the video quality allows – what is the respiratory rate? Are there signs of increased respiratory effort? Is the respiratory cycle normal, or is there a prolonged expiratory phase?

Development – assessment requires some assistance and props from parents, but this in itself gives you information about the parent–infant bond and social skills:

  • Gross motor – stacking blocks, throwing a ball, sitting/walking/cruising/running and jumping
  • Fine motor – picking up raisins, scribbling or drawing
  • Speech and Language – can the child point out pictures in a book? Read you something?
  • Social – difficult to assess via telehealth; it’s easier to obtain from history and parental/teacher questionnaires
  • Questionnaires filled out ahead of time can help gather more objective information on the developmental domains of concern (e.g. Ages and Stages Questionnaires) 

Neurological – this is very challenging to assess via telehealth, only gross assessments of tone and coordination will be possible (see above for gross and fine motor)
 

Financial Considerations

In Australia, many Medicare item numbers have recently become available to bulk-bill telehealth sessions. This includes quarantined/isolated doctors who are still able to provide telehealth from home. It is worth checking with the relevant agency in your area to see what options are available to support telehealth, and what the surrounding rules and regulations are.

 

Medicolegal Considerations

Here are some useful elements to document:

  • Your name, date, time & location of consultation
  • Patient/ carer consent for the telehealth consultation
  • Those present for the consultation
  • Video vs phone consultation
  • Limitations to quality of consultations (e.g. poor connectivity)

We recommend giving your friendly indemnity insurer a call if you have any specific medicolegal questions

 

Check out more resources here

https://www.rch.org.au/telehealth/

https://www.bmj.com/content/bmj/suppl/2020/03/24/bmj.m1182.DC1/gret055914.fi.pdf

https://www.bmj.com/content/bmj/368/bmj.m1182.full.pdf

https://www.racp.edu.au/docs/default-source/advocacy-library/telehealth-guidelines-and-practical-tips.pdf

https://www.racgp.org.au/getmedia/c51931f5-c6ea-4925-b3e8-a684bc64b1d6/Telehealth-video-consultation-guide.pdf.aspx

COVID-19 and children: what do you need to know?

Cite this article as:
Boast A, Munro A. COVID-19 and children: what do you need to know?, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23868

In late 2019, a new infectious disease emerged and spread to almost every continent, called COVID-19. As of March 11th 2020 it was declared a global pandemic by the World Health Organisation, meaning that is was being spread among multiple different countries around the world at the same time. It has changed the way we live our lives.

What we understand about SARS-CoV2 and COVID-19 has increased dramatically, with research being done at an extraordinary rate. For those of us whose business is looking after children, what do we need to know?

 

Editor’s note: This post is based on what we know today, Wednesday 15th of April 2020, and will be updated as new information becomes available.

 

What is COVID-19?

  • COVID-19 is the name of the disease caused by a new coronavirus, which has been named SARS-CoV-2. COVID-19 is the disease, and SARS-CoV-2 is the virus.
  • A coronavirus is a type of virus named after its unique appearance – with a ‘crown’ of proteins – when viewed with high power microscopy.
  • Coronaviruses very commonly infects humans (and some animals).
  • In humans, coronaviruses are a frequent cause of the ‘common’ cold – resulting in an upper respiratory tract infection with cough and coryza. There are, however, three types which can cause severe, even life-threatening disease in humans (SARS, MERS, and COVID-19).

 

What is the difference between COVID-19, SARS, and MERS?

Whilst they are all severe illnesses caused by coronaviruses, there are some important differences. Some useful things to consider include the R0 (how many people, on average, one case of the disease will spread to in others) and the Case Fatality Rate (CFR), an estimate of how many people who contract the disease will die from it. Neither of these statistics is hard and fast (and are both highly context-specific), but they provide a rough yardstick with which to compare infectious diseases.

  • SARS: This is an acronym for Severe Acute Respiratory Syndrome, a disease caused by the virus SARS-CoV. In 2002-3 the spread of SARS-CoV resulted in around 8,000 cases, with a CFR of approximately 10%. Similar to COVID-19, SARS-CoV originated in China, before spreading around the world, predominantly Europe, North America, and South America. The R0 from SARS is thought to be 3.
  • MERS: This is an acronym for Middle East Respiratory Syndrome, caused by the virus MERS-CoV . As the name suggested, it originated in the middle east in 2012, transmitted initially from camels to humans. MERS causes the most lethal infection of the coronaviruses, with a CFR of around 35%. The R0 from MERS is thought to be <1.
  • COVID-19:This is an acronym for COronaVIrus Disease 2019, the disease caused by the virus SARS-CoV-2. It is a zoonotic disease (meaning it was transmitted to humans from animals) and although the intermediate host has not yet been identified, it’s thought to most likely have originated in bats. It was initially identified in December 2019 in China, before spreading around the world. The CFR is unclear, as it is still uncertain how many people actually have the virus, and how many who currently are unwell will die from the disease. The overall CFR is thought to be about 1.3%. This is highly dependent on the country (and available health resources) but another significant factor is age, with only a handful of deaths reported in children <12 years who have confirmed COVID-19. The R0 for COVID-19 is still unclear but is thought to be 2-3.

 

What are the symptoms?

  • The symptoms of COVID-19 are similar to other respiratory viral infections. Importantly, in children the symptoms of COVID19 are more likely to be mild, and a significant proportion may be asymptomatic.
  • Infected children who are symptomatic most commonly present with cough and fever.
  • A small proportion of children also present with gastrointestinal symptoms (vomiting or diarrhoea) (~10%)
  • Sore throat and runny nose do not appear to be uncommon features in children (as opposed to adults)

 

How does COVID-19 affect children?

Evidence from across the globe (namely China, Spain, Italy and America), has shown that children are significantly less affected by COVID19 than adults. There are both fewer cases in children, and less children who are severely unwell. Younger infants appear to be most likely to be hospitalised. Overall, there have been only a small number of deaths in children with confirmed COVID-19 reported. A number of epidemiological and clinical papers on COVID-19 in children have been published, summarised on DFTB.

The exact reason why there are so few children with confirmed COVID-19 is unknown. Initially it was thought that due to the high rate of asymptomatic infection children were simply less likely to be swabbed and have confirmed infection. However, recent evidence from Iceland, Japan and Korea shows that children may also be less likely to become infected with SARS-CoV-2 following exposure.

It is yet unknown whether asymptomatic children can pass the infection on to others. In epidemiological studies children have not been found to have a significant role in household transmission. It appears children may continue to excrete the virus through their faeces (poo) for several weeks after the symptoms of infection have passed, but the role of this excretion in viral transmission is not clear (there is some evidence to show it is only viral particles rather than active virus). Regardless, hand hygiene remains of paramount importance in reducing spread.

 

If my child is unwell, can I give them ibuprofen?

There has been considerable social media interest in the use of ibuprofen in suspected or confirmed COVID-19. In the UK, the MHRA has deemed there is no evidence of increased risk of using ibuprofen even in cases of COVID-19.

 

What about neonates?

Neonates without comorbidities do not appear to be at an increased risk. A large number of case series having been published of babies born to mothers with COVID-19. Although some neonates have swabbed positive for SARS-CoV-2, there have been no reports of this being associated significant illness. Evidence about the possibility of transmission from mother to baby in the womb is currently unclear.

In the UK, the RCPCH has published guidelines (with the Royal College of Obstetrics and Gynaecology) recommending pregnant women with COVID-19 who are in labour should deliver their baby in an obstetric unit, however there is no need to separate mother and baby after birth, and the benefits of breast feeding outweigh any theoretical risks. Of note, the American Academy of Pediatrics has released conflicting guidelines, suggesting separation of the mother and baby.

 

What about children with chronic conditions?

There is limited data to guide us currently on how COVID-19 might affect children with underlying health conditions. There are small case studies of children with suppressed immune systems who have not developed severe illness, including children treated for cancer and inflammatory bowel disease. There is some evidence that children with respiratory or cardiovascular comorbidities may be at higher risk of hospitalisation, but it is still unclear. For children currently being treated for cancer, the UK Children’s Cancer and Leukaemia Group have posted guidance for families including which groups are extremely vulnerable and should be “shielding”.

 

Is there any treatment?

There is no proven treatment for COVID-19, however, there are many clinical trials underway for many different therapies. The WHO has clearly stated that experimental therapies should only be used in the context of a clinical trial. Hydroxychloroquine and remdesivir have been studied most extensively, but there remains no clear evidence of benefit. Importantly, hydroxychloroquine has been associated with significant adverse effects, highlighting the importance of its prescription only in the context of a clinical trial.

Notably, there are only a handful of clinical trials for children registered, so it is unlikely that any therapeutics will be widely used in children with COVID-19. As the disease is generally mild in children, it is not likely to often be necessary to provide anything further than supportive care.

Vaccines will hopefully provide protection against future outbreaks of COVID-19, though these are still early in the drug development pipeline and unlikely to be available this year.

 

What can I do to minimize my risk?

Two words – hand hygiene. As with other viruses spread by droplet (e.g. influenza) hand hygiene, particularly when out in public, plays a critical role in preventing transmission. Washing hands with soap and water, for an adequate amount of time, covering all areas of the hands is most effective. Hand sanitizer is effective, but no more so than usual hand washing

It is important to avoid contact with others who are acutely unwell. Wearing surgical masks will not protect you from respiratory viruses. Wearing one if you are unwell may protect others from your respiratory secretions.

Physical distancing is becoming increasingly important, with many countries now mandating various ‘lock-downs’. You should follow advice from your public health authorities, and it would be wise to reduce non essential physical or close personal contact with other people to a minimum 

 

What should I do if someone in my family becomes unwell?

 

Resources for health professionals

Many journals have made their COVID-19 resources open access including NEJMThe LancetBMJ, and JAMA

National professional resources can be found at:

 

Literature

For a comprehensive review of all paediatric English language literature to date which has informed this article please see our separate page for COVID-19 Evidence

Communicating with children with additional needs: Liz Herrieven at DFTB19

Cite this article as:
Team DFTB. Communicating with children with additional needs: Liz Herrieven at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21387

Communication is vitally important in so much we do as clinicians.  Without good communication we can’t hope to get a decent history, properly examine our patient, explain what we think is going on or ensure appropriate management.

Procedural sedation

Cite this article as:
Tadgh Moriarty. Procedural sedation, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23718

Sometimes we have to do things that children don’t like. These procedures may be scary, or potentially painful. In this post, we’ll cover a few of the more common techniques.

 

Case one: Kayla

Earlier this month, the UK Royal College of Emergency Medicine, RCEM, published new guidance on the use of ketamine for procedural sedation in children in the emergency department, superseding their 2016 guidelines. Follow Kayla through her ED visit as she helps us explore the changes RCEM recommends.

 

It’s 3 pm on a busy Friday afternoon on your PEM shift. You have just seen Kayla, a 20-month-old girl who fell from onto a concrete step and sustained a nasty L-shaped laceration to her thigh. You have satisfied yourself that her joints are not involved, and an x-ray reveals no underlying fracture. You can see a large amount of debris within the wound. Her vaccines are up to date and she has no significant medical history. She is, however, eating a large ice cream cone that her parents had purchased to pacify her. You wonder how best to proceed as you have a nasty wound that needs thorough irrigation and closure. A toddler is unlikely to tolerate local anaesthetic infiltration as the primary means of anaesthetising the wound.

 

Does Kayla need procedural sedation?

Paediatric Procedural Sedation (PPS) aims to alleviate the distress around painful procedures but should not be viewed as a substitute for good pain relief. Maximize analgesia and recruit any distraction devices to hand (iPads / parents / play specialists – these are a particularly excellent resource and should be utilized wherever possible).

Is the wound suitable for ‘LAT gel’? This revolutionary gel which combines lignocaine, adrenaline and tetracaine can prevent many sedations when used correctly. It takes 30-60minutes to be fully effective after application so be sure to allow sufficient time. Even if the patient is progressing to procedural sedation this gel will help with local anaesthesia and analgesia.

The ability to perform PPS will be based on current acuity within the department, available resources, and appropriate staffing skill mix. The three main agents used for procedural sedation in paediatrics are midazolam, nitrous oxide, and ketamine.

 

Kayla’s LAT gel has been in situ for half an hour. You return to the cubicle armed with a play specialist and nurse, along with your irrigation and suturing materials. Despite a stellar sock puppet show by your play specialist, loud sing-along songs, and Peppa Pig showing on the iPad, your attempt at irrigation is futile; Kayla remains upset. You decide PPS is needed to ensure effective irrigation, neat wound closure, and avoiding further trauma to an upset child (and mother!)

 

Which agent is best suited?

You need to consider what you hope to achieve with sedation and what level of experience and resources are available currently in the department to aid in answering this question. The spectrum of use varies from diagnostic imaging, through minimally painful procedures (e.g. foreign body removal, vascular access), to painful procedures (e.g. fracture reduction, wound washout and closure). The choice of agent, therefore, will reflect the individual patient (anxiety, co-operative, parental preference), and the staff available at the time.

 

Kayla requires a short painful procedure to be carried out and nitrous oxide or ketamine would be suitable. As you start showing her the face mask for nitrous, Kayla freaks out – Kayla had a slightly traumatic experience with a bronchodilator and spacer, her mother explains. There’s no way you’re going to get Kayla to cooperate with the nitrous mask. So ketamine is selected as the agent of choice.

Just as you are about to begin the pre-procedure assessment one of the student nurses who will be observing the procedure tells you that she has seen a lot on Twitter about the new RCEM ketamine PPS guideline recently but is unclear as to exactly what ketamine is and why it’s useful in paediatrics.

 

Ketamine is an NMDA receptor antagonist. It is a dissociative anaesthetic and potent analgesic and amnesic. Rather than the typical ‘sleep‘ which results after administration of other anaesthetic agents, ketamine induces a trance-like state, oftentimes with the patient’s eyes open but ‘nobody home‘ (it is important to warn parents beforehand about this as it can be quite scary if unexpected). Some of the many benefits of ketamine are that airway reflexes are maintained, while is augmented heart rate and blood pressure (for the most part – in the compromised circulation bradycardia and hypotension can occur).

 

The pre-sedation assessment

You begin Kayla’s pre-sedation assessment. Your assessment includes a focussed history: has Kayla undergone any previous anaesthesia or PPS? If so, did she have any reactions or adverse events? Does she suffer from any chronic medical conditions, take any regular medications or have any drug allergies? Does Kayla have any concurrent medical conditions – especially active asthma, respiratory tract infection or tonsillitis?

You then examine Kayla, ensuring you conduct as cardiorespiratory exam and an assessment of her airway anatomy, including ASA grade. You need to assure yourself that no contraindications exist.

 

RCEM’s 2020 guidance is very specific about the need for conducting a thorough pre-sedation assessment, including assessing ASA grade, all of which should be thoroughly documented for clinical auditing and safety purposes. An example proforma template is provided at the end of their guideline. This contrasts with the 2016 guideline, which included a list of contraindications, but did not require documentation of ASA grade.

 

It’s time to consent Kayla and her mum for the procedure. You remember that ketamine is considered safer than other hypnotic drugs such as Propofol but need to remind yourself of the specifics, and the side-effect profile prior to consenting.

 

How safe is ketamine?

Does ketamine have side effects? Yes, but of all sedation agents studied by Bhatt et al in 2017 (6,760 patients across 5 sites in Canada), ketamine came out on top. This looked at ketamine/propofol, ketamine/fentanyl, propofol alone and ketamine alone. There were 831 adverse events across all agents (11.7%) – these included oxygen desaturation (5.6%) and vomiting (5.2%). There were 69 (1.1% of cases) serious adverse events (SAE). Ketamine as single-agent had the lowest SAEs at just 0.4%.

Pre-procedural opioids and laceration repair were associated with increased risk of emesis. Bhatt et al noted that prophylactic antiemetics reduce the risk of vomiting by half, but these were not needed in those under 5 years of age due to the low overall risk of emesis.

This endorsed previous data from a large case series by Green et al (2009) which demonstrated low rates of adverse events with ketamine PPS; most notably, noisy breathing (not requiring any intervention other than airway repositioning) occurred in 1%, laryngospasm in 0.3% and of these only 0.02% required intubation.

Both of these large studies demonstrate ketamine’s excellent safety profile when used with the appropriate preparation and patient selection.

 

Does Kayla need to have fasted?

Let’s have a look at the current guidelines and evidence. Several large studies have looked at this controversial issue: one study in a US PED in 2001/2002 where only 44% of patients met traditional fasting guidelines demonstrated no statistically nor clinically significant increase in adverse events in the unfasted population.

A series of over 30,000 children undergoing PPS by Cravero et al (2006) reported only 1 episode of aspiration – and this was in a fasted patient!

In 2016, Beach et al published a report based on 140,000 procedural sedation events, noting that aspiration was a rare event. Furthermore, they concluded that non-fasted patients were at no greater risk of major complications or aspiration than fasted patients.

In 2014 the American College of Emergency Physicians (ACEP) altered their national guidance stating that procedural sedation “should not be delayed for children in the ED who have not been fasted.” This was based on a systematic review including 3,000 sedation events showing that pre-procedural fasting failed to reduce the risk of emesis, aspiration, or other adverse events. They acknowledged that the current evidence does not support the rationale put forth in the non-emergency medicine guidelines that adherence to minimum fasting times decreased adverse events in ED procedural sedation.

 

This is reflected in RCEM’s 2020 guidance, which states that there is no evidence that complications are reduced if the child has fasted. They advised that the fasting state should be considered in relation to the urgency of the procedure, but recent food intake should not be considered as a contraindication to ketamine use.*

 

*We cheered when we read this in the 2020 guideline. No more fasting – we’ve been saying this for years! But, a quick look back at the 2016 guideline shows that this was actually the recommendation back then too. Really careful scrutiny shows that a single word, “however”, has been removed from the start of the sentence, “traditional anaesthetic practice favours a period of fasting”, altering the tone of the recommendation to a much less dogmatic mandate about nil by mouth status.

 

Satisfied that the evidence does not suggest any advantage to fasting children before PPS (who, let’s face it, tend to be less cooperative when hungry anyway), you prepare the room, staff, and equipment for the procedure.

 

Where will Kayla’s procedure be carried out, how many staff do you require, and what equipment should get ready?

 

RCEM recommends at least three operators: the proceduralist (the clinician performing the procedure), the sedationist (clinician responsible purely for managing sedation) and a sedation assistant*. They specifically acknowledge that the clinician responsible for the sedation and the patient’s airway should be experienced in the use of ketamine, and capable of managing its complications. The 2020 guideline has elaborated further on this, coming with a recommendation for a need for suitable training, a minimum of six months’ experience in anaesthesia or intensive care medicine and an up-to-date APLS course.

*RCEM says ‘nurse’ for the third member of staff but really, it’s anyone who is experienced in monitoring children and supporting the sedationist – doctors can take on this role too.

ACEP’s 2014 position statement concurs with the need for three operators.

The recommendation is that the procedure should be carried out in a resuscitation bay or high dependency area with immediate access to full resuscitation facilities.

Monitoring (every five minutes) of heart rate, blood pressure, respiratory rate, and oxygen saturation is mandated. The American Academy of Pediatrics advised the use of capnography as an adjunct in order to detect hypoventilation and apnoea earlier than pulse oximetry or clinical assessment alone. While no evidence currently shows capnography reduces the incidence of serious adverse events, available studies show a decreased incidence of hypoxia and respiratory events.

 

The use of capnography during sedation has been affirmed by RCEM who have made it a mandatory minimal requirement in their most recent guideline iteration, in parallel with their previously recommended monitoring of respiratory rate, heart rate, oxygen saturations, ECG and BP.
The 2020 RCEM guideline also includes ‘degree of dissociative sedation’ as part of its recommended monitoring during the procedure, which is a new addition to their guidance. Ketamine is unique in that it does not conform to the ‘sedation continuum’ – the patient is either dissociated or not. This recommendation is perhaps aimed at prompting the sedation clinician and nursing colleague as to whether dissociation has occurred, and as to whether a top-up dose is required (more on that later).
The updated RCEM document specifically advises having key resuscitation drug dose calculations performed prior to the procedure and ready access to these, another new addition to their guidance, although no specific drugs are recommended.

 

Some doses you may find useful are:

As you’re checking the ketamine and emergency drug doses with your nursing colleague she asks whether you want her to draw up atropine and midazolam? She is a recent addition to the ED team and mentions that when she worked in theatre some years ago they frequently gave these medications together with ketamine.

 

Should any adjunctive agents be used with ketamine?

There was a previous vogue to co-administer a benzodiazepine to reduce the incidence of emergence. A 2018 BestBets review looked at this very question by studying 6 relevant studies (including 2 RCTs: Sherwin et al 2000, and Walthen et al 2000). These failed to demonstrate a significant difference in emergence between ketamine alone and ketamine with midazolam. In fact, the only difference demonstrated was increased rates of adverse advents when a benzo was co-administered. So, no prophylactic benzodiazepine required.

Having said this, if a child suffers severe emergence (older children, in particular, have increased risk of recovery agitation), then it is worth considering midazolam (aliquots of IV 0.05-0.1mg/kg) to treat (but not routinely or for minor / moderate emergence).

Another previous trend involved the co-administration of atropine to reduce the risk of aspiration. But the evidence does not support this practice, Green et al concluded “There is no evidence to support routine use of anticholinergic medication such as atropine to prevent laryngospasm or other adverse airway events.” Concurrent anticholinergics may actually increase the rate of airway and respiratory adverse events. There is a small increased risk of laryngospasm with oropharyngeal manipulation (including suctioning) so atropine (20 micrograms/kg IV) may be considered as rescue therapy if PPS is being used for intraoral laceration repair (although RCEM would recommend not using ketamine for these procedures for this precise reason).

A common side-effect of ketamine is vomiting. RCEM’s 2020 guidance recommends the use of IV ondansetron at 0.1mg/kg (max dose 4mg) to treat intractable vomiting.

Given ketamine’s emetogenic properties, is it worth giving an antiemetic prophylactically? It is worth considering ondansetron (0.1mg/kg IV) as prophylaxis in high risk groups: those with previous nausea/vomiting during sedation/anaesthesia, older children, or IM administration. The NNT depending on age of the patient will lie between Var7 and 9. This was further endorsed by a BestBets review published in the EMJ in 2018 which concluded that ondansetron should be considered when using ketamine for PPS, especially in older children or for those receiving preprocedural opioids. As with any drug, however, you’ll need to balance the risk-benefit ratio in your mind. Some would prefer not to use ondansetron prophylactically because of the risk of arrhythmias in children with undiagnosed long QT. But, again, long QT is rare…

 

A resus bay is prepped. Kayla and her mother are ready. Roles have been allocated; your nursing colleague is ready and is just removing the Ametop from Kayla’s hands which had been applied when PPS was considered; one of the ANPs will be the procedural clinician and your consultant will supervise you as the sedation clinician. You cannulate first go, while Kayla is distracted by Peppa Pig on screen. It’s time to dissociate.

 

But what dose will you give Kayla?

Various opinions exists regarding the exact or perfect dose; the most commonly accepted dosing schedule is 1-1.5mg/kg for intravenous (IV) administration.

 

RCEM’s guideline recommends a starting dose of 1mg/kg over 60 seconds (to reduce adverse events such as laryngospasm). This can be supplemented with top-up doses of 0.5mg/kg. This has not changed from their previous guidance.

 

You should notice onset of action within a minute. It is easy to spot as the child will develop horizontal nystagmus coupled with a loss of response to verbal stimuli. The heart rate, blood pressure and respiration rate may all increase slightly. Sedation will start to wear off after 20 minutes, with full recovery should occur by about 60 to 120 minutes.

Many departments are still using intramuscular (IM) ketamine. This can be particularly helpful in certain situations such as where IV access is difficult.

 

Due to its variable onset and offset time, longer time to recovery and increased risk of emesis, however, RCEM have now advised against IM except where senior decision-makers deem it necessary. The advice is that “clinicians should be mindful of the perceived safety benefits of having intravenous access from the start of the procedure to mitigate a rare adverse event.” This is the biggest change in their new guidance; the 2016 guideline included dosing and top-up recommendations for IM ketamine.

 

There are still some children who would benefit from IM ketamine, so if choosing the IM option, consider a dose of 2-4mg/kg, with senior clinical support. Ideally IV access could be achieved once the child is dissociated and the IV top-up dose can be administered if required. However if IV access is impossible or not obtained the IM top-up dose is 1-2mg/kg. You can expect a slightly slower onset at about 3-5 minutes with its duration extended from 15-30minutes. Recovery is variable occurring anywhere between 60-120 minutes.

 

As you walk over to the drug cupboard to collect your syringes with carefully calculated doses, your consultant asks, “Are you confident in managing any potential airway complications?”

 

Airway complications with ketamine PPS

Thankfully complications with ketamine are rare. Most events such as noisy breathing or stridor, and minor desaturation will respond to simple airway manoeuvres to ensure the airway is open, plus the use of high-flow oxygen via a mask with a reservoir bag. The most feared complication, laryngospasm, is extremely rare and most often will respond to simple airway manoeuvres. But sedationists must be competent in managing this prior to administering the first dose of ketamine. If laryngospasm is suspected, stop the procedure and call for help. Ensure 100% oxygen is administered if not already in situ. Gently suction any visible secretions. If this fails to improve the situation begin manual ventilation with ventilation via a bag-valve-mask or, if you are comfortable using an anaesthetic circuit, apply PEEP. Some guidelines (and anaesthetists) suggest applying pressure to Larson’s point, very similar to performing a strong jaw thrust. If there is no response at this point, with critical airway compromise, then RSI is required. Administer the pre-calculated dose of paralytic and intubate. Remember, Green’s reported incidence of intubation secondary to laryngospasm was only 0.02%.

The flowchart below may be of benefit – it formed part of my quality improvement project on PPS and was used as a wall chart in the sedation cubicle and included in each sedation proforma booklet. When emergencies occur, being able to cognitively offload by following step by step aide memoires and having pre-calculated doses to hand can be immensely comforting and helpful.

 

 

Kayla’s procedure is completed without difficulty and the nurse enquires as to how long Kayla needs to remain monitored for?

 

Children should remain monitored until their conscious state, level of verbalization and ambulation is back at pre sedation levels. They should be able to tolerate oral fluids. Prior to discharge, a final set of observations should be within normal limits for their age. Consider the need for a prescription (antibiotics or analgesia) prior to discharge.

 

Kayla successfully underwent ketamine PPS, allowing a thorough wash out of her wound and suturing which provided a tidy end result. She was later discharged with an antibiotic prescription and a teddy which the play specialist had found in the toy room for her. Delighted with your chance to use “Special K”, you quickly took out your phone to tweet about the latest changes in RCEM guidance in ketamine for procedural sedation in children in the ED (along with the endless uses of ketamine!)

 

The new RCEM guidance has come at an interesting time – how might it change our practice in PPS in the ED? PERUKI are soon to launch a two-level paediatric procedural sedation survey (name PoPSiCLE – we all know that a good study needs a catchy name) to inform the current status and variations in the practice of PPS in PERUKI , to provide baseline information for developing a network-wide training resource and patient registry. Watch this space…

 

Case two: Ronan

 

It’s a sunny Saturday afternoon. The smell of BBQ and summer is wafting through some open windows in the department. On your way to work, you noticed plenty of bouncy castles and trampolines in use. It’s not surprising your first patient is an 8-year-old boy who has fallen awkwardly while trying to impress some other kids at his birthday party. After examining him and his xray you see he has a midshaft radius and ulnar fracture with some angulation. Thankfully his DRUJ (distal radio-ulnar joint) appears intact, and his radial head is in joint. He needs manipulation of the fractures and application of a backslab. He’s in a lot of pain, despite the paracetamol and ibuprofen he had at triage. He tells you his favourite birthday cake is at home waiting for him and he wants to get home to blow out all the candles. You wonder if you can avoid him a trip to the operating room for a general anaesthetic. Would PPS perhaps be a safe alternative?

 

Nitrous oxide provides anaesthesia, anxiolysis, and also some mild amnesia. However, it offers limited analgesia and so co-administration of an analgesic is recommended. Several key papers, including the FAN study (2017) and Seith et al (2012) have demonstrated the safety and efficacy of co-administrating intranasal fentanyl (INF) with nitrous oxide.

Once you’re ready to go, move the child into the dedicated resus bay or sedation room. If using piped nitrous oxide with a variable concentration flow meter (ensuring the scavenging system is switched on) titrate the dose from 30-70% according to clinical response. The alternative is Entonox (a 50/50 mix of nitrous and oxygen) which usually comes in portable canisters but requires the child to be able to take a deep breath to overcome a demand valve circuit, usually tricky for the under-fives. You should notice the onset of effect in 30-60 seconds, but its peak effect will be 2-5 minutes so best to wait for this before commencing the procedure. Once the intervention or procedure is completed it is important to administer 100% oxygen for 3-5minutes post-procedure to avoid diffusion hypoxia. The offset of effects should occur within 2-5 minutes.

Does nitrous oxide have any side effects? While well tolerated by most children, transient minor side effects such as nausea, dizziness and occasionally nightmares can occur. It can cause vomiting in 6-10% of children receiving 50% nitrous dose. This rate increases with higher concentration and can increase up to 25% if an opioid is co-administered. Be sure to warn parents about this relative frequency of vomiting when using nitrous oxide, both during and after sedation. The risk of vomiting also increases with a longer duration of nitrous administration. Consider a prophylactic antiemetic if the child has a history of nausea or vomiting.

Nitrous oxide diffuses through tissues more rapidly than nitrogen alone and can expand in air-containing spaces within the body. This makes it contraindicated for use in patients with gastrointestinal obstruction, pneumocephalus, pneumothorax and after diving.

Nitrous oxide inactivates the vitamin B12-dependent enzyme, methionine synthase, and so can deplete vitamin B12 stores. Because of this, caution is advised in those at risk of vitamin B12 deficiency such as vegetarians, patients with gastrointestinal disorders and those taking regular H2 receptor blockers and proton pump inhibitors. Nitrous should also be avoided in those with metabolic diseases especially methionine synthase deficiency, methymalonic acidaemia, and homocysinuria (because inactivation of methionine synthase can affect homocysteine metabolism). There’s a theoretical risk to pregnancies in the first trimester and so guidance often suggests avoiding nitrous oxide exposure in early pregnancy.

During administration monitor heart rate, respiratory rate and oxygen saturations. At least two staff members are required; a sedationist and a proceduralist.

 

Ronan and his mum are happy for you to use nitrous oxide and eagerly his mum signs the consent form. While setting up the sedation room and recruiting a nursing colleague to assist, you administer intranasal fentanyl. Ronan successfully undergoes manipulation of his fractures and an above elbow backslab is applied. His post-reduction x-ray shows you performed a pretty awesome reduction and, in consultation with your orthopaedic colleagues, you are happy for Ronan to be discharged to return to their fracture clinic in a few days’ time. This delights Ronan, as he gets to return home to his birthday party (with strict instructions to remain off the trampoline) and he promises to bring you back some of his birthday cake later!

 

 

Case three: Chantelle

Your junior colleague has come to you for advice. She has just seen a 4-year-old girl who was hard at work in her playroom creating unicorn pictures. Her mum had given her lots of colourful supplies including some glittery sequins and beads. Chantelle became adventurous and decided to decorate herself rather than the unicorns. Unfortunately, one of the beads has become lodged in her ear and despite an attempt by your colleague using both parents, and a play specialist, the removal of the foreign body was unsuccessful. You believe the use of PPS will be required and begin pondering which agent to use.

 

Midazolam is a hypnotic agent providing anxiolysis and amnesia. It does not have analgesic properties, which is why it is important to co-administer with analgesia for any painful procedure. It can be administered by many routes, the two commonest for PPS being intranasal (IN) and orally. If used intranasally, a dose of 0.3-0.5mg/kg is suggested. You should notice its onset within 10-15 minutes, lasting about 60 minutes. This route of administration can cause some nasal irritation and burning, so some clinicians prefer to use it orally. With an oral dose of 0.5mg/kg you should notice onset at 15-30 minutes with a duration of effect for 60-90 minutes. Midazolam tastes bitter – so give it with some juice or squash to make it more palatable. Midazolam can be given intramuscularly (IM) and intravenously (IV), but it is less likely to be used in this fashion for PPS.

Does midazolam have any side effects? Yes! It can cause hypoventilation and apnoea – be aware that this risk is increased if co-administered with an opioid such as fentanyl or diamorphine. A reversal agent does exist: flumazenil (0.01mg/kg, max dose 1mg) but this is rarely required, and oftentimes using basic airway manoeuvres is sufficient. Paradoxical excitatory or agitation reactions can occur in up to 15% of children. Do warn parents of this possibility prior to administration. The best course of action if it does occur is to let the child “ride it out”. Because of this, many ED clinicians will choose ketamine or nitrous oxide as their PPS agent of choice over midazolam.

With these side effects in mind, it is prudent to ensure basic monitoring includes heart rate, respiratory rate, and oxygen saturation monitoring. At least two staff are required; proceduralist and sedationist.

 

Having obtained informed consent from Chantelle’s mother, you decide to give her intranasal midazolam. 45 minutes later you remove the mischievous bead from her left ear. Her parents are thrilled, but before you leave the room you remember the mantra of “always check the other ear”. So before packing up your tools and leaving her with your sedation nurse, you decide to check her other ear. Interesting you find two glittery sequins hiding in her right ear canal. Phew, that saved a second sedation event!

 

References

Ketamine Procedural sedation for children in the emergency department. The Royal College of Emergency Medicine. Best Practice Guideline. February 2020.

Bhatt M, Johnson DW, Chan J et al. Risk factors for adverse events in emergency department procedural sedation in children. JAMA paediatrics 2017 Oct 1;171(10):957-964

Bhatt M, Johnson DW, Chan J et al. Risk factors for adverse events in emergency department procedural sedation in children. JAMA paediatrics 2017 Oct 1;171(10):957-964

Green SM, Roback MG, Krauss B, et al. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med. 2009; 54(2):158-168.e1-4

Agrawal D, Manzi S, Gupta R, Krauss B. Pre-procedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a paediatric ED. Annals of Emergency Medicine. 2003; 42(5): 636-646

Cravero JP, Blike GT, Beach M, et al. Incidence and nature of adverse events during pediatric sedation/ anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006; 118(3):1087-1096

Beach ML, Cohen DM, Gallagher SM, Cravero JP. Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room: A Report of the Pediatric Sedation Research Consortium. Anesthesiology 2016;124(1):80-8

Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine 2014;63(2):247-58.e18

Sherwin TS, Green SM, Khan A, et al.Does adjuctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomised, double-blind, placebo-controlled trial. Ann Emerg Med 2000;35:229–38.

Walthen J, Roback M, Mackenzie T et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in Children? A double-blind, randomized, controlled, emergency department trial. Annals of emergency medicine 2000;36(6): 579-587

Green SM, Roback M, Kennedy R et al. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Annals of emergency medicine 2011; 57(5): 449-461

Dunlop L, Hall D. Antiemetic use in paediatric sedation with ketamine. Emerg Med J 2018; 35:524-525

Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006;367(9512):766-80

Nickson C. Paediatric Procedural sedation with Ketamine. Life in the Fast Lane. March 2019

Zier ZL, Liu M. Safety of high concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases. Pediatr Emerg Care. 2011 Dec;27(12):1107-12

Gamis AS, Knapp JF, Glenski JA. Nitrous oxide analgesia in a pediatric emergency department. Ann Emerg Med. 1989; 18:177-181

Comfort Kids Programme. Royal Children’s Hospital Melbourne. 2016

Peyton PJ, Wu CY. Nitrous oxide-related postoperative nausea and vomiting depends on duration of exposure. Anesthesiology. 2014;120(5):1137–1145

Baum VC. When nitrous oxide is no laughing matter: nitrous oxide and pediatric anesthesia. Paediatric Anaesthesia 2007;17(9):824-30

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence.: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, 2005

Axelsson G, Ahlborg G, Jr., Bodin L. Shift work, nitrous oxide exposure, and spontaneous abortion among Swedish midwives. Occupational & Environmental Medicine 1996;53(6):374-8

Hoeffe J et al. Intranasal fentanyl and inhaled nitrous oxide for fracture reduction: The FAN observational study. Am J Emerg Med. 2017;35(5):710-715.

Seith RW, Theophilos T, Bable FE. Intranasal fentanyl and high-concentration inhaled nitrous oxide for procedural sedation: a prospective observational pilot study of adverse events and depth of sedation. Acad Emerg Med. 2012;19(1):31-6

Kennedy RM, Porter FL, Miller JP, Jaffe DM. Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies. Pediatrics. 1998;102:956–63

Pena, B.M. and Krauss, B. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med. 1999; 34: 483–491

Wright, S.W., Chudnofsky, C.R., Dronen, S.C. et al. Midazolam use in the emergency department. Am J Emerg Med. 1990; 8: 97–100

Davies FC, Waters M. Oral midazolam for conscious sedation of children during minor procedures. J Accid Emerg Med. 1998;15(4):244–248. doi:10.1136/emj.15.4.244

Graff, K.J., Kennedy, R.M., and Jaffe, D.M. Conscious sedation for pediatric orthopaedic emergencies. Pediatric Emerg Care. 1996; 12: 31–35

Bailey, P.L., Pace, N.L., Ashburn, M.A. et al. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology. 1990; 73: 826–830

Gregory GA. Pediatric Anesthesia. 4th ed. Philadelphia, PA: Churchill Living- stone; 2002

 

Taking your trauma team to the next level: Anna Dobbie at DFTB19

Cite this article as:
Team DFTB. Taking your trauma team to the next level: Anna Dobbie at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22066

Anna Dobbie works in HEMS, PEM, and Adult ED and is a badass at all of them. She is the person you’d want leading your trauma team. Want to be just a little more like Anna? Then watch her talk and find out how to step up.

As we are so fond of saying, “You set the tone.” That first two minutes of any resus is critical – and not just because of the decisions you make. If you can appear calm and in control, your teams’ actions will reflect that. Running every trauma call the same allows for cognitive off-loading as some behaviours become automatic. Whether they are ‘real’ calls or not so serious ones the team is expected to act the same either way.

 

 
 
DoodleMedicine sketch by @char_durand 
 

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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How to be an LGBTQIA+ young persons ally

Cite this article as:
Dani Hall. How to be an LGBTQIA+ young persons ally, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23101

You know what the rainbow symbol is, right? It’s become synonymous with LGBT+ identity, solidarity and support and from Pride week to day-to-day living you’re likely to spot one fairly regularly. But, you probably also know that LGBT+ people are a minority group within our society, with huge inequalities in provision of healthcare, which is tragic given that this group have huge healthcare needs. As a step towards tackling this, national health services like the NHS and HSE (Ireland’s health service) have incorporated the rainbow with their logos and put them on a pin to show that the wearer is an LGBT+ ally, someone who an LGBT+ person can feel comfortable talking to about issues relating to sexuality or gender identity, someone who will listen to them with respect, someone who’ll create a safe space for discussion.

 

If you’re reading this post, you’re probably an advocate for LGBT+ rights. You might even have an NHS or HSE rainbow badge. Great! But wearing a badge is only one step towards being an ally. The wearer must feel confident that they will treat the young person with respect and that they’ll know what to do if a young person discloses to them. The wearer may be the first person a young person has ever felt confident enough to open up to about how they feel; it may be one of the most important moments of that LGBT+ young person’s life.

So, how can you be an LGBT+ young person’s ally?

You don’t need a rainbow badge (of course you don’t) to be an LGBT+ young person’s ally. But there are a few things that will help you on your way.

First, you need to understand what LGBT+ means.

Let’s start with some definitions.

 

+: inclusive of all identities (queer, questioning, intersex, asexual, pansexual amongst others), regardless of how people define themselves.

There are some key definitions of sexual and gender orientation and expression. Let’s go through them:

Sexual orientation is a description of who we are attracted to romantically or sexually, such as lesbian, gay, bisexual, asexual, heterosexual.

Gender orientation describes an internal sense of being male, female, neither or both, a psychological sense of who we are and who we feel we are.

Transgender: a person’s gender identity is different from the gender they were assigned at birth.

Cisgender: a person’s gender identity matches the gender they were assigned at birth.

Non-binary: a person who doesn’t identify as exclusively male or exclusively female.

Gender expression is a description of how we portray ourselves to the world; how we act, speak, talk and dress. It ranges from feminine, through androgynous, to masculine.

These definitions are explained perfectly by the Genderbread person.

 

By Sam Killerman from itspronouncedmetrosexual.com

 

OK. So you know a bit of the lingo. What can you do to be an LGBT+ young person’s ally?

 

Don’t make assumptions

We live in a heteronormative environment (where being heterosexual is considered the norm) and people often make heteronormative assumptions. This means we may make an unconscious assumption that heterosexual is ‘normal’ without even realizing we’re doing it. The example on HSEland’s LGBT+ Awareness and Inclusion e-learning module is a classic example of this…

Katy is an 8-year-old girl who has been brought to the emergency department by her two mum’s, Jill and Freda. She’s called into triage and, after inviting them to sit down, the triage nurse asks, “Which one of you is Katy’s mum?” Jill replies by saying, “Actually, we’re a family with two mothers.”

The triage nurse made a heteronormative assumption here. A more inclusive approach would have been for the triage nurse to ask Katy to introduce each of the ladies accompanying her. But, until we can shake heteronormative assumptions, it can be easily done; if you do make a heteronormative assumption, apologize and move on. And make an effort not to make a similar mistake next time.

Another assumption that’s often made is about a young person’s sexual identity based on their sexual behaviour.

Suzy is a 15-year-old girl who attends the emergency department with abdominal pain and dysuria. Her urine sample is dipped – no nitrites or leucocytes, but her beta-HCG is positive. She’s pregnant. With this information in hand, you go in and, after some gentle questioning (you’re pretty good at building rapport), you ask her how old her boyfriend is.  She looks at you with disdain and replies, “I don’t have a boyfriend.” Blustering a little, you ask whether she and her boyfriend have broken up. “I’ve never had a boyfriend,” she replies.

Suzy is attracted sexually and romantically to girls and has a girlfriend called Melissa.  And you’ve just lost her trust by assuming she was straight.  Adolescent lesbian and bisexual girls are also at risk of unintended pregnancies and acquiring sexually transmitted infections.

Yet another assumption people make is cis-normativity, the belief, or unconscious assumption, that that it is ‘normal’ to be cis-gendered.  It’s explained all too well by Emily, an 11-year-old transgender girl in the Mermaid’s #IfIHadAVoice video.

 

 

Once you feel you can actively make an effort not to make any assumptions, what else can you do to be an LGBT+ young person ally?

 

Use inclusive language

It can feel artificial to start with, but try and break the heteronormative barrier and ask a young person what their chosen gender or pronouns are.

Samuel is a transgender boy. His assigned gender at birth was female and the name on his birth certificate is Samantha. He has breast buds and looks feminine. You introduce yourself to Sam and his mother, Sandra, but as you’re explaining to Sandra that you’d like to speak to Sam alone, you say, “Would you mind stepping outside the room, while Sam and I speak together first? I’ll call you back in after I’ve examined her.” Sam looks stricken and Sandra gently explains that Sam is a transgender boy and uses the pronouns he/him.

If you accidentally misgender someone, apologize and correct yourself.  We often don’t know what name or pronouns someone would like us to use, and it’s safest to assume nothing and ask (and I mean ask everyone, because you will be caught out if you don’t), “How would you like us to record your details in the medical record?”

What about sexual orientation?  A sensitive way to ask a young person about their sexual identity is to ask if they have a partner or if they’re in a relationship. If they don’t have a partner, ask them if they’re attracted to boys, girls, either or neither.  Let’s think about Suzy again.

You’re about to see Suzy, a 15-year-old girl who attends the emergency department with abdominal pain and a positive urine beta-HCG. You call her into a cubicle and introduce yourself. After taking a history of her presenting complaint and past medical history, you start a HEEADSSS assessment (more on that later). Even though you know Suzy is pregnant, you know it doesn’t mean she’s heterosexual. As you start talking with Suzy about sexuality and gender identity, you ask her, “Are you attracted to boys, girls, neither or either?”

See what you’ve done here? Suzy can now tell you that she’s in a relationship with Melissa without breaking that rapport you’d already established, paving the way for further exploration about her sexual behaviour.

 

Reassure the young person their sexual or gender identity will be kept confidential

Let’s take a step back in time. Suzy may not feel comfortable telling you about her sexual orientation as she might be worried about whether you’ll keep this information confidential. Confidentiality is a huge one. We may feel torn between sharing information about a young person who’s at risk and maintaining confidentiality. Before you start taking a history, explain to a young person that anything you discuss will be kept confidential and private, between the young person and the team looking after them, but if you discuss anything really serious, like suicide or that someone was abusing them, then you’ll come up with a plan together to get the help needed. But, and this is an important but, even if there’s something that you need to seek help for, you’ll keep their sexual or gender identity confidential if this is what they want – this is private to them and you shouldn’t be outing the young person against their wishes.

 

Adapt the HEEADSSS assessment

We mentioned the HEEADSSS assessment.  HEEADSSS is a structured psychosocial history tool.  But when you use it, adapt it.

 

H: Home environment

Up to 40% of young people experiencing homelessness internationally are LGBT+ with figures estimated to be as high as 45% in Canada and 24% in the UK, with similar patterns reported in Ireland. A report by the Albert Kennedy Trust found that more than two-thirds of LGBT homeless young people in the UK have experienced familial rejection, abuse and violence and shockingly almost 1 in 10 16 and 17 year olds have undergone or been offered conversion therapy.

E: Education / Employment

Bullying is rife in schools. 1 in 2 LGBT+ young people in the UK and Ireland experience anti-LGBT bullying at school while 1 in 4 Irish LBGTI young people skip school to avoid anti-LGBTI bullying.

E – Eating disorders

Eating disorders are sadly also much higher in LGBT+ young people. Transgender young people are 4 times more likely to have an eating disorder compared to their cisgender peers. That’s 15% of transgender young people of any sexual orientation reporting an eating disorder (data from a national sample of almost 300,000 young American students). But it’s not just transgender young people at risk of eating disorders: any LGBT+ young person is at higher risk of an eating disorder of any type.

A – Activities

Enquire about activities. LGBT+ young people are less likely to participate in sports  than their heterosexual peers. Enquiring about their leisure time may reveal risk-taking behaviour (we’ll come to that under S for Safety).

D – Drugs and alcohol

Drugs and alcohol are also a problem for LGBT+ young people. Not only are LGBT+ young people more likely to use drugs and alcohol than their heterosexual peers, LGBT+ people under the age of 13 are more likely to have tried alcohol or marijuana than heterosexual young people aged 12 and under.

S – Sexuality

LGBT+ young people are more likely to have had sexual intercourse, have had sexual intercourse before the age of 13 and less likely to use birth control than their heterosexual peers. Birth control, that’s a big one. Remember I said earlier that teen pregnancy occurs in lesbian teenagers just as it does in cis-gendered adolescent girls? The same is true for STIs. I don’t need to say that questions around sexuality and gender identity must be asked sensitively, in a non-judgmental way, without assumption, about sexual identity and gender identity.

S – Suicide, depression and self-harm

It’s widely quoted, but mental health difficulties are much higher in LGBT+ young people, very likely related to a feeling of isolation and non-inclusion and as a result of verbal and physical abuse. More than 50% of Irish LGBTI young people aged 14-18 have self-harmed; 2 in 3 have seriously considered ending their life and tragically 1 in 3 have attempted suicide. The most common age for an Irish LGBT person to attempt to take their life is 15. These are shockingly high. But Irish LGBT+ young people mental health statistics mirror those across the world, in the UK, Australasia and North America.

S – Safety

Being LGBT+ can be lonely. LGBT+ young people are more likely to use dating apps to meet people.  You can just imagine the risk this exposes them to: unsafe sexual encounters, child sexual exploitation, and grooming. Statistics support this. These young people are more likely than their heterosexual peers to be physically or sexually assaulted.  Risky behaviour doesn’t end there. LGBT+ young people are also more likely to undertake another risky behaviour, such as not wearing a seatbelt.  Gently explore risk-taking behaviour.

 

I ask myself, “Why are all these problems seen in young people with an LGBT+ identity?” It’s likely due to minority stress – the stress associated with being treated as a minority group within our society.

 

Be an ally

Knowing the different LGBT+ terms isn’t important. What is important is listening with respect, not making assumptions and creating a safe space for discussion. An ally supports equal rights for LGBT+ people and let’s face it, we’re in healthcare because we want to help people. Healthcare is for everyone.

You may be the first person an LGBT+ young person meets in their acute healthcare. You may be the person they confide in. Their interaction with you may be one of the most important moments of their life

 

 

Where can I find out more?

Watch:

Thom O’Neill’s Be a supr doc for LGBT+ youth, SMACCDub

Aidan Baron’s Crash course in LGBTQI+, DFTB17

Read:

Butler G et al. Assessment and support of children and adolescents with gender dysphoria. Arch Dis Child 2018; 103 (7): 631-636

O’Neill T, Wakefield J. Fifteen-minute consultation in the normal child: Challenges relating to sexuality and gender identity in children and young people. Arch Dis Child Educ Pract Ed 2017; 102: 298–303

Salkind J et al. Safeguarding LGBT+ adolescents. BMJ 2019;364:l245

 

 

Selected references

Charlton BM et al. Teen pregnancy risk factors among young women of diverse sexual orientations. Pediatrics. 2018: 141(4); e20172278

LGBT youth homelessness: a UK national scoping of cause, prevalence, response, and outcome: the Albert Kennedy Trust, 2015

UK Government Equalities Office. National LGBT Survey: Research report. 2018. https://www.gov.uk/government/publications/national-lgbt-survey-summary-report

Higgins et al. The LGBTIreland Report: national study of the mental health and wellbeing of lesbian, gay, bisexual, transgender and intersex people in Ireland. 2016. GLEN and BeLonGTo

Diemer EW et al. Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. J Adolesc Health 2015;57:144–9.doi:10.1016/j.jadohealth.2015.03.003

Kann L et al. Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9-12 – United States and selected sites, 2015. MMWR Surveill Summ. 2016;65:1–202

Calzo JP et al. Eating disorders and disordered weight and shape control behaviors in sexual minority populations. Curr Psychiatry Rep. 2017; 19(8): 49

School Report. The experiences of lesbian, gay, bi and trans young people in Britain’s schools in 2017. Stonewall.

Bidell MP. Is there an emotional cost of completing high school? Ecological factors and psychological distress among LGBT homeless youth. Journal of Homosexuality. 2014:61(3);366-381

Abramovich IA. No safe place to go: LGBTQ youth homelessness in Canada: reviewing the literature. Canadian Journal of Family and Youth. 2012:4(1);29-51

https://www.hse.ie/eng/services/list/4/mental-health-services/connecting-for-life/publications/lgbt-ireland-report.html