COVID Clinician Care

Cite this article as:
Tessa Davis. COVID Clinician Care, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24454

As front-line healthcare professionals we are all feeling the pressure. Trying to balance our professionals responsibilities and our personal lives is something we have been doing for a long time, but we have never had to do it like this before.

On 30th March 2020, DFTB gathered together a panel of experts – all of whom are people I personally love as humans and wellbeing experts. We are honoured that they all said yes and joined our panel. And I was lucky enough to join them too.

We have recorded the session and are delighted to be able to share it here. Please send it to your colleagues and get in touch with any thoughts. We hope to run another one soon.

Our three key take home messages were.

 

1. Be a boundary ninja

Make sure your time off is really time off – but convey that in a kind way to your colleagues. You don’t need to be trolling through your Twitter Covid feed in the evening at home. It’s hard to switch off, but we need to try. Like many I have been dreaming about Covid every night for the last two weeks. In fact, one night last week I woke up from my dream coughing in the middle of the night (and I do not have a cough). I’m not normally an anxious person at all and yet I somatised in my sleep. We are all feeling some anxiety, stress, and worry. Set some boundaries on how much screen time you have, mute all the WhatsApp groups, and stop checking your email when you don’t need to. Importantly value the time you have with you family – you need to nurture these relationships even more so now.

 

 

 

2. Connect, connect, connect

In all the uncertainty, change, and chaos, connection can remain. Connect with your colleagues, and make time to connect with your friends. It’s easy to get bogged down in PPE or pathways (of course these are important), but remember that we are in this together. Whether we live in the UK or Australia, whether we are a doctor or a cleaner, we are all fearful – for ourselves and our families. Take time to ask your colleagues how they are really doing.

 

 

 

3. Have a quality recharge

Savour the things that are good, and make sure your down time is good time. Think about the things that nourish you and do them. Knit, dance, sign, build something with lego, do a jigsaw puzzle. Find whatever it is that will make you feel recharged.

And the final practical nugget from Alys Cole-King was to have and store a happy memory. Take a moment when you are feeling stressed or overwhelmed to recall it in as much detail as possible. Think about what happened, how it smelled, what you were wearing, what the weather was like. Bring yourself back there, and immerse yourself in it for a moment. Here’s mine. Our first day when we arrived in Australia after moving from the UK in 2011. We took our (then) two tired, jet-lagged kids and went straight from the airport and took them to Bondi Beach. I was 26 weeks pregnant with our third child. The wind was blowing, it smelled of Bondi, and possibility lay ahead. The picture is grainy. My memory of it is crystal clear. Thanks Alys (and all the panel).

 

Enjoy watching the session.

 

For those short on time or who want a refresher, here is Grace Leo’s take on the panel in comic form:
Here is a link to a PDF download of the Comic:

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

DFTB COVID Global Meetings

Cite this article as:
Tessa Davis. DFTB COVID Global Meetings, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24108

The DFTB team has organised a series of online meetings in March. These meetings have the aim of connecting the paediatric emergency medicine communities – in the UK, in Aus/NZ, and globally.

The meetings are being recorded and will be accessible to those who registered. They are password protected.

If you would like to request access to any of the meetings, please register. The form to register is at the bottom of this page.

 

UK PEM Meeting – Thursday 25th June 2020

If you registered you can watch the videos here:

 

 

 

UK PEM Meeting – Thursday 14th May 2020

If you registered you can watch the videos here:

 

UK PEM Meeting – 17th March & 8th April 2020

If you registered you can watch the videos here:

8th April 2020

17th March 2020

See Grace Leo’s fabulous summary:

 

 

Clinician Care – 30th March 2020

Watch our recording right here.

 

Global PEM Meeting – 24th March 2020

See Grace Leo’s fabulous summary:

If you registered you can watch the video here:

ANZ PEM Meeting – 19th March 2020

See Grace Leo’s fabulous summary:

And if you registered you can watch the video here:

 

 

Register here to access the recordings:

To be able to register you will need a healthcare associated email address

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

More questions than answers

Cite this article as:
Andrew Tagg. More questions than answers, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24133

Given the rapidly changing climate for all things COVID19 the DFTB wanted more information. We know our strength is in our community so we hosted a series of webinars linking healthcare workers with a special interest in paediatrics. No one person is an expert but we are all in the same situation facing similar challenges. These are some of the questions that came out of the discussions. With the proviso that information is changing on a daily basis and resources in terms of staff, space and stuff is different, let’s dive in.

This data is correct as of 19th March 2020. Please let us know in the comments if you spot anything new.

Science

NSAIDs

There has been a suggestion that non-steroidal agents are unsafe for use in SARS-CoV2-19 patients. As we have already seen the evidence for anything in the paediatric realm is very slim.  However, as of the 17th of March 2020 the WHO has recommended against using ibuprofen in patients with symptoms suggestive of COVID19. What does this mean in real terms? We don’t know which children are asymptomatic carriers.

If you look at the source of the message it is even more striking – the French health minister suggested that anti-inflammatory drugs could exacerbate symptoms. He suggested that we should not prescribe NSAID’s or cortisone/steroids to patients with suspected COVID19. Given that one of the few drugs that work in one of our more prevalent respiratory diseases, croup, is a steroid then I think we need to look to more evidence of harm over benefit. If you want a great, easy read on the matter then check out fullfact.org.

ACE-I

Very little is known on the potential impact of ACE inhibitors on COVID19 in adults, let alone children. The Venn diagram of children with the disease and on perindopril (say) is represented by two separate and distinct circles at the moment. If you are curious as to how there may be an interaction then read this great Tweetorial from Jonny Wilkinson.

It is also worth taking a looking at this letter in the Lancet to better understand the theory.

Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?. The Lancet Respiratory Medicine. 2020 Mar 11.

Vaccines and various treatments

To claim that there is a cure just around the corner or that a certain combination of vitamins and herbs will keep the virus away is pure quackery. Rather than tell you what research is going on then dashing your hopes when there is a negative outcome we’ll reserve our judgement at this stage.

 

Sorting and Streaming

A common challenge mentioned by all sites is just how do we triage? How do we sort patients so that we are not mixing potentially infected with non-infected patients? There cannot be a one size fits all approach as the needs of a single provider clinic are every different from those of a district general hospital and these are very different from a tertiary paediatric centre. Rural and remote populations have different resources to the big, shiny hospitals complete with fish tanks and meerkat enclosures.

Triage

A number of hospitals are using a concierge based approach. As a patient approaches the department they are met by a greeter (who is usually a member of the nursing staff), dressed in full PPE. They help determine the first decision point – possible COVID19 or unlikely COVID19. The latter group is pretty easy to spot. Determining what patient sub-types fall into the former is more of a challenge. In the initial phase of the disease, most hospitals have looked for the presence of respiratory symptoms PLUS a fever. If you look at the published and pre-print paediatric data around 2/3 of children with the disease have a fever and a large proportion appear to be asymptomatic. A number of patients also present with predominantly GI symptoms. Should they be treated as potential carriers? (And who should change their nappies given they can shed SARS-CoV2-19 for up to 40 days?)

An alternative triage approach utilizes a more 21sst century solution with carers/patients logging important information on a tablet-style device before their secondary medical triage. This would require the user to clean the interface after use – something that is already tough.

Children with special medical needs

There is insufficient data to make hard and fast rules about the management of children with complex healthcare needs. Adults with multiple comorbidities have increased mortality so it is biologically plausible that the same will hold true in the paediatric population. Pre-notification of attendance can help as these kids are brought in via a different entrance.

Many places are trying to replace standard outpatient visits with telehealth options on an ad hoc basis with little guidelines available on how to do this without just picking up your own mobile phone. This is not an ideal solution but is being offered to many children with diabetes, chronic respiratory conditions or children with rheumatological conditions requiring immunosuppressive agents.

The RCPCH recommends that children who have an exacerbation of their chronic respiratory illness and require admission should be considered to have COVID19 until proven otherwise.

Internal streaming

Once the children have been streamed into a respiratory disease cohort should we assume they all have COVID19 until proven otherwise? Should we treat the patient with clinical bronchiolitis or croup as a potential carrier? And what about those that are wheezy but don’t have a fever? Just what do we do then?

The number of critically ill children presenting to the ED is likely to be small but it has been suggested that these are rapidly assessed and transported to a negative pressure room in PICU for the full workup, whether they need intubation or not.

Testing

Children do not come into the hospital on their own. They often bring carers, parents, grandparents, aunts and uncles. Adjusting the policy on attendant carers is a tough sell to those that are looking after the potentially infected child. Most mixed EDs seem to be keeping the family unit together for testing. It would be interesting to know if any tertiary paediatric centres are testing the grown-ups that come with the children.

Just how accurate is the PCR test? And just how long does it take a result to come back? We are looking into the former question and can sense the frustration around the latter. Cohorting patients in negative pressure rooms just waiting five days for a swab result is not helping us clear the decks. We should be mindful, though, that there are things we can control and things we cannot. This is one of those things we have no control over at the moment.

Mixed departments

Most of us do not have the luxury of working in a tertiary paediatric centre where the only adults are dressed as clowns or doctors (or doctor-clowns). Some departments are making provisions by moving their paediatric space to allow for adult overflow. The RCPCH has also stated that paediatricians should be prepared to see patients up to the age of 25. That makes sense in a mixed environment but one wonders what happens in centres that do not routinely see any adults. With outpatients and elective surgery being cancelled across hospitals, there is a potential surfeit of doctors with markedly reduced day to day work.

There is also the question of what happens in adult hospitals when a COVID19 positive sole parent gets admitted. What happens to their swab-negative child? In some cases, the decision has been to treat them as a boarder but this can make many staff members feel uncomfortable.

Sicker children

At the time of writing this the mortality in children is exceedingly low. This is very reassuring but business will continue as usual. Treatment options may be limited dependent on restrictions with regard to aerosol-generating procedures. There have been mixed messages as to whether nebulization of medication. leads to increased healthcare worker risk. Some places are now controlling the use of nebulized treatment, as well as mandating consultant approval of high flow nasal cannula oxygenation. In centre without access to a PICU on-site how are these children being managed? What have measures have paediatric retrieval services put in place to deal with the potential increase in referrals?

Intubation teams are already being considered at a number of sites – teams of doctors, similar to a MET team, that are ready to provide critical care at the sound of a bleep, in the hope that this will reduce exposure to one of the highest risk aerosol-generating procedures – intubation. In mixed adult/paediatric hospitals it is also important to consider the implications of intubation in a resource replete setting. Some hospitals are starting to consider this and set up ethics committees to set rules early and consider just who should have access to that last ventilator. The decision is not as easy as you think.

 

Stuff

Personal protective equipment

There have been some mixed messages about what type of PPE should be worn in what scenario.  Public Health England has this handy table to guide you and, as always, be mindful of your local guidelines if they differ.

Some hospitals are requiring all healthcare providers to undergo mandatory, face-to-face training in donning and doffing PPE prior to deployment. It has been suggested that we should wear the highest standard of PPE for every encounter in order to present nosocomial transmission. Unfortunately, supplies are limited and so we should use the most appropriate PPE for the task in hand.

Aerosol generating procedures

There seems to be a lot of confusion about what an aerosol-generating procedure is. As always, it is important to follow your local clinical guidelines. But if you disagree with them, then let the evidence guide you, and seek to change the guidelines. Concerns have been raised about everything from just examining the throat, using nebulizers (a daily question), and whether we should be using HME filters on the Neopuff. Rest assured we are looking at this and a blog post will follow.

 

Staffing

Rosters

We are already overstretched – both on the floor and in the back office. Corona conditions are making this even more apparent as we are wondering whether we should stretch our elastic workforce just that little bit more before the wave hits so that we have a rested and well cohort, ready to go. Those of us that work in mixed EDs know that paediatric workforce planning is furthest from our minds as we read of the Italian situation.

Should (when?) the pandemic stretch on for months considerations need to be given to staff longevity. Will there be a burnt-out generation of ED physicians who have seen and been exposed to too much? What about those who have had much-needed leave cancelled? Perhaps some of the daily load can be taken up with doctors from those specialities who have a lower case burden? Orthopaedic registrars could oversea minor-injuries clinics in a remote location. Dermatology trainees could answer the question of “What on earth is that rash?” in a medical/non-COVID assessment area?

Healthcare workers that work across sites are already being asked to reduce cross-campus travel.

Though we go to work for our patients we also need to be mindful that we too may become patients. None of us is immune to catching the disease. In its mild form, it will be an inconvenience to us, our loved ones, and our colleagues. But healthcare workers will die. Healthcare workers have already died. How do we mitigate the risks for the more vulnerable? What should we do with the older, more at-risk, paediatrician, the immunosuppressed healthcare worker, the pregnant trainee? These are questions that have not yet been answered.

Everyday life

As we are being asked to work longer hours how many hospitals have made provision for routine, everyday tasks? How many have designated areas for staff to catch some sleep before driving home? How many are providing scrubs for staff to change into or are helping with the laundry? The last thing most of us feel like when we get home is loading up the washing machine (and then putting it out to dry. But how clean are your everyday clothes? Your stethoscope? Your phone?

How are workplaces supporting that other basic physiological need – food? With supermarkets reducing their opening hours how are healthcare workers being supported? McDonald’s in the UK is offering free drinks to those with NHS cards but you can only last so long on caffeinated brown water.

Information dissemination

The situation with SARS-CoV19-2 is a rapidly evolving one with advice changing on a daily basis. Most hospitals have set up incident management teams that meet at an executive level to discuss the changes that may impact our day to day – cancelling elective surgery, moving departments. Making sure that information trickles down from an operational level to a clinical level can be hard, especially with a workforce that might be relying on bank or agency staff. A lot of departments are trialling WhatsApp groups as a means of sharing the very latest information but it is still possible for a key piece of information to be lost in the stream.

Education

Most hospitals have now cancelled face-to-face education sessions. There are plenty of of resources available to help educators plan sessions remotely. This series from ALiEM is the standout.  The DFTB team hope to be adding more resources for you shortly (especially if we get put in isolation).

Students

A number of universities have pulled their students from clinical placements or placed restrictions on their interactions with patients e.g. not to see a respiratory patient. Many feel that they should be doing something and a number of great initiatives have been suggested. One group has launched a childcare service for healthcare providers. With schools in the UK due to close early for the Easter break this will come as a welcome relief to many who may usually rely on (at-risk) relatives. It has also been suggested that they would make excellent scribes to speed up the standard clerking process. Let us know what else is going on.

Morale

At the moment we are all nervous anticipation, stepping over wavelets or paddling our boards out ready to catch the big wave. This sense of nervous excitement is palpable in the emergency room. The feeling getting is getting stronger as regular hospital services wind down. How do we maintain our own morale in the face of hard shifts? How do we look after each other when a colleague gets ill? How do we make sure that strangers fro other services are welcome in the safe space we call work?

 

At this time of great uncertainty, it is important that we remain kind, that we show #PandemicKindness to those we meet. Everyone is working their hardest and to the best of their abilities. Take time to recognise that, whether it is the security officer that has to ask you for your ID to allow you into the building or the cleaners that we rely on. Take your time to thank them for their hard work, offer them a coffee (or a tea if they are in the Northern hemisphere. Remember that the ED is often overstretched so that serum rhubarb may not have been ordered. Be mindful that those of us who are dealing with adults as patients too and recognise that they need our kindness now, more than ever.

Please feel free to answer any of these questions in the comments section. Share your resources, your experiences, so that we may learn from each other. E-mail us at hello@dontforgetthebubbles.com with your ideas and suggestions. And be safe.

COVID19 and ACE inhibitors

Cite this article as:
Cathy Quinlan. COVID19 and ACE inhibitors, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24225

Why do my patients keep asking me about ACE inhibitors and COVID-19?

Hypertension is a common problem affecting 3.5% of children and adolescents and correlating with increased cardiovascular risk in young adults. Common first-line therapies include angiotensin converting enzyme inhibitors (ACEi), such as ramipril, lisinopril and enalapril.

Over the last few weeks, a storm has erupted over the use of ACEi with the suggestion that they could be associated with severe COVID-19. A statement by the European Society of Cardiology, was quickly followed by most national hypertension societies, including the American Society of Pediatric Nephrology and the High Blood Pressure Research Council of Australia, recommending the continuation of ACEi in patients with COVID-19. 

 

How are ACEi linked with COVID-19?

The COVID-19 literature to date has suggested increased mortality for adults with hypertension and for those with diabetes, a patient cohort frequently treated with ACEi. Although medication use has not been reported in patients with COVID-19, a letter to the Lancet postulated that the use of ACEi could be implicated in the increased mortality rate described in patients with hypertension. 

Human coronoviruses, such as SARS-CoV-2, gain entry to the cell through ACE2 which is expressed by epithelial cells of the lung and kidney. Thus a treatment that increases the expression of ACE2 at the cell surface could increase the severity of COVID-19 infection. There is animal evidence that circulating ACE2 levels are increased by treatment with ACEi. But also conflicting evidence in humans showing no association between circulating ACE2 levels and the use of ACEi. 

Interestingly, there is clinical data to suggest that ACE inhibition may actually be a potential therapy for viral pneumonia. Though it should be noted that this is confined to retrospective, observational data, clinical trials are underway to examine the use of recombinant ACE2 and losartan in adults with COVID-19, highlighting that the use of ACEi in patients with COVID-19 is not clearcut. 

 

How does this impact our patients?

A growing body of evidence, summarised by the DFTB team here, shows that children are at much less risk of severe disease than adults. Indeed, only 1 of 731 patients with confirmed COVID-19 infection in the largest study to date, had clinically critical disease. The data on ACEi in COVID-19 is inconclusive and pending further data there is no evidence to change anti-hypertensive management in children at this point in time. 

 

The Bottom Line

There is currently no evidence, in children or adults, to support changing blood pressure medication due to the COVID-19 pandemic.

 

I want to know more!

If you want to read more about HTN then please review the 2017 Hypertension guidelines from the American Academy of Paediatrics.

If you’d like to know more about ACE2, hypertension, and COVID-19 then check out the dedicated ACE2 NephJC page.

For up to date reviews of the COVID-19 literature as it pertains to the kidney along with management guidelines check out the COVID-19 NephJC page

If you are aware of resources that you think would be useful to the nephrology community then please tag it with #CoronaKidney and they will be added to the page after they are reviewed. 

 

Teaching (virtually) anywhere

Cite this article as:
Dani Hall. Teaching (virtually) anywhere, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24154

We all recognize that feeling of belonging and feeling connected that comes with learning with others. Institutions, including our own, are looking for remote learning options so DFTB, with the help of the Twitter FOAMed community, have put together this guide for virtual teaching.

But first, some thoughts about how we need to adapt our teaching to the virtual classroom (ground rules for the teachers, perhaps).

 

Safety

Maslow theorized that learners need to meet some basic needs to be able to learn. Safety is down in the foundations of the learning pyramid and hugely important. In the virtual learning world, this probably doesn’t mean safe at home, curled up on the sofa with a freshly brewed coffee (although that surely must help), but feeling safe in the virtual classroom to really be able to engage with the fabulous teaching you’re giving them. Social cues are lost in virtual learning spaces: the nuances of a smile, a nod, a ‘Tell me more” expression are slightly lost when using the thumbs up emoji. We suggest laying some ground rules for virtual learning to ensure all learners feel safe and therefore able to engage with the awesome learning you’re about to deliver. Have a look at ALiEM’s Rules of Engagement for some pre-briefing ideas.

 

Belonging

Another of Maslow’s fundamentals. It’s that feeling of being connected when we learn with others. When planning your virtual teaching, have a think about whether you’re going to deliver this to your group at the same time or whether you’re going to set some time-independent learning tasks (quizzes to complete, blog posts to read, podcasts to listen to). Whichever model you choose, and you may choose both at different times, think about how you can keep your learners connected. Perhaps you can bring them together for a moderated discussion on the learning they’ve done, either at a set date and time or on a virtual messaging space open over several days. Whichever you choose, strive to make your learners feel like they belong.

 

Helping learners learn

Some great learning can happen when the teacher and learner work together to facilitate learning (this one’s Vygotsky’s social constructivism theory). Hierarchies are flattened and teachers help their learners learn. Without realizing, you do this when you guide learners through a problem-based learning case. Ultimately it all boils down to this, as so eloquently put by our friends at St Emlyn’s: a teacher in constructivism facilitates and does not dictate. This is key to facilitated discussions in a virtual classroom.

 

But… this is a post on virtual learning. We’ll skip my favourite educational theory, Narrative Theory (maybe one day I’ll tell you why I love it so much), along with the countless other educational theories and move onto the how of virtual learning. Firstly, what platform will you use?

 

Webinars

When we asked the Twittersphere for suggested virtual learning platforms, there was a surge of comments of experiences with different webinar platforms (have a read through the Twitter thread for suggestions and experiences from our Twitter friends and colleagues).

There are many different webinar platforms out there. Some hospitals will already have subscriptions with a particular platform – if so, great. If not, or even if you do but would like some handy tips on real-time video conferencing, have a look the ALiEM Remote post on just this.

A piece of advice from an author who’s particularly IT-wary. If you’re not familiar with the software, have a play and run a trial session before your teaching event. Tapping the microphone with a puzzled look on your face while rummaging in a draw for headphones is not always the greatest way to spend the first few minutes of a Webinar. ICE Blog from the International Clinical Educators has some handy tips for smooth video conferencing.

Tessa is preparing for #DFTBCOVIDGLOBAL, an international DFTB webinar for healthcare workers looking after children during the COVID-19 pandemic, after running two national webinars this week in the UK and Australasia, #DFTBCOVIDUK and #DFTBCOVIDANZ. She chose WebinarJam after days of research and tested and retested the platform to pull off two events that together brought together more than 400 healthcare professionals, helping them feel part of a connected community.

 

Moderated discussions

It’s not all about the webinar. Incredible learning can also be facilitated on discussion forums, without the need for a camera or microphone. Taking a DFTB module guide (more on those later), you could run a two-hour session on, let’s say, head injuries in children. This is how I did just that for my department’s PED teaching this week:

  1. First, choose your discussion space. We used Slack: it’s something I’m familiar with and use pretty much daily, it’s very intuitive and learners join by invitation only. Other suggestions from the DFTB team include WhatsApp and Google Hangouts.
  2. Invite your learners. I sent email invitations to all our trainees and consultants. Our next session will include the rest of the PED team.
  3. Set some simple rules of engagement and explain how the session will work.
  4. Post some pre-learning material. Using the DFTB head injuries in children guide, I uploaded a mix of blog posts, articles, podcasts and conference videos for the learners to read, listen to and watch before the live event.
  5. Set a date and time. Two hours on a Wednesday morning, our usual PED teaching, was perfect.
  6. And then go for it! I moderated the conversation using case discussions to build on the reading, listening and watching our team had done, asking questions, letting the learners discuss and then guiding them back to key learning points. (There’s social constructivism for you – moderating not dictating).

It was a fun learning session with some really great evidence-based and practice-challenging conversations. It’ll work perfectly for a virtual journal club too, exactly our plan for next week. This was an incredibly rewarding teaching experience and I’ll definitely be using it again.

 

DFTB modules

A little word about the library of paediatric modules being developed by DFTB to help educators around the world provide excellent quality, up-to-date and evidence-backed teaching sessions on all things Paediatric Emergency Medicine. These are incredibly versatile, with pre-learning packages, case-based discussion guides and simulation packages. And they are 100% adaptable for virtual learning. Watch this space for more information.

 

Open forums

Those of us on social media love the way conversations can grow, branch and interconnect. Twitter is a fabulous open forum for teaching and it can (and has been) used for live group learning. You only have to search the hashtag #DFTB_JC to see how rich bringing together a group of people to discuss an article can be. The rules are different in open forums: moderating using a hashtag takes some skill (have a look at the DFTB post on how to be a Twitter moderator) and helping your learners feel safe in the virtual conversation isn’t as easy as a closed forum, although many will be happy to watch the conversations unfold. But it is a fabulous way of interconnecting people and enhancing that feeling of belonging.

 

Live gamification

Splicing fun into gamified education is a wonderful way to maintain staff morale. One way to do this is by running a live interactive quiz using voting and polling software.

I was thrilled to catch up with Vicky Meighan, EM Consultant in Ireland and co-organiser of last year’s IAEM conference, about her live quiz. She told me she set a pre-quiz lung ultrasound video for her team and developed an on-topic quiz with some fun questions interspersed. She then set a time and date and the quiz began. Vicky used Poll Everywhere, but Sli.do, Kahoot and many others could achieve the same thing. When I jokingly told Vicky that I’m a secret fan of the cheesy music that goes with a Kahoot quiz, she told me that many of the platforms allow you to tag songs and insert video URLs in the quiz to sit alongside questions (I could just imagine a question on B lines with some Spice Girls playing in the background). Some questions were multiple-choice, some polls and some free text. A conversation ran in parallel via WhatsApp, but Slack would be a great platform to use here too – learners could have two side-by-side windows open on their computer screen, one with the quiz and one with Slack. A starting question, “Where are you right now?” helped bring the team together as comments including, “Hello from the Southside,” and “Hello from bed!” flooded the WhatsApp group. In a time when staff need to look after each other, Vicky said the quiz was a great way to connect the team.

 

Time-independent gamification

There are many time-independent tasks you can signpost your learners towards: you could write a Google Forms quiz and send the link to your learners and watch the answers flood in, or you could choose from the wide-reaching library of FOAMed out there. Have a look at the #DFTBquiz, n=1, or choose a couple of DFTB, Radiopedia, RCEMlearning or LITFL quizzes for your team (other quizzes also available 😉).

 

Pre-recorded teaching

Sometimes bringing your learners together in the same virtual space at the same time is just impractical, particularly with staggered rosters and increasing clinical demands. Pre-record your teaching and then share with your learners, either on a hidden YouTube channel or on a shared workspace. Have a look at the comments thread to Eric Levi’s tweet about just that.

 

Virtual skills and drills

Grace told me about a Zoom teaching session she attended on paediatric chest drain insertion. But here’s an alternative platform my tweenage daughter is more familiar with than me: Instagram Live (HT @PEMDublin). Instagram Live can be adapted for virtual education: a teacher streams a video of up to 60 minutes in real-time to their team who can comment on the video and engage with both the teacher and the rest of the networked learners. The video can be saved to Instagram Stories for later viewing. I can see this working for teaching practical skills: setting up for RSI, simulated lateral canthotomy, applying a traction splint. Something to think about for sure.

 

Microteaching moments

Lastly, although we may not be bringing our learners together in one place, we’re still clinicians with a passion for teaching. Maximise those microteaching opportunities in the clinical environment. If you’re asked to review a child with diabetic ketoacidosis, spend 5 minutes talking about the latest evidence for fluids in DKA. If you’re setting up High Flow Nasal Cannula oxygen for an infant with bronchiolitis, bring your colleagues up to speed on the PARIS trial and the subsequent systematic review of HFNC. If you’re using sedation to facilitate a procedure in ED, this is a great opportunity to chat through the latest RCEM ketamine paediatric procedural sedation guidance. Run mini off-the-cuff skills and drills sessions. Teaching is your gift. In these times of stress on our health systems and social systems, remember to keep those learning connections: we all need to feel like we belong.