Pre-hospital analgesia: Part 1

Cite this article as:
Joe Mooney + Dani Hall. Pre-hospital analgesia: Part 1, Don't Forget the Bubbles, 2020. Available at:

You’re on a shift in the Rapid Response Vehicle. The radio crackles to life; a two-year-old has pulled a chest of drawers onto himself. He’s conscious and breathing but his leg is badly injured. Lights and sirens on, you wonder what is going to greet you.

The prehospital challenge

Assessing children in the prehospital environment can be challenging. As a stranger arriving at a child’s house at a time when they’re feeling unwell, hurt, or scared, we can seem frightening. Attending multi-patient scenarios, such as a road traffic collision, where both child and parent are injured poses additional challenges. Separating a child from their parent to attend different adult and paediatric hospitals can be hugely traumatic for the child (and the carer )and although we try to get another adult to the scene to accompany the child to the hospital, this isn’t always possible.

In the prehospital setting, we don’t have the luxury of time. A quick decision needs to be made: is this child sick or not sick?

For many prehospital clinicians, children make up a very small proportion of their workload. Drawing up paediatric-drug doses and administering these medications to a scared child takes training and practice.

All of this can make a clinical assessment of a child difficult. Taking off the high-vis jacket, getting down to the child’s level, making a glove-balloon character and using bubbles can all help a child feel at ease.

The prehospital assessment toolbox

There are some validated tools in our box to help overcome these challenges. The Paediatric Assessment Triangle has been used by prehospital care providers at all levels for many years, allowing clinicians to form a hands-off, quick impression about whether the child is sick or not sick.

The triangle is made up of 3 elements: A, B, and C, a mnemonic familiar to clinicians around the world. But this ABC does not stand for airway, breathing, and circulation but instead translates to Appearance, work of Breathing and Circulation to the skin.

Appearance… Is the child interacting with caregivers and ambulance crew? Are they lethargic? Crying? Consolable? Limp in caregivers arms?

Work of Breathing… Are they using accessory muscles to help move air? Are they tripoding? Nasal Flaring? Are they breathing fast or slow? Can you hear a wheeze or stridor?

Circulation to the skin… Are they pale? Cyanotic? Mottled?

If all three parts of the triangle are normal the child is likely to be stable. If all three parts of the triangle are abnormal the patient is in cardio-respiratory failure.

Assessment of pain in the prehospital environment also poses different challenges to the assessment in the hospital, for the same reasons. We use the same age-appropriate pain scales as our hospital-based colleagues: FLACC, Wong-Baker and analog pain scale. Clinical practice analgesia guidelines help direct medication choice, from simple painkillers such as paracetamol and ibuprofen, to stronger analgesics like opiates and ketamine.

The ideal analgesic

The ideal properties of an analgesic are to provide effective pain relief rapidly, with painless administration. Gaining intravenous access in children can be challenging in the field, traumatic for children, and can delay administration of analgesics. It really can’t be stressed enough how important it is not to traumatise a child with cannulation when a good alternative is available. Intranasal fentanyl has had a huge impact on paediatric pain relief prehospitally. In the UK, diamorphine is sometimes used instead of fentanyl; both are potent intranasal opioids that are rapidly and efficiently absorbed from the nasal cavity, giving significant potential for pain management in children.

Arriving at the house, you can hear a child crying; he’s maintaining his airway and is conscious. You make a snapshot PAT assessment: he’s stable. But his thigh is swollen and it’s clear he’s fractured his femur. His parents have given him paracetamol and ibuprofen. This one’s beyond the call of bubbles, so you put them away and instead draw up 0.02mg of fentanyl and give it intranasally.

The intranasal route

Analgesia can be given orally, rectally, intravenously, intramuscularly, or intranasally. Oral medications are metabolized via the hepatic first-pass pathway, meaning they are absorbed from the gastrointestinal tract and delivered first to the liver by the portal vein before reaching the systemic circulation, resulting in a relatively slow onset of action. Intranasal medications, on the other hand, are absorbed directly into the systemic circulation, completely bypassing hepatic first-pass metabolism, so their bioavailability is higher and their onset of action is much faster. And because the nasal mucosa is highly vascularized, with more blood per cubic centimetre than muscle, brain or liver, with a surface area that’s massively increased by the three turbinates in each nostril (out pouches of bone inside the nostrils that create passageways that to warm and moisten the air that flows in through the nose), it is an ideal surface through which drugs with small molecular weights like fentanyl can be absorbed.

Once absorbed into the nasal blood vessels, drugs drain to the right side of the heart via the superior vena cava, are pumped into the pulmonary circulations, and then back through the left side of the heart to the systemic circulations.

Some intranasal drugs have an even faster mechanism of action. It’s thought that fentanyl, and other drugs with very small particle sizes, can also transfer directly to the brain, via the olfactory and trigeminal nerves. This nerve superhighway means they can bypass the blood-brain barrier, and work even faster at their central receptors in the brain.

The intranasal analgesic cavalry

Fentanyl is a synthetic opioid; diamorphine is a morphine derivative. As fentanyl doesn’t cause histamine release, it results in less cardiorespiratory side effects than other opiates. Both fentanyl and diamorphine can be safely combined with oral morphine, meaning intravenous morphine top-ups are less likely to be required. When they’re given intranasally, their onset is within two to three minutes, with effects lasting up to half an hour. It’s easy to see how they’ve become a perfect choice for prehospital providers.

Ketamine, another analgesic in the prehospital analgesic armory, can also be given intranasally, although is not yet licensed via the intranasal route in children in the UK and Ireland. A few trials have compared intranasal ketamine and fentanyl and there have been some interesting results, posing the question as to whether sub-sedative doses of intranasal ketamine could be used as an alternative analgesic for children with limb trauma.

Published in Annals of Emergency Medicine in 2014, the double-blinded RCT, PICHFORK (Pain In Children Fentanyl OR Ketamine), was run in two large Australian paediatric EDs.  Children aged 3 to 13 years old with moderate to severe pain secondary to an isolated limb fracture were randomized in a double-blinded fashion to receive either 1.5 μg/kg intranasal fentanyl or 1mg/kg intranasal ketamine. 73 children were included in the analyses. Similar reductions in pain scores were seen at 30 and 60 minutes for both drugs. The ketamine group had higher patient satisfaction scores (83% compared to 72% for fentanyl) but more minor adverse events (78% compared to 40% of the fentanyl group). Published in 2017, a similar double-blinded RCT conducted in a level II trauma centre in America compared the two intranasal drugs at the same doses in 82 children aged 4 to 17. Like PICHFORK, their results showed more side effects in the intranasal ketamine group (2.2 times higher), but all were minor, with no respiratory adverse events. Analgesic effects at 20 minutes were similar in both groups. And finally, the PRIME (Pain Reduction With Intranasal Medications for Extremity Injuries) trial, a double-blinded RCT published in JAMA Pediatrics in 2019, showed similar results. 90 children, aged 8 to 17 years, presenting to a level I major trauma centre with limb trauma were randomized to receive either intranasal ketamine or fentanyl. Doses used were higher than those in standard clinical practice guidelines, with intranasal fentanyl dosed at 2μg/kg and intranasal ketamine at 1.5mg/kg. Like the other two trials, pain scores at 30 minutes were similar between both groups, while mild adverse events were found to higher in the ketamine group (with a relative risk of 2.5), although again all were transient.

So, is there a role for intranasal ketamine for children with isolated limb fractures in the prehospital or ED setting? None of these studies were powered to show a superiority of intranasal ketamine over fentanyl, but they do suggest that it’s non-inferior and a potential alternative. Although minor and transient, adverse events were higher in the ketamine groups, so it may not trump fentanyl as a first choice analgesic. But for children in whom an opiate is contraindicated, intranasal ketamine might be an alternative. More data will be needed before intranasal ketamine makes its way onto standard CPGs, but results from these trials are promising, with larger studies on the horizon.

After the intranasal fentanyl, the child settles. You apply traction to his leg, and with your colleagues’ help, you move him into an adult lower limb vacuum splint. This is a handy trick you’ve learned – the leg splint is just the right size to use as a whole body splint in small children, maintaining pelvic and spinal precautions. After moving to the back of the ambulance, he starts crying and is obviously in pain. You give him a second dose of 0.02mg fentanyl and phone medical support and discuss options with a senior clinician and get the go-ahead to give the third dose, en route to the hospital, if needed.

Ambulance control pre-alert the emergency department so they can prepare for an incoming paediatric trauma. The child’s mother sits next to the stretcher, holding his hand while you travel to the hospital. You explain to her what’s happened so far, what will you do if anything changes, and what might happen in the hospital. This calms her down. The child sleeps and that third dose of intranasal fentanyl is not required. As you pull onto the ambulance ramp he wakes. You hand him over to the waiting trauma team in resus; intravenous access is gained, IV morphine is given, and a Thomas Splint applied. After his primary survey is completed, an x-ray is taken, which confirms a femoral fracture.

The prehospital cannula

The question about intravenous access in the field is a tricky one. Inserting an IV line in a 2-year-old, particularly in the back of an ambulance, can be extremely difficult, and securing a cannula while travelling at speed requires the dexterity of a magician. If intranasal medication is working then there may not be the need for an IV line prehospitally. This always has to be balanced with the potential need for fluid resuscitation, or other intravenous drugs. Each case is a judgment call, based on the paediatric assessment triangle assessment and need for intravenous medications. But never forget, if a child’s in pain and the bubbles don’t work, don’t forget the fentanyl.

Selected reference

Reagan L, Chapman AR, Celnik A, et al. Nose and vein, speed and pain: comparing the use of intranasal diamorphine and intravenous morphine in a Scottish paediatric emergency department. Emerg Med J 2013; 30:49–52.

Graudins A, Meek R, Egerton-Warburton D, Oakley E, Seith R. The PICHFORK (Pain in Children Fentanyl or Ketamine) Trial: A Randomized Controlled Trial Comparing Intranasal Ketamine and Fentanyl for the Relief of Moderate to Severe Pain in Children With Limb Injuries. Ann Emerg Med [Internet]. 2015 Mar 1 [cited 2019 Jun 20];65(3):248-254.e1. Available from:

Watts P, Smith A, Perelman M. Nasal delivery of fentanyl. Drug Deliv Transl Res [Internet]. 2013 Feb 1 [cited 2020 Jun 8];3(1):75–83. Available from:

Goldman RD. Intranasal drug delivery for children with acute illness. Curr Drug Ther 2006; 1:127–130.

Hadley G, Maconochie I, Jackson A. A survey of intranasal medication use in the paediatric emergency setting in England and Wales. Emerg Med J 2010; 27:553–554.

Mudd S. Intranasal fentanyl for pain management in children: a systematic review of the literature. J Pediatr Health Care 2011; 25:316–322

Finn M, Harris D. Intranasal fentanyl for analgesia in the paediatric emergency department. Emerg Med J 2010; 27:300–301.

Telfer P, Criddle J, Sandell J, et al. Intranasal diamorphine for acute sickle cell pain. Arch Dis Child 2009; 94:979–980

Approaching the paediatric ECG

Cite this article as:
Anna McCorquodale. Approaching the paediatric ECG, Don't Forget the Bubbles, 2020. Available at:

The paediatric ECG is both a friend and foe to the general paediatrician. It can contain a wealth of direct information, but for most, creates an aura of uncertainty. I became interested in ECG interpretation as a junior registrar when I, on a post take ward round, was told to ‘send it across to cardiology for interpretation’. Now, whilst I do not disagree that ECGs can be tricky, and in those circumstances, paediatric cardiologists are invaluable, at that moment I wondered, why can’t a general paediatrician make a start? After all, in the adult arena ECGs are like paracetamol, you can barely make it over the hospital threshold without having one.  I firmly believe we as paediatricians are out of practice and therefore confidence, but that can be changed.


Understanding the trace

Let’s start at the start, what is an ECG? The electrocardiogram has been in use since the early 1900s and captures electrical activity emitted from the heart. Movement of ions across cell membranes is fundamentally responsible for this activity and it happened in a predictable and coordinated way in a normal heart.

P wave – represents atrial depolarization. The sinoatrial node is sited in the right atrium and as this discharges, electrical activity spreads from there across towards the left atrium. The P wave is therefore made up of two waves (RA and LA depolarization) but in time these are so close together that they become one on the trace

PR interval – a short lag as the electrical activity reaches the atrioventricular node

QRS complex – ventricular depolarisation

ST segment – an isoelectric phase immediately prior to the heart resetting itself

T wave – ventricular repolarisation

For the vast majority of children, this process will be repeated 60-150 times a minute, every minute of every day.

Having a good feel for what the trace means and where these waveforms are emitted from is key to figuring out what is going on when things aren’t normal and in what area to focus your attention if there has been a problem but things have resolved at the point of contact.


Take a systematic approach

The heart is systematic in the way it organises activity and the ECG trace produced reflects that, so we need to be systematic in our interpretation.

Information – we always check demographics. Here there is also a scale. The standard ECG should be set at 10mm/mV on the y-axis and 25mm/sec on the x-axis. All of the standard calculations depend on this so it needs to be checked. With those standardised values, one small square becomes 0.04s and a large square 0.2s.

Rate – this can be simply calculated using 300 divided by the number of large boxes between two R waves.

Rhythm – most ECGs will be normal sinus rhythm (NSR) so it important to be able to confidently characterise that. The standard criteria are:

  1. Normal rate for age
  2. Normal P wave axis (it should be upright in lead II, III and aVF). The axis of the wave gives you information about where in the RA it is situated.
  3. Normal P wave morphology (shape). This fundamentally means that the current is moving away from the sinus node in a normal pattern and over a normal time period. If the P wave looks broad and contains a notch it takes up a greater part of the x-axis/time it suggests left atrial enlargement. If it has a peaked/spiky appearance then the voltage  is high ie right atrial enlargement
  4. Normal PR interval
  5. P wave preceding every QRS complex

Note that most of the criteria for NSR, perhaps not unusually, focus on and around the P wave. If criteria 1-4 are met but the rate is abnormal then you would have sinus….tachycardia, bradycardia or arrhythmia.

Axis – here we are looking at where the bulk of the cardiac impulse is heading. Outside of early infancy, this should be towards the muscle bulk of the left ventricle. The axis is calculated by looking at leads I and aVF (but any two perpendicular leads could be used) and looking for the net deflection. This is then plotted along lead I (either in the positive or negative direction depending on whether the deflection is up or down), added to the end of the line along lead one is a similar line representing the overall deflection of aVF. A further line is then drawn from the base of the first line to the tip of the line along aVF the angle created is the cardiac axis.

Waveforms – the shape of each wave is important and the more you see the more familiar this will become, however, for me even more important that this is the return to basics. If you know WHAT the wave represents then you have identified where the issue is…

Intervals – there are reference tables for paediatrics  so remembering them is unnecessary. PR and QRS durations are straight calculations from the trace. Simply counting the number of boxes will suffice. The QT interval needs to be corrected for rate so takes a little more work.

QTc = QT/√ (RR) The machine will give you a reading, however, I advocate manual calculation for greater accuracy based on where the T wave truly ends.

Summary – I like to think of this as a case presentation, but about the child’s investigation. Given you have systematically looked through everything it should be a short process to pull this into a summary and if there are abnormalities being discussed with cardiology you will be able to succinctly highlight these, even if the diagnosis remains elusive.


Why are you looking at an ECG?

There are, of course, many reasons for performing an ECG but I’d argue this boils down to just a few important ones in acute general paediatrics. Consider what you are really looking for as some changes can be subtle and the primary complaint may have resolved to leave you with only a shadow to guide you to the underlying issue.

  • Chest pain – a common reason for ECG, but finding a cardiac problem is very unlikely – around the magnitude of 1%. How suspicious you are will depend a lot on the history but things such as pericarditis, myocarditis and myopathies might be in your differential. If they are in there then look HARD! These conditions irritate the ventricular pericardium and myocardium so changes will be seen in that latter part of the ECG.

Anomalous coronaries can also create exertional cardiac chest pain and may not have any ECG findings so again the history is key, is it convincing? Yes? Is there a better alternative explanation? No? Then you need an echocardiogram, and tell the operator what you are worried about!

  • Palpitations – you may find the arrhythmia and be in resus giving exciting drugs on a cardiac monitor. It is far more likely, and less frightening, to have a child back in normal sinus rhythm but describing something that might be an arrhythmia. So what could you look for? There might be nothing, but if the rhythm was SVT you could see an accessory pathway on the ECG – a delta wave leading from PR-QRS – it’s easy to miss. Thankfully, ventricular arrhythmias are far less common in children, especially those with structurally normal hearts, but there might be evidence of arrhythmic disorders such as LQTS. These disorders put children at higher risk of ventricular arrhythmias and fittingly, any clues are therefore found in this area so be suspicious.
  • Syncope – many adolescents have syncopal episodes due to autonomic BP control issues. The reason for the ECG is to weed out those where syncope has in fact been due to a short-lived cardiac arrhythmia.

So there you have my approach to ECGs. With a comprehensive system and one eye on what you might find they don’t have to be feared but should become part of your investigation battery and a fruitful discussion with cardiology when require.


Bottom line

  • Understand what the different areas of the trace represent
  • Be systematic and look at each area individually
  • In combination with the history be super critical of the areas where you could find a small clue to something bigger





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:

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.



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.



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.



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.



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.



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?


Don’t Forget The Brain Busters – Round 3

Cite this article as:
Team DFTB. Don’t Forget The Brain Busters – Round 3, Don't Forget the Bubbles, 2020. Available at:

The Minor Injuries Picture Quiz

Welcome to today’s Don’t Forget The Boredom Buster. We’ve learned a bit about neonates, hunted through some articles and now it’s time for the injury enthusiasts to shine. Have a look at these images and see if you can spot the injuries.

Don’t forget, when you’re done, press ‘Submit’ for the answers.

Ready? Well here goes…


Question 1

Sam, a 14-year old competitive sprinter, limps into your ED complaining of a severe pain in his left hip which came on suddenly while running. He points to a specific area of his pelvis and experiences pain on /active hip flexion, which is weaker than on the right. This is his x-ray.

What is his diagnosis?


Question 2

Tom, a 5 year old boy, is brought to the ED after a football game with his 9 year old brother went pear shaped. Tom, standing in goal, took the full brunt of a misjudged penalty shot. Luckily Tom did not lose consciousness and has not vomited but when he told his mum everything looked a bit blurry she panicked bundled him in the back of the car and drove straight to your ED. There is no evidence of bruising or contusion but when you assess Tom’s eye movements you see this when he looks up at the ceiling.

What is this a sign of? What sensory loss might you find with this injury?


Question 3

Sebastian is a 13 year old boy who is the school basketball champion. During training, leapt to deliver a slam dunk but just as he lifted into the air felt a sudden pop in his right knee. He is unable to weight bear and when you examine him it’s immediately obvious that the right knee is swollen compared to the left. He cannot straight leg raise. This is his x-ray.

What do you see? What can you measure to confirm your suspicion?



Question 4

Sophie is a 15 year old girl who was chasing her annoying 11 year old brother when she tripped over a rogue rugby ball and fell straight onto her outstretched left hand. Her left wrist is very sore and tender. This is her x-ray.

What do you see? (Tip: there’s more than one injury…)


Question 5

10 year old George was hurdling at school when he tripped and fell. He was seen at a neighbouring ED a couple of days ago who diagnosed a sprain of his knee but the pain is no better and his knee is so swollen that his mum has brought him to your ED for a second opinion. His knee exam is limited by pain. You order a knee x-ray.

What do you spot?


Question 6

9 year old Ella was jumping on the trampoline when she took a tumble: she planted her foot, hyperextending her knee and twisted. Her knee is now super sore and very swollen.

What can you see on her x-ray? (Hint: the lateral is your friend)


Question 7

Margot is 12 years old and a keen gymnast. She was practising on the uneven bars and had sudden pain in the medial aspect of her right arm during a twisting manoeuvre. Her elbow is swollen and tender medially and there appears to be some valgus laxity. This is her x-ray.

What can you spot? (or not?)


Question 8

14 year old Nicholas was out skateboarding. Super chuffed that he’d finally mastered the slide and grind, he went for a last good luck flip. Only it wasn’t so lucky – he landed on his forearm and swears he heard a crunch. His forearm is grossly swollen and incredibly sore but after some intranasal fentanyl he tolerates an x-ray.

What does his x-ray show? 


Question 9

Rebecca is 13 years old. She was playing on her pogo stick but her right foot slipped off and she landed awkwardly on twisting and externally rotating her ankle. She immediately fell to the floor on the court and couldn’t stand on it. Her ankle is very bruised and swollen and, even after intranasal fentanyl, she is very reluctant to weight bear on it.

What type of fracture does she have?

See the answers here: Round 3 answers

Burning Questions: talking to children about bushfires

Cite this article as:
Ian Lewins. Burning Questions: talking to children about bushfires, Don't Forget the Bubbles, 2020. Available at:

As we begin 2020 Australia has already seen a disaster on a scale that is unimaginable to most. By the end of last week, at least 23 people have been killed, including three volunteer firefighters. An estimated 480 million animals have been wiped out and over 10.7 million hectares of land have been razed in the fires. The smoke has blanketed our most populous cities but also spread as far as New Zealand and South America.

Here is the current heat map of the fires still burning

We, our families, our children, and our patients are bombarded with images of the fires every day. In this important podcast, Ian Lewins speaks to Liz Crowe about how we can support children in this time of stress.

You can listen to the podcast here on iTunes.


Here’s the transcript of the podcast

Ian Lewins: Hello and welcome to the podcast. I’m your host, Ian Lewins – one of the children’s emergency department consultants based in Derby in the UK, and it is my very, very great privilege today to be joined by Liz Crowe, who is an extremely experienced paediatric social worker based in Australia and internationally renowned speaker on pediatric loss, grief crisis, and bereavement work. Good evening, Liz. How are you?


Liz Crowe: I’m very well, thank you.


Ian Lewins: So you kind of reached out and well, we had a chat amongst the Bubbles team to talk about the Australian bushfires that are obviously very much in the news at the moment. I’m from the outside looking in. Is the whole of Australia on fire at the moment?


Liz Crowe: I think it probably looks like that in the media and certainly a significant part of our country has been impacted. But, you know, all of the metropolitan and urban areas of Australia are thankfully safe and while we have lost huge amounts of bushland and animal life and we’ve certainly had significant human losses, well, the bulk of Australians remain safe. And while our hearts and thoughts are constantly with fellow Australians who have been impacted, I think one of the big problems is that children are being exposed over and over again on the news, social media, listening to adults talk. And I think like the rest of the world, there are lots of children in Australia who think that they’re in that risk and danger.


Ian Lewins: I think from my perspective, very much looking out and in I’m aware that there have been bushfires and these problems over the last few years. Is this year significantly different?


Liz Crowe: Oh, this is unprecedented for the world, not just Australia. These fires have been raging now really since October -November and have gone on and on and on. We’ve had, I think, over 25 human deaths. Whole towns have been wiped out. They’re saying some of our birdlife and wildlife may not ever recover from this. But this is unprecedented. Areas of Australia look like a warzone. They look like after Vietnam or Hiroshima  – just completely wiped out. This is unprecedented, not just for Australia, but I think for the entire world. So, certainly, I don’t want to undermine or underestimate the significant loss, damage, grief, and destruction from these fires. But I guess when it comes to children, we need to be really careful about their level of exposure and their understanding. We have adults around the world who have no clue about what is the extent of damage so it’s no wonder children are feeling frightened and concerned.


Ian Lewins: And I guess. Where you’re based, is that something that you’re kind of encountering a lot at the moment, sort of on a daily basis, worries from kids? Is that your sort of interest in this?


Liz Crowe: We’re just hearing it everywhere you go. Even though I have a very open relationship with my children my 15 year old said to me last night, “Mum, are we at risk?” And I think it’s because the air quality in a lot of the major cities around Australia has been impacted for a long time. Certainly, Sydney itself as a city is not under direct threat of being attacked. But the air quality in Sydney… people have to wear masks. You wake up that the whole city is in a thick haze of smoke. And so, of course, children, like adults, are concerned and frightened. It’s slowly starting to pop up in social media – how to talk to children. I just think it’s a really important issue. And it’s not just around bushfires. I think what we’re going to talk about today is how do you talk to children about any difficult conversation or any global event or significant trauma that’s going on in the community. These are skills that will be transferable.


Ian Lewins: So I’ve got three kids of varying ages for the youngest of six to eight to 14.

If there were difficult topics around, we have them come up over the dinner table, breakfast table. And trying to manage that for different ages is incredibly challenging, particularly when the older few are very aware of things like social media and what’s popping up.

And if you look at, you know, the bushfires on social media and looking at the images coming back from sort of the firefighters, that they’re unbelievable. They’re incredible.


Liz Crowe:  And this is what I keep saying to people. This is not a mental health reaction. You know, the children feeling anxious, feeling concerned, being tearful about what they are seeing. This is not a mental health concern. This is not something we need to be worried about because the adults are doing the same thing. Emotions are normal. It is normal for children to have reactions to things. We don’t want to raise children who have no reactions to significant events. Just like we would expect children to laugh and be really joyful around Christmas and festivals and fun things that are happening on the media. They’re going to have these reactions to things like the bushfires because they’re also little humans exactly like adults. They experience emotions, exactly like adults. The problem is that they can’t process them, understand them. They don’t always have the language or the reflection skills in the ways that adults do. And so that’s what we need to be mindful of.


Ian Lewins And I guess one of the key questions when you’ve got any sort of major event like this, is trying to find the best approach. Are you very open about things? Do you actively share these things? I guess sometimes as a parent, you want to hide them away from kids? What’s the best sort of balance towards this?


Liz Crowe: Well, I just don’t think there’s any hiding away from children anymore. I think parents have always been a bit delusional and struggled around how to talk to children around difficult conversations anyway. But as I always say, you start whispering and your children adopt bionic hearing. You can stand next to a child and ask them to come to the dinner table. They don’t come. But if you’re half a kilometer away and you stubbed your toe and you swear they’ll hear you. So as soon as children pick up on any kind of nuanced change in their parents or their carer’s behavior, language, tone, they hone into that. Even babies pick up on the emotions of what’s going on in the house. So the more that we give kids information and share what the concerns are, the less chance they are to be confused thinking that they’re to blame or that there’s a problem that cannot be solved as a family. And, you know, unfortunately, I work with children who have siblings who are dying, weekly. We see that. And of course, every parent wants to protect their child from that grief.

Every parent wants to protect their child, give their child the best possible start they can in life. But if this is happening in your family, if this is happening in your community or your country, if there’s media exposure across the world, there is no protecting children from that. You walk into the grocery store today, it’s on the front page of the media. It’s on every time you click on the computer. It’s the front screen showing you what’s happening with the bushfires. It’s on all the news. Everywhere you go, people are talking about it. Nearly every major city in Australia has been blanketed in smoke.. You can’t hide that from children. And so when children don’t have the facts, when children are excluded from the knowledge or the shared understanding of adults, the only thing they can do is make it up. As an adult, you walk into the lunchroom in the hospital and everyone stops talking. You immediately think they’re talking about you. It’s the same thing with kids.

But their anxiety about what that is and what that involves is escalated. Their imagination runs wild. And what we actually do find is that we are increasing their distress rather than decreasing stress.


Ian Lewins: I think one of the things that I say to medical students who are coming to do a pediatric placement with me, who have not really been exposed to pediatric patients before, is that kids are not stupid and they know they know when you’re lying to them or not being completely honest and they don’t trust you. And as you say, we often make things potentially worse in their heads. And I guess it’s difficult, isn’t it, because, yes, we need to be open. Yes, we need to be honest. But does there come a point where there’s too much information potentially?

Liz Crowe:  I don’t think that we need to shove everything in their faces and down their throats. My kids still have a right to be kids. And you spoke developmentally before about, you know, how how do you kind of break that up? I think you aim to give information, standardized information based at your youngest child and then you respond to questions from the older children at the moment.

I think it’s really important because the exposure is so huge in Australia to say to the children these other areas of Australia  are on fire. And this is where we live. And for some families, they’re still living with the risk. And if you are living with the risk, you should definitely say your children ‘We’re living with risk. And this is our safety plan. If the fire comes closer, this is how we will know. The police will come and notify us or we will get a text message from the council on our phone. And this is what we’re going to take, including anything that’s precious to you. This is a box. You put it in here. It’s coming with us. And this is how we will take the cat.‘ And this is how to give information so that there are parameters around it. For families who aren’t at risk at all, but whose children are being exposed, exposed, exposed, I think you try to limit that. You give them information and say these are the areas that are on fire. This is where we live. This is how we know we’re not under any risk.

If we became under risk, this is how to change again. This would be our safety plan. One of the things that I think kids in Australia in particular, but certainly this may be a global problem, is all of what’s happening with the animals.  We’re being bombarded with pictures of people saving kangaroos. And I think what we need to says, yes, sadly, we have lost a lot of wildlife and a lot of birdlife and a lot of our great country has been hugely damaged. This is how the earth will recover. This is how, when animals are injured, there’s a lot of vets doing very remarkable work at the moment. Euthanizing, healing, setting up clinics  for burnt animals. And then once they have that information, move on, talk about something else, get them away from it. They don’t have to sit with it. It’s not healthy for adults to do that. Certainly not healthy for children.


Ian Lewins: Absolutely. What are we going to say if, as you say, houses and pets and belongings are destroyed? And are you finding in conversations that you’re having that it does seem to be the pets that the focus or is it sort of possessions or people or what sort of things?


Liz Crowe:  I, personally, haven’t come directly in contact with families who have lost everything. I mean, I think certainly for families who have lost everything, there’s no minimizing or hiding that from children. They’re going to have to say, “Look, we have lost all these things. You’re going to see mum and dad cry a lot. You’re going to see our friends and our neighbors cry. That’s because people are very sad about what’s happened. This is what’s going to happen next. This is where we’re going to live. This is how, you know, there’s a thing called insurance and people are making donations. We may not go back to where we used to live.”

Providing a routine and structure and reassurance about what’s going to happen next, it’s very important. For families who haven’t been directly contacted just to let kids know this is what happens. There are children out there who have lost their whole community, who don’t know where they’re going to live, don’t know where their neighbors are. And for some communities, it may be too devastating to return. Other communities, the rebuild will take years to return to any sort of sense of normal. But I think just like adults,  they need parameters. When you’re in crisis, you need to break things up into steps – this is where we’re going to sleep tonight, this is what’s going to happen next. So the children who are safe, but who are saying what’s going to happen to those pets? Pets and animals have been a big thing on the media. Provide assurance that, you know, there are lots of people working day and night tirelessly to find the injured animals.

And the animals that can’t be saved are being euthanized as swiftly and as gently as possible. Maybe you’ll need to say that, maybe you won’t. I think, be guided by what sort of questions you’re asking. I mean, you wouldn’t say that to a 4-year-old who had no clue that could happen. Just say the vet is coming in, they’re going to look after the animals. For the older kids, it will be fine to say that they’re going to be euthanized and that that happens swiftly. And that’s shocking. But that’s much better than letting an animal suffer. So it really depends. You can’t sort of say what’s the chronological age that you would talk to children about this, this and that? Because you might have a four-year-old who says what happens if there’s a koala who can’t be cured? And then you have to answer that properly.  And you could say the animals are being taken care of. So you need to be guided by what the children are asking, but lying to them… providing false securities and false hopes, that doesn’t make kids feel safe because they very much can see what the reality of what’s going on. And  fire is hugely frightening.


Ian Lewins: I just think that the thing I’m hearing a lot of through this is having a plan. Breaking it down into little bits and having a plan for each bit. is that sort of thing that provides a bit of psychological safety, I guess, for these kids?


Liz Crowe: Absolutely. Yeah, and I think parents do need to think about this before the questions come up. If parents out there aren’t sure how much their kids know, tune into them. Listen to what their conversations are. Listen to if it’s coming up in their play. If they’re finding that their children are waking more frequently, having night terrors, any of those things, ask them what it’s about and then provide assurance around that. There may be some children who just need stronger attachments at the moment. A lot more reassurance, wanting to know if they’re in the firing line . Or if there’s a lot of smoke around, playing with the kids or talking to them more. Staying with them. Putting on a night light, anything that offers reassurance. But I think that whole thing about having a plan about what to say when the questions come up is good. I think the other thing is parents really work up in their minds like I have to have this big serious conversation.

I’m going to say this. They’re going to say that. And then they interrupt children while they’re watching their favorite TV show or when a child is tired or when a child is hungry. And, of course, it just doesn’t work. And that’s not because the child’s got mental health problems. That’s because you don’t have a serious conversation with anyone hungry. Don’t have a serious conversation with anyone when they’re tired. That includes adults. So I think,  have a plan. And for those people who are potentially at risk or for those people who’ve already been impacted, break it down into small chunks about what is the plan to each day or what is the plan? Should we become under risk and have to evacuate?

Ian Lewins: I guess one of the real challenges at the moment is managing uncertainty. I’m sure you’ve come across multiple times in your work where we’re not quite sure what’s going to happen next. I mean, my understanding is that, the fires are still going and it doesn’t look like they’re stopping anytime soon.

Liz Crowe: And I guess it just keeps coming back to that plan. If you’ve got uncertainty and it doesn’t matter if it’s a fire or a flood or an earthquake or from volcanoes, any of those things. It doesn’t matter if there’s talk about separation or domestic violence. If you’re able to say to a child, “This is the plan, this is how we would know when we have to move. This is what we would take with them. Here’s a little bag and your lantern.”

You know, I grew up where we had cyclones. And when a cyclone was coming we had several nights when I was a child that we all had to bunker down in a bathroom. Four kids and our parents in this tiny bath. And the bath that was always filled with water in case we lost water or electricity. You’d hear the wind raging. We were allowed to take two precious things with us. And it was a really big thing as a child to choose what were those two precious things? But that was the rules. And we knew that. And we would take it home with us. And we knew that if something happened to the house, this would be the next step. This is where our parents would often say to us, we will be in the bathroom for at least 10 hours or we’re going to be in there for the night. So you can take two toys and a pillow. And just even those sorts of things. It provides a sense that someone is in control. Someone is keeping me safe.

And you know where to go from here. I mean, the images that are you seeing of a whole community on a beach, with this fire raging? I was brought to tears by that. We have to expect that children will react to that. And I don’t think we need to go into it. How do you look after the children who were on that beach? Because there’s such a specialized, such a small proportion and they’ll be specialized counselors going in and looking after those kids. But if your kids are saying, what happened to them on the beach, you can say, you know that they would have been frightened. But people came on boats and they looked after them and they bought the water. And this is how they got them out. And this is where they took them. And something like $80 billion has been raised so far. So to say to kids, lots of money has been raised so far and this is how we’re going to invest it. And these are the sorts of things were doing, like I’m talking to my children that, I plan in the next year or so to go to Kangaroo Island, which is an island off of South Australia that’s been hugely devastated so that we can go back and contribute to their community by tourism.

This is what we’re going to do in the short term. This is what we’re going to do in the medium term. This what we can do in the long term. Because I think what we want to also teach children is you don’t just pay attention to what’s the biggest noise in media at the time. This is going to be an ongoing issue for our country for a very, very long time. And as a community, we can’t afford to forget them. And they’re good values to teach your children going into the future – that we always remember people who had a significant loss, just like we march on Anzac Day when we remember people from World War One and we’ll look to Vietnam and all the subsequent wars that Australia’s been involved in. You know, these are the sorts of things that we have to remember both now and into the future.


Ian Lewins: Absolutely. One thing I’d pick up on that I thought was interesting is you’ve mentioned a couple of times this was saying this is not a mental health problem – these reactions, these responses, these behaviours. Do you say that because there’s potentially a push to try and label the responses as mental health problems?


Liz Crowe: I’m not a psychiatrist and I’m not a medical doctor. I’m a social worker. It really concerns me how quickly children and adults get a mental health label. This is depression. This is anxiety. Actually, to be really worried if you’re living in a bushfire area, that anxiety is real. It will not be what it’s about. It’s reactionary. It frightens me. We have children die in our unit and within a week, parents are being diagnosed with depression or kids are being diagnosed with depression. That’s grief. It’s sadness. Grief and sadness can develop into depression. Those things can be linked, but not in the acute phase. You can’t have post-traumatic stress disorder for four to six weeks. So if someone has been exposed to the fire and had to run and their kids and themselves feel very heightened, they’re in an acute critical stress response. That’s a normal response to a completely abnormal,  adverse trauma. And so I’m really keen for us to normalize kids’ distress, normalize our own distress when something distressing has happened.

When someone is anxious about something because it’s a real threat, that’s actually a protective thing. It’s not a mental health concern. If there’s a fire and I feel very anxious about being impacted, about my house burning down, that’s a healthy reaction. I’m going to run. I’m going to be alert to it. It doesn’t mean that there’s a problem. And so that’s why with kids now being exposed to all this you need to say know that’s really normal. Of course you’re worried. These are terrible, terrible things that are happening. But the kids who are affected, they’re not traumatized. They’re just impacted by what they’re seeing. So I think it’s important. Language is important. And it concerns me how quickly we go to the extremes of things. Instead of just saying they were worried. They were frightened. They were impacted. We say, straight away, they’re traumatized and they’re not traumatized. They’re going to recover from what’s happened, especially kids who haven’t actually been directly involved.


Ian Lewins: Last question then is one of the things I guess I’m interested in also was that with the job you do, how do you protect yourself? So how do we as parents or health professionals, you know, we talked about being honest with parameters. We talked about having plans to try and help and protect our children. How do you protect yourself?


Liz Crowe: Well, if you’re a parent I don’t think it’s good. Just before we go to bed at night to watch YouTube clip after clip after clip of the bushfire. That’s not going to be a peaceful, restful way to go off to sleep. So I think it’s about being very grateful, first of all. I feel very blessed that I’m in Australia. And I had neither my family and my close friends, no one’s been directly impacted. So I’m grateful for that. I feel now I have a responsibility to help those that have been. So think about being grateful for the things that we have. To do something active for those who have been impacted so that we can feel part of being. And I want to be an Australian. I want to step up and help my fellow Australians making financial contributions, doing podcasts, whatever it is, you know, making food or whatever it is that you can do to look after yourselves. I think that we just live in such a society where busy-ness is rewarded. Being exhausted and tired and frantically busy all the time is the new popularity. Slow down. Ask yourself what’s important when things like this are happening. It’s really a time of reflection, I think, where you can say, what is important in 2020? What would I like to do? Who would I like to be as a person? Whether as a parent, as a friend, as a sibling or a daughter or son, and to really invest in those things. And so often the only New Year’s resolutions you hear about people’s body image. I’m going to be super fit and had to be thin this year.

Instead of being that, say, how are you going to honor yourself? Are you going to look after yourself? What would be important? I said if people don’t talk that exercise, talking about movement in relation to eating a big burger, go for an extra-long walk, you know, have a little dance in the kitchen. Just get yourself moving. Be careful of our language that we use to ourselves and be careful of our language we use with our children. And self-care is really important. But part of that is also reminding yourself that we are part of the community. And keeping a broader perspective, because when any of us become too, over reflective or saying today, you know, if you say to someone, don’t think of the polar bear, don’t think the polar bear, first thing that happens.? Everyone thinks of a polar bear. If you go to bed every day, you think, what would it be like? This is my family. You know, what can I do for the climate? I think there’s an existential crisis to the bushfires around climate change. And what is our responsibility? If you get caught in that cycle, you build it in your mind. Whereas if you think these are the things that I can do, these are things within the realm of my power. These are the things outside the realm of my power. I’m going to really focus on the things that are within the realm of my power and that life is good and be optimistic.

 And, I did a podcast with some vets today and they were saying, while the bushfires are terrible, if you had to think about something in relation to it, that’s good… I wish we didn’t have the bushfires, but Australia has come together as a community. The world is having this huge outpouring of emotion and wellbeing and goodness and donations. That’s a good thing to know that actually humanity is still at its core, very positive, very good. And we don’t need to be hopeless about that. We can share that optimism with our children.


Ian Lewins: Absolutely. Let’s think there’s so much that people will take away in the end. I think that that positivity, the optimism is so important. So thank you so much for joining us on the podcast today and wishing you all the best.


Liz Crowe: Thank you very much. Thanks for having me. Ian.




For more on the impact of the fires on health, from those on the frontline, it is worth reading this piece from Melissa Sweet at Croakey News.

Tops tips for organising a teaching course

Cite this article as:
Tessa Davis. Tops tips for organising a teaching course, Don't Forget the Bubbles, 2019. Available at:

My first foray into organising an event was organising an end of year party in our 6th year at secondary school. I was the Managing Director of our Young Enterprise company – it was called The Firm. We were in a very civilised middle-class private school in Glasgow (Hutchesons’ Grammar School). We wanted to put on an event and run it as a business and turn a profit.

I led the planning with my team – the schedule of events, the venue, the speeches, the entertainment, who would attend, and selling tickets. The excitement was palpable.

The party was unmitigated disaster. The venue ended up serving alcohol to lots of underage school kids who lied about their age. Those who didn’t get served had smuggled in rucksacks full of vodka anyway. This led to the venue organiser finding glasses and bowls filled with vomit. Even the flowerpots were flooded with vomit.

The curtains were completely destroyed.

One of my delightful guests broke into the nursery play area owned by the venue and caused £5000 worth of damage.

The one thing I missed is exactly what you need to make any course/programme/event a success. You need to care about it being a success. You need to show that you care. If you care, the speakers will care, and the delegates will care. And the guy who trashed the nursery might have cared. But I wasn’t a good enough leader back then.

I’ve managed to pull things back since then, with three years’ experience of organising DFTB conferences. Whether you are running a conference or a short teaching day, the principles of running a successful event are the same.

Tip 1: Identify your goals

My goal in 6th year was to run a better party that the rival cool kids party that was being organised on the same day. This is not a good goal.

Think about what are you trying to achieve with your teaching event. Who is it for? What tone are you setting? How do you want people to feel when they come?

At DFTB we aim to achieve an exciting, informal, and fun community event delivering a mix of hard science and non-clinical topics, which leaves delegates feeling refreshed and inspired to do their jobs better.

Your goal will be different. Your goal might be to match the College curriculum, or to allow trainees to present, or to learn about a specific clinical area. Just work out what it is and keep it in mind when you do the rest of your planning.


Tip 2: Form your team

This is where I made my mistake in the 6th form. My tip is – don’t make up your team from a bunch of 16/17 year olds.

Get a team with skills to complement yours. Our DFTB conference team has a skill set to cover most bases. Henry is our philosopher, and our blue-sky thinker. Andy is great at schmoozing sponsors. Grace and Ross absolutely boss the speaker coaching. Damian helps to add academic weight and ensure our programme is balanced. Ben takes the hit and deals with the difficult conversations. I’m across the finer detail. Mary Freer brings that special touch of love and compassion. Everyone on the team (including those not mentioned here) is there for a reason and has a place.

We all know that the team is what makes any project a success. I’ve been part of many projects, most of which have failed. The successful ones aren’t the ones with the best ideas, but rather they are the ones with the best teams. Bring in people who care about the event, care about the goals, and who want to work with you.


Tip 3: Shape your programme carefully

Plying a bunch of 16 year olds with free booze, with one speech from me whilst everyone mills around drinking, doesn’t constitute a programme.

You need to plan your programme carefully and thoughtfully. Do not just get together a list of topics and put them all in the order that the speakers can arrive.


What level is it pitched at?

What structure will it take?

How will the audience feel throughout the day/programme?

Do you have the right mix/balance of content?

At DFTB, we pitch at the the level of the senior reg or junior consultant. We have a three day course with one day of workshops beforehand. Everyone comes together at the beginning and end of the day for keynote sessions, and then we have three concurrent sessions running together. We do this because one of our goals is for a community vibe. We want everyone to start and finish the day together as a community.

We spend a long time planning the content – balancing the mix of science/non-clinical PEM/general paediatrics. The programme is your core – spend time making it work.


Tip 4: Find your speakers


It’s time to think about who will speak at your  course. Think outside the box here. Yes, use people you’ve heard speak before, but also take recommendations from others, search online for people and watch videos of them delivering a presentation.

Avoid making a list of of speakers and then slotting them into an order. Equally avoid making a list of topics and then slotting speaker names beside them. At DFTB we do this as a fluid process alongside developing the programme. We have a very long list of potential speakers, and idea of session topics and how they might blend together in each day. And then we go through a slow process of merging these lists together while maintaining balance.

When you do this, take into account representation and equity of gender and ethnicity. For example, we know that 77% of UK paediatric trainees are women, and 53% of UK paediatric consultants are women. Therefore this should be percentage of excellent women speakers amongst the paediatric community, and they should be represented in your speaker body.

I have heard so many excuses from programme organisers as to why they don’t have representation. If you find yourself, or your organising committee, uttering any of the phrases below, then stop and think.

If you find women aren’t pitching talks, or women are saying no, or you can’t think of any women to put in your programme, then ask yourselves ‘why?’ What makes your event unattractive to female speakers? What is it about your expectations of speakers that is putting women off? What is it about your ethos or programme that isn’t open to fitting in representation?

Because it really does matter. And if it doesn’t matter to the organising committee you are on, it definitely matters to the delegates and the speakers. The following is a quote from an email we received after one of our conferences.

Representation and equity in speakers really matters.

When you have your speakers sorted, expect them to do the work. When I accept an invite to deliver a talk, I know it’ll involve hours of my time, so I make sure to only accept an invitation when I have time to do it justice. You don’t want your speakers to simply dig out an old powerpoint presentation from their hard drive (or worse – someone else’s old powerpoint presentation) and deliver the same old talk. Tell your speakers that you have invited them because you know they will deliver a fabulous presentation.

At DFTB we have a speaker coaching team who offer guidance, coaching, and support. We also tell them that their setting may be different from what they are used to – no lectern, no notes, a headset mic, and all they will see is the slide that’s behind them on the screen and a countdown timer. They have to deliver their talk within 18 minutes – no excuses for running late. No talk is made better by running over the planned time, and it impacts on the other speakers in the same session. This is where have expert session chairs comes in useful.

We push our speakers outside of their comfort zone. We make them sweat and they do feel nervous. And that’s ok, that’s how you achieve new and exciting presentations.

At DFTB19, Ross Fisher pushed himself to deliver something new in our closing keynote talk. He had three slides which were simply drawings by E.H. Shepard. He sat on an armchair and read us a Winnie the Pooh story from his book. In so doing he delivered a powerful message about curiosity in medicine.

By pushing your speakers and having high expectations of them, you will achieve a higher quality of content and delivery.


Tip 5: Don’t forget the practicalities

These affect the flow of the event and the experience of your delegates. Consider your venue – what space you need, what the capacity of the rooms are, what location you want. Think about food – hungry delegates are not happy delegates. Make sure you have a trusted AV supplier who will keep things running smoothly. And importantly make sure there is adequate WiFi – there are few things more annoying than being stuck in a conference room with no reception or wifi.


Tip 6: Consider accessibility

My 6th year party was far too accessible – they let in people with no tickets at the door as the ticket-checking system fell apart. The guy that trashed the nursery hadn’t even bought a ticket to the party in the first place. Open access made a bad situation worse.

Think about those who are your target delegates – what will be the barriers to them attending your event and how can you overcome that?

At DFTB our tickets are pretty expensive, because we have no outside funding, and we understand that that limits who can attend. So we think of other ways to improve our accessibility. One third of our tickets are discounted for trainees/allied health. We spend money recording all the talks and releasing them as FOAM content throughout the following year, and you can do a version of this relatively easily at ay teaching event your organise. At DFTB19 we had live streaming for this first time – so people who couldn’t come were able to pay a small fee and have live access to the talks as they happened. And those in low or middle income countries were able to live stream for free.

There will be plenty of creative ways to improve your accessibility. If it’s a regional teaching day and not all your trainees can attend, then you could simply audio record the talks and share them round. This would be a very crude and inexpensive way of improving access.


Tip 7: Have fun

We had no shortage of fun at my 6th year party. In this area we truly excelled.

It’s important for the delegates to have fun. These finishing touches are usually lower cost and quick to organise, but they make a difference.

At DFTB19 we had giant games (including giant operation), we had some special treats each day (popcorn, candyfloss, ice cream), we had pet therapy dogs (if you fail to feel happy when meeting these pets then you must have a heart of stone), and we bought some DFTB onesies for our DFTBabies.

These are just finessing, but the delegates really appreciate them – be creative and think about what you could do, however small, to allow your delegates to smile and have fun.



Overall: CARE

Make sure you and your organising committee care. Ensure the personal touches – contact your speakers directly, solve problems and trouble-shoot throughout the event.  Get nice thank-you gifts for your speakers and send them a thank-you email afterwards.

The key is that you and your team really care about making your event a success.

If you care, your speakers will care, your delegates will care, and your event will be a spectacular success.


ADC/DFTB Journal Club – May – Restrictive fluid boluses in shock

Cite this article as:
Charlotte Durand. ADC/DFTB Journal Club – May – Restrictive fluid boluses in shock, Don't Forget the Bubbles, 2019. Available at:

Rapid fluid rehydration is a key component in the management of paediatric patients presenting with septic shock. The 2009 American College of Critical Care Medicine – Paediatric Advanced Life Support (ACCM-PALS) guideline recommends boluses of 20mL/Kg up to 200mL/kg in the first hour. Results from the 2011 Fluid Expansion As Supportive Therapy (FEAST) trial showed an increased mortality in patients receiving bolus therapy in low-income countries, though it continues to be debated whether these findings are applicable to higher-income countries.

The Fluids in Shock (FiSh) pilot trial compared restricted bolus (10mL/kg) with the current recommendation (20mL/kg) to determine if a larger scale trial would be feasible in the UK. We discussed the paper in the May #DFTB_JC with expert input from author Dr David Inwald (@dlwanI)

Inwald DP, et al. Restricted fluid bolus volume in early septic shock: results of the Fluids in Shock pilot trial. Archives of Disease in Childhood 2019;104:426-431.

What was this study about?

The FiSh pilot was an open, multi-centre randomised controlled trial (RCT) involving 13 UK hospitals. 75 children were enrolled based on the presence of shock entry criteria (CRT ≥3s or systolic blood pressure <5th percentile for age) after an initial fluid bolus of 20mL/kg. Patients were randomised if they showed signs of shock after an initial 20mL/kg bolus to select for sicker patients. If they improved after the initial bolus they were excluded from the study group.

Boluses were delivered every 15mins (max 500mL of 10mL/kg group, or 1000mL for the 20mL/kg group) until patients’ signs of shock resolved.
79% of boluses were delivered per protocol in the 10 mL/kg arm and 55% in the 20 mL/kg arm. The volume of study bolus fluid after 4 hours was 44% lower in the 10 mL/kg group. There were no significant differences between the groups with regards to length of hospital stay, paediatric intensive care unit (PICU) admissions and PICU-free days at 30 days.

The twitter jury is still out on the reliability of capillary refill time, particularly in a resuscitation scenario. Dr Inwald gave an authors perspective on how they decided on shock criteria…

“It was difficult…in the end we went for hypotension OR prolonged CRT >=3s, in context of suspected infection – after 20 mL/kg. We didn’t use HR as too many confounders in ED. We were surprised that CRT was the main criterion in so many patients.” @Dlawni

Many had issues with inter-observer variability and confounding patient factors. Most participants emphasised not relying on CRT in isolation, but interpreting results in the context of other clinical features.

We’re in an LMIC – so, for a well nourished child, a LOT of emphasis. But – for severe malnutrition, they all have delayed CRT so no emphasis. I think even in HICs, in a case of poverty or neglect, I take it super seriously unless the child comes in looking scrawny. #DFTB_JC @mardi_steere

It’s a subjective measure, and needs to be kept in context of other signs of peripheral vasoconstriction. A CRT of 3s in a warm, perfusing child is likely either to be a) a sign I can’t count properly or b) this is a hot, annoyed child” #DFTB_JC @edd_broad


I’ve found seconds to be an extraordinarily flexible measure of time, especially in the high stakes environment of a child potentially in circulatory collapse. See also 5 second ice bath dunks in SVT – unless someone is timing, it’s usually 2 seconds tops!” @edd_broad

It’s too subjective in my opinion. Plenty of evidence there is a lot of interobserver variability. I don’t put a lot of emphasis on CRT when resuscitating.” #DFTB_JC @davidking83

This trial contained an ‘embedded perspectives’ study which allowed researchers to collect qualitative information about the randomisation process from parents and carers. Trained site staff explained the process of RWPC and the nature of the intervention, which appeared to elicit support from parents. No parents refused consent during the study. The twittersphere vibe was one of support for this methodology, with the caveat that studies using RWPC must have sound ethical oversight to ensure interventions are of equal risk/potential benefit. The wonderful @kerry_woolfall spoke about this in more detail during her talk at #DFTB19

I think it’s the only way to get good quality research in time-critical topics. The lack of patients withdrawing is a good sign that this it is acceptable to families. It needs robust ethical oversight, though, to ensure true equipoise.” #DFTB_JC @DrSarahMcNab

It’s the only way we will get answers about dealing with critically ill children in the resuscitative phase of treatment. Not necessarily the future, I think that randomisation prior to inclusion carries more scientific weight, but a useful tool in the research arsenal” #DFTB_JC @edd_broad

Crucial for resus studies, but strong ethics board to make sure both interventions truly seem equal risk / potential benefit #DFTB_JC @mardi_steere

Dr Inwald explained the process of preparing for a trial involving RWPC…

RWPC is becoming more and more common in emergency care trials. We did a lot of work in our feasibility study to make sure our process had proper steer from parents and families and was also acceptable to staff. I was blessed with great co-investigators, particularly @kerry_woolfall who led the qualitative work. “#DFTB_JC @dlawnI

Adherence to the fluid bolus volume and timing was better in the 10mL/kg group, when compared to the 20mL/kg group. Authors proposed two principal reasons for this. Firstly, the technical difficulty in delivering the larger volume of fluid in 15mins; secondly, suggestions from the embedded perspectives study that clinicians favoured the 10mL/kg boluses.

Responses from journal club participants varied widely, with a range of responses and reasoning behind their preferred bolus volume. Interestingly, these responses reflected the lack of clinician equipoise identified in the study. Twitter is not the place to go for a consensus on a topic, but the variety of responses does highlight the disconnect between current guidelines and clinical practice across the world.

I use 20mL/kg in most kids needing a bolus, but I’ve noticed many people use 10mL/kg.” #DFTB_JC @DrSarahMcNab

I personally would never give 20ml/kg, I don’t see the need. Draw up 2x 10ml/kg, give one and reassess. Esp as most pt we bolus are babies and there’s always a cardiogenic shock hiding in there”. #DFTB_JC @apsmunro

It’s not my practice but it seems to have crept in. Have seen 5 mls/kg in DKA for example.” #DFTB_JC @davidking83

I give 20ml/kg if think they need a bolus with the exception of cardiac, DKA and trauma” @begley_roisin

Kidney docs say 10 Heart docs say 10 10 very easily repeatable Sketchy science for 20>10 I like 20/kg- always have – but #DFTB_JC has led to introspection for me” @pea88

I wouldn’t criticise anyone for using 20 mL/kg as a first bolus in an ED setting though. The evidence is weak both ways. FEAST was conducted in a setting without PICU so I think has limited applicability in a high income countries.” #DFTB_JC @Dlawni

Again a biased tweet from Kenya – but FEAST was impactful for us. So well nourished kids now we tend to 10-20/kg; malnourished no bolus – and early peripheral pressors (PIV or IO). Honestly, FEAST has helped us not be scared of pressors in the ED, which is good.” #DFTB_JC @mardi_steere

Though the workings of the trial were feasible, the lack of severe illness in the study population (due to reduced burden of vaccine-preventable disease) means a large scale trial could not be completed. What part of the study to we change? Some suggested altering the inclusion criteria to include all children needing a bolus

To change practice may need an earlier intervention study including the less sick patients (more reflective of true practice?). Randomise at first bolus to 10 vs 20ml/kg. Accept we can’t demonstrate diff in mortality, but that in itself may justify changing guidelines to 10ml/kg @apsmunro

Problem is that then there will too many well kids in the study who just get 1 bolus and go to the ward. All outcomes will be good in this population whatever you do, so it’s not useful to investigate. This is kind of what happened to an extent in FiSh… #DFTB_JC @dlawnI

We discussed how to look at sicker kids by using PICU as the study site rather than purely ED or non-PICU sites.

In rural/remote Australia we pick up a decent number of septic kids with @MedSTAR_SA – maybe we need to do a better job of studying multicentre aeromed retrieval platforms. @docjohncraven @AmyKKeir #DFTB_JC @mardi_steere

So probably a multicentre study looking at early resus in multidisciplinary children’s hospitals with integral PICU and ED. If you do a study in PICU it will be too late – all the resus fluid will have already been given and there will be no separation between the arms…#DFTB_JC @dlawnI

Multinational studies. Stratify according to access? FEAST is criticised as “not our population”, but really maybe its about access & timing, not genetics. #PedsICU based studies are risky as pre-diagnosed, pre-treated rather than de novo arrivals IMO #DFTB_JC @mardi_steere

Some suggested altered end points given how difficult it is to prove mortality difference – after all, when working with these children we are considering so much more in the risk/benefit analysis than just mortality.

I don’t think it will be feasible to show a difference in mortality in a high resource setting. There seemed to be a trend towards a difference in length of PICU stay and mechanical ventilation, though. #DFTB_JC @DrSarahMcNab

Difficult one – I think community acquired sepsis is becoming a rare disease in the post vaccine age so if a study was to be done in a high income setting it would need to include “all comers” with sepsis – including HCAI. #DFTB_JC @dlawnI

Inevitably, with any discussion on fluids and sepsis we must talk about pressors, too. There is always more research to be done!

We all need to talk more about peripheral pressors and peds sepsis bundle #ED implementation 🙂 #DFTB_JC @mardi_steere

This is more likely to be the future, as underlying issue isnt true hypovolaemia, its relative to vasodilation (in most sepsis groups). Pressers correct the deficit more truely than just pumping saline in (but we need some evidence to prove it!) #DFTB_JC @apsmunro

A big thank you to everyone who participated in the chat. If you missed out, please feel free to add your thoughts via the comments below. Keep an eye out on Twitter for the date + time of the next #DFTB_JC. We will see you there!

Don’t Forget The Brain Busters – Round 4 answers

Cite this article as:
Team DFTB. Don’t Forget The Brain Busters – Round 4 answers, Don't Forget the Bubbles, 2019. Available at:


1. Appendicitis (A pen – dice – eye – teas)

You may know that appendicitis is the most common non-traumatic surgical presentation in paediatrics, but did you know that more than 50% of kids don’t have focal tenderness? Have a read of Arjun Rao’s surgical cases of abdominal pain post for a neat round-up of surgical differentials you should know.

2. Legg-Calve-Perthes (Leg – Calf – Purr – E’s)

Perthes has gained acclaim for describing avascular necrosis of the femoral head in children, but did you know that Perthes was originally described by an Austrian surgeon called Karel Maydl and has also been known as Maladie de Calvé. Have a look at Andy’s the child with a limp post for a comprehensive review of the causes of limp in kids.

3. Charcot-Marie-Tooth (Shark – O – Marry – Tooth)

Names after three neurologists who first described it in the 19th century, Charcot-Marie-Tooth disease is a hereditary motor and sensory neuropathy, also known as peroneal muscular atrophy. As the most common inherited neuromuscular disorder, it classically presents with reduced power and sensation in a glove and stocking distribution. The Charcot-Marie-Tooth Association website has some good information for healthcare professionals.

4. Kawasaki’s (Cow – A sack – Keys)

Kawasaki’s disease is a febrile illness presenting in children under the age of 5 and the most common cause of acquired heart disease in developed countries. Classically presenting with 5 days of fever plus four of rash, non-purulent conjunctivitis, mucous membrane changes, cervical lymphadenopathy or peripheral changes, Kawasaki’s can be diagnostically challenging as is a great mimicker of other febrile illnesses like measles, scarlet fever, and Steven’s Johnsons. To make things even harder, it can also present atypically. Have a read of Alyssa’s excellent incomplete Kawaski Disease post and bust a few fever myths with Ally’s epic Hot Garbage post.

5. Gastroschisis (Gas – T – Row – Skis – IS)

The savvier of you will remember we came across gastroschisis in the neonatal quiz. Gastroschisis is a congenital defect of the abdominal wall that means that the gut remains outside the abdomen after birth. If you didn’t have a chance to read Li-Zsa’s short gut post, here is it again.

6. Patent ductus arteriosus (Pay – Tent – Duck – US – Art – Ear – EOS – US)

I never cease to be amazed by the incredible way we have two entirely different physiologies, one in utero and one in the outside world. The ductus arteriosus is one of the many phenomenal plumbing shortcuts allowing blood to bypass the fluid-filled lungs from the pulmonary artery to the descending aorta. It usually closes functionally in the first 24 hours of life but can remain open, or patent, which may mean as little as an incidentally found murmur, or conversely may result in cardiac failure in our premature patients. Two particularly relevant posts are Andy’s transition from fetal physiology post and Ari’s brilliant DFTB18 paediatric murmurs podcast.

7. Angleman (Angel – Man)

Another eponymous syndrome, Dr. Harry Angelman first described this genetic cause of severe global developmental delay, ataxia, hand flapping and happy disposition in the 1960s. Due to the distruption of a gene on the long arm of chromosome 15, multiple different genetic causes have been found; although maternal imprinting is the one we often associate with Angelman’s, the most common cause is a de novo deletion. Read about global developmental delay and take a peek at our quick reference genetic syndromes post.

8. Henoch-Schoenlein purpura (Hen – Oc – Shone – Lion – Purr – Purr – A)

Purpuric rash, abdominal pain, and arthropathy: the classic triad of HSP. 40% of kids with HSP will have renal involvement and so regular dipsticks and BP review are essential. To find out a bit more about HSP, we’ve linked to a great video in this post. And if you’ve ever wondered whether steroids prevent nephropathy in HSP, take a look at this journal review to find out. And, finally, if you want to find out more about haematuria, microscopic and macroscopic, read Ben’s blood in the water post.

9. Chikungunya (Chick – N – Gun – Ya)

Chikungunya is a viral infection transmitted by mosquitoes in Africa, Asia, and the Indian subcontinent, although outbreaks have also occurred in the Americas and Europe. Its name comes from a native Tanzanian language meaning ‘that which bends up’, because it causes crippling pain in the joints. It classically presents with a sudden onset fever and joint pain, sometimes also with a rash, headache or vomiting. Sadly, low-income countries, where mosquito-borne infections are common, have much higher child mortality rates than the rest of the globe. Where living to your sixth birthday is a miracle gives the tragic narrative behind why children under five years of age born in these countries are more likely to die.

10. Rubella (‘Roo – Bell – A)

Rubella literally means Little Red in Latin. It’s also called German Measles because it was first described in Germany and has a morbilliform rash, similar to the measles rash. Alongside rash, the child has a low grade fever, coryza and lymphadenopathy. Although pretty mild in kids, it is devastating in pregnant women. Read Andy’s rubella post to learn about the presenting features of congenital rubella syndrome.


Hope you had as much fun as we did! One more round to go. This one will be a little different… it’s the kids’ round.

Don’t Forget the Brain Busters – Round 3 answers

Cite this article as:
Team DFTB. Don’t Forget the Brain Busters – Round 3 answers, Don't Forget the Bubbles, 2019. Available at:

Here are the answers to the Minor Injuries Picture Quiz. How did you do?


Question 1

Sam, a 14-year old competitive sprinter, limps into your ED complaining of a severe pain in his left hip which came on suddenly while running. He points to a specific area of his pelvis and experiences pain on active hip flexion, which is weaker than on the right. This is his x-ray. What is his diagnosis?

Sam has a left-sided lesser trochanter avulsion fracture, caused by sudden contraction of the iliopsoas muscle during sprinting. There are many different pelvic apophyseal injuries, which range from recurring painful episodes of apophysitis to avulsion fractures of these secondary ossification centres. Avulsions often present with reports of a “pop” followed by severe pain and weight-bearing difficulties. There is a reported injury predominance in adolescent males of over 70%, with sports involving kicking or sprinting most likely to be involved. Early diagnosis and appropriate management is necessary to reduce the risk of chronic pain, disability and reduced participation in physical activity. Apophyseal injuries can be misdiagnosed as “muscle strains” due to a failure to appreciate the anatomical uniqueness of this population making their injury pattern distinct from that of adults. Most injuries are managed conservatively with initial rest and symptomatic support in the form of ice, protected weight-bearing and analgesia. Gradual reintroduction to weight-bearing with early range of motion (ROM) and strengthening should be progressed under the guidance of a physiotherapist. To read more about pelvic avulsion fractures in children, take a look at Owen’s pelvic avulsion injuries post


Question 2

Tom, a 5 year old boy, is brought to the ED after a football game with his 9-year old brother went pear-shaped. Tom, standing in goal, took the full brunt of a misjudged penalty shot. Luckily Tom did not lose consciousness and has not vomited but when he told his mum everything looked a bit blurry she panicked bundled him in the back of the car and drove straight to your ED. There is no evidence of bruising or contusion but when you assess Tom’s eye movements you see this when he looks up at the ceiling. What is this a sign of? What sensory loss might you see with this injury?

Image reproduced with permission from


Tom has a restriction of upward gaze of his right eye, a sign of entrapment of the right inferior rectus muscle trapped in a blowout fracture of the inferior orbital wall. Children with orbital floor fractures may not have any facial bruising, presenting classically with only a “white-eyed fracture”, the only sign being limitation of eye movement secondary to entrapment. Children with orbital floor or medial wall fractures are at a high risk of entrapment, as paediatric bones are more prone to greenstick fracture, which then creates a ‘trapdoor’ effect ensnaring the inferior oblique and inferior rectus muscles or other orbital contents. Entrapment is a surgical emergency, as ischaemia of the involved musculature can cause permanent damage. The infraorbital nerve is commonly damaged in these injuries, resulting in numbness to the ipsilateral cheek, lip and upper gum. To read more about orbital fractures, take a look at Orla’s orbital fractures post.



Question 3

Sebastian is a 13 year old boy who is the school basketball champion. During training, leapt to deliver a slam dunk but just as he lifted into the air felt a sudden pop in his right knee. He is unable to weight bear and when you examine him it’s immediately obvious that the right knee is swollen compared to the left. He cannot straight leg raise. This is his x-ray. What does it show? What can you measure to confirm your suspicion?

Case courtesy of Dr M Mourits, From the case rID: 14476


Sebastian’s left knee x-ray shows a large haemarthrosis and suspicion of patella alta (a high riding patella). You can measure the Insall-Salvati ratio: measure the length of the patella tendon (from the lower pole of the patella to the tibial insertion) and divide by the patella length (the longest measurement of the pole). If the ratio is >1.2, this is diagnostic of patella alta, suggestive of a patella tendon rupture. Patella tendon ruptures occur during forceful contraction of the quads muscle (usually while the foot is planted and knee flexed), e.g. missing a step while climbing stairs or in jumping sports. Conditions that cause microscopic damage to the tendon blood supply such as repeated microtrauma (e.g. athletes) predispose to rupture. The inability to actively straight leg raise is indicative of serious extensor mechanism pathology and should be assumed to be a tear until proven otherwise. While rare in children, delayed diagnosis causes increased morbidity. Conservative management with immobilisation with a removal knee splint in full extension may be considered for those children with only partial tears and an intact extensor mechanism. Surgical repair is indicated for complete tears. To read more about patella injuries, take a look at Tadgh’s all things patella post.


Question 4

Sophie is a 15 year old girl who was chasing her annoying 11 year old brother when she tripped over a rogue rugby ball and fell straight onto her outstretched left hand. Her left wrist is very sore and tender. This is her x-ray. What do you see?


Sophie has three fractures: a distal radius fracture (which may well be displaced on lateral view), an ulnar styloid fracture and a scaphoid fracture. Scaphoid fractures are uncommon in young children because the scaphoid is protected during its ossification by a thick layer of cartilage and soft tissue. However, as the child enters adolescence, bony scaphoid fractures become more common. They are classically seen after FOOSH (fall onto an outstretched hand) and punching injuries. Don’t be misled by distracting wrist pain; be sure to assess for tenderness in the anatomical snuffbox, tenderness of the scaphoid tubercle and pain on telescoping of the thumb. Scaphoid fractures are often missed on plain x-ray, so if a young person has clinical features of a scaphoid fracture without any radiological changes on plain film, treat as a fracture and organise follow-up. MRI is much more sensitive at detecting scaphoid fractures so some departments are now using MRI as first-line imaging for these injuries. To read more about scaphoid fractures, take a look at Sarah’s scaphoid fractures post.


Question 5

10 year old George was hurdling at school when he tripped and fell. He was seen at a neighbouring ED a couple of days ago who diagnosed a sprain of his knee but the pain is no better and his knee is so swollen that his mum has brought him to your ED for a second opinion. His knee exam is limited by pain. You order a knee x-ray. What do you spot?

Case courtesy of Dr Yuan Ling, From the case rID: 69680


There is mild cortical elevation at the inferior patella pole: George has a patella sleeve fracture. These account for over 50% of all patella fractures in children and are caused by indirect trauma to the knee and are the result of a forceful quads muscle contraction in a skeletally immature child. Inferior pole sleeve fractures are most common. Patella alta or patella baja (low lying patella) may be present if the inferior (alta) or superior (baja) tender is disrupted. If the fracture is nondisplaced (<2mm) then conservative management is adopted with a cylinder cast in extension. If the fracture is displaced (>2mm) an ORIF (open reduction and internal fixation) to repair the tendon is usually required.


Question 6

12 year old Ella was jumping on the trampoline when she took a tumble: she planted her foot, hyperextending her knee and twisted. Her knee is now super sore and very swollen. What can you see on her x-ray? (hint, the lateral is your friend here)

Ella has a tibial spine fracture. These can be pretty tricky to spot on AP views, slightly easier on the lateral (here you can see the fracture fragment in the joint space), but often an oblique will show the fracture more obviously. These fractures are due to avulsion at the insertion of the anterior cruciate ligament (ACL). They typically occur in adolescents between the 8-14 years of age, usually associated with a fall from a bicycle or pivoting on a planted foot while playing sport. With stress, the incompletely ossified tibial eminence in the child avulses before the ligament ruptures. Stability of the knee may be difficult to assess due to pain and muscle spasm but the anterior drawer and Lachman’s test may be positive. AP and lateral x-rays of the knee should be obtained. Complicated fractures will likely need further evaluation with CT or MRI to fully characterise the injury. Splint the knee in extension and discuss with your orthopaedic colleagues: displaced fractures may need operative repair.  To find out more about proximal tibial fractures, take a peek at Deirdre’s proximal tibial fractures post.


Question 7

Margot is 12 years old and a keen gymnast. She was practising on the uneven bars and had sudden pain in the medial aspect of her left arm during a twisting manoeuvre. Her elbow is swollen and tender medially and there appears to be some valgus laxity. This is her x-ray. What can you spot? (or not)

Margot has a medial epicondyle avulsion fracture.  This is where CRITOE comes into play: Margot is 12 years old and so should have all of her ossification centres visible – and they all are, all the way to the external (lateral) epicondyle. But what about her internal (medial) epicondyle? It is visible, it’s just in the wrong place. The yellow ring is where the internal epicondyle should be. It’s actually outlined in red, way away from where it’s meant to be. 


Medial epicondyle fractures occur between 7-15 years (they account for 10% of elbow fractures in children). They are often associated with elbow dislocation 50% of the time. The degree of displacement of the medial epicondyle needs to be assessed.

Undisplaced or minimally displaced (<5 mm) fractures will not need surgical repair and can be managed in a long arm backslab (with 90 degrees elbow flexion). Displacement of 5-15 mm requires ortho input – surgical intervention usually depends on multiple factors (e.g. age, dominant hand, sports involvement).  Displacement of >15 mm or neurovascular compromise (ulnar nerve palsy) will require ORIF. Take a look at Tessa’s CRITOE Quick Quiz for more CRITOE fun.


Question 8

14-year old Nicholas was out skateboarding. Super chuffed that he’d finally mastered the slide and grind, he went for a last good luck flip. Only it wasn’t so lucky – he landed on his forearm and swears he heard a crunch. His forearm is grossly swollen and incredibly sore but after some intranasal fentanyl he tolerates an x-ray. What does his x-ray show? 

Nicholas has a Monteggia fracture-dislocation: a fracture of the proximal ulna with associated dislocation of the radial head (that radio-capitellar line goes nowhere near the capitellum). Monteggia variants have a peak incidence in the 4-10 year olds and, although rare, missing one can have long-lasting consequences. Isolated midshaft ulna fractures are very rare in children: when an ulna fracture is identified you must also get an x-ray of the wrist and elbow joints. Monteggia fracture-dislocations are most commonly classified by the Bado Classification, which categorises these injuries into four categories depending on the direction of radial head dislocation. Type 1 injuries, like Nicholas’, consist of a proximal ulna fracture with anterior dislocation of the radial head, and are the most common, accounting for about 75% of all paediatric Monteggia fracture-dislocations. The priority is for urgent orthopaedic assessment; all require urgent reduction of the radial head dislocation. To read more about paediatric Monteggia fracture-dislocations, check out Rie’s Monteggia post.


Question 9

Rebecca is 13 years old. She was playing on her pogo stick but her right foot slipped off and she landed awkwardly on twisting and externally rotating her ankle. She immediately fell to the floor on the court and couldn’t stand on it. Her ankle is very bruised and swollen and, even after intranasal fentanyl, she is very reluctant to weight bear on it. What type of fracture does she have?

Rebecca has a Salter-Harris III of her distal tibia with avulsion of the anterolateral corner of the distal tibial epiphysis, known as a Tillaux fracture. Salter-Harris III and IV fractures of the ankle are relatively common in adolescents because the lateral and deltoid ligaments are stronger than the physis itself. Tillaux fractures require an open tibial physis; the distal tibial physis closes initially centrally, then medially and finally laterally. Tillaux fractures are caused by rotational injuries, causing avulsion of the lateral part of the distal tibial physis by the anterior inferior tibulofibular ligament (and are therefore different from Pilon fractures which are axial compression injuries). An important differential diagnosis in an adolescent is a Triplanar fracture, which is very similar to a Tillaux fracture but has an additional direction of fracture in the coronal plane, evident on lateral ankle x-ray or CT. Triplanar fractures have three directions of fracture (much like the Mercedes sign, which is what they can look like on CT): a vertical fracture through the epiphysis, a horizontal fracture through the physis and an oblique fracture through the metaphysis. To read more about interpreting paediatric ankle x-rays, have a look at Tessa’s ankle x-ray interpretation post


We hope you enjoyed the minor injuries picture round. Next up: the emoji round.


Don’t Forget The Brain Busters – Round 2 answers

Cite this article as:
Team DFTB. Don’t Forget The Brain Busters – Round 2 answers, Don't Forget the Bubbles, 2019. Available at:

And here are the answers to the Bubble Wrap Treasure Hunt Round


Question 1

In Freedman et al.’s study of the management of gastroenteritis, apple juice was found to have fewer treatment failures than electrolyte maintenance solution. But how many of the recruited 647 children actually had evidence of dehydration?

And the answer is… B: 206 (31.8%)

Freedman et al (2016) investigated children aged 6 to 60 months with minimal dehydration presenting with mild gastroenteritis (defined as diarrhoea or vomiting in the preceding 24 hours, with less than a 96-hour history). They compared half-strength apple juice to a standard apple-flavoured oral electrolyte solution and found that children who were given dilute apple juice followed by their preferred fluids were less likely to be hospitalized, given iv fluids, reattend with the same illness or have a worsening clinical dehydration score within 7 days.

The catch, as alluded to in the question, is that only 31.8% of the children recruited into the trial had any clinical evidence of dehydration. So, sure, use diluted apple juice for very mildly dehydrated children presenting to your ED with gastroenteritis but keep a stock of oral rehydration solution handy!

Learning resources: Original paper and DFTB review


Question 2

In Maitland et al.’s groundbreaking FEAST study examining different fluid regimes for the management of sepsis how many children in TOTAL (of 3141 randomised) had severe hypotension (a systolic less than 50mmHg in <12 months old, <60mmHg in 1-5 year olds, <70 mmHg in older than 5 year olds plus one or more feature of impaired perfusion)

Answer (drum roll please)… A) 6

Sparking huge controversy, 2011 saw the publication of this large RCT in East Africa of over 3000 children was terminated early when it demonstrated an increase in mortality for children given a bolus of 0.9% saline or 5% albumin. Receiving a fluid bolus was associated with a worsening of respiratory and neurological function, anaemia and metabolic acidosis. These, in turn, were associated with worsening mortality. However, the study received much criticism as many children didn’t have blood pressure measured. Various rationales have been put forward as to why the study findings are not applicable to high-resource settings.

Understanding this study is important. Read the review of the 2019 Lancet re-analysis of the data, listen our podcast of Elliot Long at DFTB18 and go back and read the original paper.

Learning resources: DFTB Summary of the Lancet review, DFTB Podcast and original paper


Question 3

In Cunningham et al.’s influential BIDS study, assessing whether the 90% or higher target for management of oxygen supplementation was equivalent to a normoxic 94% or higher target for infants admitted to hospital with viral bronchiolitis what was the primary outcome measure?

The answer isn’t length of stay but… D) Time to resolution of cough

In this very clever double-blinded RCT, Cunningham’s group randomized 615 ward-admitted infants with bronchiolitis aged 6 weeks to 12 months of age to either a standard oximeter (which showed true saturations with clinicians instructed to give oxygen if sats dropped below 94%) or a modified oximeter (which showed measured sats of 90% as 94% so oxygen was not given until sats dropped below 90%). The primary outcome was time to resolution of cough. The group found no difference in time to cough resolution between the ‘true sats’ and ‘false sats’ groups (15 days) and no significant difference between adverse events between the two groups. This landmark trial has allowed us to consider managing infants with bronchiolitis, between 6 weeks and 12 months of age, to an oxygen saturation target of 90% or higher.

Learning resources: Original paper


Question 4

In Winter et al.’s 4 year retrospective review of 33185 children how many adverse events were there in children discharged with at least one abnormal vital sign?

The answer to this one is… B) 24

In a nearly 4 year retrospective review of over 33,000 patients discharged from a Children’s ED in New York, over 5,500 (17%) had at least one abnormal vital sign. There were only 24 adverse events (0.43%) in those discharged with at least one abnormal vital sign, but this was significantly different than the 0.17% risk in those discharged with normal observations. Adverse events were defined as death, representation to hospital and admission for 5 or more days, CPR, endotracheal intubation and unexpected surgery.

Have a read of Damian’s thoughts on the paper in the 10th bubble wrap as well as going back to the original article.

Learning resources: DFTB 10th bubble wrap and original paper


Question 5

In Bexkens’s et al. meta-analysis of pulled elbow how many patients do you have to treat with hyperpronation for a benefit over supination-flexion to be demonstrated?

And the final answer is… B) 4

This meta-analysis was reviewed in the first ever DFTB Bubble Wrap. It looked at the effectiveness of different manoeuvers at reducing pulled elbows. They found that hyperpronation was more effective than supination-flexion, with a NNT of 4. A subsequent Cochrane review in 2017 also found that hyperpronation is more effective but with a slightly higher NNT of 6. Check out Tessa’s pulled elbow post which reviews the evidence as well as our first ever bubble wrap.

Learning resources: DFTB pulled elbow post, DFTB 1st bubble wrap and original paper


Here’s a spoiler alert for round 3. This one will suit the injury enthusiasts out there – it’s the minor injuries picture quiz.