All paediatricians are complicit in delivering a racist healthcare service

Communication / Community paediatrics / Education / Ethics / General paediatrics / Health / Leadership
Cite this article as:
Zeshan Qureshi and Anna Rose. All paediatricians are complicit in delivering a racist healthcare service, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33938

We’re supposed to be the nice ones. The friendly, fun, caring and supportive speciality – right? We’re the ones who have teddies on our stethoscopes and know all the words to Disney songs. In the hospital, we’d like to think we’re the Good Guys – but maybe we’re not when it comes to race. 

The COVID-19 pandemic has been a monumental challenge to the NHS and has, undoubtedly, showcased the everyday heroism of our staff. It has also thrown a sharp light onto the ongoing racial inequalities in our society and healthcare systems. Racial disparities in the pandemic have been widely documented – and make for sobering reading. Analysis of national hospital data suggests that people of black and other minority backgrounds are up to twice as likely to die from the virus, as compared to white Britons – with some groups, such as black African-born men living in Britain, having an even higher risk [1]. Despite this, we have little doubt that the major impetus for the unprecedented emergency measures, national lockdowns, and political obsession was not the deaths of the poor, the ethnic minorities, or those in low and middle-income countries – but the perceived threat to wealthy, predominantly white, Westerners.

In an eerie parallel to the racial inequalities highlighted by the pandemic, the past year has also seen racial tensions in the USA reach boiling point. Following several high-profile incidents of police brutality, there was an eruption of social unrest and protest in America and around the world. The systemic disregard of black lives is not just written in blood on American pavements. It is written into the systems that surround us in our everyday working lives. As a speciality, and in the NHS as a whole, we must confront these engrained systemic inequalities, if we are to provide truly equitable care to all of our patients. 

In this blog series, we will examine how clinical outcomes for common paediatric conditions are worse for children from minority ethnic backgrounds. Stillbirth, low birth weight and preterm birth are all more common in minority groups as compared to white northern European populations [2,3,4 ]. Outcomes for common chronic conditions, such as asthma and type 2 diabetes, are also worse for children within minority groups [5,6]. This could be because care received by children with chronic conditions is worse. Non-white children with renal failure are less likely to pre-emptively receive a renal transplant, for example [7]. There are also complex social and environmental roots to these adverse health outcomes – such as increased poverty in non-White groups [8] — and we will try to investigate these issues in more detail. 

We will also explore how paediatrics has normalized white Northern European genetics, physiology and behaviour, leading to biased clinical decision making. Normalization of one ethnic group has lead to the classification of other normal values (in both the laboratory and social sense) as pathological or inappropriate. In other words – you are only normal if you are white and normal. Neutrophil counts are often lower in black babies [9]. Rather than reporting ethnically normal ranges babies often end up having multiple blood tests due to a lack of awareness of the variation. Parents get told that their neutrophil count is low, but it’s acceptable for a black baby (rather than categorically stating that their count is normal). Worst still, it might be classified as a disease – benign ethnic neutropenia – despite not being associated with increased morbidity or mortality.

Within medical education, we are guilty of peddling irrelevant and outdated racial and religious stereotypes. These hold little educational value, but risk enforcing dangerous bias within our future doctors. Any paediatrician would be able to tell you about the association between Tay-Sachs disease and Ashkenazi heritage, or sickle cell disease and sub-Saharan Black Africans. Such associations are often over-simplified and over-emphasized, to the point of creating a disease-ridden caricature, particularly in exam questions. Most of these stereotyped conditions are very rare, and over-emphasis during medical school risks blinkering us to more common diagnoses. We’ll explore how racial bias is ingrained in medical education in the UK, and try to come up with some ideas on how we can improve MedEd to be more diverse and inclusive in the future. 

There also seems to be a disproportionate concern that those from Muslim backgrounds might be consanguineous, and that we need to ask about this even when it is not relevant to the presenting complaint. Conversely, when genetic testing is being sent off, a detailed family tree needs to be drawn. It should include details of any consanguinity – yet it seems that a white family is less likely to be asked. As first or second cousin marriages are no longer a social norm in the UK, they have become defined by pathological associations with genetic conditions, such as inborn errors of metabolism. And whilst there are, of course, differences in the prevalence of disease alleles in different populations, and an increased risk of recessive disorders in families with intergenerational consanguinity, it does not automatically follow that a child from a Muslim background has a recessive disorder, or that a white British child does not. The same considerations need to be given to other cultural practices that might be different to the social norms of Northern and Western Europe. Putting children on a vegetarian diet is often classed as a ‘restrictive diet’ – despite the fact that it is only restrictive based on traditional Western standards – and might, in fact, hold health benefits [10]. 

Finally, in our series, we will examine how systemic racism within the health service tolerates – and sometimes even facilitates –  the unacceptable behaviours demonstrated by some parents. One thing that sets paediatrics apart from adult medicine is that patients are almost never seen alone, and a parent is often required to deliver care. This can present a dilemma to staff when confronted with a racist parent. Any punishment directed towards the parents might directly harm their child. We will explore how guidelines should be developed to help clinicians handle racist parents, whilst minimizing the effect on the clinical care of our patients. 

It can be painful for us – as individuals and as a speciality – to consider that we might be complicit in a racist system that ultimately leads to poorer health outcomes for some children. Just because something is painful, does not mean we shouldn’t do it. We hope that you’ll join us for this series of short articles, as we try to explore how we can begin to move from a white-centric healthcare system to a child-centred one.

James Baldwin quote on racism

Selected references

1) The IFS Deaton Review. Are some ethnic groups more vulnerable to COVID-19 than others? 

2) Gardosi J, et al. (2013). Maternal and fetal risk factors for stillbirth: population-based study. BMJ 346:f108.

3) Kelly Y, et al. (2008). Why does birthweight vary among ethnic groups in the UK? Findings from the Millenium Cohort Study. Journal of Public Health, 31:131–137.

4) Aveyard P, et al (2002). The risk of preterm delivery in women of different ethnic groups. British Journal of Obstetrics and Gynaecology 109:894-899.

5) Asthma UK (2018) On the Edge: How inequality affects people with asthma. Available at www.asthma.org.uk

6) RCPCH (2020) State of Child Health: Diabetes. Available at www.rcpch.ac.uk

7) Plumb LA et al. (2021) Associations between Deprivation, Geographic Location, and Access to Pediatric Kidney Care in the United Kingdom. CJASN. 16:194-203.

8) Office for National Statistics (2020) Child poverty and education outcomes by ethnicity. Available at www.ons.gov.uk.

9) Haddy TB, Rana SR, Castro O. (1999) Benign ethnic neutropenia: what is a normal absolute neutrophil count? J Lab Clin Med. 133:15-22.

10) Kalhoff H. et al (2021) Vegetarian Diets in Children—Some Thoughts on Restricted Diets and Allergy. International Journal of Clinical Medicine. 12:43-60.

July 16, 2021 0

Fracture hide and seek

Communication / Education / Emergency / Minor injuries / Orthopaedics / X-ray interpretation
Cite this article as:
Carl van Heyningen and Katie Keaney. Fracture hide and seek, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32819

Another winters morning. You are freshly vaccinated, caffeinated and ready for another ED shift. Your first patient is a return visit. A 7 year-old who fell onto his shoulder at school a week ago. You read your colleague’s previous assessment. On examination there was no bony tenderness and the x-ray report of the right clavicle was normal. Yet today there’s a lump over the collar bone and he’s no longer using his arm normally. Has something been missed?

X-ray interpretation is a complex human enterprise vulnerable to a wide variety of errors. The extent of missed diagnoses has been estimated to be as high as 15-20% 1,2.

There are two principle types of error:

  • Perceptual errors – those where the abnormality is simply not seen
  • Cognitive errors – where the abnormality is seen but its significance is not appreciated

You might think that such errors can simply be avoided through education, better imaging techniques and training. Yet since the 1960’s, despite doubtless advances in technology and improvements in medical practice, the rate of radiological errors has remained almost unchanged.

So what do we do? Admit defeat? Never!

Instead, let’s journey inwards and analyse these errors, why we make them and how we can improve ourselves and our approach to avoid missing fractures in children with injuries.

Causes of error

Perceptual errors are the most common and are due to many factors including:

  • Clinician fatigue
  • Distractions from colleagues and the working environment – the extrinsic cognitive load
  • High workload
  • Satisfaction of search (spotting one abnormality then failing to look for any more)

There is a reason your friendly radiologist is sat quietly in a dark room with a cup of coffee – a world away from a noisy, busy accident and emergency department. Consider yourself and your environment when reviewing an x-ray. Just as with prescribing, respect reviewing x-rays.

Even with the best conditions, what the eye sees the brain doesn’t always spot. Consider the now infamous Invisible Gorilla experiment that earned Christopher Chabris and Dan Simons an Ig-Nobel Prize in 2004. Participants were asked to watch a video and count the number of times the ball was passed between players. What they failed to notice was the large hairy simian playing the game. The brain failed to recognise what the eyes clearly saw.

The selective attention test

Cognitive errors occur for a whole host of reasons. Some of these include:

  • Lack of knowledge (e.g. how to interpret x-ray findings, ossification centres, etc.).
  • Lack of clinical information (e.g. history or examination)
  • Faulty reasoning (e.g. fracture identified but not cause of pain)
    • True positive, misclassified
  • Complacency (e.g. fracture identified but from separate injury)
    • False positive finding
  • Satisfaction of report (e.g. reliance on radiology report discourages further analysis).
  • Satisfaction of search (e.g. finding one fracture discourages search for another).  

Then there are our own cognitive biases which may also influence our interpretation…

Anchoring bias– early focusing on one feature of the image so neglecting or misinterpreting the rest of the information

“I’ve found the distal radius fracture so that is the diagnosis”. The scaphoid fracture is then missed).

Availability bias– recent experience of a diagnosis/presentation makes you more likely to diagnose the same condition

“I saw a pulled elbow the other day, it looks the same”. May miss ulnar dislocation.

Confirmation bias– looking for evidence to support your hypothesis and ignoring evidence against

“It looks like a simple ankle sprain, I think that X-ray must be fine”. Can miss fractured fibula.

Outcome bias– opting for the diagnosis associated with the best patient outcome/prognosis

“If there is a vertebral fracture, we will have to immobilise this child. It probably isn’t that”.

Zebra retreat– history and findings are in keeping with a rare diagnosis but the diagnostician is afraid to confirm this

“As Dr Cox says, if you hear hoofbeats look for horses not zebras” …sometimes it’s a zebra!

Finally, no article on medical error would be complete without reference to the good old Swiss Cheese Model. We are but one step in a sequence of events that can either prevent or lead to error. For our example case, consider the following…

Graphic showing swiss cheese model of errors
Errors were made

Can I have some examples please?

Most fractures in children are easy to spot however some may present with subtle findings, especially when they involve the epiphyseal growth plate.

Examples of where most missed fractures occur are shown below:

Common but low risk as well as rare but high risk missed fractures

Many fracture patterns are unique to children. The paediatric skeleton is more elastic, more porous, and has a relatively stronger periosteum. That makes it uniquely vulnerable to torus fractures, buckle fractures, plastic bowing and greenstick fractures. Knowing to look for such subtleties sets paediatric fracture diagnosis apart. That coupled with odd growth plates and ossification centres explains, in part, why fractures are more easily missed in children5.

There is a subtle angled fracture of the distal radius. Compare this with the normal (middle) and healing (right) – taken from Hernandez, J.A., Swischuk, L.E., Yngve, D.A. et al. The angled buckle fracture in pediatrics: a frequently missed fracture. Emergency Radiology 10, 71–75 (2003). 

A subtle angulated fracture of the proximal radius taken from Hernandez, J.A., Swischuk, L.E., Yngve, D.A. et al. The angled buckle fracture in pediatrics: a frequently missed fracture. Emergency Radiology 10, 71–75 (2003). 

Plastic bowing deformity of the left radius and ulna taken from George MP, Bixby S. Frequently Missed Fractures in Pediatric Trauma A Pictorial Review of Plain Film Radiography Radiol Clin North Am 2019 Jul57(4)843-855

Plastic deformity of the radius with upward bowing (arrows) taken from Swischuk, L.E., Hernandez, J.A. Frequently missed fractures in children (value of comparative views). Emerg Radiol 11, 22–28 (2004). 

A subtle greenstick fracture of the distal ulna taken from George MP, Bixby S. Frequently Missed Fractures in Pediatric Trauma A Pictorial Review of Plain Film Radiography Radiol Clin North Am 2019 Jul57(4)843-855

Note the upward plastic deformity of the right clavicle with the left for comparison taken from Swischuk, L.E., Hernandez, J.A. Frequently missed fractures in children (value of comparative views). Emerg Radiol 11, 22–28 (2004). 

The leftmost image shows an obvious spiral fracture. The Toddler’s fracture in the middle image is not apparent until the line of sclerosis appears with healing taken from Swischuk, L.E., Hernandez, J.A. Frequently missed fractures in children (value of comparative views). Emerg Radiol 11, 22–28 (2004). 

A Salter-Harris 1 fracture of the distal radius. Look at the widened growth plate compared with the ulna taken from Jadhav, S.P., Swischuk, L.E. Commonly missed subtle skeletal injuries in children: a pictorial review. Emerg Radiol 15, 391–398 (2008). 

We have seen how even with the benefit of the patient in front of us and the luxury of radiology reports that we are vulnerable to making mistakes. Yes, we need to first know our ischial spine from our olecranon (our arse from our elbow), but we also need to train ourselves in techniques to avoid perceptual and cognitive traps.

So how do we prevent them?

Reducing missed fractures in children

Sadly the evidence is lacking and largely focuses on the performance of radiologists. Approaches centred solely on education and training are insufficient. Slowing down strategies, group decision-making and feedback systems are, as yet, an unproven step in the right direction. Checklists, however, have a growing evidence base in improving performance despite their poor popularity.

Whether or not you are a fan of the ‘Checklist Manifesto’, less controversial are principles around workplace culture and communication. Facing up to errors, avoiding blame and frequently just talking with colleagues (the clinician, the radiographer, the radiologist, the patient) remains incredibly important.

What else?

Systems-level thinking

A growing number of healthcare trusts now implement peer learning systems. Rather than being punitive, such groups create collective opportunities to teach using diagnostic catches as well as misses. At Leicester Royal Infirmary, Education Fellow Sarah Edwards set up one such weekly group teaching session for A&E staff. It gave them the opportunity to review images with the support of a Consultant Radiologist.

Evidence also supports “double-reading” to reduce the misses. At the Royal London Hospital, we are supported by our Radiology colleagues who review all images from our paediatric emergency department within 24 hours. Furthermore, within our ED we foster a culture of learning from each other through openly sharing learning points without risk of embarrassment and most (if not all) x-rays are reviewed by two or more clinicians to share knowledge and experience.

Such principles underpin the Irish National Radiology Quality Improvement (QI) programme. Through standard setting and measuring performance they pursue a cycle of continued quality improvement.

Individual level thinking

Michael Bruno, Vice Chair for Quality and Chief of Emergency Radiology at Penn State University says “there’s a very simple fix for errors of thinking- cognitive biases.… you must force yourself to ask really open-ended questions…. what else, how else, where else could a finding be… force your mind back open again.”

To be more technical, lets consider the “dual process theory of reasoning.” In radiology, automatic system 1 processes typically enable immediate pattern recognition. In contrast deliberate system 2 reasoning enables less obvious abnormalities to be detected. Normally there is a dynamic oscillation between these to forms of thinking. The lesson is not to eliminate type 1 processing, which is prone to mental shortcuts and mistakes, but instead to be aware of our own thinking with the ability to deliberately “turn on” our type 2 brain when needed.

This discipline is termed metacognition or meta-awareness. 

For those who find such talk nebulous, there a number of practical steps that come recommended from Andrew J. Degnan (Department of Radiology at Children’s Hospital of Philadelphia).

Maintain a healthy skepticism

Reflect on your diagnostic process, challenge your interpretation forensically and question yourself objectively.

Use a structure or checklist

Structured reports help radiologists. Find your own repeatable techniques and approach each x-ray systematically, including “review areas” that are often overlooked. 

Consider the clinical findings

What is your pre-test (pre-x-ray) probability? How confident were you in your clinical assessment? Is the x-ray a rule-in or rule-out? Marrying up a thorough history and examination with a careful focus on the relevant radiographic area often bears reward.

“Injuries that are missed because of failure to image are typically because the injury was poorly localized or because of the presence of other injuries distracted attention from the injured part.”

Mind your environment

Are you fatigued? Have you had a break? Clearing your mind for even a moment can actually improve overall efficiency. A quiet work space. A few minutes away from distraction. These will all empower your type 2 thinking.

Mitigate, mitigate, mitigate

Mistakes happen. Telling parents about uncertainty is critical to them re-presenting if their child’s soft tissue injury or sprain is not improving. Importantly, this is not the same as forgoing responsibility. Yet if your routine practice includes quality safety netting, discussing cases with your friendly radiologist and chasing up on cases you may not prevent mistakes but you might minimize the harm that comes from them.

What happened with our case?

A repeat x-ray was done but again no fracture was evident. Yet to examine there was an un-deniable lump mid-clavicle. In view of persistent pain and continued non-use of the limb (right arm) the child was discussed with the radiologist who agreed upon ultrasound. Ultrasound confirmed early callus formation and a break in the cortex that was not visible on X-ray. The child went home in a sling for outpatient follow up.

Take home messages  

  • Missed fractures are more common in children and not necessarily subtle
  • Know what to look for and how to look for it
  • Process is important, don’t forget history and examination
  • Communicate clearly, speak frequently with your radiographer and radiologist

Selected references

1. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121(5 suppl):S2–S23.

George MP, Bixby S. Frequently Missed Fractures in Pediatric Trauma A Pictorial Review of Plain Film Radiography Radiol Clin North Am 2019 Jul57(4)843-855. – Images 3,5 in carousel

Hernandez, J.A., Swischuk, L.E., Yngve, D.A. et al. The angled buckle fracture in pediatrics: a frequently missed fracture. Emergency Radiology 10, 71–75 (2003) – Images 1,2 in carousel

Jadhav, S.P., Swischuk, L.E. Commonly missed subtle skeletal injuries in children: a pictorial review. Emerg Radiol 15, 391–398 (2008). – Image 8 in carousel

2. Wachter RM. Why diagnostic errors don’t get any respect: and what can be done about them. Health Aff (Millwood) 2010;29(9):1605–1610.

5. Smith J, Tse S, Barrowman N, Bilbao A, (2016). P123: Missed fractures on radiographs in a paediatric emergency department, CJEM, 18 (S1), S119-S119

Swischuk, L.E., Hernandez, J.A. Frequently missed fractures in children (value of comparative views). Emerg Radiol 11, 22–28 (2004). Images 4,6,7 in carousel

Further reading

Brady AP. Error and discrepancy in radiology: inevitable or avoidable?. Insights Imaging. 2017;8(1):171-182. 

Kim YW, Mansfield LT. Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. AJR Am J Roentgenol 2014;202(3):465–470.

Michael A. Bruno, Eric A. Walker, and Hani H. Abujudeh, Understanding and Confronting Our Mistakes: The Epidemiology of Error in Radiology and Strategies for Error Reduction, RadioGraphics 2015 35:6, 1668-1676 

Martino F., Barbuti D., Martino G., Cirillo M. (2012) Missed Fractures in Children. In: Romano L., Pinto A. (eds) Errors in Radiology. Springer, Milano.

Miele V., Galluzzo M., Trinci M. (2012) Missed Fractures in the Emergency Department. In: Romano L., Pinto A. (eds) Errors in Radiology. Springer, Milano.

Wang CC, Linden KL, Otero HJ. Sonographic Evaluation of Fractures in Children. Journal of Diagnostic Medical Sonography. 2017;33(3):200-207.

May 17, 2021 0

Following bronchiolitis guidelines

#DFTB_JC / Community paediatrics / Education / Emergency / General paediatrics / Respiratory
Cite this article as:
Ben Lawton. Following bronchiolitis guidelines, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32798

In 2016 our friends at PREDICT produced a robust, evidence-based guideline for the management of bronchiolitis. They assembled a diverse team of experts, decided on the key questions we ask ourselves when managing babies with bronchiolitis and then did a deep dive of the literature to provide answers to those questions. You can read the guideline here, or the DFTB summary here but the key messages will be familiar to regular readers of DFTB. The list of things that do not help babies under 12 months with bronchiolitis includes salbutamol, chest x-rays, antibiotics, nebulised adrenaline and steroids. In the real world, however, these ineffective treatments continue to be used – so what can we do about that? 

The authors of a new PREDICT study released in JAMA Pediatrics on 12 April 2021 sought to demonstrate whether a group of interventions they developed using theories of behaviour change would be effective in reducing the number of ineffective interventions given to bronchiolitic babies. 

Haskell L, Tavender EJ, Wilson CL, et al. Effectiveness of Targeted Interventions on Treatment of Infants With Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr. Published online April 12, 2021. doi:10.1001/jamapediatrics.2021.0295

Who did they study? 

This was an international multicentre cluster randomised controlled trial (RCT) involving 26 hospitals in Australia and New Zealand. It is described as a “cluster” RCT as randomisation was by hospital rather than by patient. The randomisation was a bit complicated. It was stratified to make sure secondary and tertiary hospitals from each country were represented in each group. Baseline data was collected from 8003 patient records from the three bronchiolitis seasons prior to the start of the intervention period. A further 3727 charts analysed from the season in which the intervention took place. The data from the three prior seasons were used to ensure baseline similarity between groups and to establish patterns of practice change that were already occurring. In short, this was a big study that ensured representation of both specialist children’s hospitals and mixed general hospitals. 

What did they do? 

Hospitals randomised to the intervention group received a package of interventions based on the Theoretical Domains Framework (TDF), developed following an earlier qualitative study that investigated why we do what we do when managing bronchiolitis infants. The TDF is one of the most commonly used frameworks in implementation science and is considered particularly good at identifying interventions to address barriers and facilitators that influence behaviour change. The package included:

  • Appointing clinical leads from medical and nursing streams in both emergency departments and inpatient paediatric units.
  • The study team meeting with those clinical leads to explore the local practice and any anticipated barriers to change.
  • A one day train-the trainer workshop to ensure clinical leads were comfortable using the educational materials provided to train local staff.
  • An education pack including a PowerPoint with scripted messages specifically designed to promote change, a clinician training video, evidence fact sheets, promotional materials and parent/caregiver information sheets.
  • Monthly audits of the first 20 bronchiolitis patients with the results shared and compared to the best performing hospital.

What about the control group?

Hospitals randomised to the control group were just left to their own devices for the year of the intervention period. They had access to the guidelines and were welcome to share that information as they would in any other circumstances. The intervention package was made available to control hospitals in the season following the study period. 

What did they show? 

The primary outcome was the proportion of infants who complied with all five of the Australasian Bronchiolitis Guideline recommendations known to have no benefit (chest x-ray, salbutamol, steroids, adrenaline, antibiotics). There was an 85.1% compliance rate in the intervention group compared to a 73% compliance rate in the control group. In other words, in hospitals that were part of the intervention group, an average of 85.1% of kids received care in line with the guidelines, compared to only 73% receiving guideline compliant care in control hospitals. This was a significant difference.

Secondary outcomes showed improvement was consistent in both the ED and inpatient phases of care. Unsurprisingly, there was no difference in hospital length of stay or admission rates to ICU. 

The DFTB verdict

On the surface this is a robust, well designed study showing that if we put some thought and some resources into supporting our colleagues in doing the right thing then babies with bronchiolitis will get better care in our hospitals. They won’t leave hospital any quicker and they won’t have a lesser chance of needing ICU but they will be exposed to fewer interventions that will not do them any good and may do them some harm. Dig a little deeper though and the big messages in this paper go way beyond the management of bronchiolitis. The implementation science based interventions used in this study can be adapted to anything, and though they have been shown to be effective in getting us to do the right thing here, we haven’t shown that their efficiency has been optimised yet. Great breakthroughs in novel medical science are exciting but there are huge improvements in care to be gained through getting the best care that we do know about to every patient every time. This paper should serve as fuel for the fires lighting implementation science’s journey from the shadows to the centre stage of improvement in clinical care. 

From the authors

The study’s senior author, Prof Stuart Dalziel gave DFTB the following take: 

“The key finding is that we can do better. By using targeted interventions, based on established behaviour change theories and developed from work looking at why clinicians manage patients with bronchiolitis the way they do, we can improve the management of patients with bronchiolitis such that it is more consistent with evidence based guidelines.

In the field of implementation science (IS) and knowledge translation (KT) a 14% improvement in care is a large change.

Changing clinician behaviour is complicated, this is especially so for de-implementation of medical interventions. Many factors influence clinician behaviour and it is thus perhaps naïve to think that a single intervention can cause a significant change to behaviour. For a number of decades the majority of clinical guidelines for bronchiolitis have emphasised that chest x-ray, antibiotics, epinephrine, corticosteroids and salbutamol are low-value care and not evidence based. Yet despite this consistent messaging from guidelines the use of these interventions has remained considerably higher than what it should be. While the interventions delivered in our study were not unique (site based clinical leads, stake holder meetings, train-the-trainer workshops, targeted clinical education, educational material, and audit and feedback) they were specifically developed, using an established framework for behavioural change, following a qualitative study that determined why clinicians managed bronchiolitis they way they do. This prior study, addressing the barriers and enablers to evidence based care, and the subsequent step wise approach to developing the targeted interventions that we used was critical in achieving the change in clinician behaviour observed in our randomised controlled trial”.

The study’s lead author, Libby Haskell, stated:

“Bronchiolitis is the most common reason for children less than one year of age to be admitted to hospital. We can improve the care of these infants, such that they are receiving less low-value care. In order to de-implement low-value care we need to first understand barriers and enablers of care, and then develop targeted interventions, built on robust behavioural change models, to address these. This approach can be used to improve care for other high volume conditions where we see considerable clinical variation in care and with clearly established clinical guidelines on appropriate management.”

Let us know what you think in the comments below 

April 13, 2021 1

Introducing the curriculum mapping team

Education
Cite this article as:
Team DFTB. Introducing the curriculum mapping team, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31674

One of the most wonderful things about DFTB is the tireless effort of our community of friends, friends who keep things bubbling away behind the scenes, never asking for recognition or thanks, but who help make DFTB as wonderful as it is.

Since DFTB’s conception in 2013, we’ve published over 1000 posts (1062 as of Christmas Eve 2020 – that’s phenomenal). In the background, our fabulous curriculum mapping team have been reading all our publications and mapping them to not one, not two… but five acute paediatric curricula from postgraduate colleges in the UK and Australasia. Just over a year ago the curriculum mapping team had mapped 102 posts of a little over 800 published. Now, 13 months later, a ginormous 900 post have been read, digested and mapped to each of the five curricula. We’ll unveil the curriculum tags in 2021 but until then, let us introduce you to the curriculum mapping team.

Dani and Henry are the lead and delegate of the team. But the recognition must go to these lovely people:

Aaron Buiza – joined October 2019. Aaron is a medical student from The University of Queensland who just wants to be a kind, wise and happy physician. He dreams of running a community paediatrics clinic one day. When procrastinating from his flashcard reviews, you can find him cooking up a new dish, trying out different restaurants in the city or playing board games with friends

Aisling Clarke – joined October 2020. Aisling is a final year medical student at University College Dublin, Ireland. She recently completed her paediatric rotation and fell in love with the speciality. In her spare time, she loves all things outdoors, especially running, sea swims and sunsets.

Stevie Barry – joined November 2020. Stevie is a medical student in the Royal College of Surgeons in Ireland with a keen interest in paediatrics and education. When he’s procrastinating his studies, he enjoys playing rugby, walking his dogs and spending time with friends and family.

Emma Chan – joined June 2019. Emma is a resident based in Brisbane, Australia. She loves teaching gym classes and going on long walks paired with a cosy mocha and almond croissant in hand.

Gemma Cooper-Hopson – joined December 2020. Gemma lives in England and is close to completing her training in General Paediatrics with an interest in High Dependency care.  She has two young girls, two dogs, a hamster and a husband. She enjoys cake, wine, the outdoors and afternoon naps. 

Diluxshy Elangaratnam – joined December 2020. Diluxshy is a paediatric registrar who has combined her love for medical education with clinical training. She enjoys seeing the light bulb moment when medical students have understood a diagnosis almost as much as she enjoys meticulously testing flat whites in St Albans. 

Jillian Fagan – joined October 2020. Jillian is a final year medical student in University College Dublin in Ireland and has just finished her placement in paediatrics. She has always thought she wanted to do paediatrics, but her emergency department placement piqued her interest in the speciality! In her spare time, she loves anything to do with music and cooking.

Jessica Hawkins – joined April 2019. Jessica is excited to start her role as an intern at the Royal Brisbane and Women’s Hospital in 2021. She has a keen interest in paediatrics and all of the wonderful joy and bubbles that it brings. She has a passion for all things sweet (brownies especially), enjoys experimenting with watercolour painting, and indulging in the perfect wine and cheese combo!

Barbara Jedelsky – joined October 2019. Barbara is a resident based in Cairns, Queensland. When not working, you can find her at the beach, and enjoying spending time with family and friends.

Ailbe Keane – joined October 2020. Ailbe is a final year medical student at University College Dublin, Ireland, with a particular interest in paediatrics. Outside of university she loves baking, running, swimming in the sea and spending time with her friends, family and dogs.

Demi Murphy – joined April 2019. Demi is originally from western Canada. She is currently an RBWH intern and is very excited to join the 2021 paediatrics team at QCH for her JHO year! She hopes to pursue a career in General Paediatrics and as the founder of UQ’s Paediatric Medicine Society she hopes to continue to help facilitate medical students with an interest in paediatric medicine to do the same. In her spare time Demi loves singing, rock climbing, and spending time with family.

Tulsi Patel – joined December 2020. Tulsi is a paediatric trainee in London. She has a passion for learning and teaching and is easily distracted by puppies and cake!

Alexandra Pelivan – joined October 2020. Alexandra is a PEM grid trainee in Leicester, UK. She is passionate about facilitating trainees’ access to PEM resources, but also enjoys adolescent emergency medicine and is interested in ways of making debriefing easier. When not at work, she says she will likely be in a coffee shop.

Calvin Skews – joined October 2019. Calvin is a paediatric trainee based in Newcastle, Australia. When not on the wards, you will find Calvin on a bushwalk, at the beach, or sipping coffee while enjoying a good book

Leah Tyndall – joined December 2020. Leah is a graduate entry medical student with a background in biomedical engineering. Her biggest interests are in paediatrics and neonatology, as well as in medical technology and device design.

This is our way of saying thank you to these hard-working people for helping make DFTB so special. Thank you.

January 3, 2021 0

A New Way To Teach

DFTB Modules / Education / Teaching Modules
Cite this article as:
Team DFTB. A New Way To Teach, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28420

At DFTB we are very excited to be able to present the DFTB Modules – a set of free, open access teaching modules which are mapped to the UK and Australasian Paediatric Emergency curriculum that you can pick up and run in your own organisation.

This is a project that has been developed by our DFTB Fellows at the Royal London Hospital – Rebecca Paxton, Helena Winstanley, Chris Odedun, and Michelle Alisio. The DFTB Modules would not have been possible without our wonderful community of writers and contributors from around the world who have spent time crafting and reviewing the modules over the past year.

We’ve prioritized flexibility in creating the modules with cases and discussions with both basic and advanced trainees in mind. This way you can adapt them to your learners and existing resources. The first 15 modules have been released and we have another 30 in the pipeline. These will be published over the next few months. We would love to get your feedback or comments at fellows@dontforgetthebubbles.com

Why did we create the project?

The DFTB mission is about taking a “World recognized leadership role in making meaning of information in paediatric medicine, for clinicians“. Our principles are structured around being collaborative, pioneering, community-focused, and evidence-based.

Opportunities for teaching and learning across the curriculum in paediatrics, particularly in paediatric emergency, are variable between hospitals often due to access to useful resources. Whilst there are many fantastic educators in hospitals, many fill clinical roles. This means that their time to prepare for teaching is limited. For trainees, who often rotate from hospital to hospital, having access to structured resources and an opportunity for case-based discussion of a wide range of topics will help strengthen their learning.

By collaborating, as a group of medical professionals across the world, in writing these modules – we are working together as an international community to support thoughtful, evidence-based sessions.

Access the DFTB Modules here

July 27, 2020 1

A beginners guide to remote learning

Communication / Education
Cite this article as:
Edward Snelson. A beginners guide to remote learning, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.27341

Many of us are finding that we are being thrust into the world of remote medical education without the training or the experience to feel that we are likely to do this effectively.  There is a huge lack of adequate training for non-experts in this field that is designed to be pragmatic and useful for those of us who are more comfortable delivering face to face medical education.  I have looked for resources that might facilitate learning for a clinician who considers themselves a novice in remote or online medical education and have found none.

To help get people started, I’ve to put together some of the things I have learned about being an effective educator in the world of online and remote medical education.

Core Principles

You are the most important educational resource.  If you are delivering the education, your learners haven’t come to get a textbook or a list of facts.  They want to know what you know and what they don’t.  Forget some of the habits of traditional medical education.  Bring more of your experience and less of what you can find in a textbook.

Online and remote medical education has many advantages.  It is more accessible and has benefits for many people’s learning styles.  You can get a greater diversity of learners involved which can also be a powerful tool.  The educator can have more control of the virtual classroom.  

Online and remote medical education also carries many risks.  IT failures and audience disengagement are probably the greatest risks.  Preparation, planning and rehearsal are key elements in overcoming these challenges.

ProblemsSolutions
IT failure (connectivity, software limitations)Good signal (WiFi or mobile data) Educator’s device must be up to the task Choose the best software application for the job
Lack of connection from the audience to the educator.  Educator less able to read the audience.Where possible, have the audience visible (e.g. all on video) Maximise interactive content Have questions via audio as well as via chat
Audience disengagement and loss of attentionMaximal interactive content Chunks of delivered education should be brief and broken up by interactive elements Use of breakout rooms Polls Virtual flipcharts Injections of humour Changes of pace Music
Educator’s unfamiliarity with online teaching as a modalityRehearsal Visual aids (session map) Repetition of session to multiple audiences
Learner’s unfamiliarity with online learningPre-session briefing and joining instructions Start meeting with an explanation of what the session will involve and explain the functions
SecurityUse of required password for Zoom sessions Link to meeting sent with clear ground rules for whether it can be shared and with whom

A Step by Step Guide

Choosing a software application

There are various packages that are available.  The decision as to which to use will depend on various factors including ease of access, user friendliness, functions available, familiarity and permissions within an organisation.

ApplicationProsCons
ZoomGood range of functions including hand raising, chat, screen sharing, polling and breakout rooms User friendly Most people are familiar with Zoom Works well across a range of audience sizesBreakout rooms are only available in pro package (cost) Software is not permitted by some organisations, requiring users to access via personal devices People have to know how to use functions such as chat Basic and entry level package limit audience size to 100 but this can be increased at further cost Users need to set up Zoom on their device prior to the session (very straightforward)
Microsoft TeamsGood range of functions Permitted by organisationsFunctions are often clunky and poorly designed e.g. breakout rooms Less user friendly than many other packages Users need to set up Teams on their device prior to the session (more complicated)
Google MeetUse is possible within most organisations SimplicityVery limited functions – essentially it is a conferencing software package
Facebook roomsSimplicity Use is possible within most organisationsUsers may not have a Facebook account
SkypePermitted by organisationsLimited functions
YouTubeAble to reach an unlimited audienceUnable to see audience Interaction only possible via chat or third party applications (e.g. polling and virtual flipchart via mentimeter) Security and governance is more difficult to manage

There are many other software packages available.  It is worth trying the different packages to see what is the best fit for the teaching that you want to deliver.  I would recommend Zoom Pro for simplicity and functionality.

Every package will have settings that you should configure to your needs. For example, in Zoom, you can set defaults such as whether people are automatically muted when they join a meeting. Tutorials and guides for how to do configure settings are available online.

Hardware and connectivity

As the person delivering the session, you do not want to be let down by the tech on the day.  You need a device which is able to run the application smoothly.  Old or underpowered devices that let you down on the day need to be avoided.  You need to have a good broadband signal.  If you are using mobile data, you need a good signal.

The best way to make sure that it all works is to try out with the device you intend to use, in the place that you will be on the day, with the software that you will using.  Don’t assume that everything will work, make sure it will.

Time and Location

You should choose a time which is well protected.  You should have no other commitments that might encroach on the session.  You should be ready and set up about 30 minutes before the official start time so you need to build that into your schedule.

The space that you use for the session should be quiet and secure.  Think about what is in your background and aim to have nothing in view than yourself if possible.  Make sure that your lighting is in front of you and that you are not backlit.

The way that you intend to deliver the session will depend on the topic, the size of the audience and the teaching style.  A large audience lends itself to a webinar style.  A medium size group best suits a classroom style session and a small group session can be delivered more like a tutorial.

You should think about what resources and teaching aids you wish to use.  These are a really important part of your planning as they help with audience engagement. Many people will choose to use a PowerPoint presentation via the screen share facility in Zoom or Teams.  If you do use a PowerPoint, make sure that it is minimal.  The number of slides should be very few and the content very limited.  Remember that your audience may be viewing the session on a hand held device and thus wordy slides simply will not be easily readable.  If you have too many slides, this will lead you to talk too much and your audience will not be able to maintain interest.

There are a number of other ways to add dimensions and variety to your session.  Features within zoom and teams allow polling and breakout rooms (with zoom, breakout rooms is only available in the pro version).  It is also worth considering using external resources.

External resourcePossible uses
Mentimeter www.mentimeter.com Polling, Agenda setting, Idea sharing , Sharing learning outcomes
Fun Retro https://funretro.io/ Agenda setting, Idea sharing, Sharing learning outcomes
Google Docs https://drive.google.com Case studies, Handouts, Links


Using external resources is a great way of facilitating learning in a way that changes the pace and keeps the audience engaged.  For example, you could get your learners to go into a breakout room having first sent them a link to a google doc that has a case study and the tasks for that exercise.  You can also give them a link and code for the mentimeter that allows them to share what they think (virtual flipchart).  While they are in the breakout room, they are engaged in the learning in a different way and you get a few minutes to do whatever you need or want to do.

If you are using external resources, it is well worth putting together a list of links for your learners and sending these to your audience ahead of time.  Proactive learners will have those resources open and ready for the session.

If you deliver a really simple session, there is little risk that you will miss bits or find that elements get lost along the way.  If you have planned a more complicated session, giving yourself a visual aid-memoire in the form of a session map can be really useful.  Unless you are using a second device screen, you will need to have this on paper and placed just above your webcam for ease.  Even for simple sessions, having checklists can be really useful.  When you are thrown a curveball in an online session (someone having technical difficulties at the start) it can easily throw you and make you forget to do something essential such as introduce yourself.

You need to decide how you want your audience to be.  Will they have cameras on or off?  Will they be muted throughout and only use chat?  Will they be unmuting to speak and then muting themselves?  Will they be unmuted throughout because it’s a very small group?

It is essential that your learners know these parameters ahead of time.  If not you may find that they have assumed that they will be passive listeners and when you ask them to turn on video you see them five minutes later in a moderately damp dressing gown!

I would recommend that you send joining instructions which include the technical things like which platform and links will be needed, along with a few key bits of information such as the need to have video and audio for the session if that’s what you want.  You should ask if anyone has access or ability issues to let you know ahead of the session.

If your session is really high level, and particularly if you are doing complicated functions, consider having a second person supporting you.  This person does not have to be in the room with you but it does help if they are.  A second person can watch the session from another device and therefore sees what your audience sees.  They can therefore tell you when something isn’t going to plan.  The second person can also monitor chat, which can be difficult to do for the main facilitator when they are focused on delivering the session.

Rehearsal is really important.  You need to familiarise yourself with the software and by trying the different features, you will discover the potential glitches.  At the very least as preparation, have a meeting with friend or family using the platform that you intend to use and play with the different functions.

If your session is complicated or your audience is of high value in some way, you really want to run the whole session fully with a test audience.  This allows you to find out the time it takes and you are very likely to find that you need to crop something.  It also helps you to work out any practicalities that will make things run smoothly.

Setting up

Make sure that you are comfortable in every way.  Have some water available to drink.

Get everything set up and open the session before you expect people to join.  It is worth having a PowerPoint slide with some sort of greeting or session title so that people know that they are in the right place and that the video feed is working.  Your audience will also want to know that their audio is working.  A simple way of doing that is to play some music through your device and share that via the screen share function on the platform you are using.

You need to look at how you appear on video.  Check that you have optimal lighting.

Depending on the platform and settings that you have chosen, you may need to let people into the session.  If not, you can leave the session running and people can join and wait for the session to start.  If you have a second support person, brief them on what you want them to do.

About five minutes before the official start time, I recommend saying hello to your audience (so far) and letting them know that the session will start on time.  You can also remind them of any settings or preparation that they need to do.

Starting the session

At the beginning of the session it is important to cover some practical points.  Some of your audience may be unfamiliar with the software and despite having sent them specific instructions, people may not have read or understood these fully.

Things to tell your audience at the beginning of a session

  • Introduce yourself.
  • Tell people what you will be doing and how long the session will last.
  • Set ground rules as appropriate.
  • Tell people whether you want them to have video on or off.
  • Tell people how you want them to let you know when they have a question.  If you want them to use a “raise hand” function, tell them that you won’t always see their video feed so if they raise their hand on camera, you might not see that.
  • Explain any special functions that you want them to use.  That includes chat.
  • Tell your audience to let you know if something is wrong.

If you have any elements to your session other than your face and a PowerPoint, I find that it is good to start by giving the audience a low-level opportunity to practice using these features at the beginning so that they can try these out safely.  For example, if you plan to use breakout rooms with information on an online document and interactive software such as mentimeter you could do the following:

Explain these elements and ask them to open the menti.com site and the linked document.  The document could be instructions for a starter task such as “Find out what everyone wants to learn in this session” and the menti.com ideas board would be one where they will write their learning objectives for the session.  Then send them to breakout rooms to complete the task.

When they come back you can talk about their learning objectives but also deal with any user or technical difficulties encountered.

Even if you are delivering a bare-bones session, get your audience to use the simple features such as chat or hand raising right at the start.

The main event

Now go for it.  In order to be as effective as possible, you want to engage your audience and maintain their attention and enthusiasm.  There are lots of ways to help you achieve this.

  • Have your audience put their video feeds on. It can help you as a teacher to see people.  More importantly, it makes it less likely that they will be engaged in other tasks.  The classroom equivalent of an invisible online audience is a room full of people texting or checking emails while you talk.  
  • When your video feed is on, look at the webcam.  Eye contact is very important.  If you are looking anywhere else, your gaze is tangential which is subconsciously disengaging for your audience.  If you have a thumbnail of your own webcam feed on the screen, place this as close to the webcam as possible as your tendency will be to look at your own face much of the time.
  • Smile.
  • Be animated, including the use of hand gestures.
  • Use humour.
  • Limit the amount of time that you speak continually.  Even if you are going to continue speaking again, every few minutes ask the audience a question and leave time for them to think and answer.
  • Make your session about three quarters interactive in whatever way fits the modality.
  • Vary things as much as possible. You can switch from PowerPoint to webcam, then video.  Using interactive elements such as polling, breakout rooms or large group discussions are all possible ways to keep the session varied.

Managing the question and answer element

Q&A is one of the most basic yet effective means that is available for an educator to engage their audience and improve the depth of learning.  It helps the session facilitator to find the level needed for the teaching and meet the specific needs of the audience.  If you are delivering an online session with more than a few people, it is a very different experience from a face-to-face setting.

Q&A in a remote teaching session is often the element that requires the most management.  You should be prepared for the possibility that your audience has already become disengaged or distracted by other things.  It can be useful to give people a warning that a question is coming, “I hope you’re all paying close attention, because I’m going to ask you all a question in a moment.”  This might result in a few people putting away their phones (on which they were commenting on something on social media or answering an email) in time to be fully engaged when you need them to be interactive.

If your audience is muted when you ask a question, you can manage that in a number of ways.  Remember that regardless of audience size, it may be difficult to get your participants to answer, so encourage them as much as possible.

Method 1 – answer via chat

This is most likely to get responses as people won’t be worried about interrupting someone and they may feel safer in terms of constructing an answer when they can review and edit it before sending it.  The facilitator needs to allow enough time for people to do this, so don’t ask a question and assume that no-one is answering after a few seconds.

If you use chat as the means for answering questions, it can be a really good way of engaging people more if you invite individuals to expand their question verbally.  “Mohammed, you’ve put ‘what about POPs scores?’ in the chat.  Could you please unmute your mic and tell me what you’ve been told about POPs scores and how they are used?”

Method 2 – hand raising

Software such as Zoom allows participants to hit a button called “raise hand” which comes up as an alert to the host.  The facilitator can then invite that person to unmute their mic in order to ask their question.

Method 3 – Verbal free for all

Most platforms give the host the opportunity to unmute everyone’s microphones at once.  This can be used to create something closer to a classroom experience where people can just start talking.  There is a risk that more than one person will talk at once, which becomes greater with large groups.  There is also the risk that any background noise from other participants becomes audible.

It is worth trying different methods to see which works well.  Within any session, if you find that one method isn’t getting any or much response, you can see if a different method works better as all audiences are different.

Other Top Tips and Resources

Here’s a list of tips and tricks that may help:

  • Use headphones to avoid feedback and a microphone to reduce background noise.  A standard mobile phone microphone earpiece set works well.
  • If you have a second device logged into the same meeting in the same room, one of them must always be muted and have speakers off otherwise there will be an echo.
  • Remember that even when your video feed is off, people can hear you if you are not muted.
  • Remember to stop screen sharing when you have finished showing something to your audience.
  • Backgrounds are a fun way to inject humour into a session but you need to have a plain backdrop and there is a risk that it affects the applications function.
  • Your software may allow you to record the session which can then be used as a resource for you to review what went well and what could be improved.
  • Recordings of webinar or lecture-style sessions can be recorded and used as an educational resource.
  • Most conference software has multiple views to choose from.  Try using each view both in rehearsal and when delivering a session.
  • Each time you deliver a session, you will become more familiar with the technical and educational aspects of online learning.  Delivering the same session multiple times in a short period of time will help you to learn and improve.

DFTB are proud to share with you our first 15 remote education modules that you can pluck off the virtual shelf.

Finally, a short list of other resources that have explored the issue of becoming an effective educator in an online setting:

https://dontforgetthebubbles.com/teaching-virtually-anywhere/

https://www.aliem.com/teaching-age-covid19-real-time-video-conferencing/

https://icenetblog.royalcollege.ca/2020/03/17/teaching-remotely-in-response-to-covid-19-10-tips-to-improve-your-digital-classroom/

https://www.youtube.com/watch?v=HCK_1ydMhiE

July 27, 2020 0

Connecting Advanced Care Practitioners

Communication / Community paediatrics / Education
Cite this article as:
Team DFTB. Connecting Advanced Care Practitioners, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.26520

Our last ACP teaching session was on Thursday 8th October 2020. It covered case-based discussion, head injuries that may not be head injuries, and neonatal emergencies. See the recording below.

Our ACP webinar series is an opportunity for Advanced Practitioners who see children to connect with each other and to share knowledge.The webinars are delivered by and aimed at ACPs from any background who would like to share and improve their knowledge about caring for children in acute settings. The sessions are free, and anyone is welcome to join. Each session will comprise three short talks followed by a panel discussion and time for questions. We will be covering clinical and non-clinical topics, from a range of presenters. We will hear from some experienced speakers, as well as giving less seasoned speakers the opportunity to have their voice heard. If you have an idea for a topic you’d like to present, or if there’s something you have a burning desire to find out more about, please get in touch.

October 2020 – case-based discussion, head injuries that may not be head injuries, and neonatal emergencies

July 2020 – antibiotics, lymph nodes, and team leading

July 2, 2020 1

Getting in to training – Australia / New Zealand

Communication / Education / General paediatrics
Cite this article as:
Claire Chandler. Getting in to training – Australia / New Zealand, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.26173

Finding and securing a training position is tough. Claire Chandler has done it. Whilst these lessons are related to the experience in Australia there are a lot of lessons that apply to any application.

Crucial things

  • Do your RESEARCH – Start with college websites then move to statewide training programs then to the specific hospitals and rotations. Different positions open, close and send offers at all different times of the year so it’s worth drawing up a little timeline.
  • Give yourself PLENTY OF TIME to write your application – some of the answers may be equally weighted with your CV – it’s worth investing your time here. Start prepping weeks out from the due date, not days.
  • PROOFREAD the application and your CV – or even better, get someone else to as well. Fresh eyes help.
  • Use your colleagues and consultants for support and ADVICE. Try seeking out trainees in their first few years of training as their knowledge of the application processes and requirements will be most helpful.
  • Only applicants get the job. Don’t psych yourself out. SEND IT.

If you know early that you want to do paediatrics

You can give yourself a head start by building your CV from medical school. Try to get as much contact with your proposed specialty as possible.

Check out what conferences are on and go to them! They’re inspiring, you will network with like-minded people and get valuable advice for the future. It can be expensive – but there are often early bird prices, student and junior doctor discounts, plus a few scholarships, particularly for rural students.

Consider getting involved in paediatric focused audits or research.

Leap into the fabulous worlds of Twitter and FOAMed. I cannot overemphasize how helpful it is in forming connections with health professionals from a huge variety of backgrounds, all over the world. If you are a bit nervous when introducing yourself to the superstars of paediatrics, it‘s a great help when you find out you are already Twitter friends.

Consider a postgraduate course like the Sydney Child Health Program.

What if you only decided on paeds more recently?

Hit the short courses! Find out what you could get to, including:

  • Paediatric Basic Program
  • APLS
  • Resus4kids
  • Neonatal Resus
  • Leadership courses
  • Teaching on the Run
  • US Guided Cannulation Workshops

Know the job

  • Read through the job description
  • Check you meet college and registration requirements
  • Research the hospital – its facilities, expertise, institutional values, geography.
  • Visit the physical location or check out their website. The extra effort of contacting or visiting the department in advance may be enough to score you an interview

Your resume

Your resume is your sales pitch. The key to getting your interview. You need to stand out but for the right reasons! You need to succinctly and clearly state why you should be given the job. Aim for an absolute maximum of 3 pages keeping all information relevant to the position.

Think about an opening statement that summarises who you are, why you want the job, and why the employer would want to employ you. Here’s an example of one of mine

I am a PGY4 doctor with the goal of becoming a General Paediatrician in rural and remote Australia. I have extensive experience working in Emergency and General Paediatrics in the Northern Territory. I have spent my extracurricular time building my skill set to be proficient in leadership and education and have completed my APLS, Paediatric Diploma, and Paediatric ICU Basic course. I have researched your hospital online and spoken to some Paediatricians in the department. I truly believe my enthusiasm, dedication, and intelligence would be an asset to your hospital. I have always wanted to improve the lives of kids out bush and see this position as the perfect way to start doing that. 

Formatting

  • Pay attention to the criteria: Is the institution dictating the format? If so you need to follow this.
  • Think about adding a small number of visual effects to help it stand out. You could make the title a colour or add a simple neutral coloured frame. Ensure that the font is large and simple.
  • Think about the order that you present information. It may be useful to put more pertinent information or experiences first rather than just presenting the lot in chronological order.
  • Number your pages. This will help make sure no pages go missing.
  • Edit your content to make sure it is all relevant. Highlight the most relevant parts – think larger or bold font to draw the employers’ eyes. You need to make this CV look like it has been specifically created for this particular position.
  • Let your personality shine through! Let the employers know you have a life outside of medicine and what makes you different from all the other applicants

Experience

  • Your relevant experience since you got your degree.
  • If there are any gaps it is best to explain them. The employer would rather know that you went on a gap year rather than assuming the worst i.e that you had your medical registration suspended for the year.
  • Think about what elements of your pre-medical life would make you more employable and why. Did you grow up in a rural location that would make you more suitable for a rural position? Did you do an elective rotation somewhere exciting? You’re looking for points of connection with the interviewers – things that will help you stand out from the other applicants.
  • Find experiences within your previous rotations that will demonstrate the attributes employees are looking for. Rostering, junior teaching and supervision, overnight decision making, neonatal resuscitation experience, paediatric cannulation and lumbar puncture experience, participation in education programs, junior doctor representation to hospital executive – all of these things help.
  • At high school did you do anything out of the ordinary? Include it.

Work history

  • What did your life look like before medicine? Think about what elements of those past jobs fits the application criteria or your chosen specialty
  • Medical: Here include any association with hospital, state, or national committees. Include any publications, research, courses, conference attendance, and presentation.
  • Non-medical: Hobbies, volunteer work, language skills (AUSLAN), IT systems.
  • SPELL CHECK!
  • Don’t undersell yourself. And don’t lie!

Referees

Think carefully about your referees. Ensure that they know you well, have worked in your most recent job, and, importantly, will give you a shining reference. Ideally pick someone who has given you end of rotation feedback, that way you have a very good idea of what they’re going to say to the prospective employers. Have a conversation with them and make sure that they too think you can do the job!

Send your referees your CV so that they have the same information that you are providing the employer. Finally, ensure you have the correct contact details for your referee.

Welcome to the jungle of copious links, PDF downloads, and painful IT systems. Check everything that is required and in what format with plenty of time to spare! A single wrong click in a box could exclude you from the entire process so read the instructions carefully.

In each application, you will be required to download various types of evidence. This will be very difficult if you decide to take an overseas holiday at the time as I did. It helps to have a cloud storage system or portable hard drive where you can keep:-

  • Proof of ID and medical registration
  • Scanned copies of medical and postgraduate degrees
  • Proof of immunization status
  • Certificates of attendance for courses or conferences
  • Statement of employment and rotations at past hospitals
  • Some applications will even ask the specific dates your past hospital rotations were and when you took leave!

Finally check the character count. A friend of mine typed 130-word replies only to find out it was 130 characters including spaces.

Find an experienced buddy to practice with you. Consider a formal interview where your dress up, have time limits etc. and record it then debrief.

  • Are you umming and ahhhing too much?
  • Do you sound confident?
  • Are you addressing the questions whilst also selling yourself?
  • Could you be more succinct?
  • How is your posture? Are you sitting straight, smiling, looking like someone you’d want to employ?

An approach to your answers

  • Ask yourself why the interview panel is asking the particular question? How does it relate to the position criteria?
  • If you don’t understand the question or can’t think of an appropriate answer, ask for the question to be reworded.
  • If you need some thinking time you could paraphrase the question or give a comment like “that’s an interesting question” or “Yes that’s a complex scenario, let me think about how I would approach it on the ward…”

Keep you at the focus of the interview. How can you sell yourself in each answer?

Consider (and practice) the ‘STAR”  approach to structured question answering:

  • Prepare answers to some of the common questions so you can practice them.  Even if you don’t use the exact phrasing, it takes away the “I have to think of an example on the spot” part of the interview.  There are many questions that are SO common that it’s crazy to not have prepared.
  • Tell us about yourself
  • Why do you want this training position?
  • A time you made a mistake
  • How to deal with conflict
  • How to deal with a colleague that isn’t performing (showing up late, showing up drunk, not doing work etc.
  • A time you showed leadership
  • How you deal with a stressful situation

An approach to specific question types

Clinical questions

  • Use a structured approach to question answering. Don’t forget the basics of resuscitation and calling for senior help as required. DRABCDEFG, HoPC, relevant PMHx, pertinent exam findings, bedside investigations, initial treatment, more complex investigations, and treatment.
  • If you have absolutely no idea what to do, just go with a sensible approach. Resuscitate, seek help (hospital guidelines, online prescribing resources, senior nurse, and doctor assistance).
  • Know your limits. How comfortable are you dealing with this scenario? When will you seek support? Employers want to know that you are safe.

Conflict resolution

  • Employers are looking to see if you are respectful, a good listener, and will escalate concerns if it’s needed.

Communication

  • Employers are looking to see if you are a good communicator – empathetic, and sensible.
  • In regard to an under-performing colleague – do you know how to escalate concerns to senior colleges? Are you aware of mandatory reporting?

Weaknesses or mistakes

  • What did you learn from the mistake? How did you address your shortfalls?
  • Try and pick a simple error and potentially one with a happy ending. It helps to have thought of one or two in advance.

Do you have any questions?

  • Prepare a question that sells yourself. Here are some examples
Whilst speaking to one of the other registrars I found out that you run simulation training. I have experience in running simulations and am eager to be involved in your program. Who can I talk to about this?

I heard a presentation about your research program by Dr X at the DFTB19 conference I was moderating at. Are there any similar research programs that I could be involved with?

What will you do if you don’t get this job?

  • Employers are sussing out if you cope with failure? Do you have a plan B? Does this job actually mean anything to you? Will you be upset?

  • Get plenty of sleep the night before and ensure your phone is charged.
  • Ensure you know where to be and when. Have the contact details of the interviewer on hand in case you get lost.
  • Put some effort in to your appearance. If you have a suit, wear it.  No one will ever judge you for being too formal, but they will definitely judge you for being to casual. Don’t be afraid of a little splash of colour or fun – after all this is paediatrics.
  • Arrive at the hospital with plenty of time to find the interview room. Don’t be late.
  • Don’t forget to be kind and confident with everyone you meet on the day – you never know who will be watching.
  • Consider a mindfulness meditation.

In the interview

  • Try to exude confidence. Fake it till you make it.
  • You are likely to be surging with adrenaline. Take a breath and reflect on the question asked. Start with a smile.
  • After you’ve answered the question take a deep breath. See if the interviews have any questions for you. If there is silence you can add some additional detail.
  • Observe your interviewers and be aware of the cues they are giving.
  • If you tank a question, try to move on with a light heart – you’ll be showing the interviewers you can pull yourself together when things are tough.
  • Smile at the panel before you leave, say thank you.

This wait can feel excruciating at times. Ensure you are looking after yourself mentally and physically and have a buddy to support you. I don’t think I talked to one person who felt 100% confident with their performance in the application process so please don’t worry if you are suffering from low confidence or imposter syndrome.

If you got the job – WOOHOO! Get your paperwork done quickly and completely. Start off on the good side of the administrators. You’re likely to need to provide police checks, immunization status, copies of your graduation certificate, AHPRA registration, and some proof of identification. Some of this may need to be signed copies by a JP.

And if you didn’t get the job

This may not be the end. You may be in the running for some 2 and 3 round offers for various sites. Seek feedback from the employer. They will often be able to tell you where your short fallings were or how the other candidates outshone you. Use this information to build a better application or do a better interview next time.

July 1, 2020 0

Virtual simulation

Communication / Education / Simulation
Cite this article as:
Nick Peres + Tim Mason. Virtual simulation, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.26002

What do you think of when you hear the words Virtual Sim? If your mind goes to Neo (Editors note: Keanu was actually quite good in the first Matrix- feel free to argue) then we are of like mind. If you think of the stereotypes of mainstream media, you will likely think Ready Player One, Tron, or even Lawnmower Man!

COVID-19 has changed our world with “socially close” teaching universally banned. Simulation is no different and I, for one, miss it! We know sim has its benefits, in situ, and for hands-on practice. Can we get back to that reflective learning we know and love?

Medical simulation is a tactile, experiential teaching modality, however, as sim trainers, we are often told “the learning is in the debrief”. This leaves us to beg the question – can we re-create or port something like a debriefing session virtually? And if so, should we be pausing activity in our sim centres and giving all trainees a VR headset?

 

 Looking at the realm of Twitter and our practical experience, how have people tried to bridge this gap? What’s out there?

Remote sim

Passive: Watching a live simulation session streamed to a video conferencing application via the sim centre camera(s) (or mobile) whilst a team perform the sim. This is then followed by a facilitated debrief taking place remotely, again utilising a video conference platform.

Interactive: A simulation takes place but there may be some interactivity with a confederate in the room being directed via video by a learner as a team lead. The debrief then follows on the video conferencing platform. Pre-recorded video can be repeated as appropriate.

 

A quick note on cameras

We are investigating the types of camera that best convey a remote simulation scenario. These include fixed-angle cameras (such as utilising those cameras already within a simulation suite), handheld or accessible cameras, such as a body-worn GoPro or even utilising a 360-degree camera, which can then be explored by participants or debriefer using their mouse to navigate the 360 recorded space.


 

The advantage of the passive approach is that we do get to be involved in the process, however, there may only be one or two fixed-view cameras impacting on your impression of the scenario. It may recreate some of the visceral feelings we get in a resus but you are still physically and psychologically removed. The alternate scenario adds an element of interactivity but the action in the room won’t reflect reality as it won’t directly represent the real team. Both measures will need clear learning objectives that fit these new methods. One interesting thought is if this actually represents the way senior doctors view their department and “direct” their juniors remotely without the need to physically be present (i.e. overnight on calls)?

Others have tried methods such as Telesimbox where a video is played whilst a facilitator guides the learners (over video) through a pre-set scenario.

Other paid-for services include app-based 360° films which may have a degree of interactivity or higher-tech solutions using headsets.

 

360° Sim

We’ve been doing something a little bit different which is 360° Virtual sim. 360° video is filmed using a fancy camera that can record all the way around it with two fisheye lenses. The camera then stitches together the images into a sphere which you can then look around by swiping the screen on a tablet or moving your head around a VR headset. 360° video has been used as a debriefing tool in itself with some success. Medical students found it gave them a deeper appreciation of their communication skills during the simulation.

Two years ago I was helping run a Return to Paediatric Training Sim course in the south-west, We didn’t have any time to add in resus but felt that it was an area people worry about. With the expert help of Nick of the Torbay VR team, we made a Neonatal Life Support (NLS) and an Advanced Paediatric Life Support (APLS) simulation utilizing  360° video which participants could access at home. The learners on the course loved it, though some felt it was stressful or uncomfortable, The sights and sounds of the room meant everything soon felt familiar. For others, it inspired them or put them back in the zone.

 

When the world became socially distant, it gave us the opportunity to debrief these videos over a video conferencing platform. Using 360° videos, the viewer becomes an active observer right in the centre of the action.  Although they can’t truly interact with the scene, they are still placed in media res. This really helps to bring about discussion of non-technical skills, with associated feelings and humanistic considerations, in the debrief.

If you have content that is created and shared with you to use, it then essentially becomes an accessible and free setup with no need for manikins, faculty, or dealing with the frustrating lack of parking spaces. Here’s an example of a 360° sepsis sim we ran and debriefed remotely.

 

There is also the potential to teach larger groups than what would normally be run through an in-person simulation session.  

 

Making your own 360° content

  • Write your simulation with learning objectives appropriate to your learners – think, medical, technical and non-technical.
  • Think about which scenarios work. Emergencies with lots of different teams to follow may be fun, but think about the difficult communication scenarios (safeguarding, breaking bad news) as it may be a safe way to sharpen communication skills.
  • A 360° camera (roughly £400) and stand (grip/ microphone stand).
  • A computer capable of editing (it needs a good graphics card)
  • When filming, position your camera at eye height in the centre of the action (hanging from the curtain rail is good).
  • Take away all patient identifying info if in situ (the camera sees all).
  • Think if you are going to tell the sim participants the theme of the sim. It adds to psychological safety but you may not get the authentic simulation experience.
  • Film it again if things go wrong as it is harder to edit afterwards.
  • Editing- steep-ish learning curve but simple things can be done easily in free packages.

 

Running your remote or 360° virtual Sim teaching session

  • Planning is key- time and place are less of an issue but think of your learners. How is the session going to meet their learning needs? Is there something particular that you are going to focus on?
  • Pick your video conferencing application of choice – we all have our favourite/ the one our trust allows us to use. Are you sharing your screen? Are you using sim centre cameras or mobile phones?
  • Practice using the kit/ technology before you do it live – not once but a good few times.
  • Solid Pre brief/ ground rules for the session are important.
  • Beware of “Zoom Fatigue”- try not to run a session longer than 1 hour. Most of ours have been 45 minutes at most.
  • Is the Wifi good enough? Will the videos cut out?
  • During the sim think about allowing learners/ observers to type thoughts and feeling that come to mind that you can then cover in the debrief.

 

Some thoughts on the virtual debrief

In a study looking at debriefing after medical serious games, in-person and virtual debrief both rated highly (self was the lowest). Remote debriefing has been used to train teams and faculty  in countries that do not have access to resources or experience in simulation.

 Make sure someone is designated to lead the debrief. Use the standard sim structure- Defusing, Discovery and Deepening. This model is based on Kolb’s experiential learning theory. This has made its way into many different models including Diamond, Pearls and ITRUST.

Who’s watching the watchmen? We’ve had more consultants during our sessions than the usual weekly sim. This changes the dynamic of the discussion. It skipped the medicine and went straight to the communication and processes seen. This may not be a positive for the junior members who needed experiential medical learning.  If using pre-recorded 360° content that is not live make sure you make it personal exploring real-life experiences. Has anyone seen this before? How does this work in your ward? Where’s the protocol kept?

As with all forms of online facilitated tuition, it is important to set the ground rules at the offset. Do you have learners muted? This will depend on the numbers in the debrief considering microphone echo verus silence.  You may need to use a signal to talk (i.e. Zoom thumbs up!). Everyone should keep their cameras on so you can see everyone and try to “read the room” keeping all involved.

So what might the future hold? It may be live streaming 360° content (which a lot of 360 cameras can do), a virtual space we can easily watch 360° video together, or Mozilla hubs where our avatars we can meet to watch content together. I don’t see this a replacement for regular simulation. It is an adjunct, a complimentary tool for the SBE toolkit.le.

June 22, 2020 0

Teaching (virtually) anywhere

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

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

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

 

Safety

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

 

Belonging

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

 

Helping learners learn

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

 

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

 

Webinars

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

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

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

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

 

Moderated discussions

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

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

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

 

DFTB modules

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

 

Open forums

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

 

Live gamification

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

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

 

Time-independent gamification

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

 

Pre-recorded teaching

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

 

Virtual skills and drills

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

 

Microteaching moments

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

 

March 22, 2020 1

Decade

Education / General paediatrics
Cite this article as:
Andrew Tagg. Decade, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.22033

Decade, not just an amazing Duran Duran greatest hits album, but also a unit of time. The last 10 years have seen great changes in all of our lives and whilst the births of various children do rank quite highly, the founding of Don’t Forget The Bubbles is also a highlight in many of our lives.  When we started it back in 2013 we could not have imagined what it has morphed into.

 

Some key events of the decade

The beginning of the (?) teens saw the introduction of the first iPad. It was not as revolutionary as the iPhone but allowed us to read the paper in bed and engage in a more mobile form of entertainment consumption.

2010 saw the official opening of the tallest building in the world, the Burj Khalifa, and led Tom Cruise to wonder “what would happen if I climbed up this”?

2011 saw the first proper royal marriage in ages as HRH Prince William married Catherine Middleton in front of 22.8 million television viewers.

2012 saw the rise of K-Pop as Gangam Style became the most-watched music video ever reaching over a billion hits on YouTube. It was also the year that the Higgs-Boson, long thought to exist, was finally discovered.

2013 saw the introduction of CRISPR, the gene-editing technology that could change everything and user in a new era of designer babies if some scientists had their way. It also introduced the world to Anna and Elsa and a million children dreamed of building snowmen that would come to life.

2014 was the year we lost some of the greats – Rik Mayall, Casey Kasem (the voice of Shaggy in Scooby Doo), Maya Angelou, Robin Williams.

By June 2015 same-sex marriage had finally become legal in the US. It also saw the release of Star Wars: The Force Awakens, a film that would finally help us rid our memories of those dreadful prequel movies.

Pokemon Go was the flavour of the day in 2016 launching augmented reality into the mainstream and reality became a little more distorted as Donal Trump was elected the 45th President of the United States of America.

2017 was the year of our very first conference in Brisbane, something that we never thought we would be doing when we started the website some years earlier. Now our year seems to revolve around planning the next one.

2018 highlights the deepening climate crisis as Penrith in Sydney hits 47.3 degrees. 2018 also saw the death of one of the world’s finest – Stan Lee – at the age of 95.

In 2019 Rick Deckard hunted down the Nexus-6 replicants and Roy Batty gave that famous speech.

 

Some of the top papers of the decade

*Not necessarily the most important

2011

Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, Nyeko R, Mtove G, Reyburn H, Lang T, Brent B. Mortality after fluid bolus in African children with severe infection. New England Journal of Medicine. 2011 Jun 30;364(26):2483-95.

Roberts KB, American Academy of Pediatrics. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011 Sep;128(3):595-610.

2013

Powell C, Kolamunnage-Dona R, Lowe J, Boland A, Petrou S, Doull I, Hood K, Williamson P, MAGNETIC Study Group. Magnesium sulphate in acute severe asthma in children (MAGNETIC): a randomised, placebo-controlled trial. The Lancet Respiratory Medicine. 2013 Jun 1;1(4):301-8.

2014

Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Pediatric Anesthesia. 2014 Dec;24(12):1204-11.

Everard ML, Hind D, Ugonna K, Freeman J, Bradburn M, Cooper CL, Cross E, Maguire C, Cantrill H, Alexander J, McNamara PS. SABRE: a multicentre randomised control trial of nebulised hypertonic saline in infants hospitalised with acute bronchiolitis. Thorax. 2014 Dec 1;69(12):1105-12.

2015

Riskin A, Erez A, Foulk TA, Kugelman A, Gover A, Shoris I, Riskin KS, Bamberger PA. The impact of rudeness on medical team performance: a randomized trial. Pediatrics. 2015 Sep 1;136(3):487-95.

Cunningham S, Rodriguez A, Adams T, Boyd KA, Butcher I, Enderby B, MacLean M, McCormick J, Paton JY, Wee F, Thomas H. Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. The Lancet. 2015 Sep 12;386(9998):1041-8.

McNab S, Duke T, South M, Babl FE, Lee KJ, Arnup SJ, Young S, Turner H, Davidson A. 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial. The Lancet. 2015 Mar 28;385(9974):1190-7

2016

Cronin JJ, McCoy S, Kennedy U, an Fhailí SN, Wakai A, Hayden J, Crispino G, Barrett MJ, Walsh S, O’Sullivan R. A randomized trial of single-dose oral dexamethasone versus multidose prednisolone for acute exacerbations of asthma in children who attend the emergency department. Annals of emergency medicine. 2016 May 1;67(5):593-601.

2017

Irwin AD, Grant A, Williams R, Kolamunnage-Dona R, Drew RJ, Paulus S, Jeffers G, Williams K, Breen R, Preston J, Appelbe D. Predicting risk of serious bacterial infections in febrile children in the emergency department. Pediatrics. 2017 Aug 1;140(2):e20162853.

2018

Tagg A, Roland D, Leo GS, Knight K, Goldstein H, Davis T, Don’t Forget The Bubbles. Everything is awesome: Don’t forget the Lego. Journal of paediatrics and child health. 2018 Nov 22.

2019

Lyttle MD, Rainford NE, Gamble C, Messahel S, Humphreys A, Hickey H, Woolfall K, Roper L, Noblet J, Lee ED, Potter S. Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE): a multicentre, open-label, randomised trial. The Lancet. 2019 May 25;393(10186):2125-34.

Dalziel SR, Borland ML, Furyk J, Bonisch M, Neutze J, Donath S, Francis KL, Sharpe C, Harvey AS, Davidson A, Craig S. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomized controlled trial. The Lancet. 2019 May 25;393(10186):2135-45.

 

We’d love to hear what you think are some of the key papers of the last decade. Drop us a line in the comments section.

So what is next for DFTB?

Curriculum mapping

Dani Hall and a team of intrepid data-miners have been working on a curriculum mapping project to get a better idea of what we have in the 850 posts we have already published as well as to guide content creation. With the help of the RLH/DFTB fellows, we are then going to be creating some core modules for clinician-educators. Imagine you want to run a session on, for example, bronchiolitis. We are going to create the package for you, complete with pre-reading, some key papers complete with discussion points and controversies, and some fun activities to match.

Knowledge translation

One of our core aims at DFTB is to make current research more accessible. Whether that is breaking down the latest research with the help of PERUKI and PERN, showcasing original research or busting long-held beliefs we will continue to keep you up to date.

Conferences and beyond

When the idea of holding a DFTB conference was first suggested some years ago we laughed and suggested we’d struggle to fill 50 seats. We’ve gone on to sell out our first three conferences and are well on our way to doing the same in Brisbane for www.dftb20.com.  We love the conferences bringing our community together, raising the profile of the patient, and sharing knowledge and so we are already planning for DFTB21.

We also recognize that the conference cannot be everything and so we are creating some more educational options, an amuse-bouche to the conference main course if you will. Look out for more details in the New Year.

December 30, 2019 1

Meet our next DFTB Fellows…Helena Winstanley and Chris Odedun

Education
Cite this article as:
Tessa Davis. Meet our next DFTB Fellows…Helena Winstanley and Chris Odedun, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21953

Team DFTB is excited to announce that over the next two years we will have six DFTB Fellows working in the Paediatric Emergency Department at the Royal London Hospital with specifically dedicated DFTB time each week. We will introduce you to them all as they start – they are a mix of paediatric and EM trainees, most of whom are at the end of their training, and who come from the UK, Ireland, Australia, and South Africa. You’ve already met our first DFTB Fellow, Rebecca Paxton. Now it’s time to meet the next couple.

Read more
November 29, 2019 0