How to be… a conference chair

Cite this article as:
Ian Summers. How to be… a conference chair, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.12545

You check your in-box and there it is, another e-mail from one of those pesky conference organizers. You make sure it is not just a repeat of the one about being a Twitter moderator but this time  the tag line is different.  “Dear X, would you be interested in being a chairperson for a session at our upcoming conference?” Again it is time to hit up some friends for their words of wisdom.

DFTB go to Berlin – #SMACCmini

Cite this article as:
Tagg, A. DFTB go to Berlin – #SMACCmini, Don't Forget the Bubbles, 2017. Available at:
https://dontforgetthebubbles.com/dftb-go-to-berlin-smaccmini/

Having flown 16,893 kilometres to visit family, a short hop over the Berlin was nothing. This year Tessa and I were honoured to be able to help out with SMACCmini – the paediatric workshop before the main event.  DasSMACC is the second-most* anticipated conference of the year and we wanted to make sure the delegates left better able to look after critically unwell children.

Coping with errors

Cite this article as:
Tessa Davis. Coping with errors, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11227

When you lie in bed at night and have moments of reflection about your work, what do you think about? The patient whose abnormal blood result you didn’t spot? The time you prescribed the wrong drug dose for a patient? The child who died unexpectedly and you wonder what you should have done differently?

The good old days

Cite this article as:
Andrew Tagg. The good old days, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11095

As I introduced the latest batch of interns to the department I thought back to my first few days as a doctor and how I have changed. I qualified in 1997 and I still remember lots of things about my first year. I remember the fear of being on-call, the physical and mental exhaustion that would result in me falling asleep on the toilet, and I remember the colleagues that helped me through it.

Munchausen by Proxy : Fabricated & Induced Illness

Cite this article as:
Henry Goldstein. Munchausen by Proxy : Fabricated & Induced Illness, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9772

I recently attended a superbly insightful presentation by Dr Sue Wilson, the psychiatrist for our Consultation Liaison team here at Queensland Children’s Hospital. Some years ago, I was involved with a case of FII / Munchausen’s syndrome by Proxy, and – as is often the case – the case continues to resonate and evoke strong feelings. She has kindly offered her source material for this post.

Theoretical conceptualizations

Fabrication and Induction of Illness (FII) tends to be conceptualized as a rare/severe form of child abuse. The term Munchausen’s syndrome by proxy is used less in clinical practice, as it places an emphasis on the abuser rather than the victim. We’ll mostly use FII hereafter in this post, although there’s a short explainer about Munchausen himself later on.

An alternative view is that fabricated illness occurs along a broad spectrum that ranges from exaggerated reporting of symptoms by very anxious parents to the actual production of symptoms, with varying degrees of risk. This broader definition includes a far wider range of motivations and behaviours that represent clinical reality.

Here’s a 5 point summary:

  1. MBP/FII is a rare and severe form of child abuse. The behaviours may be considered on a spectrum of induced symptoms.
  2. Focus needs to be on caring for the child, not diagnosing the carer.
  3. Consider FII whenever you come across a perplexing presentation – it’s more common than some of the other, very rare, diagnoses we chase.
  4. A key differentiator is the parental response to a proposed medical change of direction.
  5. If you are even considering FII as a differential diagnosis, make early contact with your hospital’s child protection team – as you would for a consulting service to see an opinion.

Important to remember


The line between volitional and non-volitional processes in the caregiver is difficult to identify. To be clear, volitional means the cognitive process whereby a person decides on and commits to a particular course of action. The harmful effects on the child are very similar, irrespective of the parent’s actions and motivations.

The focus must be on the outcomes or the impact on the child’s health and development and not initially on attempts to diagnose the parent or carer.

Detailed descriptions of the impact of the carer’s behaviour on the child are more useful than diagnostic labels which may distract from the central issue of harm to the child. Recognition of the carer’s difficulties is neither necessary nor sufficient for the diagnosis of FII.

So, who was Munchausen?

Munchausen refers to a satirical character based loosely on Hieronymus Karl Friedrich von Münchhausen, a German nobleman born in 1720. He gained notoriety in German aristocratic society after returning from a number of foreign wars with literally unbelievable stories. An author, so inspired by the Baron’s tales, expanded them into satire and farce and published them widely, much to the rage of Munchausen himself. This last point, to me, serves to reinforce the point above about volition versus non-volitional processes – I’m sure the original Baron von Munchausen did not intend to leave this kind of legacy! The satirical Munchausen features in a number of books and movies, most recently in a 2012 TV movie.

munchausen

Right then, back to it…

Perplexing presentations vs FII

FII are one sub-group within the category of perplexing presentations – FII should be considered as a differential diagnosis when some of the other indicators are present. Think to yourself, “What doesn’t make sense about this child’s presentation? ” What differentiates perplexing presentations from FII is the parental response to a proposed medical change of direction – from investigation to rehabilitation. That is, some parents persist in seeking medical opinions and investigations and decline or do not participate in the rehab process. They find difficulty in enabling their child to function and cope better.

Indicators which should alert professionals to the possibility of FII


Several indicators can give clues to an FII presentation. These include a carer reporting symptoms and signs which are not explained by any known medical condition, physical examination and investigations that do not explain reported symptoms and signs, inexplicably poor response to medication or other treatment, or intolerance of treatment or acute symptoms that are exclusively observed by/in the presence of the carer.

Additionally, on resolution of the presenting problems, the carer may report new symptoms or symptoms in different children.

The child’s daily life and activities may be limited beyond what is expected due to any disorder from which the child is known to suffer e.g, poor or no school attendance; use of seemingly unnecessary special aids.

Occasionally there is objective evidence of fabrication – history from different observers in conflict or being biologically implausible; test results (toxicology or blood typing); covert video surveillance (this is a minefield and we heavily caution against this course of action, even if you loved The Sixth Sense!!).
Sometimes a carer expressing concern that they are under suspicion of FII or relatives raising concerns about FII may be an indicator, as is a carer seeking multiple opinions inappropriately.

Characteristics


Characteristics of parents who fabricate or induce illness in their children should be applied with caution – many of them are also true of many parents. Additionally, they should not be used to confirm or deny the existence of FII and ultimately the identification of characteristics consistent with parents or carers fabricating or inducing illness in children may add to suspicions during the investigation process but do not constitute a profile. Nonetheless, we know;

  • Typically carried out by women, specifically mothers (95%)
  • Usually the child’s primary carer
  • Often present initially as “good” carers

(Yes, the three above points are also true of a very, very high proportion of carers…)

  • Usually accomplished liars and manipulators
  • Usually the only ones consistently present or associated with the onset of the child’s symptoms (when the carers are absent, symptoms or illnesses are not reported or may begin to improve)
  • They may have a history of self-induced symptoms/illness exaggeration, falsification or induction
  • They may have mental health evaluations indicating they are “normal” – psychiatric disturbance may be well-concealed from the observer
  • They may have no prior involvement with child protection services
  • They may appear to be overanxious, overprotective, mistaken or deluded
  • They may have a background in the health profession (14-30%) or an unusual degree of knowledge about health
  • They may seek publicity or attention from a variety of people

These parents or carers do not necessarily stop their behaviour towards the child when under suspicion or caught, but change tactics by:

  • Changing health professionals.
  • Denying all or part of what they have done, even in the face of overwhelming evidence.
  • Accusing their accusers, and shifting blame onto those who are aware of their behaviour. 

Risk factors of mothers for creating Abnormal Illness Behaviour in children

Remote or longstanding risks include;

  • Loss or separation from parent
  • Abuse/neglect
  • Foster care
  • History of lying in adolescence
  • History of self-harm

Recent or acute risks include;

  • Current somatoform disorder
  • Current factitious disorder
  • In receipt of disability living allowance
  • Child missing school
  • Frequent visits to doctors (symptoms unexplained)
  • Frequent moves of house and GP
  • Parent requests disability living allowance for child

Psychopathology of Fabricators

There is no clear relationship between any mental disorder and abusive behaviour towards children.  Many mothers with Borderline Personality Disorder (BPD) or history of abuse do not abuse their children in this way. Such a history may be a trigger to look more closely but doesn’t constitute proof; it’s important to remember that FII is a behaviour to be identified, not a medical or psychiatric diagnosis.

There are a number of associated conditions for those parents/caregivers whom fabricate;

72% somatoform disorders
55% self harmed

21% misused alcohol &/or drugs
89% personality disorder especially Borderline (by interview)
23% personality disorder (by self-rating scale)

Additionally, symptoms of depression and anxiety are common, as well as a high prevalence of somatising and factitious disorder. It’s worth noting that Factitious disorder and FII in children can co-occur; Somatoform disorder in the mother indicates some abnormality of illness behaviour and relationships with health professionals. Detection of factitious disorder in a mother of young children should provoke a search for FII in her offspring.

Fabricators are classically highly persuasive and have a tendency to split between staff (the idealisation of some, whilst devaluing others). FII involves all social classes (not just Barons). There may be a history of significant lying behaviours and deception dating back to childhood. One study notes 1 in 4 abusing carers had a history of being victims of child abuse, whilst another found high rates of deprivation, childhood abuse, significant loss or bereavement in the mothers, however FII is not necessarily associated with young, inexperienced parents or deprivation.

Possible explanatory mechanisms and motivations


The motivations of FII are complex and vary from case to case. However, it can be noted that extreme anxiety leading to exaggeration of symptoms and signs to encourage the doctor to rule out or identify any treatable disorder may play a roles. As can the need to confirm (false) beliefs about the child’s health (e.g, developmental disorder, food allergy) including beliefs held by caregivers with ASD and rarely with a delusional disorder. There may also be a wish for attention or deflection of blame for the child’s (usually behavioural) difficulties. FII also maintains closeness to the child and may invoke a material gain e.g. carer’s benefit. There may be an underlying hostility to doctor or even the child themselves.

In one study motivation for the induced illness in children was unclear in 2/3 of cases.

Intergenerational transmission of abnormal illness behaviours


There appears a common theme amongst caregivers that there is a past use of illness behaviours in relationships with other individuals, including health professionals. FII may at times represent extensions and distortions of childhood patterns of behaviour whose function was to obtain comfort and protection from others, with clinicians now placed in the caregiving role.

This adaptive use of deception develops early in life, and becomes entrenched over time and further distorted by subsequent losses and traumas. From early childhood some caregivers report feigning symptoms in order to avoid beatings or to prevent contact visits with abusive parents/carers. This makes sense if “playing sick” saves you from physical or other abuse.

When parents have been exposed to significant loss and trauma their behaviour is likely to be motivated by trauma-related triggers in situations where they feel threatened or perceive their children to be threatened; it’s worth noting that these ways of thinking and behaving are not always accessible to conscious reflection.

Disturbed attachment

 It may be more useful to see FII as a function of a disturbed mother-child attachment bond, influenced by mother’s own attachment experiences; insecure attachment is associated with higher levels of somatisation. Indeed, a study of attachment models in mothers who fabricated or induced illness found high levels of insecure attachment and unresolved bereavement. This may, in turn, sensitise individuals to see others as more sick than they really are.

Mother-child relationship

Remember, the mother may appear to have a close and caring relationship with the child (may not be so), with presence of separation anxiety and over protectiveness noted.
FII has been described as a “symbiotic bond”, although symbiotic infers mutually beneficial, and in FII it’s pretty hard to see any benefits for the child.  However, illness is the way for this child to maintain a relationship with his/her parent and perhaps preserve the parent’s mental equilibrium.


Consequences

Half of the patients suffer psychological harm including emotional and behavioural problems, school non-attendance and concentration difficulties, whilst a high percentage are affected by other forms of maltreatment or neglect or a repetition of FII. There are usually  compromised attachment relationships as a result.

Short-term effects include;

  • Self-image of self as sick or disabled
  • School absences
  • Miss normal developmental opportunities
  • Impact on peer relationships
  • Only way to achieve nurture or interaction with parent may be via the sick role
  • Impact of possible collusion in older child
  • Following confirmation, must consider child’s developmental stage, level of attachment, effect of separation from sibs and others

Long-term effects include

  • Impairment of overall development
  • Risk of psychological harm
  • Long term implications for child’s mental health including risks of Factitious disorder
  • Long term implications for attachment – effect on trust
  • Relationships and caring mediated through illness
  • Little research on harm from verbal fabrication

Role of mental health

Since no psychiatric diagnosis is pathognomonic of a perpetrator of this type of abuse, psychiatric assessment should not be used to determine whether FII has occurred, however there is a role for mental health after the behaviour has been confirmed, by way of;
  – assessment: parents, family dynamics, parenting skills, child
  – treatment planning: opinions re possibility of family intervention

The Mental Health team may be asked to assess parents who have a history of psychiatric disorder, especially if it seems that parental anxiety or misinterpretation may be contributing to the presentation. The main role for mental health is providing support for the team behind the scenes and taking part in case discussions; this process can be very stressful for all members of the team!

Given the early life experiences of caregivers, they tend to draw clinicians into close relationships in which boundaries can become blurred; this may be a red flag as well as an issue that can be explored in staff support meetings. There is also the potential to cause splitting in the team and arouse strong feelings (including around diagnosis and methods of investigation).

This is particularly challenging as medical & nursing staff must balance the need to remain engaged with the family as clinicians, whilst also being involved in observation and complex case discussions about the family; the period of growing suspicion and investigation is often the most difficult.

Areas of uncertainty

 FII is an area that has some intrinsic uncertainty, often as cases evolve over time. It’s important to always come back to impact on the child. Additionally, consider is this just an overanxious parent, perhaps exaggerating symptoms? Is there something medical being missed?  How much medical investigation is enough? For the parent?  For the treating team? Could it be conversion or somatoform disorder in the child rather than FII?


In older children, there is also a potential for coaching and collusion.


Plus, it is possible that a child may actually experience symptoms of a psychological nature (e.g. headache) which parent insists must have a medical cause.

Management

 Pragmatically, it is essential to notify your local child safety/child protection organisation. In some jurisdictions, including Australia, this is mandatory for health practitioners. One key message from Dr Wilson’s presentation was that if you are beginning to suspect FII, then making early contact with your hospital’s child protection team – as you would for a consulting service to see an opinion – can facilitate the diagnosis and subsequent management. Generally speaking, psychological treatment is not indicated for individuals who cannot admit their behaviour.

In some cases, reunification is possible eg specialist unit in UK.  Better outcomes are associated with:

  • Acknowledgment of fabrication
  • Less severe abuse
  • Improvement in parent’s psychological functioning and empathy for the child
  • Improved parent-child relationship and child attachment behaviour
  • Change in the family system
  • Therapeutic alliance with the partner and extended family – safety network

Training for Paediatricians

So, how can Paediatricians & Paediatric trainees improve, with the above in mind? Clinical skills in consultations are always  being sharpened; with experience clinicians, become increasingly aware that parents need to be listened to but not always agreed with. Additionally, the skills of managing the potential conflict in the doctor-patient relationship also develop with time. In FII, there is a shift in emphasis so that the child truly becomes the primary client.

In the case of perplexing presentations, exploration of childcare perspective of children’s problems in addition to medical disease model, as well as identification of behavioural and interactional cues may assist in the recognition of FII.

Be mindful of obstacles which stand in the way of paediatricians recognising FII:
  – discomfort with not believing a parent, on whose history paediatricians rely
  – discomfort with not understanding the child’s presentation
  – concern about missing a treatable condition
  – concern about litigation or complaints.

References:

Jureidini JN, Shafer AT, Donald TG.”Munchausen by proxy syndrome”: not only pathological parenting but also problematic doctoring? Med J Aust. 2003 Feb 3;178(3):130-2.

Proops & Sibert (Eds), Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians. RCPCH, 2009. (Dr Wilson also referenced the 2002 edition of this publication in her talk.)

Bass C, Glaser D. Early recognition and management of fabricated or induced illness in children. Lancet. 2014 Apr 19;383(9926):1412-21.

Kozlowska K, Foley S, Savage B.Fabricated illness: working within the family system to find a pathway to health. Fam Process. 2012 Dec;51(4):570-87.

Kozlowska K.When the lie is the truth: grounded theory analysis of an online support group for factitious disorder. Psychiatry Res. 2014 Dec 30;220(3):1176-7.

Bass C, Jones D.Psychopathology of perpetrators of fabricated or induced illness in children: case series. Br J Psychiatry. 2011 Aug;199(2):113-8.

Bools CN, Neale BA, Meadow SR.Follow up of victims of fabricated illness (Munchausen syndrome by proxy). Arch Dis Child. 1993 Dec;69(6):625-30.

Adshead G, Bluglass K. Attachment representations in mothers with abnormal illness behaviour by proxy. Br J Psychiatry. 2005 Oct;187:328-33.

Adshead G, Bluglass K. A vicious circle: transgenerational attachment representations in a case of factitious illness by proxy. Attach Hum Dev. 2001 Apr;3(1):77-95.

Fish E, Bromfield L and Higgins D. A new name for Munchausen Syndrome by Proxy: Defining Fabricated or Induced Illness by Carers. Australian Institute of Family Studies. 2005; 23.

Are you okay?

Cite this article as:
Andrew Tagg. Are you okay?, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9785

Today (8th September) in Australia is RUOK? day. It’s a time for people to come together and think about more than themselves and meaningfully connect with others. I wrote recently about the prevalence of bullying in medical society and some of it’s consequences. The 2013 Beyond Blue survey on depression in the medical workforce showed that one in five doctors suffer from depression and that a quarter  had thoughts of self-harm or suicidal ideation.

But today, I’d like you to remember that mental health concerns only remain hidden because of stigma.  By talking out loud we can help smash the stigma. It’s a topic I’m going to expand on at next year’s DFTB17 conference. If one in five Australian doctors suffer from depression and (if it’s not you then) there is a good chance that one of your friends or team members does.  Don’t be afraid to ask the question – and listen to the answer without judgement.

For more information on RUOK? day then take a look at their official website.

If you need help then contact:-

BeyondBlue

Playground behaviour – in adults

Cite this article as:
Andrew Tagg. Playground behaviour – in adults, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9377

This week Lieutenant General David Morrison AO (Retd) has been invited to my healthcare to a give a talk on workplace bullying and harassment.  Earlier this week I wrote about the pervasiveness of childhood bullying and asked you all to reflect on what it might mean for us at work. In light of recent findings in Ballarat changing culture becomes even more important.

Personal Learning Networks

Cite this article as:
Andrew Tagg. Personal Learning Networks, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9228

What sort of health practitioner do you want to be? Nobody wants to be average, as Simon Carley tells us, so how do we go about growing? Professor C. offered us lots of great advice and there will be more to come when the #smaccDUB podcasts get released.
This week, I have once again sacrificed myself to the roster gods, and got a week off to attend the Teaching Course in Melbourne. Without wanting to sound like a shill for the course on day one, I wanted to reflect on something that really resonated with me.

DFTB in Dublin – the Second Day

Cite this article as:
Tagg, A. DFTB in Dublin – the Second Day, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-the-second-day/

Small children prevented Henry and I spending too much time out on the town enjoying what Dublin has to offer. One advantage of this was that we were both able to enjoy the mornings sessions without the hangovers that so many of our friends and colleagues had.

The theme for the morning plenary session was “Slaying Sacred Cows”. Four excellent speakers took the time to challenge long held beliefs and make us question some of our ingrained ideas.

Leadership: not (just) for men

Resa Lewiss began by talking about leadership. To some of us the word ‘leader’ conjures up images of old white men with power ties and masculine poses.  Res reminded us that over half the medical population are women and it is time for us to realise this. Just as we have seen #Ilooklikeasurgeon trend worldwide she wanted to trend #IIlooklikealeader. With many strong leaders in the world of paediatrics this is something that we at Don’t Forget The Bubbles support wholeheartedly.  SMACC has tried hard this year to ensure gender equity with the speaker panel and this is one of our core aims for #DFTB17.

Resa had the following tips for those that want to inspire and lead:-

Praise in public, criticise in private

Make decisions – don’t be indecisive

Concentrate on your strengths and let others cover your weaknesses

Make people feel good about themselves

If you don’t ask you don’t get

As someone who is an extreme introvert it was this final point that really made me reflect. Nat May has already written a superb post on impostor syndrome but it is worth remembering that there is power in breaking free of the self-imposed shackles of quietitude and putting yourself out there and just asking for help. 


Things that scare me

Paediatric surgeon and presentation skills guru Ross Fisher showed why he is so well respected as a speaker. Eschewing supportive media he took to the stage to speak about fear.  Over the course of twenty minutes he spoke about some of the times in his life in which he had been truly scared.  Not the sort of fear you get riding on an out of control roller-coaster but the sort of deep, visceral fear that makes your mouth dry up, your head pound and your legs shake. By the end of his talk there was barely a dry eye in the house (or on the stage).  This is a must watch talk when it comes out and is the one that really made me just stop and think.

Emergency management of the agitated patient

Reuben Strayer concentrated on something that we don’t see very often in the emergency department. We do occasionally have to deal with agitated teens and it’s worthwhile looking at this alternative take.

What's love got to do with it?

The morning was topped off by the fabulous Liz Crowe.  She reminded us that we obviously all love our jobs – most of us seem to spend over a third of our lives there – but like any relationship we can have good times and not-so good times.  Just as any marriage takes effort to make it work the same is true for our relationship with our job.  We need the support of our work husbands and wives when times are tough and to remind of us of those times when we basked in the afterglow of our first successful resuscitation.

And whilst we love our jobs Liz reminded us that we must also love our patients. We must treat them all with kindness and compassion. They did not, would never, choose to be in hospital.  We must always, always remember that.  A kind word, a cup of tea, a warm blanket go a long way.

Later that same day...

After coffee we broke for concurrent sessions. I went to the session entitled “Time to gas, time to cut”. Karim Brohi spoke about Zen and the Art of Trauma, again reinforcing the need for the leader to be the centre of calm.  That calmness is infectious. We’ve heard about tools we can use in the moment to help use regain calm but Karim reminded us that calmness is a learned behaviour. It is paying attention to the minor details, reducing errors and variance in the system. It is understanding when less is more, that some patients do not need every conceivable test but only the necessary tests to get them to theatre. And it is mentally rehearsing for every possible outcome.

And whilst some of the talks may seem heavy, the morning session was completed by the (not safe for work) Suman Biswas.  I’ll leave this here…

But the question on everyones mind was where would SMACC be in 2017?

DAS SMACC

So start asking for annual leave now if you want to travel to Berlin.

DFTB in Dublin – the Workshops

Cite this article as:
Tagg, A. DFTB in Dublin – the Workshops, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-the-workshops/

Having braved international flights half of the team from DFTB (Andy and Henry) have made it to SMACCDub. For those of you not in the know the Social Media And Critical Care conference is in it’s fourth year now and partly inspired us to start Don’t Forget The Bubbles.  Although the editors regularly chat online this was the first time Henry and I have met in person.

In order to make the most of our time abroad we had both booked into the #SMACCmini paediatric workshop.

SMACCMini

With a line of speakers encompassing the best and brightest from the world of paediatrics (apart from us) we were excited to see what they had to offer. With a variety of lightning 10 minute talks over the course of the morning topics ranged from communication to caring for the critically ill child.

Resuscitation update

Natalie May was our leatherette clad hostess and kicked off the proceedings with an update on the 2015 ILCOR guidelines.  Whilst little has changed in resuscitation of the infant it is the rare resuscitation of the newborn that scares us the most.  Whilst a precipitous delivery in the department may be a rare event, it does happen.  Babies may be born in less than ideal circumstances – on the leather back seat of their husband’s new car, in the toilet (literally) or in the lift up to the birthing suite – but thankfully the need to perform complex interventions is rare. We need to know what to do before help arrives. This short video may help those who are paralysed by fear.

PEM literature update

Tim Horeczko took to the stage next, disguised as an event organizer. Despite technical issues that were out of his control he took us on a whirlwind tour of some paediatric literature that most of us in the room were not aware of.

Approaches to spotting the sick child

The Wonder Woman of Leicester, Rachel Rowlands, then took to the stage (along with her constant companion, Norman the dinosaur) to remind us of the importance of gestalt in spotting the sick child, a theme that would echoed by many speakers throughout the morning.  She took us on a choose-your-own adventure style quest, not to find the treasure, but to save the life of a young boy that had swallowed a button battery.  If you want to know more about the dangers of these deadly discs then take a look at her video.

Spotting sepsis early

Adrian Plunkett talked eloquently on the the use of the NICE traffic light system and other early warning scores to predict sepsis. But really he gave us two key take home points to lock onto:-

  • Be worried if there is a change of state – they are not the same as they were yesterday
  • Be worried if this illness is like no other illness they have ever had

By using these two key questions in the history we might become more alert to the risk of potential deterioration and look for ways to validate our fears – order the extra blood tests, keep the child in for a period of further observation.

Sick neonates are simple

Trish Woods, a neonatologist from WA, reminded us that all neonates want is to be protected.  When they are threatened, be that in the form of imminent airway or breathing difficulty, their physiology wants to return to the womb.  By understanding the transition from safe, warm and comforting intra-uterine life to the harsh outside world we can guide our resuscitation.

Mistakes and pitfalls in critical care

Phil Hyde, who gave an excellent talk about the use of real children during simulation at last years conference urged us to use our fear, not because it leads to the dark side, but to help us step towards the stressful.  We have all been in a resuscitation when there is a palpable sense of half-repressed panic.  Voices are raised and critical instructions missed, mistakes are made. But just as the emotions of the team leader can have a negative impact on the team they can also act to stop the sweating.  By being the slow, smooth voice of calm the team leader can imbue all of the group with the same feeling.

This can be a challenge so there are things we can do to mitigate the internal stress. Cliff  Reid talks of using the high fidelity simulator that is our brain to visualize these high stress scenarios, before they happen.  That is all when and good if you are experienced and have seen a lot of sick kids. But what do you do if you haven’t.  Phil suggests visiting your local PICU and asking questions of doctors and families, stepping towards the fear.  He also suggested using www.spottingthesickchild.com, a free online resource (though you need to register) to make you more comfortable in your assessment of deteriorating infants.

Paediatric ultrasound

The southern hemispheres Wizard of the Wand, Giant of the Gel, Prince of Probes, himself – Casey Parker – demonstrated how easy it is for us all to perform lung ultrasound on children.  In just 8 minutes he reminded us that our clinical exam counts for very nought and that a normal appearing chest x-ray can be deceptive in a child that you think has pneumonia from the history.  Waving the magic wand is easy and can be taught in just four minutes.  It is certainly a skill that I am going to take home to my place of practice.(Ed. I’d just like to give a huge thanks to Casey for encouraging me to write after the first SMACC in Sydney and publishing my very first blog post.)

What paediatric surgeons wished you knew

The esteemed paediatric surgeon, Mr Ross Fisher of p cubed presentations, then took us through some of personal bugbears.  After learning that there is no such thing as a normal bowel habit in a child, a fact that most parents can attest to, to decrying the lack of  proper physical examination prior to imaging he put us in his shoes.  Surgeons have no special ability to rule out appendicitis, but often have the benefit of experience to help determine what else may be going on.

Paediatric toxicology

As we came towards the end of the first half of the morning Nat Thurtle reminded us that children like to put things in their mouths that no normal person would.  Eschewing the usual list of one pill kills she talked about some newer toxins that most of us would not find palatable – e-liquids, laundry detergent pods and synthetic cannabinoids’s. By using the powerful Resus RSI DEAD mnemonic we can have a framework with which to risk stratify and deal with any potential toxic ingestion.

Paediatric trauma

As we were getting ready for our morning coffee Nat May reminded us that paediatric trauma often presents to non-paediatric centres and that we should all be able to recognize and deal with it.  Mechanisms of trauma vary with age from the drunken horse riding antics of teenagers, to younger children who skateboard in front of cars.  Paediatric trauma can be very confronting and how we approach our parents and their families can have a great impact on their long-term outcomes.

The SMACCmini superheroes

Appropriately caffeinated we headed back to the hall for another round of talks.

Excellence in critical care

Adrian Plunkett started off the session on a positive note.  Whilst it is easy to criticise bad practice it is much harder to praise the good.  He urged us to learn from the things we do well.  By actively promoting best practice within your network a culture of positivity and a ‘can-do’ attitude arises.  If you visit the Learning from Excellence website you can learn from others peer-reported episodes of excellence in practice.    Similar to the ‘Awesome and Amazing’ antithesis to the monthly M&M conference we need to let others in the team know they are doing a great job.

Communication: Kids and families

We all have had occasions when we think we have done a great job with our young patients and their families. Roisin McNamara brought us down to earth with a tale of when things that she thought had gone well had been perceived very differently by the family involved.  When harsh words are spoken it is important to have the emotional intelligence not to snap back, not to get angry. Often parents are not angry at you but at the situation but the doctor in front of them is the visible face of a systemic problem.  Parents may feel they are being dismissed as time wasters if time is not spent taking a thorough history and appropriate physical exam before pronouncing that their darling daughter has no medical cause for their symptoms.

Communication: Adolescents

Most of us know how to talk to children but, via the power of video, Thom O’Neill, spoke passionately about an issue we should all know more about- dealing with LGBT adolescents and youths.

Most traditional textbooks of paediatrics have yet to cover the subject and Thom gave us a useful framework to hang a conversation on, starting with recognising the child or youths right to be called what they want and to identify themselves how they want.  We hope to get Thom to write more on this subject for Don’t Forget The Bubbles. 

Resource poor settings

Nat Thurtle returned to the limelight to talk about her time working in resource poor settings.  Those of us that work in the developed world are incredibly lucky to have access to the resources we have. As she told her moving story of almost insurmountable challenges we al stopped and reflected on how lucky we truly are.

Complex kids

After hearing about children that don’t have access to even supplemental oxygen when it is needed Tim Horeczko talked about technology dependent children and their complex needs.  Whilst we are unlikely to encounter a child with a ventricular assist device outside of a quaternary centre we may well be exposed to children with a VP shunt, or a child that suffers from an incurable neuromuscular or mitochondrial defect.  As is nearly always the case in paediatrics – the parents know best, so listen.

Surgical surprises

Ross Fisher then urged us to “Keep Calm and Carry On” when confronted with potential paediatric surgical nightmares. He reminded us time and again that we know how to do the basics – analgesia, fluid resuscitation, investigate – and that there is nothing that we should be afraid of.

Neonatal procedure tips

Having previous told us that looking after sick neonates was easy-peasy, Trish Woods then went n to teach us how. By focusing on the ABC’s of resuscitation she walked us through the neonatal airway and breathing before showing some great slides and giving us all the tools we need to insert an umbilical line. At the time of neonatal resuscitation early vascular access as a means of giving fluids and adrenaline can save a life.  

Intubation tips

This great procedural talk was followed by Tim Horeczko on his top three tips for intubating infants.  We know that critical procedures are rarely performed by paediatricians let alone general emergency physicians but by adding these three things to ones repertoire we should increase our chance of first pass success.

  • Use the shoulder bump
  • Use the jaw thrust
  • Change your position and look high

Ventilation tips

Once we have successfully intubated (and confirmed tube placement with waveform capnography) Phil Hyde talked about ventilation strategies. By using PEEP and low tidal volume breaths (6-8mls/kg) we can adequately ventilate most children titrating to a pH>7.2 and and an SpO2 >92%. Attention to the simple things such as sedation, paralysis and monitoring can make all the difference.

Phil Hyde on the basics of neonatal ventilation

Patient experience

The final session of the day brought home to all of us in the room why we do what we do.  We heard from Emer, a brave 11 year old girl, who had spent 5 days in ICU with tracheitis, of her experience, both in the emergency room and in the unit.  Her clinical care was excellent and could not be faulted but if there was one thing she wanted us all to take away it was ‘Don’t use long medical words’. We doctors assume a common tongue and use medical terminology as a technical shorthand with our colleagues.  We occasionally slip into this mode of talking with patients and their relatives. Emer reminded us to think before we speak.

The organizing committee and all of the faculty did an amazing job of fitting such a wide array of topics in such a short time frame. Never did the audience feel overwhelmed with knowledge and most of us just stopped tweeting and just listened, quietly reflected and were inspired to do better. If you came along to the workshop and took away something that will change the way you treat children (or their parents) then please feel free to comment below.

pablo

 

Brown on APLS instructor attributes

Cite this article as:
Tagg, A. Brown on APLS instructor attributes, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/pac-conference-brown-on-apls-instructor-attributes/

We have teamed up with APLS to share the videos from their Paediatric Acute Care Conferences. These videos have never been open access before, so if you weren’t able to attend the conferences, then now’s your chance to catch up.

The PAC Conference is run each year by APLS and consists of presentations on a range of topics relevant to paediatric acute and critical care.