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