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Meredith Borland

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The Paediatric Emergency Department is a relatively unique area in medicine as the registrar workforce usually comes from one of two backgrounds: Emergency or Paediatrics. Consequently, we strive to have the optimal combination of both specialities – The Sweet Spot.

The two groups come with very different skill sets and approaches to medical care. In some cases, the Emergency trainee may not have cared for children previously, or the Paediatric trainee not have worked in the ED since their intern year.

In this edition of the Sweet Spot, we’re hearing from Dr Meredith Borland, Director of Emergency Medicine at Princess Margaret Hospital for Children in Perth, Australia.

“I came to Paediatric emergency medicine after working as a GP for 8 years and realising my passion was paediatrics and emergency medicine. It seemed logical to return to training through the ACEM. This was when the JTC PEM was still being negotiated and I was lucky to complete training in WA and Vic and commence full time as a PEM consultant position in 2004. Since then I have enjoyed developing the field of PEM for both paediatric and emergency trainees.”

For Paediatric doctors new to the ED setting:

What are some common stumbling blocks and how can these be avoided/fixed?

Minor trauma (fractures, lacerations etc) – don’t avoid seeing these patients – actively seek them out and use local resources to get familiar with the procedures you need to develop – nurse practitioners, consultants or ED trainees are valuable resources – just don’t hand the patient over though … do it yourself.

Getting bogged down chasing rare conditions  – most children in ED need no or very few investigations – take a good history, perform a focused and appropriate examination and develop rapport with the child and their family. Then you can educate and discharge without unnecessary tests or treatments and you’ll be more efficient.

How does their mindset need to evolve?

Working in tertiary hospitals during training you see lots of uncommon things such as children with brain tumours or leukaemia but not every child with a bruise or a headache has cancer. You need to recognise the flags to be worried about and put in place appropriate investigations. Over-investigating is not a substitute for a good assessment to reassure parents.

What are some knowledge deficits that can be ameliorated…”

– quickly and easily?

Getting up to date with the latest resuscitation protocols.

– with concerted study and experience?

Understand the adult clinical decision rules for ordering CTs in head and neck trauma and how to apply them to paediatrics.

Recognition of early sepsis

The skill/attribute that differentiates an average registrar from an exceptional one is…?

The capacity to recognize the need put the foot down – to churn through the workload while still keeping the quality of the assessments

They use current evidence to question practice and challenge dogma and learn how to incorporate this into practice.

What is the most under-used feature in the History / Examination / Investigation?

History – the social history

Examination – the heart rate

Investigation – avoid ordering unnecessary tests

What is the most over-used feature in the History / Examination / Investigation?

Blood cultures

VBG

How is the communication different…

– with parents? Should be inclusive – work as a team for the child, respectful instructive and knowledgeable

– with medical and nursing colleagues? Supportive, knowledgeable – encourage to think rather than follow protocols without rationale

– with senior staff? Respectful, and ask questions to help inform practice.

A strength that this group might be surprised they have is…?

Friendly, supportive and capable group of junior doctors.

My top five tips for this group:

Don’t be scared of being in resus

Your input is valuable

Read up on resuscitation protocols

Take up any simulation or airway sessions offered

Learn to recognize serious illness in a child

The most important piece of advice for Paeds Reg new to ED is:

The opportunity to work in ED develops your capacity to differentiate the worried well from the seriously ill – immerse yourself in all that is offered and your confidence in managing acute illness throughout your career will be enhanced.

For Emergency doctors new to the paediatric setting

What are some common stumbling blocks and how can these be avoided/fixed?

Assuming that children don’t have serious illnesses like adults and failing to recognize subtle signs

How does their mindset need to change/evolve?

Realise that the only way to recognise subtle serious illness signs is to see lots and lots of children with common childhood illnesses.

Recognising the child is part of the family unit and just because the child looks well doesn’t mean you have reassured the parents if you don’t address the parent’s concerns directly.

What are some knowledge deficits that can be ameliorated…

– quickly and easily? How to relocate a pulled elbow

– with concerted study and experience? Common neonatal problems – from sepsis to feeding difficulties and how to reassure the parents.

The skill/attribute that differentiates an average registrar from an exceptional one is…?

Recognise the subtle signs of serious illness – it is hard to teach gut instinct but you can develop a sharper instinct with time and experience.

Capacity to recognise the need put the foot down – to churn through the workload while still keeping the quality of the assessments.

They can use current evidence to question practice and challenge dogma and learn how to incorporate this into practice.

What is the most under-used feature in the History / Examination / Investigation?

History – the social history

Examination – the heart rate

Investigation – rationale use of investigations

What is the most over-used feature in the History / Examination / Investigation?

Blood cultures

VBG

How is the communication different…

– with parents? It must be inclusive – work as a team for the child, respectful instructive and knowledgeable

– with medical and nursing colleagues? They must be supportive, knowledgeable and encouraged to think rather than follow protocols without rationale

– with senior staff? Respectful, ask questions to help inform practice

A strength that this group might be surprised they have is…?

Know how to work hard and prioritise workload.

My top five tips for this group

Don’t be scared of neonates and babies

Your input is valuable but don’t try to impose adult approaches

Read up on common paediatric presentations

Take up any simulation or airway sessions offered

Always look at the observations and repeat them if they’re not within normal range for age

The most important piece of advice for an Emergency Reg new to Paeds ED

PED staff love emergency registrars with their confidence, resuscitation and trauma skills. Don’t try to impose ways you have seen things done differently – question and read up on why and as the staff in the PED and you get to know each other you can learn from them and they can learn from you.

About the authors

  • A General Paediatrician and Adolescent Medicine Fellow based in Queensland, Australia, Henry is passionate about Health Systems and Complex Care, with a strong interest in Medical Education & Clinical Teaching. His 'Dad jokes' significantly pre-date fatherhood, and he stays well by running ultramarathons. @henrygoldstein | + Henry Goldstein | Henry's DFTB posts

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