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Natalie May

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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.

This edition of the Sweet Spot is brought to us by Dr Natalie May; Dr Natalie May is a Consultant Emergency Physician with speciality training in Paediatric Emergency Medicine. She works at the famous Sydney HEMS in Prehospital & Retrieval Medicine.

In addition to liking tea, running and singing at FOAMed conferences, Nat has been instrumental in editing and contributing to StEmlynsBlog.org and PEMLit.org and tweets prolifically as @_NMay. She is one of the eminent contributors to #FOAMped worldwide and is a member of the SMACC organising committee.

For Paediatric doctors new to the ED setting

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

The biggest stumbling block I’ve seen is a tendency to migrate towards your comfort zone. You guys are excellent at dealing with sick kids (and not-so-sick kids), particularly neonates. But that doesn’t challenge you, and you won’t get the most from the department. Paediatric EDs are usually very well supported by senior staff, especially consultants. We would rather you challenge yourself and get the most from our learning environment.

Please also respect that, whatever your existing opinion of government-set targets (like the 4-hour target in the UK), our service depends on our ability to perform within them, and we expect you to understand their importance to the department’s function. You’ll get a far greater appreciation of the significance of ED flow from working within the department, so hopefully, that will persist if you return to paediatric practice.

How does their mindset need to change/evolve?

The key to successful Emergency Department work is teamwork – once you join us in our department, we consider you one of ours – we will support you and back you up. We just ask that you try to believe it and wholeheartedly join us! There will be great opportunities to impart your knowledge to junior colleagues and medical students, and we welcome that.

Remember that the cohort of patients we see is typically a few hours earlier into the clinical course of their illness than you might be used to seeing; signs and symptoms may not be so obvious and you will have to rely on subtle concerning features and a shorter observation period than you might have in a child already referred for admission. This is part of the skill and the nuance of the job (and the reason we love it). It also makes safety netting even more important when children are discharged and finally it makes us humble – we have all seen patients come back significantly more unwell. It happens and it doesn’t mean you have missed something or done something wrong – but there will always be something to learn. Be open and honest and we can all learn from one another.

What are some knowledge deficits that can be ameliorated…

– quickly and easily?

Traditionally paediatric trainees have been comfortable with all things illness and less with trauma, mainly minor injuries. Major trauma is pretty straightforward – familiarity with local and national guidance is critical.

– with concerted study and experience?

Minor injuries are not as straightforward as their name implies, particularly in kids. If radiology teaching is available to you in the ED, take that opportunity! Knowing when – and what – to x-ray is a skill that improves with experience.

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

Understanding and respecting the ED staff. Many nurses are exceptionally skilled; most have good instincts for seriously ill and injured children. There’s usually a good reason if they ask you to do something. They have great instincts for wound management and often bring the voice of common sense. Similarly, our allied professionals, porters and receptionists are vital to the department’s function and developing and maintaining good working relationships is critical.

What is the most under-used feature in the history / examination / investigation?

ECG – there’s an intrinsic fear of the paediatric ECG because it looks so different; there are all sorts of different numbers and ranges to remember. But in truth you don’t really need to have that knowledge wedged in your brain to find a paediatric ECG useful. Familiarity grows with exposure; some things will just jump out at you and the rest you can work through with a good resource. I’ve been caught out with relying on a monitor to read heart rate and nearly missed an SVT. If the child is tachycardic without explanation (or has had a collapse under any circumstances), get an ECG. And take your time to look at it carefully, with a friend if you want to!

What is the most over-used feature in the history / examination / investigation?

Chest x-rays – I very infrequently order them for children with respiratory complaints because they rarely change my management. Neonates are an exception to this rule (as the x-ray can give useful cardiac information too), as well as those kids with fever, slightly lower SpO2 than normal on air, increased respiratory rate and just a little extra work of breathing – they are usually the ones with a lobar pneumonia. That said, I’m not sure the x-ray changes anything as I’d almost certainly be giving that group of children antibiotics in any case. It’s a nuanced approach though, and a conversation I’m happy to have with juniors.

How is the communication different…

– with parents? Parents are almost always anxious and looking for reassurance. Being a parent is a complex interplay of fear that something awful will happen to your child and societal pressure telling you that you’re inadequate if you’re not hugely concerned about a minor bump on the head. We must try to understand these influences and give them the airtime they need so that when the child gets worse (it will happen one day!), they aren’t afraid or angry to bring the child back to you.

– with medical and nursing colleagues? One of the things I love most about paediatric EM is how smoothly things often seem to work compared to adult practice. Your colleagues seem genuinely interested in helping patients – it feels a lot more like you are on the same page, and that can be refreshing when the adult side has been feeling like an uphill struggle. It isn’t always that way, though – so your politeness, respect and good temper are just as important.

– with senior staff? I am always interested to know what is happening in the ED when it’s my responsibility. As the named consultant, I am responsible for the care delivered – being oncall is what I get paid for! When I leave the department in the evening I try to impress upon the junior doctors AND nursing staff that they are welcome to call me, for anything they want to call me for – if they even think it’s something I might want to know about, I want to know about it! I am sure that my ED colleagues would agree with this mindset. I hope my colleagues in other specialties do too. Generally, if a consultant from another specialty is in the ED seeing a sick patient, I want to know about it.

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

Comfort with newborns. Many non-paediatricians have inverse fear: the smaller the child, the more terrifying they are. Working with neonates is a huge advantage in knowing what matters in history and examination, having excellent procedural skills and even knowing how to pick up a baby.

My top five tips for this group:

  1. Work outside your comfort zone
  2. Be willing to share your knowledge and skills: the ED is a place where everyone is learning, every day
  3. Ask for help!
  4. Involve the consultant for sick patients – that’s what we are paid for
  5. Enjoy the diversity – every day is different and ED is a great place to learn and work.

The most important piece of advice for paeds registrar new to ED is…

It will feel uncomfortable – relax! You are well supported and appreciated. This is an excellent opportunity to stretch yourself, and then when your friends’ kids fall over, and they expect you to know what to do, you’ll feel far more confident (and know who to speak to in the ED if you think they need to attend).

For emergency registrars new to Paediatric Emergency

What are some common stumbling blocks & how can these be avoided?

Just like the paediatricians, ED docs tend to migrate to their comfort zone – it’s just a different comfort zone! Take the opportunity to get good at looking after sick kids (not just minor injuries) – as much as it might be soul destroying to spend a whole shift seeing snotty nose after snotty nose, somewhere in there might be a child who is really unwell. This is the time and place to learn how you can identify them and what to do with them when you do. That said, if you do have a shift like that – spend the last hour seeing minor injuries and give yourself a break!

How does their mindset need to change/evolve?

It would be best if you were flexible in paediatric consultations. Getting the confidence of the child and their parent or carer is paramount. Examinations rarely follow the same pattern – you need to learn to rapidly identify the child who is about to cry (and listen to their lungs before they do). Sometimes a little time/food/paracetamol/sleep will make your assessment of a child a lot easier – you’ll learn which situations those are and when it’s safe to let those things happen (it usually is)!

What are some knowledge deficits that can be ameliorated…

– quickly and easily?

There are critical components of the paediatric history we don’t think about in adult practice – birth history, immunisations, family and social history, school – you’ll get into the swing of that rapidly, but it does matter.

– with concerted study and experience?

Paediatric fractures are tricky – I spend a lot of time in the paediatric ED reviewing x-rays both at the time with our junior doctors and afterwards (with our missed fracture reports). I’d prefer the former, so if you’re unsure, ask! You’ll get to know what injuries you might see and how they are subtly different.

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

Willingness to listen to parental concerns. We can get frustrated in the adult ED when there are lots of people in the cubicle, all trying to contribute to the story, but it’s essential in paediatrics and often the reason the patient is there in the first place. Be patient, ask specifically about concerns and remember to ask if there’s anything else you can help with while the family is present in the ED.

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

They are asking the child to give the history first. This is a great way to build rapport with children who can try (realistically, children from about 2yrs can point to the bit that hurts or nod and shake their head; older children might give you a complete story of injury or illness). Don’t dismiss the child, even if the parent tells you it’s total nonsense! You’ll find that taking time to make the child part of the consultation (including asking them which ear to look into first) makes things go much more smoothly.

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

Blood tests in general. Most children don’t need any, and considering the amount of distress involved for everyone in obtaining bloods, it’s probably worth just running any plan involving venipuncture past a senior doctor before you start poking kids with needles.

How is the communication different…

– with parents? New parents deserve a special mention – they are often spectacularly overwhelmed and not having nearly as much fun as they feel they should be having. Give them the time and space to tell you how they are going. Your care responsibility doesn’t start and end with the child.

– with medical and nursing colleagues? You’ll generally find referrals a little easier (but not always). In many EDs, there will be nursing staff who can perform venipuncture but do not expect this: you’ll need to be willing to perform procedures your patient needs (arguably, this is also the case in the adult ED…). That said, paediatric nurses are highly skilled; never attempt procedures on children without a nurse. A doctor is no substitute!

– with senior staff? You’ll often find senior teams beyond the ED more involved with patient care than in adult specialities. It isn’t unusual to speak to registrars about referrals, and consultants in tertiary specialities usually want to know that their patients are in the ED (especially in-hours).

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

An ability to know when something isn’t right. Don’t ignore those feelings; talk to a senior doctor. We are here to help, and even if it turns out there’s nothing serious going on, it’s an ideal time to fine-tune your spidey senses with some wisdom from someone senior.

My top five tips for this group:

  1. Don’t be scared – most kids will respond cooperatively if you smile!
  2. Learn the basics of the language of children – know the name of Peppa pig’s little brother, for example. This helps children see you as part of their world and less threatening.
  3. Never attempt procedures without a nurse. Just don’t.
  4. Invest pre-procedure time in planning, preparation and communication. You want things to go smoothly and this time is never wasted.
  5. Know some primary necessary drug doses (think APLS) and keep other vital doses stored somewhere easy to access under pressure (?mobile phone).

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

Safety netting really matters. Take the time to provide adequate reassurance, a clear explanation of what you expect to happen to the child and when to return. When the first kid returns because you told the parents to look out for something and it actually happened, you’ll find it much easier to sleep at night.

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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