Liberian Girl

Cite this article as:
Josie Goodyer. Liberian Girl, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31426
Liberia, west Africa

In general, I hate going first. Ask anyone in my family, my friends, my colleagues, my supervisors, they will all attest to this. 

I woke New Year’s Day, 2020, in Canberra to the world’s worst air pollution with the knowledge friends and colleagues were in the midst of active bushfires engulfing the south coast of NSW during the worst bushfire season the country has seen. 

I spent time indoors, cogitating about what to pack for my first assignment with Médecins Sans Frontières/Doctors Without Borders (MSF), my first experience living in Africa, my first experience working overseas. 

I’d always wanted to work for MSF and to dedicate part of my career to humanitarian work, helping those most vulnerable whilst gaining experience working in fascinating areas of clinical medicine with limited resources. 

The day I flew out of Canberra to Sydney for my final debriefings and onward flights to Liberia, the town just south of the ACT border was evacuated. Residents in Canberra were told to activate their bushfire survival plans. I left with my bushfire survival plan stuck to the fridge with magnets. 

 A side view of the Bardnesville Junction Hospital in Monrovia, Liberia. © Josephine Goodyer/MSF

I was making my way to Liberia to take on a role as the paediatric doctor in MSF’s paediatric hospital. Liberia, on the west coast of Africa, is on the opposite side of the globe from the east coast of Australia. The MSF Paediatric Hospital, or Bardnesville Junction Hospital (BJH), was established in 2015 in response to the need for high acuity general paediatric care for children between one month and 15 years of age. MSF has had a longstanding presence in Liberia, a country that has experienced two civil wars, followed by a devastating Ebola outbreak, resulting in a significant depletion of its health workforce.

I arrived in Liberia after 28 long hours of travel. Driving into the capital, Monrovia, from the airport we passed long queues of cars and motorbikes waiting to get into petrol stations. There was a severe fuel shortage in the country. This had a huge economic impact and a direct effect on hospital staffing. 

As for firsts… The clinical medicine and acuity at the hospital was challenging, rewarding and career-changing. I ran simultaneous resuscitations in ICU on my first day and clinically diagnosed cardiac tamponade on my second. 

In six months, I witnessed cardiorespiratory arrest from all the reversible causes. A young patient named Surprise taught me to clinically diagnose severe hypokalemia (<1.5mmol/L, once we had access to electrolytes) in children with severe acute malnutrition, children who were so floppy that in Australia your top differential diagnosis would be a primary congenital neurological diagnosis. Without an ECG, Princess too was diagnosed with severe hyperkalaemia (based on bradycardia responsive to salbutamol). 

One-month-old Success presented with a temperature of 33.3̊C and a respiratory rate of 10, but her clinical severity was recognised and managed early, resulting in complete recovery within 48 hours. Promise had severe hypoxia from numerous causes managed well with our consistent, reliable supply of oxygen and bubble CPAP. 

Blessing presented with hypovolaemic shock secondary to severe anaemia, with significantly low haemoglobin levels. Like almost all children who were admitted to the ICU, Blessing’s condition resulted from acute illness in addition to complex co-morbidities including malaria, E. Coli sepsis and severe acute malnutrition. Blessing made a complete recovery following blood transfusion and early antibiotics – managed and initiated by the local emergency room staff. 

Prince had severe subcutaneous emphysema resulting from complications of bubble CPAP with likely tension pneumothorax. Godgift had unrecordably high liver transaminases from paracetamol toxicity (paracetamol being readily available in the community), and undefined local herbal treatments. Prayer had symptoms consistent with venous sinus thrombosis with ongoing neurological recovery. 

Not all children survived.

I was briefed before arriving that the mortality rate was unusually high, even for an MSF hospital in a low-resource setting. This is mainly because many children present very late to the hospital due to lack of access to primary healthcare and poor health-seeking behaviours. I have welcomed plenty of advice in my career. Some of it was pertinent during my time in Monrovia. Palliative care specialists and general practitioners have taught me not to abandon dying patients and to keep in mind that as doctors, although we do not treat dying patients differently, families can often feel abandoned. This advice was a stalwart of my practice in Liberia, however difficult it was to uphold. I’d read a blog before departing from a paediatrician who worked at BJH, which said, “you’ll never get used to the screaming [of grieving parents]”, and you don’t. 

I don’t know that any doctor, particularly a paediatric doctor, has a clear sense of how to professionally and personally deal with an overwhelmingly high mortality rate, though, the support and experience of the local staff and the wider MSF community has proven invaluable. 

MSF staff in the Bardnesville Junction Hospital in Monrovia (from left to right) Gibson, Richard, Josie, Richard, George, Samuel, and Comfort. © Josephine Goodyer/MSF

Those who worked in the project before me had suggested that the clinical work was not the only challenge. As an Australian paediatric trainee, we have excellent training, fabulous clinical skills and knowledge. In the project, however, there are additional difficulties that come from other aspects of the job: working in a new context, movement restrictions due to security reasons, the tropical and humid weather, and living with those you work with.

Despite that, outside of clinical work, I swam on the west coast of Africa for the first time, learnt to run in 96 per cent humidity and participated in my first friendly staff kickball match on the beach!

The COVID-19 pandemic made its way to Liberia in March 2020. Liberia was one of the first countries in the world to close its borders internationally and enforce a period of mandated quarantine in addition to a nationwide curfew. 

MSF staff and volunteers carry out a COVID-19 hygiene awareness campaign and distribute soap to households in Logan Town, near the capital city, Monrovia. © Ruud van der Linden/MSF

COVID-19 meant that the hospital had to suspend the surgical program due to even greater difficulties with staffing. The acute shortages led to my first experience writing recruitment tests, sitting on an interview panel and planning staff rosters. Staff transitioned to working in surgical masks, and arrangements were made to manage suspected or confirmed COVID-19 cases. The local staff adjusted their skills and ensured the hospital continued to function at a high level. 

Initially, I was worried that I would not be able to contribute more than what MSF, the hospital and Liberian staff would teach me. I experienced so many firsts and I am thankful to have done so in a setting with such a legacy – and most certainly didn’t expect to do so in the midst of a global pandemic! I am most thankful to the children of Liberia, the patients and their families, and their humour. From the nicknames: ‘Chinese woman’, ‘white woman’, ‘big doctor’; to teaching me the ‘ABC’, how to count, language, how to ‘bus’ and offering to accompany me home in my suitcase! 

This year has been like nothing else. Do I still hate going first? Absolutely. Would I do it again? Absolutely. 

Click here to find out more about working with Médecins Sans Frontières. 

About Liberia

According to the CIA World Factbook (yes, it is a thing!), has one of the lowest GDP per capita in the world, ranking at 221* (out of 228). Over 60% of the countries 5 million people are under the age of 25. Unfortunately, it also has one of the woods highest maternal mortality rates (661/100,000) that is heavily influenced by the high incidence of female genital mutilation.
And the name? Liberia was founded as a homeland for freed African-American slaves in 1847. The flag bears a remarkable similarity to the star-spangled banner. Perhaps one of the reasons that Steve Mnuchin got the two confused?

* In case you were wondering Ireland is 10th, USA is 19th, Australia is 29th and the UK is 39th.

Don’t Forget The Christmas Quiz: the Ho Ho Ho Holiday Hunt answers

Cite this article as:
Team DFTB. Don’t Forget The Christmas Quiz: the Ho Ho Ho Holiday Hunt answers, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31403

Don’t forget to post your selfies using the hashtag #DFTBHolidayHunt

Question 1

Andy talks to us about frequency of critical procedures in the paediatric emergency department. How many years does Andy need to practice to get the required number of intubations to maintain competency?

Answer: 106 years (from Andy Never Enough)

In 2016, Andy reviewed Nguyen et al’s paper looking at paediatric critical procedures in the ED. The article was a retrospective chart review of every paediatric attendance that required a resuscitation cubicle in three Victoria hospitals in 2013. Of almost 55,000 attendances, only 37 required any form of critical procedure – approximately 7 per 10,000 presentation.

83% of doctors working at the campuses in the study did not perform a single critical paediatric procedure. At the time Andy was working part time in the hospital and may have seen no more than 20 children a week. He reckoned it could take him 17 months to perform a single critical procedure. 

Andy quotes Ross Hofmeyr who suggests clinicians need to perform 75 intubations a year to maintain their competency and calculated it would take him 106 years to get just get to 75 intubations (Ed: what a statistic!)

Question 2

Preparing for major trauma is a vital pre-patient step, and improvisation can be key. How does Shane say you can improvise a bite block for a Le Fort II/III fracture?

Answer: Use a few tongue depressors taped together! (from Shane Broderick’s Professionals Prepare Properly)

Shane talks us through his approach to preparing for trauma. Quoting his Cian McDermott he tells us that “professionals prepare properly”. He lays out a series of superb tips, with number 5 being “better to be looking at it than looking for it” (aka check and recheck equipment). And when you can’t find it, can you improvise? Shane says, “No McKesson bite blocks for your Le fort II/III? No problem! Use a few tongue depressors taped together (Thanks to Jason van der Velde).”

Question 3

Kids love talking about poo, as do paediatricians! But if you have a sibling with Hirschsprung’s Disease, how much more likely then the general population are you to have it too?

Answer: Siblings of children with Hirschprung’s Disease are 200 times more likely than the general population to have Hirschprung’s; 4% vs. 0.02% (from the post Hirschprung’s Disease by Peter Tormey)

Question 4

General David Morrison AO (Retd), an outspoken opponent of gender bias and discrimination, gave a talk on workplace bullying and harassment. Andy uses General Morrison’s talk to discuss bullying in the workplace: discrimination, unjustified criticism, verbal threats, undue pressure and having jokes made at someone’s expense. Which heroic duo does Andy say characterise ‘defenders’ in the bullying arena?

Answer: Hermione and Ron (from the post Playground behaviour – in adults)

This is such an important post. Andy concludes with “It is okay to speak up and speak out. If you witness bullying, in any off its forms, it is your moral duty to pluck up the courage of Neville Longbottom and stand up for what is right.”

Question 5

At DFTB 2019 Russ and Cian demonstrated how useful POCUS can be. What favourite snack can help you to do a supra-pubic aspiration?

Answer: Toast! (from the post POCUS: Russ Horowitz and Cian McDemott at DFTB19)

Question 6

And finally, our Christmas question. In 2016, the Journal of Happiness published an article entitled, “What makes a merry Christmas?” But, what does make a merry Christmas?

Answer: we are happier when our Christmas plans involve family or faith and less happy when spending money and receiving gifts is the overwhelming aim. (from the post Happy Holidays!)

And that’s our cue to wish you a wonderful festive season and safe and healthy 2021.

from the DFTB team x

Don’t Forget The Christmas Quiz: the Ho Ho Ho holiday hunt

Cite this article as:
Team DFTB. Don’t Forget The Christmas Quiz: the Ho Ho Ho holiday hunt, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31400

We’re wrapping up the Don’t Forget The Christmas Quiz with a Jolly Holiday Christmas scavenger hunt through the DFTB website. Each clue leads you to a DFTB article. Follow the clues, find (and read!) the article, and grab a selfie with the associated prop. Improvisation is welcome if you don’t have access to the required prop. Post to Twitter (#DFTBHolidayHunt) to join in on a global scale, or just follow along at home.

Have a super holiday season wherever you are.

Question 1

Andy talks to us about frequency of critical procedures in the paediatric emergency department. How many years does Andy need to practice to get the required number of intubations to maintain competency?

Selfie with your airway kit please!

Question 2

Preparing for major trauma is a vital pre-patient step, and improvisation can be key. How does Shane say you can improvise a bite block for a Le Fort II / III fracture?

This time, a selfie with your ENT kit.

Question 3

Kids love talking about poo, as do paediatricians! But if you have a sibling with Hirschsprung’s Disease, how much more likely then the general population are you to have it too?

This one needs some Christmas coordination… selfie with your friendly surgical team.

Question 4

General David Morrison AO (Retd), an outspoken opponent of gender bias and discrimination, gave a talk on workplace bullying and harassment. Andy uses General Morrison’s talk to discuss bullying in the workplace: discrimination, unjustified criticism, verbal threats, undue pressure and having jokes made at someone’s expense. Which heroic duo does Andy say characterise ‘defenders’ in the bullying arena?

Selfie with your wonderful team.

Question 5

At DFTB 2019 Russ and Cian demonstrated how useful POCUS can be. What favourite snack can help you to do a supra-pubic aspiration?

Selfie with your favourite snack!

Question 6

And finally, our Christmas question. In 2016, the Journal of Happiness published an article entitled, “What makes a merry Christmas?” But, what does make a merry Christmas?

A final selfie with your workplace Elfie.

Don’t Forget The Christmas Quiz: the picture round answers

Cite this article as:
Team DFTB. Don’t Forget The Christmas Quiz: the picture round answers, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31333

Here are the answers to the picture round. How did you do?

Question 1

a) What name is given to this two-piece intra-articular fracture of the base of the 1st metacarpal of the thumb?

Bennett fracture

This is a Bennett fracture: an intra-articular 2-part fracture of the base of 1st metacarpal bone, named after Edward Hallaran Bennett, an Irish surgeon from Dublin.

Thumb metacarpal base fractures require surgical opinion. Disruption of carpometacarpal joint congruity can result in significant functional impairment.

A similar intra-articular fracture-dislocation of the base of the 5th metacarpal bone is called a reverse Bennett fracture. This fracture pattern is inherently unstable.

b) If the fracture was in three parts, what would it be called?

Rolando fractures of the base of the 1st metacarpal are similar to Bennett fractures, but with at least 3 parts, and a less favourable prognosis. 

Read more about bony finger (and thumb) injuries in this bony finger injuries post.

Question 2

What tendon is being tested in this image?

Flexor digitorum superficialis (FDS). FDS and flexor digitorum profundus (FDP) tendons should be tested individually.

To check FDS function, hold all adjacent fingers in extension and then release the finger you want to assess. Ask the child to flex the free digit at the PIP joint.

To examine FDP, hold the middle phalanx in extension and ask the child to flex the DIP joint.

For more finger examination tips, including digital cascade, wrist tenodesis and assessment of extensor tendon function check out the tendon and ligaments finger injuries post.

Question 3

What type of injury is demonstrated below?

Mallet finger

This is a mallet injury. The top image is a ligamentous mallet injury due to rupture of the extensor tendon. The lower image is a bony mallet injury due to an avulsion fracture of the insertion point of the terminal extensor tendon at the distal phalangeal epiphysis – this is the more common injury type in children. Children present with a flexion deformity and inability to extend at the distal interphalangeal joint. These injuries must be managed by hand specialists, either with 6-8 weeks of splinting if the injury is closed, or operatively if the injury is open, or if the avulsion fragment is larger than 30-50% of the articular surface. 

Finger Tips – tendons and ligaments (dontforgetthebubbles.com)

Question 4

a) What are the names of the three highlighted areas in this shoulder x-ray?

b) What injury is demonstrated in this x-ray?

This is a Y-view of the shoulder. The humeral head is no longer sitting over the glenoid and is instead sat under the coracoid process. This is an anterior shoulder dislocation. Bonus points to anyone who noted flattening of the humeral head suggesting a Hill Sachs lesion (and those are real bonus points as the shoulder dislocation post hasn’t yet been published – but watch this space!)
For more tips on interpreting shoulder x-rays, check out our shoulder x-ray post.

Question 5

This child presents with worsening foot pain with no history of trauma. Which bone is affected and what is this condition called?

Kohler’s disease

The x-ray shows thinning and sclerosis of the navicular bone. This is Kohler’s Disease, an osteochondrosis of the navicular. Osteochondrosis is a disorder of bone growth primarily involving the ossification centres at the epiphysis.  It commonly begins in childhood and results in osteonecrosis of the growth plate.  This can lead to altered bone and cartilage formation beyond the growth plate. A better known osteochondrosis is Perthe’s Disease of the femoral head.

Although often confused with apophysitis, which is more clearly due to traction overuse injuries, osteochondrosis is often described as idiopathic osteonecrosis as there has been no definite cause found.  There have been some links showing genetic factors and high activity levels can increase a person’s risk of developing osteochondrosis. Read more about the different osteochondroses in our ostrochondrosis post.

Question 6

This child has been complaining of heel pain. What does his x-ray show and what is this condition called?

Sever’s disease

This x-ray shows an increased density of the calcaneal apophysis, typically seen in children aged between 7 and 14 years with Sever’s Disease. Apophysitis is a term used to describe a group of overuse traction injuries which commonly cause pain in adolescents. The most common is Osgood Schlatter disease, but other common anatomical areas of apophysitis include the inferior pole of patella (Sinding-Larsen-Johansson), calcaneal tuberosity (Sever’s), medial epicondyle of the elbow (within spectrum of Little League elbow) and various sites on the pelvis. They’re subtly different from osteochondrosis, which is instead due to changes in the epiphyseal ossification centre. Read more about apophysitis in our apophysitis post.

Question 7

Describe this fracture.

Question 8

What type of fracture is this? (Clue: it involves a dislocation. Bonus points if you can name the injured joint)

Galeazzi fracture-dislocation

This is a Galeazzi fracture-dislocation – a fracture of the radius (usually distal third) with dislocation of the distal radio-ulnar joint (DRUJ). They’re often missed but must be checked for – the DRUJ dislocation must be reduced before casting. Always examine the DRUJ on x-ray in any child with an isolated radius fracture.
Read more about Galeazzi fracture dislocations and other wrist injuries in our wrist injuries module.

Question 9

What type of fracture is this?

Tillaux fracture

This is a Tillaux fracture: a Salter-Harris III fracture at the anterolateral distal tibial epiphysis. There is usually avulsion of the tibial fragment by the tibiofibular ligament, attaching it to the fibula.

This is different to a Triplane fracture because there is no fracture through the coronal plane.

Tillaux and Triplane fractures are seen in adolescents. If not recognised and therefore no managed correctly they can be associated with long term morbidity.

Read more about Tillaux fractures and Triplane fractures in these two posts: Tillaux fractures and Triplane ankle fractures

Question 10

Name the Christmas movie

Love, Actually (Ed: Both Andy and Dani profess to loving this movie)

Thank you to @leejrichardson3 for our very own DFTB Lego version

Well done everyone! Happy holidays!

Don’t Forget The Christmas Quiz: the picture round

Cite this article as:
Team DFTB. Don’t Forget The Christmas Quiz: the picture round, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31326

Ready for a picture round? We’ve collated some of the best images from 2020 for you and your teams.

Question 1

a) What name is given to this two-piece intra-articular fracture of the base of the 1st metacarpal of the thumb?

b) If the fracture was in three parts, what would it be called?

Question 2

What tendon is being tested in this image?

Question 3

What type of injury is demonstrated below?

Question 4

a) What are the names of the three highlighted areas in this shoulder x-ray?

b) What injury is demonstrated in this x-ray?

Question 5

This child presents with worsening foot pain with no history of trauma. Which bone is affected and what is this condition called?

Question 6

This child has been complaining of heel pain. What does his x-ray show and what is this condition called?

Question 7

Describe this fracture.

Question 8

What type of fracture is this? (Clue: it involves a dislocation. Bonus points if you can name the injured joint)

Question 9

What type of fracture is this?

Question 10

Name this Christmas movie.

Good luck everyone. Answers will be posted tomorrow.

Don’t Forget The Christmas Quiz: the bubble wrap answers

Cite this article as:
Team DFTB. Don’t Forget The Christmas Quiz: the bubble wrap answers, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31314

And here are the answers…

Question 1

In Nijman et al.’s 2020 single centre prospective evaluation of sepsis screening tools how many febrile children, aged 1 month−16 years, with greater than one warning sign of sepsis across 1,551 disease episodes had an invasive bacterial infection?

Answer: b) 6 (0.4%) children

Only six children (0.4%) had a final diagnosis of an invasive bacterial infection. The authors looked at the utility of sepsis screening tools to predict the presence of an invasive bacterial infection, serious bacterial infection or PICU admission; there were a huge number of false positives. The number of children needed to treat to detect one invasive bacterial infection was 256. 

This study shows us that serious infections are rare and most children who are categorised as ‘at risk of sepsis’ can be managed conservatively with observation. Current guidelines have very poor specificity; and while they tell us to investigate and treat lots of children, a lot of the time we choose to rely on our clinical judgement. Observation and good clear red flagging must not be underestimated. 

Read the original article and our review of it.

Question 2

In Waterfield et al.’s 2020 multi-centre Petechiae in Children (PIC) study, of the 1334 included children (fever and petechial rash) how many had confirmed meningococcal disease? 

Answer: a) 19 (1.4%)

Nineteen children had confirmed N. meningitidis and 8 of these needed intensive care treatment.

The primary outcome of this study was to assess the performance of 8 clinical guidelines on identifying children with invasive meningococcal disease. All 8 guidelines had a sensitivity of 100%, identifying all children with meningococcal disease, but specificity varied from 0% (NICE sepsis guideline) to 36% (Barts Health NHS Trust).

Read the full article and the DFTB review.

Question 3

In a retrospective evaluation by Reeves et al. how many children presented with a suspected magnet ingestion in the United States between 2009 and 2019?

Answer: c) 23756

An estimated 23,756 children (59% males, 42% < 5 years old) presented with a suspected magnet ingestion in a 10 year study period between 2009 to 2019. The U.S. Consumer Safety Commission removed these products from the market in 2012 until a federal court decision reversed this decision in 2016. After 2017, there was a 5-fold increase in the escalation of care for multiple magnet ingestions.

At Christmas, parents and grandparents with full stomachs may not be quite as on the ball at minding children with new toys with magnetic parts. Be aware of the dangers of ingested magnets and be sure to investigate if there’s any suspicion.

Read the original article and the Bubble Wrap Plus it was listed in.

Question 4 

In a single centre study Watkins et al. undertook Bayley Scales of Infant-Toddler Development (BSID-III) and neurologic examination at 18-22 months of corrected age for survivors of birth before 26  weeks. In the surviving infants, no or mild neurodevelopmental impairment in surviving infants was 3 of 4 infants at 24-25 weeks. What was the proportion in the 22-23 week group? 

Answer: d) 2 of 3

This is a retrospective study assessing the survival and neurodevelopmental outcomes of infants born at 22-23 weeks compared with those born at 24-25 weeks of gestation in a single site. The cohort was stratified into 22-23 weeks gestation (n=70) and those born at 24-25 weeks gestation (n = 178). Both groups received antenatal steroids, intubation, surfactant replacement therapy, and high-frequency ventilation as the primary mode of ventilation. Survival to hospital discharge was 78% at 22-23 weeks and 89% at 24-25 weeks or gestational age (P=0.02). At 18 months, surviving infants with no or mild neurodevelopmental impairment at 22-23 weeks was 64% (29/45; 95% CI, 50%-77%) and at 24-25 weeks was 76% (94/124; 95% CI, 68%-83%; P = .16) at 24-25 weeks.

Read the original article and the bubble wrap review.

Question 5 

Trivić et al. undertook a systematic review and meta-analysis evaluating strain-specific probiotic interventions for paediatric functional abdominal pain (FAP) including 9randomised controlled trials published up to April 2020. How many studies reported the authors’ primary outcome which was the number of children with the cessation of pain symptoms after intervention?

Answer: a) 0

Trivić et al. suggest that the probiotic Lactobacillus reuteri can effectively reduce pain intensity and increase the number of pain-free days in children with FAP. But, there was no significant reduction in pain frequency or school absenteeism and no study actually reported the cessation of pain. Probiotics are considered safe in children, but the literature is very heterogenous with different doses and formulations and a diverse range of outcomes, making it difficult to interpret and therefore draw accurate conclusions.

Read the original article, the bubble wrap review and Henry’s 2016 post on probiotics in review.

Question 6

Park et al sought to find evidence to support the claim that Santa Claus “knows if you’ve been bad or good, so be good for goodness sake” in their retrospective observational study of 186 members of staff who worked on paediatric wards in the UK over Christmas. But which of the following did they find?

Answer: e) Distance to the North Pole in km did not have a statistically significant effect on whether Santa Claus would or would not visit a paediatric ward

Park et al found that Santa visited all 8 of the children’s ward in Northern Ireland, with Scotland in second place with 93% coverage. Santa Claus doesn’t discriminate between children who live in areas with surrogate markers for “naughtiness.” There was no correlation between a visit from Santa and primary school absenteeism or young person conviction rates or distance to the North Pole. After Santa, the most popular local superhero visitors to the children’s wards were his elves, followed by footballers. Elsa came way down the list at joint fifth with firefighters. 

This is an amusing study but it revealed a sobering fact: Santa Claus is less likely to visit children in hospitals in deprived areas. As paediatric clinicians, our role is to care for children and it may be that that care involves helping Santa access those “hard to reach” areas so that every child is happy at Christmas.

Read the original article.

Well done! Stay tuned for the Christmas Picture Quiz.