Ultrasound Guided Peripheral Vascular Access

Cite this article as:
Trent Calcutt. Ultrasound Guided Peripheral Vascular Access, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.23253

One of my favourite things in paediatrics is the expanding role of ultrasound guided vascular access.

When I started as a paediatric registrar, I’d just finished an adult ICU term where I’d become spent a majority of time supporting provision of a vascular access service, and as part of this had become a PICC line insertion instructor. Eventually, I got to the point where I dreamt of abstract grey shapes. But then I started a paediatric job in a regional hospital where it seemed that ultrasound was used for vascular access rarely if at all. Initially, I thought there must have been something different about paediatric vascular access that I was unaware of. One day, when looking after a young lady with Rett’s who was known to be difficult to cannulate, I reached for the ultrasound. In the five years since, ultrasound has been a standard part of my practice in achieving vascular access in children, with technique adapted to fit the age of the patient.

Ultrasound-guided vascular access and paediatrics seem like such a natural partnership. The concept of a DIVA (“difficult IV access”) patient is receiving increasing interest and research. Criteria for a DIVA can include prematurity, inability to see or feel a vessel, or an episode of multiple prior attempts. These criteria would be met by a huge number of the kids we care for, in particular toddlers or the previously premature infant. 

Chonky baby arm
Spot the veins

Why is ultrasound not the first-line adjunct in these tricky kids? It’s probably multifactorial, but certainly, ultrasound is more difficult in children than adults. Its utility is varied in the NICU context and for infants under 2.5kg, although can still have a role with a modification to technique. It’s also harder to learn ultrasound in a population who are scared, angry, impatient and poorly tolerant of a prolonged period of needle-through-skin. For these reasons, I think that there is less appeal to replace the familiar (cannulating without an ultrasound), with the unfamiliar (cannulating with an ultrasound). As I’d experienced, this also leads to a culture where ultrasound is infrequently utilized, decreasing the likelihood of implementation by new or more junior staff.

Once the learning investment is made to reach a proficient level of ultrasound competency (about 20 cannulas in adults) the potential benefits are significant. Decreased time spent performing a procedure, decreased number of attempts and subsequent patient trauma, and increased cannula longevity are all achievable.

I’ve spent a lot of time thinking success optimisation in paediatric ultrasound guided cannulation, both during my own development of proficiency and then in an effort to verbalize this skill when educating others. Below are my 5 top tips to enhance your ultrasound-guided cannulation skills:

I’m hoping that some of these words may help avoid some bits of the inevitable trial and error process that comes with learning a new skill.

There is sometimes a general impression of both practical and personal inconvenience in using ultrasound for vascular access. An ultrasound may not be nearby. There is the fear of “looking silly” in front of other people, as turning on, adjusting, and then physically coordinating the use of the ultrasound may be unfamiliar. During the period of establishing proficiency, an approach to decreasing this sense of unfamiliarity is to get in the habit of bringing the ultrasound with you do a cannula. Turn on and optimize the ultrasound to view vessels, and spend a period mapping out candidates for cannulation using your non-cannulating hand. Draw on the patient with a skin pen if you want to keep track of the best sites. Then, discard the ultrasound and cannulate using whatever technique is most familiar to you, but with the added knowledge of vessel location, depth, size, and direction. If this becomes a routine and almost ritualistic process, the mental barrier created by a lack of familiarity with ultrasound settings and holding the transducer should decrease over time. It is a relatively small step from performing vascular mapping to placing a cannula under real-time ultrasound guidance.

The preparation otherwise is quite straightforward. In addition to the set up that you use for all other cannulas, you need the following four things:

  • An ultrasound with a linear array probe (the smaller the footprint and the higher the frequency, the better)
  • Sterile lubricating gel and some form of sterile barrier to cover your probe (this varies institutionally)
  • Cavilon wipe or skin prep (securement devices / dressings / tape doesn’t like to stick to ultrasound gel so will need some encouragement)
  • An extra person (one of your hands is out of action, so you need an additional person to perform the task that your non-dominant hand would normally do; this is typically stabilization of the distal limb)

The ultrasound sits on the opposite side of the bed to the operator, so as to minimize truncal movement in looking from the puncture site to screen. Aside from making sure the correct probe is selected, the only 3 settings you need to know how to adjust are depth (typically as shallow as possible), gain (similar to a ‘brightness’ setting to highlight blood-filled vessels), and a midline marker (for physical-digital landmark referencing).

As alluded to above, pre-scanning is a useful skill even in the absence of cannulating under real-time ultrasound guidance. It’s a good idea to scope out the most appropriate vessels and puncture sites prior to picking up your cannula. Essentially the objective is to place a cannula within a vessel with as few attempts as possible, as quickly as possible, with as little pain as possible, and in a site that will provide the greatest longevity. Characteristics of vessels that tend to correlate with these outcomes are:

  • long and straight stretches
  • vessel 6mm or less below the surface
  • vessels greater than 2mm in diameter
  • vessels that don’t cross a joint (provides freedom of movement and less extravasation)
  • vessels without upstream thrombosis or obstruction

Mid-forearm vessels often meet the above criteria.

The greater length of cannula able to be placed within the vessel can correlate with longevity, however larger cannula diameter may increase the phlebitis and decrease longevity. This requires consideration of the balance between length and diameter of device. Of the commonly available devices, a good balance is a blue cannula (22G). There are several specialised less widely available devices that are longer versions of small diameter cannulae (24G and 22G).

In practical terms, to find these vessels you can start in the antecubital fossa (more familiar area for most of us) and track them down, or plonk down on the forearm and pan circumferentially. Scanning in the short axis / transverse axis / cross-sectional view tends to work best in kids. To assess suitability, translate the probe up and down along a vessel to get an idea of the direction. If it’s running diagonally, rotate your probe until it’s running along the same plane as the vessel to act as a mental reminder of the angle/direction that you need to insert your cannula. Pick the specific spot on the vessel that you’d like to puncture, bearing in mind that you will be puncturing the skin millimetres back from that point. Pick the patch of the vein that is the longest, straightest, shallowest, and biggest. Have a second fallback site planned out elsewhere for if required. Lastly, make sure to track the vein proximally as far as you can to ensure that it doesn’t run into a large thrombosed/occluded/recannalizing patch of vessel.

Obscure angles make things more challenging, in my experience. Right angles and parallel lines are your friends because they assist in mental unburdening and allow you to devote energy to troubleshooting issues. As mentioned above, map the vessel prior to puncture. Part or all of a vein will often wander diagonally along its journey, so approaching from the wrong direction increases the likelihood of punching through the side of the vessel. The centre of the image corresponds to the arrow/marker along the long edge of the probe, so you have a reference point between digital (screen) and physical (skin). Use the ultrasound as a mental reminder of your plane of approach; rotate the probe until the vessel is consistently sitting in the very centre of your image as you plane up and down. In other words, the ultrasound image is perfectly perpendicular to the plane of the vessel.

Speaking of right angles, I prefer to keep the ultrasound at right angles to the surface that you’re scanning. Angling back and forth creates a loss of contact and a distorted image as the ultrasound bounces of structures and does not return to the transducer. This creates a less clear image where vessels artificially look larger. If you need to change your view, translate/glide the probe along the skin, rather than introducing angle. It can be useful to temporarily angle the transducer perpendicular to the shaft of the cannula if you lose sight of it as this will light it up more clearly.

This is a big one. Thinking of your cannulation as a two-phase puncture process is something that I find extremely helpful. Your objective is not to puncture the skin and end up inside the vessel in a single action, and in fact, attempting to do this seems decrease the likelihood of success. 

 

Puncture Phase 1

Puncture 1 is the process from skin puncture to positioning the tip of your cannula on the superficial wall of the vessel. To achieve this, align your probe to achieve a view with the vessel in the centre of the image. Puncture the skin with the cannula a few millimetres distal to the probe. This bit is painful, so do this with a decisive action so that 2-3 mm of the cannula is within the soft tissue. Increase your angle of insertion to 30-45°. Your next objective is to find the tip of the cannula. Moving your non-dominant (ultrasound) hand, translate/slide the probe towards the puncture site until a glimmering white dot becomes apparent in your image. Once you are convinced that you are viewing your cannula, you need to ensure that you are viewing the tip at all times.

The most important thing to remember is the only way to be certain that you are viewing the tip of your cannula is when the glimmering dot disappears when you move the probe 1mm proximally (away). It is frustratingly easy to think that you are viewing your cannula tip when instead you are halfway along the shaft, with the tip out the deep wall of the vessel. Maintain this view via a “walking” approach. For each 1-2mm advancement (step) of the cannula, make an equivalent proximal movement with your ultrasound probe (step). Move the ultrasound away so that you cannot see cannula tip anymore, and then advance the cannula into view. If needed, intermittently stop advancing your cannula and check your tip position as described above. I find advancing at 30-45° until you reach the vessel works well as minimal cannula is wasted on the journey there.

If you find yourself wandering off track, keep the ultrasound focused around the vessel as the centre of your image (as this is your target). Correcting if off centre is slightly counterintuitive. Move your cannulating hand away from the direction that you want to move your cannula tip (ie- moving right will move the tip left). Continue inserting until your cannula tip is sitting at 12 o’clock on top of your vessel. As you reach this point, the tip of the cannula may gently tent the roof of the vessel, turning an “O” shape into a “❤️” shape. This is a good test of correct positioning. Once you’ve reached this point, you’re ready for puncture phase 2!!

 Puncture Phase 2

Puncture 2 is the process of entering the vessel to feeding your cannula fully in. With the tip of your cannula in view and the roof of the vessel tented (❤️), continue incrementally advancing your cannula with tiny movement, walking the ultrasound forward to ensure the tip remains in view (as above). Gently decrease your angle of insertion so that the superficial wall is not tenting towards the deep wall but rather into the potential space of the proximal vessel. Eventually, your tented vessel (❤️) will suddenly encompass the cannula and return to a circular shape (O). This may be associated with a tactile pop. You can check for flashback for additional confirmation of vessel puncture, but I prefer to not take my eyes off the ultrasound screen at this point.

Continue decreasing your angle of insertion to maintain the tip of the cannula in the top 50% of the vessel (keep the sharp bevel away from the deep wall). This may eventually require you be pushing the cannula into the skin, which really requires your assistant to get out of the way. Don’t lose site of your tip! Continue to step forward; cannula then ultrasound. To check whether you are in the vessel and not in soft tissue or dragging on the vessel wall, waggle the tip of the cannula around gently (left, right, up, down). There should be absolutely no distortion of the soft tissue surrounding the vessel; completely free cannula tip movement. I tend to leave the metal stylet in until the plastic catheter is fully inserted to the hub because of greater visibility and added rigidity. This does, however, carry the risk of puncturing the back or sidewall of the vessel if you don’t keep a close eye on your cannula tip. At the very least, ensure 3-4mm of the cannula is inside the vessel lumen prior to gliding the plastic catheter off (to avoid tissuing / tearing the vessel roof). Once this is done, you’ve just successfully place a real-time ultrasound-guided cannula! Well done!

I think it’s reasonable with each healthcare interaction to measure success both in the resolution of issue (beneficence) and in minimization of harm / traumatic experience (non-maleficence). Vascular access is our commonest painful procedure, hence representing a significant potential burden of pain, anxiety, and trauma. Undertaking steps to minimize vascular access attempts, maximize speed/efficiency, and maximize cannula longevity are important considerations in the healthcare interaction. Even if we manage to achieve the elusive goal of a single puncture hospital admission, this still requires a single puncture. 

This discussion is not really directed towards addressing the specifics of analgesia and sedation but suffice to say that time permitting these should be used and optimized readily. A topical anaesthetic is valuable, although in the case of an ultrasound-guided cannula application by the operator is useful in ensuring good placement. Evidence is increasingly suggesting that topical anaesthetic is appropriate in all ages including neonates.

The power of social stories, rehearsal, music therapy, and just general distraction cannot be undervalued. There is a multitude of approaches to this. 

Unfortunately, it is not an uncommon experience to be in a situation where vascular access is required with a degree of clinical urgency. In this circumstance, oral/intranasal/topical medication may have not had time to work, and a specialist in distraction may not be readily available.

In this circumstance, I have found that playing calm and quiet music more useful than positioning a video in front of a child. Maintaining a minimum of people speaking, and using quiet calm voices is valuable. I have had some success using the ultrasound itself as a distraction modality while telling the child a story of the “doughnut that has lost its hole” (vein and cannula tip respectively) as the tip tracks toward the vessel. A variant is the “star that fell from the sky into the lake” (cannula tip and vein respectively). There are many approaches to pain reduction through distraction.

It is my sincere hope that these tips are of some practical and clinical value in your cannulating endeavours. If it makes a difference for a single child, then surely it’s worth it. Good luck!

Communicating clearly

Cite this article as:
Liz Herrieven. Communicating clearly, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32916

The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) produces guidance for ambulance services across the UK. I was thrilled to be asked to contribute to this in the form of a new chapter on patients with communication difficulties. This post expands on that guidance, which was written to support pre-hospital clinicians in providing the best possible care to their patients who face challenges with communication. This may be due to a wide variety of underlying conditions, including learning disability, autism, hearing loss, dementia and dysphasia.

Communication is vital to all that we do – from the first contact with a patient, through history taking and examination, to initiating treatment and explaining procedures. We have to do our very best to get it right. This is perhaps even more important, and more difficult, in the pre-hospital field, where stress levels are high, the environment can be unpredictable and time is short. Clinicians meeting patients for the first time need to quickly assess the situation and also win trust and gain understanding.

Communication is a two-way thing. It sounds obvious, but it becomes even more important when patients find communication difficult. Not only do we have to try our best to make ourselves understood, but we also have to try our best to understand our patient.

It’s also important to remember that communication and understanding are two very different things. Someone may be able to communicate quite well but understand very little. Conversely, someone may not be able to communicate but may have a very good understanding, including things being said about or around them. Dysphasic or dysarthric patients may appear to be unable to understand when actually their difficulty is in expressing themselves.

So, how can we improve our communication?

Minimise fear and anxiety

Communicating and understanding become more challenging when there is fear and anxiety. The first step is to keep calm and reassure the patient. The specific nature of any communication difficulty needs to be recognised quickly then addressed. Patients with a learning disability may not understand what is happening so careful explanations may help. Some autistic patients may have difficulty interpreting information verbally or non-verbally, or they may have significant sensory processing difficulties which means that loud noises, bright lights and physical touch can be distressing or even painful. Deaf patients may be able to better understand if they can see the clinician’s mouth – difficult with PPE.

Make simple adjustments

Communication might be made easier with simple changes such as speaking slowly and clearly and avoiding jargon. And give time – time for your patient to respond. For some patients, including those with Down syndrome, it can take several seconds to respond – time to receive the auditory information, decode it, understand it, formulate an answer and produce that answer as the right set of noises. We’re all busy so that seven or eight seconds can feel like an age. It’s absolutely worth the wait, though.

Adapt the environment

Can we do anything to make the environment less distracting, quieter, less stimulating? Would it be better to assess the patient in familiar surroundings rather than in the ambulance? Can noisy, scary or flashing equipment be switched off, removed or covered? If the patient has to be moved can they bring something, or someone, familiar with them?

Pay attention to non-verbal communication

Would eye contact help? It often does, but for some autistic patients it can be distressing. Some people respond well to a reassuring touch (I’m a toucher and a hugger) but others find it really uncomfortable – check before extending that hand! Do we need to support our verbal communication with gesture or sign? Pictures or symbols might help to explain what we are saying, but if we don’t have any to hand then pointing to body parts or pieces of equipment can help. We absolutely need to pay attention to our non-verbal communication, body language, posture, facial expression and so on, and also watch for non-verbal cues from our patient. Those who know our patient best might be able to help with this – how would their loved one usually let someone know they were in pain, for example? Pain is often poorly assessed and managed in people with a learning disability (LeDeR – the Learning Disability Mortality Review Programme). We often hear about people having a “high pain threshold” and whilst it’s true that pain is perceived differently by different people, we can’t assume that someone does not feel pain just because they can’t verbalise it.

Play to your patient’s communication strengths

Some patients may have particular strengths and weaknesses when it comes to communication. People with Down syndrome often find it more difficult to understand and remember auditory information, due to a variety of issues including fluctuating hearing impairment and poor short term auditory memory. They may, however, find it much easier to remember and understand information presented in a visual format. Using gesture, sign language (such as Makaton), photos or symbols (such as PECS) may support the verbal information and make things much easier for both the patient and the clinician.

Family and carers can help to identify how best to communicate with the patient but consider other resources too – is there a hospital passport that can give you some clues? These are often used to list medications and past medical history, but their real beauty is in detailing likes, dislikes, behaviours associated with pain, interventions that might be difficult to tolerate, and so on. A care pathway can also give great clinical information and guide management.

Adapt your examination

Your standard examination might need to be altered a little. Give clear warnings before touching the patient, particularly if they have any visual impairment or a sensory processing disorder. Start with those parts of the examination that are less intrusive – watching and observing position, demeanour, breathing pattern, and movements can all give a huge amount of information before you even get your stethoscope out. Distraction might be useful for some patients but for others, including those who may have had previous bad experiences, it might not work. Family and carers may know how best to support your patient through the more distressing parts of the examination and any following interventions.

LeDeR has also found that early warning scores were less likely to be calculated in people with a learning disability, and they were less likely to be acted on if abnormal. There are many likely reasons behind this, including clinicians being reluctant to cause distress to their patients. Things like blood pressure or oxygen saturation measurement can be very uncomfortable, particularly for those who may not understand what is being done or who may have sensory processing difficulties. Those patients still need to be assessed and treated appropriately. If a BP or sats, or any other part of your assessment for that matter, is likely to give important information then it should be done. There may, however, need to be some thought about how best to carry it out. Explanation, communication, visual information, distraction – what will help your patient tolerate the examination?

There is a common misconception that patients with chronic health problems always have an abnormal early warning score, so what’s the point? Any score, normal or abnormal, in a previously healthy patient or not, should be taken in context with the rest of the examination. It can be helpful to know what the patient is like (behaviour, level of alertness, comfort, interaction, early warning score) when well, to help to identify how ill they may be now. Again, family and carers can give vital information about this.

Be attuned to “soft signs”

“Soft signs” can help, too. These are things that family might notice long before health professionals. They are not specific to any particular illness or disease process, but give an indication that the patient isn’t well. For example, someone might be a little paler than usual, not want to get out of bed, not want to finish their favourite meal and not want to watch their favourite TV programme. A family member would know that these things mean their loved one is not themselves, and likely to be unwell. Healthcare professionals can learn a lot by listening out for soft signs.

Beware diagnostic overshadowing

It’s really important to watch out for diagnostic overshadowing. This happens when a patient has a pre-existing diagnosis, and any new symptoms are assumed to be down to this diagnosis. For example, an autistic person might present as being quite agitated, carrying out repetitive, stereotypical movements and it might be tempting for us to assume that this is all because they have autism. However, if we do that, we may miss the fact that they are in pain or feeling unwell. Again, we have to find out more about what our patient is like when they are well, to know how ill they may be now.

All of this boils down to making reasonable adjustments, which are required by law (Equality Act 2010). We can sum it up with the TEACH mnemonic:

Time: assessing someone with communication difficulties may take more time, but that time is absolutely worth it.

Environment: pick the best environment to assess your patient in. Keep things quiet and calm, remove distractions. Keep things familiar to the patient if you can, or let them have something familiar with them.

Assume: don’t assume anything about understanding – communication aids understanding, but someone who has difficulties with communication may still have very good understanding.

Communication: how can you best communicate with your patient? How can you help them make themselves understood? Would symbols or signs help? Pictures or gesture? Writing things down?

Help: what help does your patient need? What help do you need??

None of the interventions suggested are particularly tricky or difficult, but all have the potential to make a huge difference to our patients. For those working in UK ambulance services, the JRCALC guideline chapter will hopefully help as a prompt. For others, whether pre-hospital or not, I hope this blog helps a little.

https://www.jrcalc.org.uk

https://www.bristol.ac.uk/sps/leder/

Crash course in feeding tubes

Cite this article as:
Georgina Bough, Ana Waddington, Rachel Radley and Rebecca McConnell. Crash course in feeding tubes, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32900

Flatter tubes

Gastrostomy button (Low profile balloon gastrostomy e.g. MIC-KEY button®, MiniONE button®)

Gastro-jejunostomy button (G-J button e.g. MIC-KEY gastro-jejunal feeding tube®)

Dangly tubes:

PEG tube (e.g. Freka® PEG, CorFlo® PEG)

PEG-J tube: (e.g. Freka® PEG-J, CorFlo® PEG-J)

Balloon gastrostomy (e.g. MIC gastrostomy®):

Ok, got that … Troubleshooting

Complications often depend on the type of tube – balloon or PEG, gastrostomy or gastrojejunostomy.

Tube has fallen out

This is probably the most common ED problem. They tend to be a balloon tube (the balloon bursts) and then it’s an urgent problem. If the tract is left empty it will close up in hours and may need a laparotomy to replace the tube.

Replace the tube if you can (family will often have a spare and many will do this at home). Otherwise put a foley catheter in the tract, tape it to the skin and call the relevant surgical team if you can’t replace the tube.

Lie the child down on the bed, bring a selection of catheters (6Fr, 8Fr, 10Fr, 12Fr) and lots of lube, aim to gently place the largest catheter that will go in, insert about 5cm in a larger child, 3cm in a smaller child. Tape the tube securely to the tummy.

DO NOT do this if this is a primary balloon gastrostomy.  See below.

The jejunal part has fallen out / flipped up

Again this is an urgent problem. The family may report milk coming back through the gastric port/ milky vomiting, a PEG-J that is strangely easy to flush, a tube that looks different to normal or a jejunal tube in the nappy or stoma bag!

PEG-J’s are made from different parts.  The jejunal tube is fed through the gastric part and can fall off (into the patient).  This can be confirmed on x-ray and a radiologist will need to re-thread a new jejunal tube. The old tube will usually pass out per rectum or via a stoma. Don’t use the jejunal part of the tube until it has been replaced.

Balloon gastro-jejunostomies are made as one piece but the jejunal end can flip back into the stomach (can be confirmed on x-ray). A radiologist will need to re-site the tube. Don’t use the jejunal part of the tube until it has been re-sited.

The tube is leaking / split

Leaking from skin level

This can happen if the child is unwell and the gastric motility is reduced (higher than normal pressure in the stomach). 

Is the PEG/PEG-J loose? If the tube moves in and out a lot, pulling it snug and securing the flange may stop the leak.  

Balloon tubes may have too little water so changing the water and adding 1ml may help. Padding the tube with a thick dressing or using a shorter tube may also help.

The family should have contact with a CNS who can help.

Leaking from further down the tube

This is often due to a split tube or connector on a PEG / PEG-J. It can be fixed without an anaesthetic as long as the split isn’t close to the skin. You need to find the parts that are specific to the tube, then cut the damaged part off and put a new end on – like DIY or Lego. Usually a nurse specialist or paediatric surgeon does this but knowing which tube the child has is essential.

The tube is blocked

This usually happens with longer tubes. Hospitals often have a protocol for unblocking, and there are a lot of hospital guidelines on the web. If simple measures don’t work change the tube (see below).

Skin problems

These can occur when a tube leaks, is infected or a granuloma forms. The family should have a CNS or enteral feeding nurse who should be able to help

  • Infection: swab the site for bacteria and fungi and treat. Use a dressing to stop the tube rubbing
  • Leaking: See leaking tube.  
  • Granuloma: Usually not an ED problem. More common in clinic or on the ward.

Summary

Tube typeDangly?Number of ends?How is it held in?Who changes it?
Gastrostomy buttonNo1BalloonAnyone trained (unless it is a primary gastrostomy button placed within 6 weeks, see below)
Gastro-jejunostomy buttonNo2BalloonPaediatric radiologist
PEGYes1 (varies by brand)Plastic discSurgeon/gastroenterologist
PEG-JYes2Plastic discIf jejunal part has fallen out - radiologist, if the whole thing is broken - surgeon/ gastroenterologist
MIC-G tubeYes1BalloonAnyone trained

** unless this is a primary gastrostomy button and was placed for the first time within 6 weeks. If a primary button falls out within 6 weeks call the surgical team who did the operation urgently.

a The PEG ends vary between brand. Here’s a couple of pictures of PEG tube ends and PEG-J ends for reference

Special cases

There are always exceptions! 

Primary gastrostomy buttons

Some surgeons create a new gastrostomy and use a button as the first tube (primary button). Many place a PEG first and then change the PEG for a button once the tract has healed. If a primary button falls out before the tract has healed (in the first 6 weeks) placing a new tube roughly could push the stomach away from the abdominal wall and leave the end of the tube in the peritoneum. After 6 weeks, the gastrostomy tract has healed and is like an ear piercing – you can change the tube without worrying where it will go. Ask the surgical history. The tract starts to form when it is first made, a general anaesthetic is required and they won’t have had a gastrostomy before then.  

Other uses for balloon gastrostomies

These are brilliant devices, they can be used in other ostomies e.g. vesicostomies, jejunostomies. Changing them is the same but they usually sit somewhere else in the abdomen (rather than in the left upper quadrant or epigastrium as gastrostomies do).

Other tubes

There are lots of other tube types out there and other brands including malecot tubes, Cor-flo PEGs. If in doubt ask a senior or your local friendly surgical registrar, if you can take a photo of the tube (with consent) this will help the conversation.

Combination tubes

As the PEG tubes can be assembled/disassembled like Lego® occasionally people will have odd-looking tubes.  This lass has a Corflo PEG end with a Freka securing device (external flange). Combination tubes should be the minority.

Moral injury HEADER

Psychological distress in healthcare workers

Cite this article as:
Gladymar Perez and Rie Yoshida. Psychological distress in healthcare workers, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32653

We know that healthcare workers are at a greater risk of burnout, however you chose to define it. This study takes a look at the impact of COVID on the psychological distress of those on the frontline.

Roberts T, Daniels J, Hulme W, Hirst R, Horner D, Lyttle MD, Samuel K, Graham B, Reynard C, Barrett MJ, Umana E. Psychological Distress and Trauma in Doctors Providing Frontline Care During the COVID-19 Pandemic in the United Kingdom and Ireland: A Prospective Longitudinal Survey Cohort Study.

Background

This study aimed to assess the prevalence and extent of psychological distress and trauma of doctors working in the UK and Ireland during the first wave of the COVID-19 pandemic.   

Doctors working in Emergency Medicine (EM), Anaesthetics and Intensive Care Medicine (ICM) were asked to complete online surveys at the acceleration, peak and deceleration of the COVID-19 first wave, providing an insight into their psychological well-being at different phases of the pandemic. Exposure to previous infectious disease outbreaks have shown that elevated psychological distress is associated with the development of chronic stress, depression, anxiety, physical health problems, increased sickness rates, emotional exhaustion and impaired performance at work. Given that the COVID-19 pandemic will undoubtedly have a significant impact on the mental health of healthcare workers in the UK and Ireland, this study is important to understand the extent of the pandemic’s impact in these settings. The study also looked at personal and professional factors associated with increased distress in an attempt to identify those who are most at-risk and may benefit from early intervention.  

Methods

The study was carried out using a prospective online three-part longitudinal survey administered at the acceleration, peak and deceleration of the COVID-19 first wave.  Primary outcome measures were psychological distress and trauma, measured using the General Health Questionnaire for distress and the Impact of Event Scale -Revised for trauma.  These tools have been extensively utilised across different settings and cultures. The survey was distributed to doctors working in Emergency Medicine (EM), Anaesthetics and Intensive Care Medicine (ICM) in the UK and Ireland through existing trainee research networks, faculties and Royal Colleges.   Following participation in the first survey, the subsequent surveys were emailed directly to participants.  Survey distribution dates were decided based on public health data on the number of confirmed cases and deaths in the UK and Ireland.   The following dates were used:

  • Acceleration phase UK: 18/03/2020 – 26/03/2020, Ireland: 25/03/2020 – 02/04/2020
  • Peak phase UK: 21/04/2020 – 05/05/2020, Ireland: 28/04/2020 – 12/05/2020
  • Deceleration phase UK: 03/06/2020 – 17/06/2020, Ireland: 10/06/2020 – 24/06/2020

Personal and professional characteristics relating to participants’ current role, and their preparedness and experiences during the pandemic were also collected. 

Results 

Of the estimated 34,188 eligible doctors, the response rate for the initial acceleration survey was 15.9% (n=5440).  Peak and deceleration response rates were 71·6% (n=3896) and 56·6% (n=3079) respectively. (Ed. note- Though you could argue that the peak and deceleration responses were actually 11% and 9% of all eligible doctors). Prevalence of psychological distress was highest during the acceleration phase at 44·7% then declined through peak and deceleration phases of the first wave to a level comparable to pre-pandemic levels, reflecting a degree of natural recovery. The prevalence of trauma was highest at the peak of the pandemic at 23·7%. The figures for both psychological distress and trauma were substantially higher than for the general population.  The most significant personal and professional predictors associated with distress and trauma related to familial safety; personal safety and established mental health conditions.  Whilst ethnicity was not strongly associated with distress, it was a stronger predictor of trauma (R2 = 0·03).   

Strengths

This is a large-scale longitudinal study that prospectively examined the psychological wellbeing of frontline doctors, using GHQ-12 and IES-R, validated self-report measures for assessing  distress and trauma respectively. These outcome measures have been used in previous infectious disease outbreaks. A pre-specified analysis plan was published and is available online. 

This study included responses from 5440 frontline doctors throughout the UK and Ireland, an impressive response rate given that it was undertaken in the midst of a pandemic and was achieved thanks to the collaboration of multiple Emergency Medicine and Intensive Care research networks. (TERN, PERUKI, RAFT, ITERN, TRIC)  

Due to the extent of data collected, findings from this study offer an essential insight into the mental health of frontline doctors in an infectious disease outbreak.  These can be used to inform policy-makers on the development of interventions in the current pandemic and future outbreaks.  The three phase approach means interventions can be targeted in a timely manner.    

The study identifies ethnicity as a novel, key predictor of trauma.  By including the impact of ethnicity in the study the researchers have recognised the important role that ethnicity has played in this pandemic, given the higher rates of reported mortality in ethnic minority groups.  

Limitations

The surveys were distributed in a specific time frame that was based on the number of cases in both countries as a whole without accounting for the regional variation which occurred. 

As such, the researchers recognise that the variation in regional peaks may have influenced accurate capturing of psychological distress and trauma rates. In addition, pre-pandemic levels of distress and trauma in the cohort included in the study, remain unknown. 

There was a considerable drop-out rate in responses throughout the study with a 56.6% response at the final deceleration phase.  The researchers note that there was no significant difference in either the GHQ-12 or IES-R scores between those who dropped out and those who remained in the study.  However, the reason for participants’ lack of response is unknown and these participants may have been experiencing increased distress. Alternatively, a number of those without any concerns may have felt it no longer necessary to complete the survey, therefore, exaggerating the finding of significant trauma in those who did respond.

Bubble Wrap PLUS – May

Cite this article as:
Anke Raaijmakers. Bubble Wrap PLUS – May, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33235

Here is a new Bubble Wrap Plus, our monthly paediatric Journal Club List provided by Professor Jaan Toelen of the University Hospitals in Leuven (Belgium). This comprehensive list of ‘articles to read’ comes from 34 journals, including Pediatrics, The Journal of Pediatrics, Archives of Disease in Childhood, JAMA Pediatrics, Journal of Paediatrics and Child Health, NEJM, and many more. 

This month’s list features answers to intriguing questions such as: ‘Does the administration of colostrum reduce mortality in very preterms?’, ‘Can suffocation explain 20 or 50% of sudden unexpected infant deaths?’, ‘Is maternal fever a reliable predictor of neonatal sepsis?’, ‘Can clinicians discriminate children with pneumonia who develop severe complications from those who do not?’ and ‘Do rapid diagnostic methods improve antibiotic prescribing in pediatric bacteraemia?’.

You will find the list is broken down into four sections:

1.Reviews and opinion articles

Safe emergency neonatal airway management: current challenges and potential approaches.

O’Shea JE, et al. Arch Dis Child Fetal Neonatal Ed. 2021 Apr 21:fetalneonatal-2020-319398. 

Optimal administration of bronchodilators with valved holding chambers in preschool children: a review of literature.

Csonka P, et al. Eur J Pediatr. 2021 Apr 20:1-9. 

Maltreatment of Children With Disabilities.

Legano LA, et al. Pediatrics. 2021 Apr 19:e2021050920. 

Renovascular hypertension in pediatric patients: update on diagnosis and management.

de Oliveira Campos JL, et al. Pediatr Nephrol. 2021 Apr 13. 

Adolescent Consent for Human Papillomavirus Vaccine: Ethical, Legal, and Practical Considerations.

Zimet GD, et al. J Pediatr. 2021 Apr;231:24-30.

2.Original clinical studies

Viability and thresholds for treatment of extremely preterm infants: survey of UK neonatal professionals.

Di Stefano LM, et al. Arch Dis Child Fetal Neonatal Ed. 2021 Apr 29:fetalneonatal-2020-321273. 

Ethical issues in treatment of babies born at 22 weeks of gestation.

Lantos JD. Arch Dis Child. 2021 Apr 14:archdischild-2020-320871. 

Does oropharyngeal administration of colostrum reduce morbidity and mortality in very preterm infants? A randomised parallel-group controlled trial.

Aggarwal R, et al. J Paediatr Child Health. 2021 Apr 28. 

Breastfeeding, Physical Growth, and Cognitive Development.

Wallenborn JT, et al. Pediatrics. 2021 Apr 22:e2020008029. 

Explaining Sudden Unexpected Infant Deaths, 2011-2017.

Parks SE, et al. Pediatrics. 2021 Apr 27:e2020035873. 

Cerebral Oxygenation and Perfusion When Positioning Preterm Infants: Clinical Implications.

Jani PR, et al. J Pediatr. 2021 Apr 12:S0022-3476(21)00329-2. 

Predicting the Need for Phototherapy After Discharge.

Kuzniewicz MW, et al. Pediatrics. 2021 Apr 26:e2020019778. 

Simplifying Hyperbilirubinemia Risk Estimation.

Kair LR, et al. Pediatrics. 2021 Apr 26:e2020046284. 

Rates and Determinants of Mother’s Own Milk Feeding in Infants Born Very Preterm.

Dharel D, et al. J Pediatr. 2021 Apr 23:S0022-3476(21)00388-7. 

Is peripartum maternal fever alone a reliable predictor of neonatal sepsis? A single-centre, retrospective cohort study.

Gupta S, et al. J Paediatr Child Health. 2021 Apr 22. 

Neonatal hyperglycaemia is associated with worse neurodevelopmental outcomes in extremely preterm infants.

Zamir I, et al. Arch Dis Child Fetal Neonatal Ed. 2021 Apr 16:fetalneonatal-2020-319926. 

Effect of Enteral Lipid Supplement on Severe Retinopathy of Prematurity: A Randomized Clinical Trial.

Hellström A, et al. JAMA Pediatr. 2021 Apr 1;175(4):359-367. 

Evaluation of parameters associated with growth retardation in children with coeliac disease.

Taskin DG, et al. J Paediatr Child Health. 2021 Apr 28. 

Is Fecal Calprotectin a Useful Marker for Small Bowel Crohn’s Disease?

D’Arcangelo G, et al. J Pediatr Gastroenterol Nutr. 2021 Apr 14. 

Efficient implementation of the ‘non-biopsy approach’ for the diagnosis of childhood celiac disease in the Netherlands: a national prospective evaluation 2010-2013.

Meijer CR, et al. Eur J Pediatr. 2021 Apr 15. 

Is Celiac Disease Testing Necessary in Functional Abdominal Disorders? A Study in Predominantly Latino Children.

Falcon AC, et al. J Pediatr Gastroenterol Nutr. 2021 Apr 1;72(4):542-545. 

Could automated analysis of chest X-rays detect early bronchiectasis in children?

Clark AR, et al. Eur J Pediatr. 2021 Apr 28:1-9. 

Clinician Gestalt in Managing Pediatric Pneumonia: Can We Predict the Future?

Fatemi Y, Bell LM.Pediatrics. 2021 Apr 26:e2020048637. 

Predictive Value of Clinician “Gestalt” in Pediatric Community-Acquired Pneumonia.

Gao HM, et al. Pediatrics. 2021 Apr 26:e2020041582. 

Survival outcomes of in-hospital cardiac arrest in pediatric patients in the USA.

Hamzah M, et al. Eur J Pediatr. 2021 Apr 26. 

Pneumococcal Conjugated Vaccines Decreased Acute Otitis Media Burden: A Population-Based Study in Israel.

Marom T, et al. J Pediatr. 2021 Apr 21:S0022-3476(21)00351-6. 

Comparative Efficacy of Bronchiolitis Interventions in Acute Care: A Network Meta-analysis.

Elliott SA, et al. Pediatrics. 2021 Apr 23:e2020040816. 

“Don’t Just Do Something, Stand There”: Embracing Deimplementation of Bronchiolitis Therapeutics.

Lipshaw MJ, et al. Pediatrics. 2021 Apr 23:e2020048645. 

Burden of respiratory syncytial virus bronchiolitis on the Dutch pediatric intensive care units.

Linssen RS, et al. Eur J Pediatr. 2021 Apr 23. 

Association Between Proton Pump Inhibitor Use and Risk of Asthma in Children.

Wang YH, et al. JAMA Pediatr. 2021 Apr 1;175(4):394-403. 

Strikingly Decreased Community-acquired Pneumonia Admissions in Children Despite Open Schools and Day-care Facilities in Switzerland.

Kohns Vasconcelos M, et al. Pediatr Infect Dis J. 2021 Apr 1;40(4):e171-e172. 

Assessment of Peak Inspiratory Flow in Young Infants with Acute Viral Bronchiolitis: Physiological Basis for Initial Flow Setting in Patients Supported with High-Flow Nasal Cannula.

Milési C, et al. J Pediatr. 2021 Apr;231:239-245.e1. 

Examining differences in parents’ perceptions of children’s physical activity versus screen time guidelines and behaviours.

Jarvis JW, et al. J Paediatr Child Health. 2021 Apr 23. 

Factors Predisposing to Post Dural Puncture Headache in Children.

Bandatmakur M, et al. J Child Neurol. 2021 Apr 21:8830738211007699. 

Ultrasound for the diagnosis of malrotation and volvulus in children and adolescents: a systematic review and meta-analysis.

Nguyen HN, et al. Arch Dis Child. 2021 Apr 20:archdischild-2020-321082. 

Health Outcomes in Young Children Following Pertussis Vaccination During Pregnancy.

Laverty M, et al. Pediatrics. 2021 Apr 19:e2020042507. 

Clinical prediction of iron deficiency at age 2: a national cross-sectional study in France.

Guivarch C, et al. J Pediatr. 2021 Apr 6:S0022-3476(21)00321-8. 

Subconcussive Head Impacts and Neurocognitive Function Over 3 Seasons of Youth Football.

Rose SC, et al. J Child Neurol. 2021 Apr 9:8830738211004490. 

Validation of the Rule of 7’s for Identifying Children at Low-risk for Lyme Meningitis.

Garro A, et al. Pediatr Infect Dis J. 2021 Apr 1;40(4):306-309. 

Kawasaki Disease Shock Syndrome Versus Septic Shock: Early Differentiating Features Despite Overlapping Clinical Profiles.

Power A, et al. J Pediatr. 2021 Apr;231:162-167. 

Do rapid diagnostic methods improve antibiotic prescribing in paediatric bacteraemia?

Faugno AK, et al. J Paediatr Child Health. 2021 Apr;57(4):574-580. 

Perinatal COVID-19: review of current evidence and practical approach towards prevention and management.

Vardhelli V, et al. Eur J Pediatr. 2021 Apr;180(4):1009-1031. 

COVID-19 and Pediatric Ingestions.

Lelak KA, et al. Pediatrics. 2021 Apr 27:e2021051001. 

Compassionate Use of Remdesivir in Children With Severe COVID-19.

Goldman DL, et al. Pediatrics. 2021 Apr 21:e2020047803. 

Compassionate use of remdesivir in children with COVID-19.

Méndez-Echevarría A, et al. Eur J Pediatr. 2021 Apr;180(4):1317-1322.

4.Case reports

Vaping the Venom: Oral Cavity Cancer in a Young Adult With Extensive Electronic Cigarette Use.

Klawinski D, et al. Pediatrics. 2021 Apr 29:e2020022301. 

Unilateral Facial Paralysis.

McHugh CI, et al. J Pediatr. 2021 Apr 21:S0022-3476(21)00358-9. 

A Previously Healthy 18-Year-Old Male With Fever, Arrhythmia, and Shock.

Umapathi KK, et al. Pediatrics. 2021 Apr 13:e2020017624. 

Tic Disorder in an 8-Year-old Boy.

Coppola C, et al. Pediatr Infect Dis J. 2021 Apr 1;40(4):382-384. 

Interesting case of vasculitis or suspected child abuse: A fast evolving story.

Nagar S, et al. J Paediatr Child Health. 2021 Apr 19.

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!

Fracture hide and seek

Cite this article as:
Carl van Heyningen and Katie Keaney. Fracture hide and seek, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32819

Another winters morning. You are freshly vaccinated, caffeinated and ready for another ED shift. Your first patient is a return visit. A 7 year-old who fell onto his shoulder at school a week ago. You read your colleague’s previous assessment. On examination there was no bony tenderness and the x-ray report of the right clavicle was normal. Yet today there’s a lump over the collar bone and he’s no longer using his arm normally. Has something been missed?

X-ray interpretation is a complex human enterprise vulnerable to a wide variety of errors. The extent of missed diagnoses has been estimated to be as high as 15-20% 1,2.

There are two principle types of error:

  • Perceptual errors – those where the abnormality is simply not seen
  • Cognitive errors – where the abnormality is seen but its significance is not appreciated

You might think that such errors can simply be avoided through education, better imaging techniques and training. Yet since the 1960’s, despite doubtless advances in technology and improvements in medical practice, the rate of radiological errors has remained almost unchanged.

So what do we do? Admit defeat? Never!

Instead, let’s journey inwards and analyse these errors, why we make them and how we can improve ourselves and our approach to avoid missing fractures in children with injuries.

Causes of error

Perceptual errors are the most common and are due to many factors including:

  • Clinician fatigue
  • Distractions from colleagues and the working environment – the extrinsic cognitive load
  • High workload
  • Satisfaction of search (spotting one abnormality then failing to look for any more)

There is a reason your friendly radiologist is sat quietly in a dark room with a cup of coffee – a world away from a noisy, busy accident and emergency department. Consider yourself and your environment when reviewing an x-ray. Just as with prescribing, respect reviewing x-rays.

Even with the best conditions, what the eye sees the brain doesn’t always spot. Consider the now infamous Invisible Gorilla experiment that earned Christopher Chabris and Dan Simons an Ig-Nobel Prize in 2004. Participants were asked to watch a video and count the number of times the ball was passed between players. What they failed to notice was the large hairy simian playing the game. The brain failed to recognise what the eyes clearly saw.

The selective attention test

Cognitive errors occur for a whole host of reasons. Some of these include:

  • Lack of knowledge (e.g. how to interpret x-ray findings, ossification centres, etc.).
  • Lack of clinical information (e.g. history or examination)
  • Faulty reasoning (e.g. fracture identified but not cause of pain)
    • True positive, misclassified
  • Complacency (e.g. fracture identified but from separate injury)
    • False positive finding
  • Satisfaction of report (e.g. reliance on radiology report discourages further analysis).
  • Satisfaction of search (e.g. finding one fracture discourages search for another).  

Then there are our own cognitive biases which may also influence our interpretation…

Anchoring bias– early focusing on one feature of the image so neglecting or misinterpreting the rest of the information

I’ve found the distal radius fracture so that is the diagnosis”. The scaphoid fracture is then missed).

Availability bias– recent experience of a diagnosis/presentation makes you more likely to diagnose the same condition

I saw a pulled elbow the other day, it looks the same”. May miss ulnar dislocation.

Confirmation bias– looking for evidence to support your hypothesis and ignoring evidence against

It looks like a simple ankle sprain, I think that X-ray must be fine”. Can miss fractured fibula.

Outcome bias– opting for the diagnosis associated with the best patient outcome/prognosis

If there is a vertebral fracture, we will have to immobilise this child. It probably isn’t that”.

Zebra retreat– history and findings are in keeping with a rare diagnosis but the diagnostician is afraid to confirm this

As Dr Cox says, if you hear hoofbeats look for horses not zebras” …sometimes it’s a zebra!

Finally, no article on medical error would be complete without reference to the good old Swiss Cheese Model. We are but one step in a sequence of events that can either prevent or lead to error. For our example case, consider the following…

Graphic showing swiss cheese model of errors
Errors were made

Can I have some examples please?

Most fractures in children are easy to spot however some may present with subtle findings, especially when they involve the epiphyseal growth plate.

Examples of where most missed fractures occur are shown below:

Common but low risk as well as rare but high risk missed fractures

Many fracture patterns are unique to children. The paediatric skeleton is more elastic, more porous, and has a relatively stronger periosteum. That makes it uniquely vulnerable to torus fractures, buckle fractures, plastic bowing and greenstick fractures. Knowing to look for such subtleties sets paediatric fracture diagnosis apart. That coupled with odd growth plates and ossification centres explains, in part, why fractures are more easily missed in children5.

There is a subtle angled fracture of the distal radius. Compare this with the normal (middle) and healing (right) – taken from Hernandez, J.A., Swischuk, L.E., Yngve, D.A. et al. The angled buckle fracture in pediatrics: a frequently missed fracture. Emergency Radiology 10, 71–75 (2003). 

A subtle angulated fracture of the proximal radius taken from Hernandez, J.A., Swischuk, L.E., Yngve, D.A. et al. The angled buckle fracture in pediatrics: a frequently missed fracture. Emergency Radiology 10, 71–75 (2003). 

Plastic bowing deformity of the left radius and ulna taken from George MP, Bixby S. Frequently Missed Fractures in Pediatric Trauma A Pictorial Review of Plain Film Radiography Radiol Clin North Am 2019 Jul57(4)843-855

Plastic deformity of the radius with upward bowing (arrows) taken from Swischuk, L.E., Hernandez, J.A. Frequently missed fractures in children (value of comparative views). Emerg Radiol 11, 22–28 (2004). 

A subtle greenstick fracture of the distal ulna taken from George MP, Bixby S. Frequently Missed Fractures in Pediatric Trauma A Pictorial Review of Plain Film Radiography Radiol Clin North Am 2019 Jul57(4)843-855

Note the upward plastic deformity of the right clavicle with the left for comparison taken from Swischuk, L.E., Hernandez, J.A. Frequently missed fractures in children (value of comparative views). Emerg Radiol 11, 22–28 (2004). 

The leftmost image shows an obvious spiral fracture. The Toddler’s fracture in the middle image is not apparent until the line of sclerosis appears with healing taken from Swischuk, L.E., Hernandez, J.A. Frequently missed fractures in children (value of comparative views). Emerg Radiol 11, 22–28 (2004). 

A Salter-Harris 1 fracture of the distal radius. Look at the widened growth plate compared with the ulna taken from Jadhav, S.P., Swischuk, L.E. Commonly missed subtle skeletal injuries in children: a pictorial review. Emerg Radiol 15, 391–398 (2008). 

We have seen how even with the benefit of the patient in front of us and the luxury of radiology reports that we are vulnerable to making mistakes. Yes, we need to first know our ischial spine from our olecranon (our arse from our elbow), but we also need to train ourselves in techniques to avoid perceptual and cognitive traps.

So how do we prevent them?

Reducing missed fractures in children

Sadly the evidence is lacking and largely focuses on the performance of radiologists. Approaches centred solely on education and training are insufficient. Slowing down strategies, group decision-making and feedback systems are, as yet, an unproven step in the right direction. Checklists, however, have a growing evidence base in improving performance despite their poor popularity.

Whether or not you are a fan of the ‘Checklist Manifesto’, less controversial are principles around workplace culture and communication. Facing up to errors, avoiding blame and frequently just talking with colleagues (the clinician, the radiographer, the radiologist, the patient) remains incredibly important.

What else?

Systems-level thinking

A growing number of healthcare trusts now implement peer learning systems. Rather than being punitive, such groups create collective opportunities to teach using diagnostic catches as well as misses. At Leicester Royal Infirmary, Education Fellow Sarah Edwards set up one such weekly group teaching session for A&E staff. It gave them the opportunity to review images with the support of a Consultant Radiologist.

Evidence also supports “double-reading” to reduce the misses. At the Royal London Hospital, we are supported by our Radiology colleagues who review all images from our paediatric emergency department within 24 hours. Furthermore, within our ED we foster a culture of learning from each other through openly sharing learning points without risk of embarrassment and most (if not all) x-rays are reviewed by two or more clinicians to share knowledge and experience.

Such principles underpin the Irish National Radiology Quality Improvement (QI) programme. Through standard setting and measuring performance they pursue a cycle of continued quality improvement.

Individual level thinking

Michael Bruno, Vice Chair for Quality and Chief of Emergency Radiology at Penn State University says “there’s a very simple fix for errors of thinking- cognitive biases.… you must force yourself to ask really open-ended questions…. what else, how else, where else could a finding be… force your mind back open again.

To be more technical, lets consider the “dual process theory of reasoning.” In radiology, automatic system 1 processes typically enable immediate pattern recognition. In contrast deliberate system 2 reasoning enables less obvious abnormalities to be detected. Normally there is a dynamic oscillation between these to forms of thinking. The lesson is not to eliminate type 1 processing, which is prone to mental shortcuts and mistakes, but instead to be aware of our own thinking with the ability to deliberately “turn on” our type 2 brain when needed.

This discipline is termed metacognition or meta-awareness. 

For those who find such talk nebulous, there a number of practical steps that come recommended from Andrew J. Degnan (Department of Radiology at Children’s Hospital of Philadelphia).

Maintain a healthy skepticism

Reflect on your diagnostic process, challenge your interpretation forensically and question yourself objectively.

Use a structure or checklist

Structured reports help radiologists. Find your own repeatable techniques and approach each x-ray systematically, including “review areas” that are often overlooked. 

Consider the clinical findings

What is your pre-test (pre-x-ray) probability? How confident were you in your clinical assessment? Is the x-ray a rule-in or rule-out? Marrying up a thorough history and examination with a careful focus on the relevant radiographic area often bears reward.

Injuries that are missed because of failure to image are typically because the injury was poorly localized or because of the presence of other injuries distracted attention from the injured part.”

Mind your environment

Are you fatigued? Have you had a break? Clearing your mind for even a moment can actually improve overall efficiency. A quiet work space. A few minutes away from distraction. These will all empower your type 2 thinking.

Mitigate, mitigate, mitigate

Mistakes happen. Telling parents about uncertainty is critical to them re-presenting if their child’s soft tissue injury or sprain is not improving. Importantly, this is not the same as forgoing responsibility. Yet if your routine practice includes quality safety netting, discussing cases with your friendly radiologist and chasing up on cases you may not prevent mistakes but you might minimize the harm that comes from them.

What happened with our case?

A repeat x-ray was done but again no fracture was evident. Yet to examine there was an un-deniable lump mid-clavicle. In view of persistent pain and continued non-use of the limb (right arm) the child was discussed with the radiologist who agreed upon ultrasound. Ultrasound confirmed early callus formation and a break in the cortex that was not visible on X-ray. The child went home in a sling for outpatient follow up.

Take home messages  

  • Missed fractures are more common in children and not necessarily subtle
  • Know what to look for and how to look for it
  • Process is important, don’t forget history and examination
  • Communicate clearly, speak frequently with your radiographer and radiologist

Selected references

1. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121(5 suppl):S2–S23.

George MP, Bixby S. Frequently Missed Fractures in Pediatric Trauma A Pictorial Review of Plain Film Radiography Radiol Clin North Am 2019 Jul57(4)843-855. – Images 3,5 in carousel

Hernandez, J.A., Swischuk, L.E., Yngve, D.A. et al. The angled buckle fracture in pediatrics: a frequently missed fracture. Emergency Radiology 10, 71–75 (2003) – Images 1,2 in carousel

Jadhav, S.P., Swischuk, L.E. Commonly missed subtle skeletal injuries in children: a pictorial review. Emerg Radiol 15, 391–398 (2008). – Image 8 in carousel

2. Wachter RM. Why diagnostic errors don’t get any respect: and what can be done about them. Health Aff (Millwood) 2010;29(9):1605–1610.

5. Smith J, Tse S, Barrowman N, Bilbao A, (2016). P123: Missed fractures on radiographs in a paediatric emergency department, CJEM, 18 (S1), S119-S119

Swischuk, L.E., Hernandez, J.A. Frequently missed fractures in children (value of comparative views). Emerg Radiol 11, 22–28 (2004). Images 4,6,7 in carousel

Further reading

Brady AP. Error and discrepancy in radiology: inevitable or avoidable?. Insights Imaging. 2017;8(1):171-182. 

Kim YW, Mansfield LT. Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. AJR Am J Roentgenol 2014;202(3):465–470.

Michael A. Bruno, Eric A. Walker, and Hani H. Abujudeh, Understanding and Confronting Our Mistakes: The Epidemiology of Error in Radiology and Strategies for Error Reduction, RadioGraphics 2015 35:6, 1668-1676 

Martino F., Barbuti D., Martino G., Cirillo M. (2012) Missed Fractures in Children. In: Romano L., Pinto A. (eds) Errors in Radiology. Springer, Milano.

Miele V., Galluzzo M., Trinci M. (2012) Missed Fractures in the Emergency Department. In: Romano L., Pinto A. (eds) Errors in Radiology. Springer, Milano.

Wang CC, Linden KL, Otero HJ. Sonographic Evaluation of Fractures in Children. Journal of Diagnostic Medical Sonography. 2017;33(3):200-207.