When I’m not working in the emergency department, playing with my children or doing DFTB ‘stuff’ I work for the state retrieval service. As the name Adult Retrieval Victoria implies I spend my time moving and coordinating the movement of critically ill or injured adults around the state. There is a dearth of retrieval textbooks out there and so I was excited to see the Oxford Handbook of Retrieval Medicine make it into print.
Minh Le Cong has done a great review of the book that you can listen to here. Given that Don’t Forget The Bubbles is a website dedicated to all things paediatric I thought it might be worthwhile taking a look at those sections that might be of particular import regarding the retrieval and transfer of critically ill neonates and children – something which I have very little experience in.
The paediatric retrieval chapter was put together by Dr Felix Oberender who is a specialist in Paediatric Intensive Care at the Royal Children’s Hospital in Melbourne. It covers a wide range of retrieval experience from the seemingly simple retrieval of an intubated child with status epilepticus to the highly complex task of ECMO retrieval. As with NETS there is an emphasis on the role of the specialised team as well as the individual. This is not the sort of task that someone who has never dealt with an intubated child should undertake.
The clinical environment is a challenging one. Practitioners may be going into an unfamiliar department with stressed staff. This requires a particular set of skills that can be taught. There is also the challenge of looking after a critically unwell child in the back of metal tube flying through the air at 333 mph, where you have limited access to the patient and no auditory cues to deterioration. As Oberender points out, it is also not the right environment to be taught in. Retrievalists need to have the skills to manage any circumstance that might arise at 10,000 ft. If you are busy figuring out how the suction works when the child you are transporting starts vomiting then it is too late.
After going through the basic equipment required by the retrieval team and some of the specific challenges of air control, ventilator support (be that mechanical or via high flow nasal cannula O2 or CPAP) and vascular access, the book then covers some of the more common paediatric conditions that might require transfer to a tertiary centre. My favourite aspects of the chapter are the pop-out boxes that relate to key messages for the reader, such as the early involvement of anaesthetic staff. It is easy to feel that we should be able to do everything for our young patients but managing unwell children, be they critically unwell or not, is a team sport. As someone who spends a couple of days a week figuring out who to send and how to move critically unwell adults around Victoria, I was also especially interested in the areas related to co-ordination. Suggestions are made as to appropriate time frames for movement – important when there are limited resources and a condition might be time-critical e.g. an extradural haemorrhage. The chapter ends on a sobering reminder that the retrieval service can also be a great source of advice or help in difficult circumstances. Those of us that work in larger centres might forget that we have colleagues out there dealing with the sick and dying child on their own. There is always a voice on the end of the line to offer words of encouragement or to help make the hard, hard decision to stop resuscitation, when appropriate.
I’d like to thank Felix for going beyond the call of duty and answering some of my burning questions…
When did you first get involved in paediatric retrieval? What attracted you to the speciality?
My first impression of paediatric retrieval was as a junior doctor in London. A child had deteriorated, needed intubation and transport to the nearest PICU. I remember the relief when the retrieval team arrived. A doctor, a nurse and boxes of equipment landed on our ward. In a breeze, the space was turned into a mini-ICU, the child saved and whisked away – all with a friendly word and a smile. The team were awesome and I wanted to be part of it. A couple of years later, I was working at C.A.T.S., the North London paediatric transport service. Needless to say that instead of feeling awesome there was rather a lot of ‘oh my god’ and ‘keep calm and carry on’ when you walked into unfamiliar places and met kids who were really, really, REALLY, sick. The attraction of acute transport medicine, however, stayed with me.
What attracted you to this project?
The opportunity to cast paediatric intensive care retrieval into one practical chapter. Writing for the Oxford Handbook offered a great chance to provide an evidence-based guide and to include some of the clinical pearls that we all pick up along the way but never find in papers or big textbooks.
Who is the target audience of your chapter?
Retrieval specialists and, importantly, the clinicians who care for a critically ill child prior to transport. I hope readers will find a useful guide when faced with a very sick paediatric patient – a companion that provides essentials and warns of pitfalls.
What changes have you seen in the practice of paediatric retrieval over the last 10 years?
Clinically, two big developments come to mind. On the ‘lighter’ side of the disease spectrum, high-flow oxygen therapy swept through PICU and has arrived in paediatric retrieval medicine. On the ‘heavy’ side, high-performing retrieval services now can offer established ECMO capability.
Just as important, however, has been the professionalisation of paediatric critical care transport. Increasingly, throughout the developed world, there is a recognition that transporting critically ill children is best done as part of a system that combines medical and nursing expertise with high-performance logistics and communications. In essence, every child and every clinician should have ready access to intensive care when needed. What such system looks like, whether it is stand-alone, combined or PICU-based, depends very much on caseload, retrieval environment as well as on geography – and on funding.
That said, the most impressive retrieval I have ever witnessed happened not in Australia, Europe or the US but in Cambodia: for a patient in septic shock presenting to the distant satellite clinic of a children’s hospital. Within 30 minutes the child was resuscitated, intubated, ventilated, on inotropes, packaged in the ambulance and on the way to the main hospital. It was a testament to great teamwork by the local Cambodian team and to the good processes of their hospital.
If you were not limited for space what would you like to have included?
I’m actually very happy that the chapter is quite comprehensive in its range. Of course, one could always go more into depth. However, I don’t think that would serve the Oxford Handbook reader who I imagine is after a concise brief on each topic.
Can you give an example of a resource readers can access to learn more about paediatric retrieval?
To my knowledge, there is no ‘standard text’ on paediatric retrieval medicine. The big textbooks on Paediatric Intensive Care (e.g. ‘The Fuhrman’ or ‘Roger’s’) have a chapter on the subject – very good primers but not exactly further reading. Each, however, provides in-depth background on specific diseases or therapies.
Your local retrieval service may offer access to worthwhile further learning, for instance through web-based guidelines on scenarios, diseases, the referral process as well as on transport (e.g. https://site.cats.nhs.uk/in-a-hurry/cats-clinical-guidelines/ ). Many retrieval services also offer course-based teaching (e.g. https://www.rch.org.au/piper/education/Paediatric_Education/ ). In addition, I can recommend the Paediatric B.A.S.I.C. courses run in Queensland, South Australia, NSW and Victoria (https://www.aic.cuhk.edu.hk/pae_basic/country.php ). Transport is but one small (and fun) part of these courses but they offer a great overall opportunity to delve a little further into critical care for children.
Are there any common mistakes you see made (by referrers) that should be avoided?
Referring late. As paediatric retrieval specialists, we like to know and be there early – with advice, over-the-phone support and, if necessary, retrieval. Only about 50% of referrals actually end up being specialist-team transports but the retrieval service can offer both clinical and logistical support, allowing treating clinicians to focus on looking after the sick child. Never hesitate to ‘phone a friend’.
Are there one or two key messages that you would like readers to take away from your chapter?
Having to treat a critically ill child doesn’t happen very often for many clinicians. Hence, if you find it scary, you’ve correctly gauged the mission. Next, it’s basic principles of good medicine, a quick read in the Oxford Handbook and a call to your paed retrieval friends.
My bottom line is that this chapter is a great addition to a pocketbook that should be in most emergency departments, not just to guide treatment but also to empower early referrals and thoughtful discussions.
(Time for me to declare my conflict of interest – two of the editors (MK and CE) are my bosses at one of my workplaces. They don’t look after children.)