Treating big people (adults) with COVID…

Cite this article as:
Vicki Currie. Treating big people (adults) with COVID…, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32313

Reflections from a Paediatric Registrar

‘I won’t touch the feet- I’ll do ANYTHING else’. Avoiding adult feet was one of the reasons I chose a career in paediatrics was one of my responses when I found out that the PICU I was working in was being converted to an adult COVID ITU. I chose paediatrics as a career for so many other reasons, but this was the first thing that popped into my head. 

The world has been turned upside down by this pesky virus.If one year ago you would have told me that I would be looking after adult ITU patients with this new disease I would have refused to believe it. For so many, working lives have changed, roles have been adapted or learnt at lightning speed and working outside your ‘comfort zone’ has become part of the ‘new normal’. 

After a few weeks of looking after adult COVID ITU patients on a PICU I have had some time to reflect on how different things have been. Some things will change my practice forever, some of the big differences in ways of working between those looking after big and littler people. As a general paediatrician doing a stint on PICU, intensive care was new but the steep learning curve after 6 years of looking after ‘littler people’ was even steeper. 

After working closely with adult ITU team members for the last few weeks, we have had a chance to see how each other works. It has proven an opportunity to learn form each other. There are a lot of similarities, and a few differences. There are also some things which both sides can hopefully take forward into our future practice. 

Handover

As paediatricians we LOVE a handover- in some places I have worked it can feel like handovers take over the entire day. One of the biggest differences is the way the adult team do handover.  It seems so much more business-like – especially at the end of a nightshift. There’s no messing around. Any issues? Who is stable or not\? Salient points only. The paediatrician’s in the room added their own twists ‘Had the family been updated? What had they eaten today? What did their poo look like? And how had they slept?’

After a few weeks a happy medium had been found. There was a nice balance achieved between getting the night team off on time, and reducing information that could be found out easily on the morning round whilst including some of the more holistic aspects of care.

Communication with relatives and patients

Those who look after children are used to having to flip between conversing with patient and family. This is a great advantage. We are constantly thinking about updating relatives and keeping family informed. Using FaceTime allowed us to communicate with relatives. They could see their loved ones when they could not be with them. 

The adult team, who have had much more practice with the difficult conversations, seemed to be so slick, having the same realistic and honest conversations. It was business-like and well-rehearsed. Delivering the information succinctly meant that time could be spent talking to more families. 

Patients told me that the way medical and nursing staff spoke with them was different when they made the move to the PICU. Many patients told me that they could tell we were used to dealing with children. The way we spoke was cheery, informal, and most importantly, personal.  I wonder if this was always what they wanted though, especially when delivering difficult news. With the help of the adult ITU team, a delicate balance was maintained. 

Attachment

The adults with COVID in the ITU seem to be long- stayers.Having the same set of patients for a few weeks is great in some ways; and hard in others. Often, with PICU patients, there can be prolonged stays but one of the things the adult team found hard was the attachment they formed to their patients  from seeing them shift after shift. Couple this with the need to look after so many patients on adult ITU , whilst rotating through different pods. On PICU it was one area with the same patients.

On the plus side, you knew the patients REALLY well. You understood things in detail things, like what ventilation strategies they responded to- or didn’t. You knew what previous infections they had been treated for and you knew what families had been told. The downside: you became more attached. It was harder, emotionally, when a patient you knew deteriorated or didn’t better. I wonder if we carry more of an emotional burden in paediatrics because of this. Any doctor will get emotionally attached to certain patients. But are we more likely to do so by seeing fewer patients but more often than our adult counterparts? 

Teamwork

Without question, the amazing paediatric ITU nurses stepped up to the challenge of looking after grown-ups. The incredible camaraderie, between nursing staff, paediatric doctors and the adult ITU team, proning the most unwell patient at 2 in the morning is something which should be bottled up and stored for reuse when this is all done. Truly working together to pull, not only the patients but also each other through the difficult shifts. 

The adult ITU team helped whenever they were needed. They supported us and also credited us paediatricians on many occasions for out strict attention to detail – with anything from charting blood results to charting fluid balances. 

This has been an eye-opening experience. It has been challenging, terrifying, devastating at times. It has also provided opportunities to work with amazing colleagues and witness teamwork between medical and nursing staff like never before. It has been a unique opportunity for adult and paediatric teams to work side by side and siphon bits of each other’s practices. 

As for the feet- it wasn’t as bad as I expected- but I drew the line at a request for a foot massage!

An excellent resource for those working on the front line who are struggling or just looking for that little bit of extra support…

https://www.rcpch.ac.uk/key-topics/your-wellbeing-during-covid-19-pandemic

Safety Netting

Cite this article as:
Carl van Heyningen. Safety Netting, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28803

Safety netting is a cornerstone of paediatric practice. 

Children are a vulnerable group. Their condition can deteriorate and improve rapidly. Uncertainty is inherent in paediatric emergency medicine. From the child with a fever to the infant with vomiting, it is up to us to safeguard children from harm.  

Of course, we can’t admit every child to the hospital. Nor should we. The vast majority of patients in A&E return home with reassurance. Easy right? Reassure. Give advice. Send home. Simple?

You’re at the end of a busy shift and you have a train to catch. You’ve put in blood, sweat, and tears and feel happy your last patient has a simple throat infection. You advise fluids, paracetamol for symptoms of headache and neck pain and to come back if worried. The mother is anxious, you give them a leaflet on fever and rush out the door. 

Typically, our focus is on the front door of care not the exit. Discharge care is often overlooked. Even in the best of circumstances, we are under pressure to maintain patient flow especially as our emergency departments begin to become busy again. 

The next morning, coffee in hand, you walk in the department and hear the words that strike fear into the hearts of all that hear them… 

“Do you remember that child you saw yesterday? They’re being admitted to intensive care, it looks like meningitis.”

What could you have done differently? More tests? Not necessarily needed, no? More time? They had been observed and appeared well for several hours. Senior review? You’d seen them with the Consultant and agreed on the diagnosis. Then what? 

Safety netting

Why is it important? 

Acute illness remains one of the most important causes of childhood mortality in the UK. Early illness is notoriously non-specific. Take meningitis. In only half of cases, diagnosis is made at the first presentation. So what do we do? We must educate parents about uncertainty. Discuss the potential for deterioration. Explain the importance of seeking further help if necessary. We must safety net. 

What is it?

The term was first formally described in 1987. Today, it has come to mean “advice about what to do and what to look out for to empower parents and carers to seek help if the child’s condition deteriorates further or if they need more support.”  

What else should it cover? 

In addition to the above, it is critical to cover how they should seek help, what they should expect ahead (the disease course) and when to become worried.

How should it be done? 

Whilst verbal and written formats exemplify current practice, ranging from information leaflets to printed discharge letters, audiovisual and online resources are growing in abundance. Families report wanting this varied range of approaches.

Let’s consider the options. 

Face to Face – individualized, personal but highly variable and time-dependent

TOP TIP – be adaptable (don’t just simply recite the same information each time)

Social, educational, and cultural differences may all necessitate adapting your usual spiel in order to truly achieve understanding. Remember, the parents are in an unfamiliar, often noisy, and stressful environment in addition to feeling worried about their child. Expect them to be distracted a little. 

Leaflets – standardised, quality assured but not necessarily up to date and potentially bland and uninteresting. 

TOP TIP – use leaflets to re-enforce verbal information

When taken home written materials can often act as an aide memoire.  

Audio-visual – engaging and memorable with the potential to overcome literacy and language barriers if well designed, though resource intensive and expensive upfront   

Internet, social media, websites, apps – there are many innovative methods of connecting families with health information. Our responsibility is thus to navigate the clutter, signpost reliable resources, dispel myths and thus champion true evidence based materials. 

TOP TIP – keep the message simple, it can be easy to overwhelm parents with information. 

Remember, many parents may not wish to go on the internet. A few may even not have access to it. 

Why tailor the information? 

As ever, before talking we must first listen. For example, one interview based study found a mother worrying about “their child with cough dying at night through choking on phlegm.” If we do not listen to such fears how can we expect our own advice to be heard. 

Parental priorities

Parents priorities include… 

Emotional distress (addressing this)

Physical symptoms (addressing these)

Information (providing this, particularly reassurance, diagnosis and explanation)

Care (basic care, including food drink and friendliness)

Closure (finding out what’s wrong and, where possible, going home)

An awareness of these priorities can inform our conversations, helping us to better look after our patients from their perspective.

Ok, but what is the reality?

“You don’t actually know how much of that leaflet they’re gonna actually understand, take in, comprehend… going through things step by step, listening, understanding and explaining, I think is more beneficial” (Paediatric ED doctor). 

“It’s very difficult to know ‘cause often they’ll nod their heads and say “yes I understand everything you say” and walk off and they might have no idea what we’ve just said”  (ED staff nurse). 

“If you’ve got a sick child at home and they’re moaning at you, you haven’t got the time to go on the internet… you’ve got a child hanging off your leg going, “Mummy I feel poorly, mummy I want this, mummy I want that”” (Mother).

“My doctor did give like an information leaflet… and I did read through it, because when you’ve got a sheet at least you can find time to do that” (Mother).

So how can we do it best?

After reviewing the literature and FOAMed (see further resources) here are my top tips for giving the very best safety netting advice, enjoy! 

  • Sit down – it has been shown to increase the perception of empathy 
  • Verbalize back concerns – be explicit important conditions have been excluded 
  • Explain things – share reasoning, show your process 
  • Highlight red flags – signs that necessitate reattendance
  • Be specific – ‘If x happens, do y’
  • Reinforce – provide written leaflets
  • Avoid criticism, foster understanding – put yourself in their shoes 
  • Document advice – yes, write down what you said 

And as with all good communication, ensure a quiet, private area and avoid using jargon. 

Finally, directly ask if parents understand and are happy. Don’t assume they are. 

Here is one good example to get you started… 

“…your little guy is likely to continue to have vomiting and diarrhoea. If he remains well in himself, is drinking the amount of fluid we have discussed and is having wet nappies then he is unlikely to become dehydrated. If, however, he becomes drowsy, develops a fever or fails to stay hydrated please call this number and come back to us.” 

We must stop thinking of reattendance as a failure – patients do get worse and some need to return. 

Good quality safety netting means both you and your patients can get a better nights sleep. 

References

Gill P, Goldacre M, Mannt D, Heneghan C, Thomson A, Seagroatt V and Harnden A (2013) ‘Increase in emergency admissions to hospital for children aged under 15 in England, 1999–2010: national database analysis’, Archives of Disease in Childhood 98, 328–34.

Wolfe I, Cass H, Thompson MJ, Craft A, Peile E, Wiegersma PA, Janson S, Chambers T, McKee M: Improving child health services in the UK: insights from Europe and their implications for the NHS reforms. Bmj 2011, 342:d1277.2. 

Thompson MJ, Ninis N, Perera R, Mayon-White R, Phillips C, Bailey L, Harnden A, Mant D, Levin M: Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006, 367(9508):397–403.3. 

Neighbour R. The inner consultation. Lancaster: MTP Press, 1987.

NICE guideline [NG143], Fever in under 5s: assessment and initial management, November 2019

Available at https://www.nice.org.uk/Guidance/Ng143/evidence

Almond S, Mant D, Thompson M: Diagnostic safety-netting. The British journal of general practice: the journal of the Royal College of General Practitioners 2009, 59(568):872–874

Jones CH, Neill S, Lakhanpaul M, et al. Information needs of parents for acute childhood illness: determining what, how, where and when of safety netting using a qualitative exploration with parents and clinicians. BMJ Open 2014;4:e003874.

Neill SJ, Jones CH, Lakhanpaul M, et al. Parent’s information seeking in acute childhood illness: what helps and what hinders decision making? Health Expect 2015;18:3044–56. 

Austin PE, Matlack R, Dunn KA, et al. Discharge instructions: do illustrations help our patients understand them? Ann Emerg Med 1995;25:317–20.

Scullard P, Peacock C, Davies P. Googling children’s health: reliability of medical advice on the internet. Arch Dis Child 2010;95:580–2.

Mackert M, Kahlor L, Tyler D, et al. Designing e-health interventions for low-health-literate culturally diverse parents: addressing the obesity epidemic. Telemed J E Health 2009;15:672–7.

Knight K, van Leeuwen DM, Roland D, et al. YouTube: are parent-uploaded videos of their unwell children a useful source of medical information for other parents? Arch Dis Child 2017;102:910–4.

CS Cornford, M Morgan, L Risdale, Why do Mothers Consult when their Children Cough?, Family Practice, Volume 10, Issue 2, July 1993, Pages 193–196

Body R, Kaide E, Kendal S, et al. Not all suffering is pain: sources of patients’ suffering in the emergency department call for improvements in communication from practitioners, Emergency Medicine Journal 2015;32:15-20.

(15) Jones, C.H., Neill, S., Lakhanpaul, M. et al. The safety netting behaviour of first contact clinicians: a qualitative study. BMC Fam Pract 14, 140 (2013)

Jones, C.H.D., Neill, S., Lakhanpaul, M., Roland, D., Singlehurst-Mooney, H. and Thompson, M., (2014) Information needs of parents for acute childhood illness: determining ‘what, how, where and when’ of safety netting using a qualitative exploration with parents and clinicians. BMJ Open 4 (1). 

Further resources

RCPCH (2015) Facing the Future: Standards for acute general paediatric services. RCPCH.

RCPCH Safe System Framework, resources accessed 19th November 2019,  https://www.rcpch.ac.uk/resources/safe-system-framework-children-risk-deterioration

Dr. Natalie May, MBChB, MPHe, MSc, PGCert Medical Education, FRCEM, FACEM, #CommunicatED 1: Discharge & Safety Netting in ED, available at https://www.stemlynsblog.org/communicated-discharge-safety-netting/

Bruera, Eduardo & Palmer, J Lynn & Pace, Ellen & Zhang, Karen & Willey, Jie & Strasser, Florian & Bennett, Michael. (2007). A randomized, controlled trial of physician posture when breaking bad news to cancer patients. Palliative medicine. 21. 501-5.

Sarah Jarvis, Medico-legal adviser

BSc MBBS MRCGP, Playing it safe – safety netting advice, available at https://mdujournal.themdu.com/issue-archive/issue-4/playing-it-safe—safety-netting-advice

Damian Roland, BMedSci (Hons) MBBS MRCPCH, PhD, TIGHTEN UP YOUR SAFETY NET #WILTW, available at 

https://rolobotrambles.com/tightenyoursafetynet/

Safety netting – a guide for professionals and parents of sick kids from GP Paedtips

Shame. How it affects patients and their relationships with health care professionals. https://abetternhs.wordpress.com/2012/11/16/shame/ 

Communicating with children with additional needs: Liz Herrieven at DFTB19

Cite this article as:
Team DFTB. Communicating with children with additional needs: Liz Herrieven at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21387

Communication is vitally important in so much we do as clinicians.  Without good communication we can’t hope to get a decent history, properly examine our patient, explain what we think is going on or ensure appropriate management.

Cutting edge burns management: Fiona Wood at DFTB18

Cite this article as:
Team DFTB. Cutting edge burns management: Fiona Wood at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18295

Professor Fiona Wood, AM, is one of the worlds leading burns surgeons.  Having qualified from St Thomas’ in London she decided to do what so many of us do and move down under. Since the early days of her career, she has recognized that to improve the outcomes of burns victims involves not just scarless skin but also healing in mind and spirit. Along with Marie Stoner, she pioneered the use of ‘spray-on skin’ and is well known for the care she provided to the victims of the Bali bombings back in October 2002.

In this talk, she talks about the past, the present and the future of burns care whilst championing the roles of women in medicine and surgery. As a mother of six children, she reminds us all that there is nothing that cannot be achieved if you ask for it.

 

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

 

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A future towards zero: Warwick Teague at DFTB18

Cite this article as:
Team DFTB. A future towards zero: Warwick Teague at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18203

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.