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

DFTB go to SMACC

Cite this article as:
Andrew Tagg. DFTB go to SMACC, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18334

Without SMACC there would be no Don’t Forget the Bubbles. But little did Tessa and I know that despite being at the same conference it would be another four years before we actually met in person at DFTB17 in Brisbane.

Nobody knew what to expect at that first SMACC as we sat in the dark waiting for the conference to begin.  I had just signed up with Twitter and was just excited to be in the company of people who thought the same as me, who were excited to learn, and were using this new thing called #FOAMed. As I am the shy retiring type I barely said hello to people that now, a lifetime later, I would be proud to call friends. Instead, I just sat in the audience and absorbed all the knowledge and positivity that flooded my way.

Flash forward a few years and those friendships, forged online, have grown as Twitter avatars are replaced with real people. No longer am I as shy to go up to someone I have never met in real life and I’m glad others have taken up the challenge too (Andrew and Sarah,  I am looking at you).

Tessa and I feel very privileged to have played some small part in the success of SMACC as we run the very final SMACCmini paediatric workshop. If you couldn’t come along then here are some of the things you missed.

 

Sweet Child O’ Mine (A neonates journey) – Trish Woods

Trish is no stranger to the DFTB ethos and as a neonatologist stopped to make us reflect on one of our basic assumptions – just who is the patient.  Just because our tiniest patients lie in their cribs, helpless, requiring help with all of their daily cares, does not mean that we should not consider them as people. It might be an alien thought to some – that the patient in front of us hears what we say, and how we say it, but they are not just a disease or a problem to be dealt with or the one in pod 3. They are a person with a name.

Seeing the team through the eyes and ears of the patient, Trish helps us enter the sensory (and often-overstimulating) world of the NICU.

Why not take a look at this paper on some of the ways we can start treating the patient and not the disease.

Roué JM, Kuhn P, Maestro ML, Maastrup RA, Mitanchez D, Westrup B, Sizun J. Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit. Archives of Disease in Childhood-Fetal and Neonatal Edition. 2017 Jul 1;102(4):F364-8.

I Want Candy (neonatal pain relief) – Justin Morgenstern

Justin Morgenstern, one of everyones favourite Canadians, has recently relocated to our side of the world and is practicing in New Zealand. Knowing that he is such a fan of evidence based medicine we set him the task of finding out if sucrose is as good as we think it is as an analgesic in neonates.

Here, for your delectation, is his take on analgesia for kids.

I don’t want to spoil his conclusion but this slide might give you just a little clue…

He started by challenging a fundamental assumption – that we can accurately tell whether a neonate is in pain or not. Or, more accurately, he challenged our assumption that we could tell when a medication worked.  We know the limitations of the traditional Wong-Baker Faces scale in older children and most of us probably use some combination of our clinical gestalt and the FLACC (Face/Legs/Arms/Cry/Consolation) score in neonates. But is it some sort of surrogate marker for distress, rather than pain? If fMRIs show no difference in an infants brain when they receive sucrose does that mean it does nothing for pain?

Of course there are a lot of things we can do that we know do work:-

  • Limit painful procedures
    • If venipuncture is less painful than a heelprick why not use it.
  • Let nurses treat the pain
    • Nurses are amazing (full stop) but they are also so much better at giving analgesia by the clock than any doctor
  • Address the underlying issues
    • Splint the obviously broken arm  before x-ray rather than waiting for them to get some imaging and then feeling guilty about it.
  • Consider non-pharmacological adjuncts
    • Dogs, clowns and bubbles are all powerful distractors.

 

Straight Up (bilious babies) – Camille Wu

Camille Wu last spoke for us at DFTB17 on testicular tribulations so it was a pleasure to welcome her back to join us to talk about surgical causes of bilious vomiting.

Rather than put words in a parents mouth she suggested asking exactly what colour was the vomit. If they answer Pantone 2565C then you are in trouble. Green vomit suggests a higher up obstruction that might require surgical intervention and certainly requires surgical assessment. Likewise rather than asking if the vomit was projectile, it is better to ask “How far did it go?

Whilst it is important to remember that there are a number of significant medical causes of bilious vomit (such as sepsis and CPAP belly) we really need to be concerned about surgical causes. Camille broke these down into mechanical causes and functional causes.

Mechanical causes

Intrinsic

  • Duodenal atresia
  • Small bowel atresia
  • Ano-rectal malformation

Extrinsic

  • Malrotation/volvulus
  • Congenital bands
  • Intestinal duplication

Functional causes

  • Hirschsprung disease
  • Meconium ileus/plug
  • Necrotising enterocolitis

The more proximal the obstruction the less bubbles of gas you will see on initial imaging. Camille reminded us that early imaging and intervention can make all the difference. If in doubt, pick up the phone, no matter the time of day or night.

The Safety Dance – Linda Durojaiye

Linda Durojaiye is a staff specialist at Sydney’s Children’s Hospital at Randwick. In her talk on leadership and patient safety she owned up to mistakes that have been made and shared some lessons from her department on how they have created a safer environment where everyone is accountable. Given that we have no control over who comes in we need to take ownership of what happens to them once they pass through our doors.

Linda and her team created a culture of safety – starting with regular team huddles to identify potential threats to safety. Using a strong leadership team they created a model of care that engaged both medical and nursing staff as well as the patient/parent consumer. She highlighted the resources freely available on the Institute for Healthcare Improvement website.

If you want to know more about the Clinical Emergency Response System then you can find it here.

 

One Vision (VR in paediatrics procedures) – Andy Weatherall

If your idea of virtual reality is still stuck in the last century and The Lawnmower Man (a poor 34% on Rotten Tomatoes) then you might not be aware of some of the advances that are putting the technology in the hands of normal people. Andrew Weatherall is the co-chair of paediatric anaesthesia at the Children’s Hospital at Westmead and has been looking at the role virtual reality may play as an adjunct to standard anaesthesia techniques.

He has written about his experiences here. Whether as a means to reduce anxiety before a procedure or as a distraction from the procedure itself virtual reality is no longer priced out of possibility. With Google Cardboard costing just a few bucks and lots of open source software available it won’t be long before we see more departments trying it out. We hope to hear more from Andrew and his team in the near future to see how they are going.

The Model (3D printing in paeds) – Jasamine Coles-Black

Carrying in on with technological advancements in paediatrics Jas Coles-Black from the 3D lab at the Austin in Melbourne made the audience realise just how affordable 3D printing can be. A technology that once cost six figures is now cheaper than the average consultants coffee habit. After a quick jaunt through the various methods of printing she went through some of applications relevant to paediatric practice. With printable task trainers costing just a couple of dollars (after the capital expenditure) we could all have our own paediatric can’t intubate – can’t oxygenate model. Or perhaps you want your trainees to learn how to ultrasound the neonatal spine to improve their success at lumbar puncture – a task trainee is yours for less than a latte.

3D printing can also be used to help patients understand complex ideas and a number of cardio-thoracic surgeons have used 3D printed models of congenital heart defects to help explain complex anatomy. We are looking forward to hearing more from Jas about this exciting technology and how it can benefit all of us. And, if people are interested, we could create our very own DFTB 3D printing workshop at a future conference.

Jas' favourite 80s movie

https://www.youtube.com/watch?v=1g3_CFmnU7k

(Yes – I know it was 1977 – Ed)

Sound and Vision (Critical care ultrasound) – Tom Rozen

SMACCmini was competing against the very practical paediatric ultrasound workshop but we couldn’t make it through without mentioning it at least once. Tom Rozen, intensivist at the Royal Children’s Hospital, used the example of René-Théophile-Hyacinthe Laennec’s (yes, really!) most famous invention, the stethoscope, to demonstrate how medical fashion has changed. A device that once took up an entire room can now fit in your pocket and with ultra-cheap, ultra-portable devices entering the market it will not be long before clinicians can have a device of their very own.

If you want to know what all the fuss is about then why not sign up for one of our pre-DFTB19 workshops.

Too Shy (20 minutes of bottom jokes) – Ross Fisher

Mr Fisher was set the challenge of making talking about constipation interesting and he succeeded. From his opening Limahl tribute to the crowd singalong he soon had us tapping our toes to the 1983 Kajagoogoo classic. He began by asking us to turn to the person sitting next to us and take a bowel history. After a round of sniggers a fair percentage of the delegates were unable to complete the task. Fortunately I was sitting next to Tessa and we know each others bowel habits intimately. If we are too shy shy to ask a grown up about what they get up to in the toilet no wonder we are pretty awful at asking children. Most children are all smell, noise and little substance in the bathroom so the only way to really find out what they are up to is to ask them, in their own language.

Constipation and its consequences can be stigmatising to a child and so the mindful clinician should sit and listen to the parent and their concerns, without judgement. Treatment can be a long and drawn out affair taking as long to fix as the child has had the problem for.  Take a look at our series on constipation here.

Faith (It takes a team) – Bec Nogajski

The final talk of the morning, by Bec Nogajski, brought it all together and reminded us of the importance of teaming. We’ve all been a part of dysfunctional teams and Bec challenged us to look at our role in the team, not as a passive sheep to be lead around, but as an integral unit with worth. There are many ways of finding out how you might fit in the team – Belbin’s team roles, DISC, Myers-Briggs (INTJ in case you were wondering) – but it is worth considering  that there is no perfect recipe for an effective team.

The team sets the behaviour, what is tolerated and what is not. As David Morrison said, “The standard you walk past is the standard you accept.” So do you check your mobile phone during clinical handover, and allow others to do the same or is this type of behaviour below the line?

 

 

Our eternal thanks, as always, to the SMACC OC throughout the years, especially, Chris, Roger and Oli who made such an impact on four aspiring paediatricians that they decided that they could run their own conference. If you want to see what all the fuss is about then there are still a handful of tickets left for www.dftb19.com in London, this June.

Leadership: overused term, underutilised skill

Cite this article as:
Damian Roland. Leadership: overused term, underutilised skill, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3167

Let’s not leave leadership out in the cold…it’s a skill we all need.

 

While training in paediatrics there are a number of things that are obvious you need to learn. These may be practical (e.g. a lumbar puncture), knowledge-based (recognising when a prolonged illness may in fact be Kawasaki’s disease) or communication centred (how to discuss sensitive issues with a distressed teenager).

However, traditionally a number of skills that are relevant to doctors of all specialties have not been prominent in curricula and are often left to a two-day course in the last year of training. Medical management, clinical leadership, understanding health policy all come into this, often poorly learned and delivered, facet of medical training. There are a number of reasons for this:

 

Misunderstanding

Concepts of leadership conjure up images of Winston Churchill and a sense you can only be a medical leader if you model yourself on Lord Darzi. This is completely incorrect – leadership is a shared responsibility, which everyone can contribute to. Running a ward round, leading an arrest, planning a rota devoid of middle grades are all facets of leadership and management that paediatric trainees face every day and yet insufficient time is spent exploring these areas, particularly by consultant trainers.

 

It’s just a fad

Leadership and Management appear to be buzzwords attached to any document in order to increase its impact. In the same way that everything needed to be “evidence-based” a decade ago, there is a sense that these terms are just tag-ons for CVs or portfolios and convey very little practical benefit. Well, evidence-based medicine is here to stay and pervades all aspects of our practice. In the same way, it is likely, although the process is moving more slowly, that these attributes will become fundamental parts of training. The current president of the RCPCH in the United Kingdom, Dr. Hilary Cass, is a passionate advocate of trainees becoming more integrated and involved in the delivery of paediatric care (and not just seeing patients!). And the recent Keogh report into fourteen failing, struggling trusts identifies that junior doctors are a key part of effecting change.

 

Someone else will do it

The reforms of health services in response to rising demand proposed by the government and the medical colleges throughout the world are likely to result in changes to how departments and units are run. An increased focus on value (which requires both an understanding of the quality AND cost of care) will mean paediatricians will need to understand how developing systems will function. They will need to do this from their first day as a consultant as it will not be possible for a clinical director to do everything themselves. As the current generation of trainees begins to work through training pathways, it is likely that these core skills may become key factors at consultant interviews.

There are many ways to access learning resources to develop and learn more about this exciting but also challenging area. Social media provides an easy way to access these but also listen to the ongoing debate, which can sometimes be very challenging. We hope there will be a regular stream of blogs on leadership and management via this site to start the conversation.