The Paediatric Emergency Department is a relatively unique area in medicine as the registrar workforce usually comes from one of two backgrounds: Emergency or Paediatrics. Consequently, we strive to have the optimal combination of both specialties – The Sweet Spot.
The two groups come with a very different skillset and approach to medical care. In some cases, the Emergency trainee may not have cared for children previously, or the Paediatric trainee not have worked in the ED since their intern year.
In this edition of the Sweet Spot, we welcome Dr Damian Roland, whose weekly insights of “What I Learned This Week” offer some wonderful and profound reflections on aspects of clinical and academic emergency medicine.
Dr. Roland is also a Consultant and Senior Honorary Lecturer in Paediatric Emergency Medicine at Leicester Hospitals and University. He has an academic interest in Educational evaluation and Scoring Systems for children in urgent and emergency care. He developed the Paediatric Observation Priority Score , an award winning system that assists in illness recognition and safe discharge. He is active on social media and enjoys the debate and networking that it provides.
For Paediatric doctors new to the ED setting
What are some common stumbling blocks, and how can these be avoided/fixed? How does your mindset need to change?”
The pace of the Emergency Department can be quite overwhelming to begin with. In my experience, the biggest issue for the paediatric registrar new to this setting is understanding their responsibility to ALL patients in the department, not just those who appear to be the sickest. Essentially, you can’t focus on just one child at the expense of others.
This challenging balancing act often goes against the grain for paediatricians. Once the ABCs are sorted, though, if the department is chaotic with high inflow, some things might need to be left for the in-patient team (however frustrating they may find this, and you may feel by doing it!).
What are some knowledge deficits that can be ameliorated?
– quickly and easily?
Learn fundamental first aid injury treatments (Can you put on a sling? Do you know basic wound dressings? What are the right dressings for different burns, etc)
– with concerted study and experience?
Fracture management can be confusing at first but is fairly logical. Pattern recognition helps with X-ray diagnosis (i.e need experience), and management will come from a good textbook (or minor injuries DVD by Dr Ffion Davies)
What is the skill/attribute that differentiates an average registrar from an exceptional one?
Honesty: “I have lost control of the department, and this is what I am doing to re-gain it”, as opposed to trying to make up something about each patient but not knowing key detail
Reliability: This meansnot just turning up on time but also completing the tasks set and reporting when they are done.
Pro-active: Those who start to predict what needs to be done before being asked to do it. A good theatre nurse will have the tool the surgeon needs before she asks for it. A good register will have started morning handover/reviewing patients and not just wait for the consultant to arrive.
Approachability: Juniors trust you for advice. You are good fun to work with but generate an ethos where people will work hard and not get distracted from urgent tasks.
What is the most under-used feature in the history/examination/investigation?
History
“You have told me about the fever, cough etc. But what is it that the parents are MOST concerned about?”
Examination
Tibial torsion (flex the knee and hold here while holding the foot with your other hand – twist gently at the foot so slightly twisting the tibia) and axial load (flex the knee and apply pressure from the foot while pushing down gently on the knee – therefore putting pressure through the tibia) for tibial fractures.
A proper abdominal examination which involves distraction.
Investigation
Observation
What is the most over-used feature in the history/examination/investigation?
FBC
Respiratory Rate (this is counter to popular teaching), but often, the RR alone in asthmatics is used as an indicator for readiness for transfer/discharge. Children with moderate/severe asthma will have a raised RR by definition. It is the trajectory of work of breathing that is important, not isolated clinical features)
How is the communication different
… with parents?
Clearly, you can not be rude, abrupt, or dismissive with parents. However, you do need to find ways of maximising information transfer (both ways, i.e., parent to you and you to parent) in short time periods. You can’t spend 30 minutes on an individual consultation as you will lose departmental oversight. If you are pulled into a long discussion, you must let someone else know.
… with nursing colleagues?
ED nurses are brilliant but can be abrupt. Paediatricians can find being told what to do a little unsettling. Gain trust by being humble. Don’t lose it by being arrogant.
A strength that this group might be surprised they have is?
Leadership skills in an emergency. A good resuscitation is not the sole preserve of ED and ICU staff. My experience is that paediatric registrars can find and hone their skills when placed in (safe) learning environments.
My three top tips for this group
I think I have covered most things above, but if there is one thing to take away from an ED attachment, it is to understand why ED do what they do.
As a paediatrician, I understand why there can be frustration about referrals or decisions made about patients in the ED. I do my best to mitigate these and teach others about them. My ask would be to do the same in reverse. You will receive what you believe to be poor quality referrals in the future – use your ED attachment to understand why this may be and help ED staff improve them and your local staff to be less disparaging. This can only be for the benefit of patients.
The most important advice for Paeds Reg, new to ED is…
You are the ED’s eyes and ears. You need to constantly monitor all patients, not just the next patient in the queue.
A General Paediatrician and Adolescent Medicine Fellow based in Queensland, Australia, Henry is passionate about Health Systems and Complex Care, with a strong interest in Medical Education & Clinical Teaching. His 'Dad jokes' significantly pre-date fatherhood, and he stays well by running ultramarathons.
@henrygoldstein | + Henry Goldstein | Henry's DFTB posts
