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.
The DFTB crew have answered some key questions with advice for each group; they will be posted separately on consecutive days. The contributors are Andy Tagg (AT), Ben Lawton (BL), Tessa Davis (TD) and Henry Goldstein (HG).
In coming editions, we’ll put the same questions to a raft of experts in the field, to find out how they find The Sweet Spot. Stand by!
Part 2 – For Emergency doctors new to Paediatric Emergency
I think one of the hardest things going in is that paediatrics seems to be 80% history, 15% examination and 5% investigations. In adult emergency medicine we often front-load our patients with investigations (x-rays and blood tests) at triage in order to get through them as quickly as possible. This is neither possible nor appropriate with kids. There needs to a be a change of mindset. One way to help is for the doctor to sit down, either on a chair, or on the floor with the patient. By sitting down it helps you relax and take some time with your history taking. (AT)
Don’t underestimate how sick a neonate can be: you can’t tell much when they’re just being cuddled to Mum’s chest. (HG)
Also remember that kids do not see the world in the same way that grown ups do. They see things literally. Kindness and simple words go a long way. (AT)
One of the things I love about paediatrics (of all kinds) is the compassion and softness. I’m not by any means saying that adults don’t receive compassionate care but comparatively – when was the last time you saw self-induced disease in a child?
Particularly this pertains to adolescents, who can sometimes be perceived as mature adults just because they’re tall/hairy/pubertal. They’re still almost all really scared kids with worried parents. (HG)
My experience is that sub-specialty consultants want to know about their patients. I have no qualms about either seeking the advice of, or notifying these consultants about their patient at 0300 if it’s warranted. Find out the lay of the land early in your term. (HG)
… quickly and easily?
There are a few basics that you should know going in – important history questions such as immunisation status, developmental history, and what is going on with siblings. (AT)
Learn how to assess hydration status and what is normal. This is much easier if you have your own kids. (AT)
Learn quickly to assess effort and effect of breathing (AT)
Read up on the management of croup, bronchiolitis, gastro and asthma and that will cover over half of your work load. (AT)
Take every opportunity to look at kids and work out if they are sick or not sick – the difference can sometimes be subtle and the only way to know is experience. (AT)
Find the local guidelines and have a skim down the titles; you may be surprised what is protocolised in your department. (HG)
Keep a paediatric pharmacopeia on your smartphone. I like Shann’s Drug Doses – not free, but has a nice recipe for a Diablo Chocolate Cake. (HG)
… with concerted study and experience?
Learn something about serious illness – neurological, cancer related – as often the ED is the first port of call for worried parents and you might be the one to diagnose AML. (AT)
Think about the developmental milestones: you’re presented a broad range of kids and some will seem “not right” – why? Do they have few words? Is there a lack of eye contact? Not every FACEM trainee needs to become a developmental paediatrician, but don’t take it as gospel when a parent tells you their child is developmentally normal – look for it for yourself. (HG)
The ability to elicit a good history and behave in an age-appropriate way when communicating; coupled with an ability to synthesise information, come up with a differential and be able to pick up the bronch that does not quite fit the pattern. (AT)
Identifies their own weaknesses and seeks advice from colleagues. Typically, this might involve asking the junior paediatric registrar about management of constipation or croup rather than just bashing out a best-guess in isolation. We are all on the same team. (HG)
Smiles. Blow bubbles, play peek-a-boo, tell jokes, work on your tricks to get smiles out of kids of different ages. They are very reassuring and it gives the parents the impression you have seen a child before and therefore know what you are doing. (BL)
History = lalking to the patient (child) not the parents. Examination = playing with the child. Both of these can be a challenge for the registrar used to speaking to adults. And remember what Damian Roland would say, “Observation is an investigation” (AT)
Examination = Your examination is important and relevant; do not ask the child “can I listen to your lungs?”. Gently and firmly tell them what you are going to do. (HG)
“Well appearing neonate with a fever”
Urine dipstick in the case of diarrhoea. (HG)
… with parents?
Most children are actually well and your job is reassuring them and informing them. Part of your job is also educating them when to come to the emergency department and when to go to the GP. (AT)
Most adult trainees are much more used to dealing with cuts, grazes, and broken bones than their paediatric colleagues. (AT)
Likewise, trauma is rare in paediatrics. The paediatric trainees may have never seen a serious trauma call; they will learn from your example. (HG)
- Take babies seriously. (HG)
- Teach the paed registrars about trauma and learn from them about common stuff – they’ve seen more bronchiolitis, croup and constipation at all stages of the disease. (HG)
- Sit with your patients to take a history. (AT)
- Not quite in keeping with the main topic of the post, but if you’re working in a mixed department and there’s a very sick child, get the paed reg involved early. They will ‘value add’ in terms of parental communication, a spare pair of hands and diagnostic acumen. (HG)
- Kindness and simple words go a long way. (AT)
Kids are very aware of what is happening around them and, like dogs, can sense fear. Don’t be scared of children, have fun with them. And if they are sick, and on the inside your heart is racing away, don’t be scared on the outside as both they, and their parents will pick up on it. (AT)