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 specialities – The Sweet Spot.
The two groups come with very different skillsets and approaches 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’re excited to interview Dr Sean M. Fox; the energy, brains and action behind Pediatric EM Morsels, as well as working as an Associate Professor in Paediatric Emergency Medicine at the Carolinas Medical Center in Charlotte, North Carolina, USA. Why “Morsels?” He likes dessert more than jewellery (also known as pearls).
Sean was a resident in training for 5 years as both a Pediatric trainee and an EM trainee. So, he actually knows what it is like to be a Pediatric doctor covering random pediatric hospital floor emergencies in the middle of the night with limited resources as well as what is like to be a junior EM resident trying to not look completely overmatched in a trauma code.
For Paediatric doctors new to the ED setting
What are some common stumbling blocks and how can these be avoided/fixed?
One of the biggest stumbling blocks for Pediatric trainees when they start working in the ED is feeling like she or he is an outsider. This can lead to a feeling of detachment. One of the most powerful and rewarding aspects of working in the ED is the collegial atmosphere and team-based approach to patient care. I would be useless without my nursing and tech staff. I would not be nearly as proficient without my amazing residents. It is truly a team in the ED, and if a trainee doesn’t attempt to belong to this team, it is detrimental to everyone and can negatively affect the educational value.
Additionally, considering oneself as an outsider dissociates that person from some of the pressing workflow issues. Teammates don’t just “pick up the next patient,” they appreciate the triage process and nuance, they listen for when the next critical patient is due to arrive via EMS and anticipate the fact that multiple tasks are being done concurrently and not linearly. I have found that once Pediatric trainees become invested in the team concept then the enjoyment and educational opportunities increase exponentially.
In addition, thinking of the ED as merely an aspect of Pediatrics that is either “for you” or “not for you.” Yes, Emergency Medicine is a branch of medical practice that can be “home” for some and “hectic” for others; however, the time spent in the ED offers so much opportunity to refine one’s clinical practice and can give insight into the medical system as a whole that will be valuable regardless of what branch of pediatrics a trainee is most drawn towards. A common sentiment that I hear is that if a trainee is going into, say, primary care, then she/he doesn’t really need to focus on a lot of what happens in the ED. Let’s be real, A LOT of what happens in the Ped ED is primary care. Additionally, if the pace seems to be too much, let’s just ask some of our seasoned primary care providers. If a trainee hopes to have a leisurely clinical practice, then I gently ask if she or he has a secret financial reserve, because otherwise there will be a rude awakening. There are very few leisurely aspects of the care and management of people, of any age. So, it can be wise to look at working in the ED as an opportunity to refine skills to assist with expeditious histories and physical exams. These skills will help trainees to be successful regardless of which field of practice they intend on going.
What are some knowledge deficits that can be ameliorated?
Obviously, the primary care topics they will be more comfortable with, but still should not overlook them. That being said, the evaluation of minor and major trauma is always a good idea to concentrate on during the ED rotation. Along with this, intimate knowledge of medical resuscitations and resuscitation procedures is vital. Other commonly encountered issues that cause children to be potentially critically ill like diabetic ketoacidosis or Ingestions/Intoxications are valuable.
The attribute that differentiates an average registrar from an exceptional one is…?
Exceptional learners exude a passion for caring for patients and an equal passion for appreciating the TEAM dynamics and striving to be an active member of that team! Essentially, showing a willingness and eagerness to help the team in an effort optimize patient care. When one does this, then she/he will actually augment her/his own learning opportunities.
The most important piece of advice for Paeds Reg new to ED is:
Become comfortable with being uncomfortable. Strive to glean as much from every rotation as you are able to and no rotation will give you a better opportunity to learn as much as the Emergency Department.
Pursue patients with complaints that you are not as familiar or comfortable with. While you may end up working in a Primary Clinic and never see severe trauma again, learning some basic concepts about their management will help you understand the medical system and know when certain patients need to seek care in the ED
For emergency doctors new to the paediatric setting
What are some common stumbling blocks and how can these be avoided/fixed?
The biggest challenge working in both the adult and pediatric ED is that your perception of illness can become distorted. Adult patients are more often critically ill than children (which is good for kids!). This makes it easy to learn that we need to assume adult patients are ill until proven well (i.e., rule out the worst first). Conversely, the fact that children are generally well, can make it easiest for novice clinicians to assume kids are well until proven to be sick, because their experience has reinforced that, generally, kids do well. This approach can be very detrimental, especially when we consider that children are able to compensate for illness extremely well — until they suddenly decompensate!
It requires an active and vigilant mind to continue to be alert for the covert and subtle signs of significant illness in children. Assuming children are well, however, is often not actually detrimental, because, the odds are in favour of the child actually being relatively healthy. This playing of the odds can encourage complacency. It is complacency that kills!
I also find that it is the complacency, and the notion that kids usually just have a virus, that makes the role of the Emergency provider boring. This further dissociates the provider from the task at hand and reinforces sloppiness. Obviously, a bored EM provider is a bad EM provider.
So, then, the question is how to remain vigilant, yet reasonable. We don’t want or need every kid with chest pain to get a troponin level. Equally, we need to be vigilant for myocarditis. Essentially, the task of working in the Ped ED is like looking for grenades in large haystacks. {Why grenades instead of needles? Needles might inflict a little bit of pain if you miss it and it pokes someone. Lost grenades, like missed significant pediatric illness, cause death and destruction for all who are near it… potentially, even to the providers.}
I have found that one of the best strategies to remain vigilant is simply by training your brain to actively search for illness (what was that kid’s cap refill?) and use your history and exam skills to help weed through the big, bad, and ugly conditions. Then, instead of telling the family that “it’s just a virus” (Please remove this phrase from your lexicon as it does not actually reassure families and can actually harm their opinion of you – there is literature to support this), tell the family all of the terrible things that it is not.
“Well, I am super glad to be able to tell you that your daughter/son does not have meningitis or pneumonia. Right now we are seeing a lot of viral illness in the community causing many of your child’s symptoms, so I believe that is actually what is going on. Importantly, I don’t see any signs of complications of typical viral illness, but please continue to watch for X, Y, and Z.”
Additionally, appreciate and anticipate the parental concerns (they are not coming to the ED because they are worried about a “virus.”) and address them upfront clearly. Spending 3 more minutes discussing their concerns for appendicitis, etc, will save countless minutes and hours later trying to either convince them that you did a thorough job or responding to complaint emails/letters.
What are some knowledge deficits that can be ameliorated?
A lot of what gets covered and cared for in the Ped ED is in the realm of “primary care topics.” I don’t think that you need to do a fellowship in Primary Care to work in an ED, but knowledge about typical growth and development really assists in finding subtle signs of illness. Pyloric Stenosis? Not likely in the kid who is growing in the 98th percentile and consuming a gallon of formula a day. Knowing how much a young child should eat is a topic that always proves to be useful in the Ped ED.
The most important piece of advice for an Emergency Reg new to Paeds ED is:
Stop reiterating “Kids aren’t little adults.“
I know that seems counter to what I should support; however, I believe that clinicians are prone to use this statement as a justification for “opting out” of taking care of children. “Kids aren’t little adults! I am comfortable with adults. I don’t take care of kids.”
Let’s be honest, the statement was meant to reinforce the fact that children have different anatomy and physiology that must be accounted for, but this does not make them an alien population. Kids aren’t aliens. They are a special population of little humans that require some special considerations for their specific anatomic and physiologic differences.
I believe approaching children as a special population rather than aliens empowers EM providers and promotes becoming more comfortable with caring for them. This approach is vital to ensuring that kids are afforded excellent care EVERYWHERE, not just in large cities with giant pediatric speciality care centres, which are not numerous enough to care for all of the children who need it.
