Henry Goldstein. Tim Horeczko, part 1, Don't Forget the Bubbles, 2016. Available at:
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’re thrilled to interview Dr Tim Horeczko, protagonist of the Pediatric Emergency Playbook at PEMplaybook.org.
Dr Horeczko is an emergency physician with subspecialty certification in pediatric emergency medicine and an Assistant Professor of Clinical Emergency Medicine at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). He’s known for his contributions to emergency medicine education, research, and free open access education (FOAMed) through his monthly educational podcast, the Pediatric Emergency Playbook at PEMplaybook.org; you can follow Tim on twitter at @EMtogether.
Part 1 – For Paediatric doctors new to the ED setting:
1. What are some common stumbling blocks & how can these be avoided/fixed?
2. How does your mindset need to change?
I think the first thing to say here is: relax.
Nowadays, you will not be left to your own devices, and you will have supervision and/or back-up. It’s going to be ok.
Having said that, there is an adjustment that needs to be made when seeing patients in the Emergency Department (ED). In the clinic, we are biased toward wellness. Patients are typically well enough to schedule an appointment with you, and they often do well, no matter what your intervention. In the unclear cases, you have the option (read: luxury!) of seeing the child again in the near future for a re-check. Inevitably, someone will worsen, and as a caring and dutiful primary provider, you can always send them to me in the ED, and we’ll lend a helping hand.
In the ED, we are biased towards disaster. It is not our charge to diagnose the common cold or constipation. We acknowledge that those entities exist, but our obligation is to evaluate and treat for the possible pneumonia or appendicitis lurking underneath seemingly benign signs or symptoms.
The point here to explain a little about our mindset in the ED. You may at first feel we “over-do” it, but our patient populations – and our obligations to the individual patient in space and time – are different.
As such, and on the other side of the coin, the ED is not a drop-in clinic. Just because we can do advanced imaging or send-out laboratory work or generate non-urgent referrals, doesn’t mean we should. The reason is context. We have to be good stewards of our substantial resources; as a specialty we fought hard to get them, for the right reasons. In addition, our hastiness to diagnose a non-hasty disease is an open invitation to medical error and iatrogenia. We try to choose wisely and act judiciously.
– quickly and easily?
– with concerted study and experience?
I think the hardest thing for a pediatric registrar with little prior emergency medicine experience is to see the undifferentiated child and decide if he or she is sick or not sick. Now, before you sigh (“here we go again with the sick/not sick”!), this determination is different whether you’re at home, on the ward, in the intensive care unit, in post-anesthesia recovery, or in clinic. Be mindful that you are sometimes seeing the first few minutes to hours of disease.
Ok, enough of that. The real high-yield thing for pediatric registrars to do before starting a rotation in the ED is to review your Pediatric Advanced Life Support (PALS), and/or your Advanced Pediatric Life Support (APLS). Familiarity with the algorithms will help you to remain focused and ready when a sick child is brought in to your care.
Take ownership of your patient. Nothing stymies care and learning more than asking the attending “so, what do you want me to do?”. This is not to say that you should not ask questions and advice from your attending or senior registrars – not at all! This means coming up with a plan – as far as you can muster – and then asking questions to fill in gaps or to check your logic. Passivity kills: it kills your learning, and well, we’ll just leave it at that for now.
The general impression is the single most important piece of information in the pediatric patient.
It just so happens to be the first arm of the Pediatric Assessment Triangle, which is the first step in PALS. See where I’m going with this?
There is undoubtedly a lot to absorb when you rotate through the ED. We talked about a change in perspective and mindset. We talked about priorities. That should be plenty for now.
However, if you can take away one piece of specific advice each from the history and the physical exam, here they are:
In the history, wait for the caregiver to “vent” his or her frustrations, anxieties, concerns, and experiences. If after all that, the diagnostic or therapeutic path is clear, then go for it. If you are still left trying to sort out the multi-faceted nature of the chief complaint(s), try asking in a non-judgemental, supportive tone: “It looks like it’s been pretty rough for you lately. I’m going to help you. Just so I can understand the situation better, what made you decide to come in today?”
It will go a long way to defuse the situation if you can: help them to feel better about not having seen the primary care physician; show that you understand their predicament; and underplay any possible panic, etc. Just be the caring physician you are.
In the physical examination, remember to keep symptoms separate from signs.
Patients can have all the symptoms they want. Some are concerning, some are baffling, some are amplifications of what is expected. Symptoms are the patient’s.
Signs – objective findings – are yours, and yours alone. As an example, abdominal pain can be challenging, because its presentation differs so much by age, developmental stage, and disease process. Abdominal tenderness to palpation is a sign that you elicit, hopefully increasing your specificity by distracting the child as much as possible. Please, please, please, don’t ask a child (or anyone, for that matter) “does this hurt?” when you are doing an abdominal exam. A good exam is not exactly comfortable in a healthy patient. The young child will say “yes” to please you. The older child will answer “yes” because it validates his need for your attention and care. Distract, re-examine, and re-examine some more. If you truly feel this child is tender in the belly, then act on it.
… with parents?
Be courteous, kind, and genuinely concerned about the reason for the visit. Transmit confidence and your sense of ownership to the parents, who are often frightened. Be transparent when you are unsure, and let them know your plan to remedy the gap. We have precious little time to establish rapport in a pressurized environment. Now is your chance.
… with nursing colleagues?
Show them that you are being conscientious. Pediatric ED nurses are lovingly territorial. They truly care, and react well when they see that you do as well. They can also sniff out malarkey a mile away. Be honest, open, courteous, and even solicitous with them – they want you to succeed, so treat them accordingly.
… with senior staff?
Of course, all of the above applies when working with your seniors. What a good senior wants from a good junior is that he be conscientious, thoughtful, and thorough. Don’t assume that they will catch your mistakes. Work as if you did not have them there to help you – that is how they will add value to your patient’s care and to your development. They are there to help you do a better job, not to do your job. Be humble, easy to teach, eager to learn, and remember above all else – it’s never about us; it’s about the patient.
As a pediatrician, you are very skilled in understanding family dynamics and normal development. This is a huge advantage, as many issues in acute care are informed by these.
- Get help early. If you are unsure about the best plan of action, collect your thoughts briefly and speak with your senior or supervisor as soon as possible. In the stable patient, this may obviate unnecessary testing; in the unstable patient, you are doing everyone a big favor.
- Keep the mission of the ED foremost in your mind. Detect the dangerous disorders. Leave the rest for other providers. Remember, your patient is not only the one in front of you, whose parent is pleading for an MRI of the chronically itchy pinky-toe, but your patient is also everyone else in the ED and its environs, including the one quietly decompensating in the waiting room, getting worse because we are spending too much time on squeaky wheels.
- You are here for a reason. You add value to the department, and you will help your future patients, regardless of the setting, with your experience in the ED. Relax, learn, ask questions, and share your talents with your patients and the staff.
Think worst first, diagnose and treat important things, and for everything else, time is on our side.
Coming tomorrow, in Part 2; Tim’s tips for Emergency Doctors new to Paediatrics