Henry Goldstein. Tim Horeczko, part 2, 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 2 – For Emergency doctors new to Paediatric Emergency
They’re not all fine.
They’re not all dying.
Find out where your personal biases are and do your best to seek balance.
In working with adults, disease is dumber. It is more obvious. It is either manifest in something objective, like a vital sign abnormality, a red-flag complaint, or something that will call your attention. Even if you are not on your game that day, something will cue you; the patient or family member will often be vocal (and/or relentless) about his symptoms. In adults, sensitivity is ratcheted up, sometimes at the detriment to specificity.
The motto for children is: “play or die!”. Children do not want to be sick. They distract themselves well. They don’t typically complain unless there is a reason for it (granted, that reason may be secondary gain, but this is much less likely in this group).
This is not the only thing that makes disease trickier in children. They compensate very well for illness – until they precipitously fall off the cliff. Pediatric illness is often subtle early on. Of course, parents often bring in their children early in the process, which just makes it that much more difficult to sort out sometimes. In children, sensitivity is low, but specificity can be helpful. Spend a few extra minutes in the history to get to the core of what is really going on.
It’s our job to move through the forest of URIs and not trample over the sapling of sepsis.
Use your observational skills – even before your enter the room or before the patient is aware of your presence – to get a sense of where your little patient is on his trajectory of illness.
… quickly and easily?
… with concerted study and experience?
In Emergency Medicine, we have to know what we have to know, and we have to know one step further (thanks, Stuart Swadron!). When you have a child with an unfamiliar disease process, especially if you are sending him home, look into what will be needed in the next few days and weeks. What testing will he need? What treatment decisions need to be made? What complications can occur later? All of these questions will help you to counsel the family and coordinate aftercare. The pediatricians have this down pat. Why not be as awesome as they are?
Emergency Medicine is Emergency Medicine, whether your patient is 1 day old or 36,500 days old. All of the factual, procedural, and cognitive abilities you are working hard to hone will serve you well in emergency pediatrics.
Balance your suspicion for a particular condition with your obligation to diagnose it.
When your obligation to detect a disorder is higher than your suspicion, go after it. Society expects us to “own” certain life-threatening conditions. Even if this is not likely, if we have more than a passing concern, we should look into it. That is what we are here for – to be the diagnostic sharpshooter.
On the other hand, when your obligation to make that diagnosis today is so underwhelming that it falls under your threshold for suspicion, then it is perfectly acceptable, and often favorable, to refer the child back to his primary care physician. Unlike other legendary creatures, like the unicorn and the centaur, the primary care physician does exist, and what’s more – he wants to be involved. Repatriate the well child back to his clinical homeland.
Really work hard to perfect your general impression. Review the Pediatric Assessment Triangle
If you tell me that the ear “looks a little red” when the child is crying, and you want to give antibiotics, please go back and look when he is calmer. Acute otitis media should look like a red, angry donut screaming out at you. One does not have a “touch of the erythema” and call it a day.
In the febrile, fussy older infant (typically after 6 months) or toddler (up to 2 years) who has a fever without an obvious source, before you go assaulting the urethra, get a good look in the back of the throat. Sometimes you have to have the parent restrain him so that you can gag him, but often the recognition of viral pharyngitis can save further work-up.
… with parents?
In the stable child, take the time to sit down and show your concern. Parents are very anxious in the ED, and if they feel they are being “blown off”, you have taken what could be a simple social visit and turned it into a battle royale. Validate their concerns. Compliment them on what they are doing right. Encourage them. Basically, jump-start their confidence again so that they can continue to care for their child at home.
In the unstable child, show command of the situation and ask parents only pointed questions that will help in the resuscitation. Get them a chair, and kindly but firmly get them to sit down. If at all possible, have someone stay with them, like a social worker, nurse assistant, or even a clerk – they need true moral support.
… with medical & nursing colleagues?
As in any good EM care, there is no such thing as over-communication. With the proliferation of the electronic medical record, we are losing the face-to-face communication that is so important in care. Take 10 seconds to explain to the nurse your thoughts, ask them if they have any additional concerns, and update them on the plan, and what to prioritize and what to look out for. It’s not only the professional thing to do, but it also reduces errors and speeds care. The pace and patient turnover in the pediatric ED is often faster, and so solid communication is that much more important.
… with senior staff?
Your background may be different from your supervisor’s. Even if you had just heard some cool cutting-edge über-awesomeness on a podcast that may not completely synchronize with your senior’s plan, bear in mind that all of us have a lot to learn, and that in any one encounter there are many factors to consider. If you see a potential gap in knowledge (we’re all human!), then politely point out your own gap in understanding (“I have been taught ___. Does that apply here?”) You’re giving your only-too-human supervisor a chance to refresh his memory, or at least save face. If you act with charity, honor, humility, and the eagerness to benefit all, you will not go wrong.
You have a complement of medical, surgical, and critical care skills that are the envy of the House of Medicine. Trust in your training.
Despite this, some subspecialists (or general pediatricians for that matter) may like to point out our shortcomings, and over-generalize their experience, but you have three things going for you:
- you know your patient and his current condition better than anyone at the moment;
- although their particular expertise is appreciated, your holistic view of the patient is to be trusted; and
- in the end, someone has to be captain of the ship and take responsibility – that is you, my friend. There is power in your position as advocate.
- In the stable child, find out what the family situation Often the motivations and expectations of the visit are hidden in a bramble of frustration, anxiety, pressure, or dysfunction.
- In the unstable child, trust your instincts. Children are not another species. They will respond to the same critical care maneuvers as adults. There is a reason that pediatric intensivists interpolate adult critical care studies and apply them to children (and the fact that adult critical care patients are much more numerous – another reason to trust your hard-won skills).
- Be present, be patient, be supportive, but when all else fails, just do what is best for your little patient in front of you, regardless of the vocalizations of the peanut gallery.
You will not break them.
You can do this.
Use all of your skills for all of your patients.
Thanks again, Tim!
(Check out part 1 of Dr Horeczko’s interview here.)