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The Sweet Spot


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 have not 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!

For paediatric doctors new to the ED setting:

What are some common stumbling blocks and how can these be avoided?

Don’t worry about the number of patients waiting on the screen, concentrate on doing a good job for the patient in front of you. Don’t be afraid to ask questions, in ED there are usually consultants around (during the day) so they are often more accessible than they can be in some ward jobs. On that note speak to your consultant before calling inpatient registrars, ED bosses know how to manage a lot of simple fractures and don’t always need the opinion of the orthopaedic reg immediately. (BL)

Think about disposition – does this patient obviously need to be in hospital? If so, under whom? (HG)

How does your mindset need to change?

Pre-test probabilities of disease change as you move through the medical system, which changes the positive and negative predictive values and the diagnostic utility of tests i.e patients you see in clinic who have had that symptom the whole time they have been waiting for their OPD appointment are just more likely to have that weird and wonderful diagnosis than patients presenting to their GP or ED with the same symptom that they have only had for two hours.

It doesn’t mean you can fob that symptom off as benign but it does mean you have to think about the optimal timing for ordering the big dose of radiation that comes with the CT scan or the thousands of dollars’ worth of blood tests that might eventually be part of the work up.

Common examples of this: if you hear a murmur after you have just given a kid a burst of ventolin it’s often sensible to listen again when they are well before referring to cardiology. When you see microscopic haematuria on a urine dipstick in a febrile kid it’s sensible to recheck when they are better (or ask the GP to do so) rather than starting a renal work up. (BL)

Watch Reuben Strayer’s screen cast on “How to think like an emergency physician”, twice. (HG)

What are some knowledge deficits that can be ameliorated…

…quickly and easily?

Find out which guidelines are preferred locally and where to find them (BL)

Practice your simple sutures at home, especially if it’s years since you’ve done any! (HG)

Know your clinical decision rules for head and neck injuries and how to clear a c-spine (HG)

Learn about good pain relief – drugs available and appropriate dosing (TD)

…with concerted study and experience?

Find an emergency registrar colleague and let them teach you about trauma – from preparation to tertiary survey and all in between, pick their brains! Similarly, learn the skill of receiving handover from the ambulance and unloading the patient safely under a broad array of conditions. (HG)

The skill or attribute that differentiates an average registrar from an exceptional one is…?

Understanding that a lot of what we do is grey rather than black and white and being able/willing to discuss the rationale for their treatment choice not just insisting that the treatment for X is Y. Understanding that much of Paediatric Emergency Medicine is looking for needles in haystacks (or looking for rare but devastating diseases in a population of largely well people) and not getting complacent with those presentations (like fever). Understanding the importance of safety netting and that people bring their kids to ED because they are worried about them. So, if you can explain their child’s problem and equip them with an understanding of the things that they need to look out for with that condition, then that was a consultation that actually was worth you being up at 3AM for. (BL)

Foresight. Although it’s less reliable and much harder to obtain than its cousin hindsight, having an idea about the evolution of particular pathology or clinical scenarios allows you to plan your workflow. Examples include, the second blood gas always looking worse in the child with DKA, or knowing that picking up the febrile 5 week-old infant will be time intensive for the next wee while – if you need to progress another patient’s care in the interim, identify moments to do so. (HG)

What is the most under-used feature in the history / examination / investigation?

Heart rate – don’t send kids home with a tachycardia unless you are very sure about what is causing it, equally don’t send them home before you know what their heart rate is. (BL)

“You have a face; use it!” – one of my consultants strongly eschews the use of shiny toys, flashing lights and gadgets. Instead, he says, we should use our smiles and funny faces. I think the main message in this context, is that you don’t need lots of bells and whistles to amuse or calm the child; just be engaged both in their presence and in their story. (HG)

What is the most over-used feature in the history / examination / investigation?

CRP on a febrile infant (with no focus) – this wastes two hours of everyone’s lives and shouldn’t affect your decision anyway. If it comes back as 49, how is that going to change your management (it shouldn’t)? Treat a febrile infant based on physiological parameters and clinical assessment. Then use the blood results to help track their progress over the next few days. Don’t use the blood results to decide whether or not to treat them with antibiotics. (TD)

Blood tests, especially “routine” ones. A short period of observation is a much more useful diagnostic tool than a white cell count in many circumstances – (see Tessa’s DFTB post on positive predictive values and pre-test probabilities)(BL)

Borderline oxygen saturations in a supine, sleeping patient. (HG)

Blaming everything on erythematous throat and mildly dull tympanic membranes. (HG)

How is the communication different…

… with parents?

They are usually worried, try and understand why, it may not be immediately obvious. (BL)

Explaining your reasoning goes a long way to ameliorating parental concerns. If you’ve thought “it’s highly unlikely this kid is meningitic – he’s giggling at my jokes, I’ve just folded them into a ball without pain and there’s not a skerrick of photophobia”, it’s probably okay to say that out loud. If you are concerned, talk through the next steps of diagnosis or management. If you don’t know what’s happening, it’s okay to say it along with what you’re doing next. I think this is about respect for parents whilst keeping parents informed. Importantly, it moves us away from that physicianly nodding and “Hmm”-ing that some of us can be prone to doing. (HG)

… with medical and nursing colleagues?

EDs are teams, the nurses spend more time looking closely at patients than we doctors do so I think usually get better at picking up the subtle signs that kids are not well much earlier in their careers than we do. If one of your nursing colleagues thinks a kid is sick listen to them and take them seriously. (BL)

Tell your nursing colleagues what you’re thinking, and keep them updated. Having a shared mental model isn’t just for the resus room. (HG)

You’ll be making lots of referrals – don’t meander through the story. Especially if you’ve done the same registrar job that you’re referring to, anticipate the questions and likely investigations. (HG) Use a structure for your referral phone calls such as described here by Chris Nickson.

It’s really easy as an inpatient registrar to mutter about the quality of ED referrals; try to give the kind of referrals that you would want to receive, and understand why this can’t always be the case. Find a safe, courteous medium that you are proud of and can reproduce. (HG)

… with senior staff?

Most EDs seem less formal than many departments, I think most ED consultants expect to be called by their first names and most of us understand that hierarchy hinders communication at critical moments. Every now and then someone gets confused and interprets that as meaning a clinical plan a consultant has advised them to follow is a suggestion they are free to overrule, it’s not. If you disagree with a seniors plan your input should be welcomed but it’s essential that you discuss this with that senior rather than taking an alternative path. (BL)

If you’ve started discussing a patient with one consultant, unless they’ve gone off shift or directed you elsewhere, don’t pick a new boss to discuss with. It’s poor form and leads to convoluted, repetitious care. (HG)</s

A strength that this group might be surprised they have is…

They have often got a lot of CRM/teamwork based resuscitation skills from neonates that translate well into the ED resus environment. (BL)

Not surprising, but a huge strength is the ability to cannulate anyone. (HG)

Five key tips for this group:

Revise your APLS algorithms before you hit the floor. (HG)Actively seek opportunities to practice simple procedural skills (plastering/suturing) under supervision. The learning curve for these is very steep so you will be comfortable in a very short time if someone shows you how to do it and explains the principles underlying these things. Practicing on your mates (plastering) or an orange (suturing) will get you comfortable with the materials/tools before you have to do it in front of parents which is always a bit more awkward if you don’t know which forceps to use for what. (BL)Communicate openly and actively with your nursing staff. (HG)Think about sending a patient home as an option! Our tendency as inpatient registrars with patients “knocking on the door” is to let them in, sometimes that’s not the best thing. (HG)What does this patient need right now? (HG)

The most important piece of advice for a Paeds Reg new to ED is:

Ask lots of questions, even if you know how to manage things, you will often have lots of colleagues around so take the opportunity to explore other peoples perspectives, even on simple things. (BL)

For emergency doctors new to Paediatric Emergency

What are some common stumbling blocks and how can these be avoided?

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)

How does your mindset need to change?

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)

What are some knowledge deficits that can be ameliorated…

… 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 skill/attribute that differentiates an average registrar from an exceptional one is…

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)

What is the most under-used feature in the history / examination / investigation?

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 = talking 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)

What is the most over-used feature in the history / examination / investigation?

“Well appearing neonate with a fever”

Urine dipstick in the case of diarrhoea. (HG)

How is the communication different…

… 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)

A strength that this group might be surprised they have is…?

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)

Five key tips for this group

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)

The most important piece of advice for an ED reg new to paeds is

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)



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