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Tim Horeczko

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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 skill sets 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 thrilled to interview Dr Tim Horeczko, protagonist of the Pediatric Emergency Playbook at PEMplaybook.org.


Tim Horeczko


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

For Paediatric doctors new to the ED setting

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

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 backup. 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 possible pneumonia or appendicitis lurking underneath seemingly benign signs or symptoms.

The point here is 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 speciality 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 iatrogenic. We try to choose wisely and act judiciously. 

What are some knowledge deficits that can be ameliorated…”

– 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-anaesthesia recovery, or in the 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 into your care.

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

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.

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

The general impression is the single most important piece of information

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?

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

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, and some are amplifications of what is expected. Symptoms are the patients.

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 for 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.

How is the communication different…

… 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 are 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.

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

As a paediatrician, 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.

My three top tips for this group

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 favour.

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.

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

Think worst first, diagnose and treat important things, and for everything else, time is on our side.

For ED doctors new to the paediatric setting

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

They’re not all fine.

They’re not all dying.

Find out where your personal biases are and do your best to seek balance.

How does your mindset need to change?

In working with adults, the disease is dumber. It is more obvious. It 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 to the detriment of 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.

What are some knowledge deficits that can be ameliorated?

… 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?

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

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 of 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 favourable, 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.

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

Really work hard to perfect your general impression. Review the Pediatric Assessment Triangle.

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

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.

How is the communication different?

… 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 and 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, what to prioritize and what to look out for. It’s not only a professional thing to do, but it also reduces errors and speeds up care. The pace and patient turnover in the pediatric ED are often faster, 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.

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

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

Three key tips for this group:

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 manoeuvres 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, and 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.

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

You will not break them.

You can do this.

Use all of your skills for all of your patients.

About the authors

  • A General Paediatrician and Adolescent Medicine Fellow based in Queensland, Australia, Henry is passionate about Health Systems and Complex Care, with a strong interest in Medical Education & Clinical Teaching. His 'Dad jokes' significantly pre-date fatherhood, and he stays well by running ultramarathons. @henrygoldstein | + Henry Goldstein | Henry's DFTB posts

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