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#PaedsTips Tips for Kids You Won’t Find in Books
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Paediatric Tips You Won't Find In Books - @_NMay at SMACC Gold

Sep 22, 2014

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Health & Medicine

Paediatric Tips You Won't Find in Books - talk by @_NMay at SMACC Gold (Broadbeach, Gold Coast; March 2014)
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#PaedsTipsTips for Kids You Wont Find in BooksThis is a fantastic concurrent, isnt it? My colleagues here are going to take your through the nightmares of every clinician. But Im here because actually, those nightmare scenarios represent a tiny proportion of the children we see.@_NMayI have a huge list of tweetable clinical tips Im going to share over the next couple of weeks using the #paedstips hashtag, but we dont have time to cover all of that today, so Ive boiled this talk down to the essentials of understanding the approach to paediatric patients.Paediatric Pep TalkTips for Kids You Wont Find in BooksSo this is the purpose of this talk: the majority of paediatrics is common sense medicine. This is certainly true in the developed world. In fact, many of the children we see in the paediatric ED and rural GP arent presenting with life threatening illness/injury and most will get better despite what we do to them. But that doesnt mean its easy, but its not hard.

Image courtesy of WallpapersWide.comKids are supposed to thrive, grow up, make everyone proud, have their own kids and die at a ripe old age. They are not supposed to be critically unwell or critically injured, let alone die. When bad things happen there is a huge emotional burden.

Image courtesy of E.B. Image / FlickrA major aid to coping with seeing tragedy in childhood is being able to take refuge in knowing that you did everything possible. We know weve done everything we can because we know in advance how we are going to approach life threatening illness and injury. Cliff Reid says How we train is how we fight. Dont be a cowboy; if you routinely see sick/injured kids, get good at managing them.

Image courtesy of WallpapersWide.comAPLS and similar courses provide great starting points but APLS is a three day course and brilliant as I am, I cant condense it into 20mins. SO: here are some thoughts from the paediatric ED which will help you look after your paediatric patients and get you off on the right foot

Image courtesy of WallpapersWide.comIt might not feel like it but serious illness and injury in children are rare. And whats more, unlike adults kids rarely fake it. They have much better places to be than in the ED (although playing in the WR is awesome fun).

Image courtesy of Creative Donkey / FlickrPAINFEVERFATIGUEFEARHowever, assessment of paediatric patients is made more difficult because of pain, emotional immaturity, fatigue and fear. If you can recognise and properly address these factors, your job will be easier. Sick, injured and scared kids regress developmentally. Even adult-sized rugby-playing teenagers are not emotionally adult and may not behave in the way you expect them to.

Image courtesy of FurnessRovers / FlickrBut PEM is a team sport and the most important part is the pre-match huddle. Choose your team carefully and get everyone on the same page and playing in the same direction before you start: pay particular attention to getting mum and dad on your side if you can. Allocate roles and explain responsibilities in all PEM situations whether a resuscitation or a routine examination. Invest time in preparation for non-emergency procedures. Play to your teams strengths; get your best players (the paeds nurses) up front; for goodness sake dont try to play without them.

Much of medicine is actually performance and pretending to be something you are not - which is good, because it means you can practice. Have and learn a pep talk script you can perform to parents. It is in your interest to make things run smoothly. You are investing in future ED attendances, not just in your patients childhood but in their experiences into adulthood too.

The most important skills in Paediatric EM are communication skills. You have to know how to talk to kids and their families, to instil confidence in them. A child who trusts you will believe you and its your job to bring calm and reassurance to the consultation. Do not lie to children; this will backfire and the childs mistrust of you will carry over into future consultations.

Image courtesy of abc.net.auYou need to understand the world children live in. The best prep for paeds is to hang out with kids; learn how to play with them, learn what they like to talk about, learn the name of Peppa Pigs best friend. If a child recognises you in the context of the world they know and understand, you will become less threatening. Know about popular television shows, compliment children on their spiderman t-shirt; show an interest in who they are.

Image courtesy of MeggyLooWho / FlickrChildren need to be the focus of the consultation. Give all but the very sickest children an opportunity to tell you about their illness story. We can treat our patients better, whatever their age, when we understand their priorities; ask the child about the problem that has brought them to the ED - and make sure you address it.

Image courtesy of WallpapersWide.comHospitals and healthcare settings are scary in their own right, even to adults. Try to see children in a designated paediatric area. Toddlers are the most difficult age group because they transition from fear of strangers to fear of being separated from their parents. The worst thing you can do is combine these fears into a single event. Parents know this; google separation anxiety and youll find discussion boards of parents asking how they can make medical and dental attendances less stressful for their terrified offspring. Parents find this emotionally challenging too.

Image courtesy of omgponies2 / FlickrAt the other end of the spectrum, being a teenager is complicated. There are lots of opportunities to make a difference to young people; offer to see them alone, state its part of my practice

Image courtesy of FlickrRecognise that the patient is not always the child in front of you. Being a parent is tough. Its REALLY tough. Parents selflessly sacrifice for their children in ways we can barely imagine. Sometimes the most important thing is to allow mum & dad to share their concerns, worries, anxieties and frustrations. This is especially true of new parents. I would strongly advise that whenever you see a neonate you take the time to ask the parents how things are going. Validate feelings of helplessness and exhaustion in parents and carers of children of all ages. You have a vital role in providing support here.

Image courtesy of FlickrSituational awareness is crucial in PEM. One of the best examples of this is obtaining IV access in the septic, clapped out, shut down LLS kids. Sick kids need treatment so make this your mantra; two strikes and youre out - in a sick kid MAXIMUM two attempts at IV before IO access. If you are someone who knows they might be tempted to break your own rules in this situation, take the EZ-IO out, give it to the nurse and tell them to give it to you after the second failed attempt. Share your mental model to get your team on the same page and give them permission to hold you to account.

Image courtesy of WallpapersWide.comIf things are going badly, make early an decision to phone a friend. Sometimes when we see adults and ask for help, we get resistance from specialties and other services. One of the best things about PEM is that this is rarely the case. Two heads are better than one; make the most of the expertise and skill sets available to you.

Babies - neonates in particular - deserve a special mention because they are special. They are different from all other human beings; they do very unique things and deserve careful consideration. And now the good news; its your professional responsibility to hug babies. Its an important part of the assessment of their tone. It also makes them stop crying when theyre held by someone calm and well slept :-) You need to get used to hugging babies. Practice!

Image courtesy of Benoudina Samir / RadiopaediaChildren of all ages feel pain. Treating it is not only necessary, it also helps assessment. Pain in the neonatal period alters clinical outcomes, brain development and subsequent behaviour. Theres evidence that neonates who experience pain develop increased pain sensitivity and hyperalgesia, and is associated with changes in behavioural stress responses, ultimately leading to psychosomatic pain and psychiatric disorders in later life. However, inflicting pain to relieve pain - if you want to give IV/IM meds - is not something that most children can rationalise. Therefore, consider alternatives; femoral nerve blocks for femoral shaft fractures.

Make use of the intranasal route for severe pain: in Manchester we primarily use intranasal diamorphine, other options include fentanyl and ketamine

Image courtesy of Lauri Andler / Wikimedia CommonsIn babies who are too young for topical anaesthetic, sucrose has been shown to reduce distress associated with the pain of venepuncture and cannulation in babies; breast milk is an alternative. Be kind!

LAT gel is a wonderful thing: combination of lidocaine, adrenaline, tetracaine for open wounds (alternative TAC). Rule of Jenner - if kid allows you to put it on, they will usually allow you to clean/suture the wound.When things dont add upYou need to be systematic and think critically. There will be times when things dont quite add up and it is the way we approach these situations that not only makes EM challenging and interesting but it also defines us as EM clinicians.

Image courtesy of docfiles / FlickrIf things dont make sense, check a blood sugar: hypo and hyperglycaemia present in all sorts of weird and wonderful ways. Easy to treat, easy to miss.

Image courtesy of FlickrBeware the child with unexplained tachycardiaThere may be badness there

If in doubt, get an ECG. Monitors lie. The heart rate here is not 164/min despite what the analysis says.

Image courtesy of WallpapersWide.comBe on the ball: examine the scrotum and testes in male kids and adolescents with abdo pain (vomiting?). As Ross Fisher, paediatric surgeon, advises; Play gently with scrotum for best resultsTortion hurts like being kicked in the nuts. In an emergency, untort like opening cupboard doors: nothing to lose by trying this if in middle of nowhere

Image courtesy of tesa l / FlickrBe thorough, be systematic; avoid anchoring and be aware of the influence of heuristics and bias. E.g. non-specific abdo pain localises to T10 (the umbilicus). This does not mean the umbilical hernia is obstructed/incarcerated! They almost never need surgery and virtually always resolve in kids