spotting the sick child

Dr Ffion DaviesFRCEM, FRCPCH

Consultant Emergency Physician

University Hospitals of Leicester UK

SPOTTING THE SICK CHILD

EM PHYSICIANS DISCHARGE MOST OF THEIR PATIENTS HOME

EM doc

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THE GREY ZONE

The hard part of being an emergency physician…..

Well

Sick

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EXPERIENCE + LEARNING

E-learning website www.spottingthesickchild.com

NHS England Re-ACT series 10 minute video https://www.youtube.com/watch?v=N35J3NLJW_s

1) PHYSIOLOGY 2) PSYCHOLOGY

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PHYSIOLOGY

“3-minute toolkit” www.spottingthesickchild.com- a proper top-to-toe in 3 minutes + PHYSIOLOGY

ABCDENTTT (ENT temperature tummy) RR, HR, SaO2, peripheral coolness / (cap refill)

PEWS type scores help with THE GREY ZONE

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PNEUMONIA AS AN EXAMPLE

Chest wall recession x SaO2? Often normal Auscultation? Often normal

Unwell, lethargic

TachycardiaTachypnoea

Salmonella septicaemia Small bowel malrotation with perforation Viral myocarditis……………….

THE CLUE:

LESSONS FROM THE CORONER’S COURT

170 +

1

WHAT ABOUT FEVER?

1 2 3

Triage

1 hour

< discharge

PSYCHOLOGY

STORY 1

Girl aged 2 ½ 4 week history of swollen face, abdominal pain, lethargy and weight loss Two days prior to admission, saw GP:• Δ throat infection• Rx penicillin Taken to ED as parents not happy: FBC taken, sent home FBC result rang through from lab and parents recalled to ED Hb 60g/l ; Plt 88 ; WCC 672.4 (of which 584 = blasts)

8 week old baby with apnoeic episode at home

“He looks fine, you can go home”

30 seconds later baby goes apnoeic, blue, floppy

Crash call / code

IT’S THE SAME BABY AS IT WAS 60 SECONDS AGO!!

Apparent life-threatening event

STORY 2

PSYCHOLOGY: WHAT DO THESE STORIES HAVE IN COMMON?

MORE PSYCHOLOGICAL FACTORS….

Parent

Doctor ChildParents are stressing me

Parents are unnecessarily stressed

My preciousss?

“Children are precious and special”

Child “Adult” Elderly

Homo Sapiens

INCREASED COGNITIVE LOAD

WHY IS THINKING RELEVANT TO PAEDIATRIC EMERGENCY CARE?

Automatic thinking

Non-automatic thinking

AUTOMATIC THINKING

Several tasks can be performed simultaneously

Limited cognitive burden

KNOWLEDGE

TYPE 1 THINKING (REF P CROSKERRY)

EXPERIENCE

TYPE 1 THINKING

Analytical

Fragile if cognitive load increases eg stress

KNOWLEDGE WEAK

COMPLEX SITUATION

Non-automatic / type 2 thinking

“If things start happening, don't worry, don't stew, just

go right along and you'll start happening too.”

- Dr Seuss

INCREASED COGNITIVE LOAD IN PAEDIATRIC EMERGENCY CARE

Simple skills may be difficult:Arithmetic

Recall from memory

Errors in critical thinking ability:

“Paralysis by indecision”

Confirmation bias

SCARED

TYPE 2 THINKING

NO TIMENO KNOWLEDGE

I NEED TO ENGAGE BRAIN. HMMM……

COGNITIVE OVERLOAD

ERROR: “HE’S FINE: KIDS USUALLY ARE”

SEEK HELPSpecial ist

SeniorDr Google

SOP

DENIAL

ERROR Charts, cheklists+ dril ls

CAN’T BE BOTHERED

SO WHAT DO WE NEED TO DO?

Get some PEM knowledge

Use resuscitation aids & checklists

Train by stress inoculation therapy (military)

- regular practice drills / simulation exercises

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THE GREY ZONE

1 more top tip…. Use risk stratification

Well

Sick

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RISK STRATIFICATION

Absolute age (<2 months, 2-6m, 6m-2y, 2+)

Ex-prem Cardiac disease Any chronic disease or syndrome

Young parents with poor social support

TOP TIPS FOR SENDING THE RIGHT KIDS HOME

PHYSIOLOGY

Is your mind safe? DENIAL? SCARED?

TOP TIPS FOR SENDING THE RIGHT KIDS HOME

PSYCHOLOGY

THANK YOU! ffion.davies@icloud.com

PSYCHOLOGY

PHYSIOLOGY