decision making in pediatric emergency medicine ivan steiner md, mcfp-em, fcfp university of...
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Decision Making in Pediatric Decision Making in Pediatric Emergency MedicineEmergency Medicine
Ivan Steiner MD, MCFP-EM, FCFP
University of Alberta,
Edmonton, Canada
Goal for todayGoal for today
To review a simple, personal, time tested tool for decision making in the ED.
Game plan Game plan
Look at the difference between ED, wards and clinics.
Review the components of decision making process in the ED.
Outline my template for decision making. Answer questions. Provide a summary.
Warm upWarm up15 patients waiting in the waiting room when a 7
month old baby boy is brought by his parents into the E.D. of
A peripheral hospital. He is unresponsive and is visibly
covered by a rash. His BP = 60/?, P = 160, RR = 50, to = 40o,
O2% = 96% on R.A.
What is the problem?
What are your priorities in this case?
The ED a distinct environmentThe ED a distinct environment
Question:
In what way is the ED different than the wards and clinics?
The ED a distinct environmentThe ED a distinct environment
Lack of control over volume of patients. Variable acuity and availability of resources. Triage. Unknown patients. Short intervention time. Limited information. “One shot” approach. Uncertainty of dealing with unknown, or previously not
encountered problems.So what does this mean to the clinician?
The ED a distinct environmentThe ED a distinct environment
Functioning in an environment with limited , variable resources AND dealing withfrightened,
possibly hostile patients and families .
Key skills and attitude/behaviours required to be successful in the ED:
Prioritized, organized approach to each situation. Empathy, respect, tact. On going, two - way communication.
Take home message for Part 1.Take home message for Part 1.
Decision making may have to start with the little or no information.
The “traditional” approach to patient management does not work in the ED.
A PEP is a “people person”. Rapport!
Decision making:Decision making: key questions to ask oneself key questions to ask oneself
The three “Stop” signs:
1st “Stop” sign
What are the first four key questions to ask oneself ?
Back to our caseBack to our caseA 7 month old baby boy is brought into the
E.D. of a peripheral hospital by his parents.
He is unresponsive and is visibly covered by a
rash. His BP = 60/?, P = 160, RR = 50, to =
40o, O2% = 96% on R.A.
What are the first 4 key questions to ask ?
Decision Making:Decision Making: Key Questions to Ask Oneself Key Questions to Ask Oneself
1. Is the patient in the right institution ? 2. Is the patient in the right part of the ED?3. Is there a need for immediate resuscitation, or
potential for resuscitation of LIFE, limb or salvage of function?
4. What immediate information/resources are required to start management of the patient?
These questions lead to good triage and care!
How do we make decisionsHow do we make decisions
First step: trust your eyes, smell, hearing, touch.
Second step: check vital signs. Third step: asses chief complaint.
How do we make decisionsHow do we make decisions
Start with patient presentation and NOT diagnosis.
Anatomy and physiology are great guides!!!!
Take home message Part 2.Take home message Part 2.
A good PEP anticipates problems. In the ED, the clinician is first and
foremost a clinical physiologist. He/she is an expert at managing
multiple, often limited resources.
Template to decision makingTemplate to decision making
The 7 step approach.
How to get “Steinerized”
Template: the first 7 stepsTemplate: the first 7 steps
Resuscitation. Monitoring. Symptomatic treatment. Investigations. Diagnosis/definitive treatment. Disposition. Social.
TemplateTemplate: step 1: step 1
Does the patient need resuscitation or stabilization of physiological parameters ?
The 1st “Stop” sign
Life = resuscitate.
Limb = reestablish circulation.
Function = prevent further injury. (P.R.I.C.E.)
Template: step 2Template: step 2
Does the patient need monitoring?
Life = VS=BP, P, RR, to, O2%, weight, sugar, (Co2).
Limb = pulses, colour, sensation.
Function = as above or specific (Visual Acuity)
Template: step 3Template: step 3
Is there a need for symptomatic treatment?
Provide symptomatic treatment based on
need and using the most effective route!
Offer it to the patient even though he/she
may choose not to accept it.
Template: step 4Template: step 4
Does the patient need prioritized investigations?
The 2nd “Stop” sign
Body fluids = blood & all other.
Diagnostic imaging = simple & complex.
Other = things that start with “E”.
Template: step 5Template: step 5
Do we know what is definitively wrong with the patient and what the definitive treatment options may be?
Usually the answer is NO.
Back to our case.Back to our case.
Do we know what is wrong and what the definitive treatment options are?
Template: step 6Template: step 6
Do we know where this patient will end up?
Too sick to go home = ward vs intensive care.
Will go home = only obvious cases.
Not sure = most patients fit in to this category.
Remember: Starting presumption is that you aredealing with the worst case scenario.
Template: step 7Template: step 7
Are there any immediate social issues ?
Consider these issues early and use the
appropriate resources: social worker, etc.
Template: the first 7 stepsTemplate: the first 7 steps
Resuscitation. Monitoring. Symptomatic treatment. Investigations. Diagnosis/definitive treatment. Disposition. Social.
Template: the first 7 stepsTemplate: the first 7 steps
How do I make it work? A = Asses.
I = Intervene.
R = Reassess.
The sicker the patient, the more often one repeats A.I.R. and charts each intervention.
Template: the final 7 stepsTemplate: the final 7 stepsThe 3rd “Stop” sign
Resuscitation. Monitoring. Symptomatic treatment. Investigations. Diagnosis/definitive treatment. Disposition. Social.
Template: the 3 “Stop” signsTemplate: the 3 “Stop” signs
1. Before triage & resuscitation
2. Before ordering all investigations
3. Before disposition of the patient
Take home message Part 3.Take home message Part 3.
The 7 point template provides a simple and safe starting point.
The 7 point template provides a safe exit strategy.
The number of A.I.R. are dictated by the clinical status of the patient.
The 3 “STOP” signs help PEP slow down and make good decisions!
Distilled summaryDistilled summary
Good PEP use a patient/family centered approach in decision making.
Early decisions are based on patient presentation and NOT diagnosis.
Physiology and anatomy never lie! The 7 point template used on entry and exit +
A.I.R. + the 3 STOP signs have been proven, useful and simple to use tools over time.
Teaching Pediatric EM to all medical students and residents who are treating children is essential.