spotting the sick child
TRANSCRIPT
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
4
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
