Don’t cause unnecessary distress! P.R.E.D.I.C.T before your paediatric procedure #WILTW

This is the 106th #WILTW

For those working with acutely ill and injured children there aren’t many more important things we can do than relieve distress and pain. Sadly though there are times when procedures need to be performed in Emergency Departments which will not be completely pain free.

Screaming Child

Clearly every effort is made to ensure that the management of fractures, insertion of sutures or removal of foreign bodies is as comfortable for the child as possible. Standard text books will list some analgesic agents and those with any experience will ensure they have a repository of distraction techniques and preferably a play specialist[1] with them. The real life situation is a little more complex and, as with any task, a little preparation can go a long way to improving everyone’s satisfaction with the process. One of my recommended follows in Paediatric Emergency Medicine is Brad Sobolewski (@pemtweets). This week Brad wrote on draining abscesses in children.

Abscess Tweet

His post started with the factors that will impact on a child’s tolerance of the procedure. The list was actually relevant to many procedures and it got me thinking about the unconscious processes that I go through performing them.

The sequence can neatly be described by P.R.E.D.I.C.T

Personality – maybe the most important component. What is the child like? What makes them tick? What are there fears? Do they know what is going to happen? This may be obvious but sometimes it does take some unpicking (and why play specialists are worth their weight in gold). Some children and young people are very rational, and others less so, especially when they have been through a traumatic event to bring them to the Emergency Department in the first place. From 18 month onwards you can get a sense of how children may react; this information is invaluable

Relatives (or carers) – I’m always mindful of one of our play therapists quotes “as calm as you are is as calm as she’ll be“. Anxious parents can make for anxious children.

Experiences of the child –  If one thing is going to change your approach it will be the parent saying ‘the last time this happened we had to…’ Children remember like elephants. This is why it is so vital any procedure is as pain free as possible. One poorly performed blood test makes all subsequent blood tests 100 times more difficult. Make sure you are aware of past history.

Duration of the procedure – Some manipulations may take seconds whereas an embedded earring may take much longer (and why a good nerve block sometimes essential!). A schoolboy error is not to plan for a long procedure because you are overconfident (see below)

Interruption – while sometimes procedures have a time critical element; not all do. Ensuring you are aware of other potential distractions in the department is important (there may be lots of procedures happening simultaneously at any given time on a busy evening!)

Confidence of success – Plastering a child with a deformed forearm is unlikely to go wrong. But if you don’t fish out the small plastic ball from the ear canal at the first attempt its not always a simple next step. I always tend to think about will happen if things don’t go to plan. What are your get out strategies and what other techniques or pain relief might be needed?

Team – My final thoughts revolve around who I have available to achieve the best outcomes. A play specialist is always invaluable, as are nursing and associated staff experienced in minor procedures in children. Sometimes less is more for the frightened child, conversely a couple of ‘holders’ (noting that brutacaine is not an acceptable approach) are necessary.

So P.R.E.D.I.C.T’ing your procedure is important and I think relevant to all children including those with development delay or a neuro-disability.


What have you learnt this week #WILTW

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[1] In the United State Play Specialists are called Child Life Specialists I think


Risk and Change: Useful in an Emergency? #WILTW

This is the 105th #WILTW

A past president of the Royal College of General Practitioners and the Chief Transformation Officer of NHS England briefly debated change on twitter this week:

The imposition of change is a concept that everyone is not only familiar with but also probably weary of.

Change energises risk takers?

This statement stuck with me. Change has been a  dirty word in the past and to some it still is. Currently many health care systems around the world are at breaking point. Something must give. Is it more change that is needed?

or is it something else? There is an innate desire in health care to improve; but improvement tends not to happen by chance alone. Either with something, by someone or just somehow, a change will need occur.

Emergency Medicine is a dynamic and exciting career. The demand and pace of our work dictates that change is not an infrequent occurrence. This is a result of external influences (such as hugely increasing demand) and the impact this has on organisations to respond to them. Emergency Medicine is not a specialty that sits still. It is therefore not surprising that those in Emergency and Critical Care were the early adopters of the social media revolution that has transformed the delivery of education around the world. And while we never expose our patients to unnecessary risk we must live with risk all the time. Not every patient with a headache can be admitted, not every patient with a fever receive antibiotics.

Do we therefore potentially enjoy change? Is it in the blood of the emergency physician to relish trying different things in exactly the same way there’s something appealing about not knowing what is going to be wrong with the next patient who comes through the department doors? I think many in the UK may baulk at this analogy. At present the sheer number of patients coming through the doors is reducing the excitement somewhat.

Regardless I think it is worth noting there will always be those looking for something different and those who need time in the status quo. As Helen states a shared purpose is vital and as Clare alludes to energy is not limitless.

What have you learnt this week? #WILTW

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Filter Failure – not just knowledge overload #WILTW

This is the 104th #WILTW

The videos from the “Health of the Nation” TedX Leicester event were released this week. A colleague, Pro Mukherjee, spoke on “Another Way”

Click here if the video doesn’t play

Pro starts his talk with the parable of the wise master and the eager, but over confident, student. The student is keen to learn but incredulous as the the master keeps pouring water into a cup until it overflows. The student shouts for him to stop and the master smiles:

You are like this tea cup, so full that nothing more can be added. Come back to me when the cup is empty. Come back to me with an empty mind

This is one of those stories you sit there and listen to thinking “I get that!” but subsequently forget to action anything about it as it’s displaced 15 minutes later by another interesting meme.


The parable is not just about factual knowledge but emotional and spiritual capacity as well. Knowledge is much more easy to encapsulate though.

“Knowledge is learning something every day. Wisdom is letting something go every day” – Zen Proverb

Letting go of overbearing emotions much harder than forgetting an old definition of sepsis or the causes of erythema nodosum. I suspect I spend a lot of time with a full, but very dynamic cup, the contents of which fluctuate on a regular basis. Choosing what, and when to let go, is probably an unconscious task and I think we generally learn to manage what comes in, rather than what comes out.

Filter Failure’ is a term coined by Clay Shirkey to describe the fact that information overload isn’t the problem – it is our inability to filter what we need the real issue. He argues you don’t get a cold sweat when you walk into a bookstore or library despite the volume of information in them being immense. It is so well catalogued you can go straight to what you need. Sadly 21st century life is not ordered in this way…

I wonder if filter failure can also apply beyond being overwhelmed by the core knowledge needed for work but also to sensory and emotional inputs. There are no easy solutions to keeping your cup at a balanced level, whether it be for professional or personal aspects of your life. Being aware that you might be near tipping point probably a good place to start! And perhaps we all empty our cups metaphorically, as well as practically,  everytime time we share a ‘drink’ with friends or family….

What have you learnt this week? #WILTW

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During the writing of this blog I asked twitter for its best sources of advice in regard to information overload (list below) fully aware that this ‘knowledge’ based approached is only part of the answer.

Drinking from the Firehose 

The path to insanity

The mind palace

Information Overload

Five strategies to effectively use online resources in Emergency Medicine

Thanks Simon Carley, Olusegun Olusanya, Seth Trueger, Janos Baombe

What healthcare can’t learn from Leicester’s football success #WILTW

This is the 103rd #WILTW

In England this week the football league’s rank outsiders (starting odds 5000-1) were crowned champions after their closest opponents failed to gain the points needed to be able to catch them  in the title race.

According to the BBC Leicester City winning the Premier League trophy was at one point less likely than Elvis turning up alive. To overuse a term, it has been a fairytale journey, especially when you consider their manager has technically been sacked from his last 5 jobs 

Obviously with this background you might want to consider if there is something to learn.

or perhaps not then.

There is a great temptation to start analysing the circumstances of these amazing events. They certainly make great stories and have an inherent appeal that there’s something you can learn to apply in your own life, team or organisation.

BBC Screenshot
Story via BBC Sport and picture insert via Getty Images

How do this apply to healthcare though? What can specialised exercise regimes and cryotherapy (both used by Leicester) do to help staff treat patients more quickly and effectively? And while the principal of  marginal gains has clear face validity e.g.  if ALL healthcare staff washed their hands appropriately would they get ill less often thereby improving productivity; this isn’t a new or even special thing.

Sometimes I suspect things just click. The right team members with a similar purpose provided with consistent leadership and a sprinkling of luck are always likely to overcome most obstacles. Clearly team spirit is vital over the course of a season and Leicester seem to have this by the bucket load. But I’d argue healthcare doesn’t have much to learn from Leicester Football Club because a lot of things they do – so do we. Perhaps not consistently or coherently (we are not out to win titles) but fostering team spirit is something we are good at. We achieve great things sometimes from very little and are generally a very humble and good natured lot.

I don’t think we’ll ever know why Leicester dominated the 2015/16 season but I think we understand what getting stuck in, supporting your colleagues and treating each other like equals can get you.

What have you learnt this week? #WILTW

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Hospital Humour #WILTW

This is the 102nd #WILTW

What do you enjoy at work:

Positive feedback….?

The challenge of meetings targets or deadlines…?

The pay….?

It is likely that there are lots of reasons, all of which change over time, and perhaps even within a given day! In healthcare enjoyment often results from a sense of camaraderie. Team spirit, derived from shared experiences which are both good and bad, evolves to ensure even on the most hectic shift staff look out for each other. This involves anything from giving each other hugs to acknowledging those nearly imperceptible verbal or physical gestures that mean someone is getting stressed. But most frequently of all is the use of humour.

Having fun at work is a pre-requisite to resilience and avoiding burn out. It must clearly be contextual and used appropriately as medical humour can be very dark. While this is often upsetting to patients and the public actually very little on-the-shop banter is what might be perceived as ‘gallows humour‘.


I know this because the environment of healthcare briefly changed this week in the UK. The Junior Doctors strike brought together  consultants who are used to working in series rather than in parallel. This week I got to work with my colleagues, rather than hand over to them. It was great fun. Fun that was not dark or cynical but opportunistic, and at times, educational. And it is not that no fun is had with other staff groups but this was a unexpected reminder of its value.

I do not wish to diminish the experiences of patients who had operations cancelled or appointments delayed. It is sad that the negotiations have resulted in a protracted stalemate. But I do look for positives in all situations and it is clear there is value from working alongside your peers. The novelty value clearly had some impact, so although I am not sure some school ground-esque antics would be maintained over time, it was refreshing to share real time experiences and stories.


There is much negativity surrounding healthcare at present. As Richard Smith highlights there is an anger in a generation that has been left simmering for too long. While external policy is outwith the control of staff there are things we can do to ensure we maintain morale. I’m reminded that an appropriate sense of fun plays an important role in all healthcare environments.

What have you learnt this week? #WILTW

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Children’s experience of emergency care as a measure of quality #WILTW

This is the 101st #WILTW

This week I attended the International conference of Emergency Medicine Conference (#ICEM2016) in Cape Town. I was lucky enough to have been asked to present on a few topics, one of which was  defining ‘quality’ in Children’s Emergency Care. Having discussed the 6 domains of quality previously I won’t revisit that aspect of the talk.

Quality Matrix
US Institute for Healthcare Improvement

While there is a great deal of literature on Quality and Improvement there isn’t much specifically on the care of Children in emergency settings. A determined researcher, Eveline Allesandrini, has produced a very useful toolkit for health care professionals who work in Children’s Emergency Care. One of things that is perhaps missing from the framework is the Child’s or Young Person’s experience (only Parent/Carer satisfaction is part of the Patient-centered performance measure)

I would argue that experience is important and to this end have collected a selection of children describing experiences relevant to Emergency or Urgent care setting. A big thanks to those who contributed (both to the parents and children themselves). While there are somethings we can’t change (you may have to have a blood test) and there are somethings that can’t be avoided (when we are very busy you may wait a long time to be seen) we can work hard to make sure a Child or Young Persons experience is as good as it possibly can be.

Please do watch (with the sound on!)

If the video link doesn’t work please click here

What have you learnt this week #WILTW

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What I learnt this week: Who are unprofessional professionals? #WILTW

This is the 100th #WILTW

What is unprofessional behaviour?

(click here is the video doesn’t play)

Over the last 100 weeks I have reflected on many themes. From patient safety to team work, from removal firms to work-life balance. Interestingly professionalism has rarely been a topic of focus yet it is an aspect of our working lives that impacts on us greatly.

via applied educational systems
via applied educational systems

The General Medical Council released a blog by a junior doctor this week entitled “Why unprofessional behaviour is like pornography.” It explored the challenge of defining exactly what being unprofessional is. While professionalism might be obvious…

The set of values, behaviours and relationships that underpins the trust the public has in doctors” Royal College of Physicians 2005

….its opposite is not so clear. The severe end of the spectrum – being openly rude, or perhaps inebriated, is obvious but, should, and when do angry retorts or persistent snide remarks become an issue?

What I found really fascinating was a comment challenging the author they had not considered whistleblowers in their argument. The commentator states “It gives credence to a belief system that disloyalty to the profession comes before loyalty to patients,that you can be branded unprofessional because you stand up for what is right“. I didn’t quite follow all their logic but it goes to prove unprofessionalism is not an easy concept to define.

A tweet of mine once ended up being used in the Daily Mail to demonstrate how badly doctors can behave towards each other.

In hindsight I wasn’t proud of the tweet but I am not sure it counts in isolation as being unprofessional. The importance of having a meaningful definition is exemplified by the current #juniordoctors strike in the UK which has challenged some peoples expectations of professionalism. There have been calls by regulatory bodies for junior doctors to consider their position on all out strike action while others have cited poor behaviour on behalf of the government in their imposition and lack of engagement on the terms of the contract.

There are clearly no easy answers but as I reflect on nearly two years of #WILTW I am increasingly aware of the impact I have on others. Not just through my words but through my actions and behaviours. I am mindful things I once thought may have been acceptable no longer are (and vice-versa). ‘Who’ I am is important to me and being confident of my professionalism vital to that.

What did you learn this week? #WILTW

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