Category Archives: FOAM

Unspoken stories: Going beyond the paediatric history

This post was inspired by a teaching session I run for our junior doctors during their induction (orientation) to our Children’s Emergency Department.  I shared some of the content with Liz Crowe and thanks to her amazing insight she has shaped this into a immersive #FOAMed experience. We really hope this will challenge all of those who work with Children to think that bit harder and look that bit closer. I’m hugely grateful to Liz for her patience and input. 

In paediatrics we cannot always rely on the patient to give the history, explain symptoms or give a complete story and may be dependant on the parents or caregivers to give us information, especially historical symptoms, about the children we see. It is not just the narrative we are told that is important though, it is the way we are told it. Family context is a major indicator as to the wellbeing, safety and potential compliance of the patient to treatment. Clues to that context can be as obvious, or as subtle, as the signs of respiratory distress.

Lets examine the same clinical scenario and see what we can learn from parental engagement.

You are working a long shift in ED.  An outbreak of gastroenteritis and a late bronchiolitis season means the waiting room is full of miserable children with a variety of complaints.  You are tired and hungry.  The next patient is an 8 week old accompanied by both parents.

They have been waiting around 90 minutes which is short compared to many in the waiting room. It is reported to you that the parents are ‘demanding’ and have come to the desk on a couple of occasions to enquire about the waiting time. Normally patients less than 3 months old are prioritised in your department but there were no concerns on initial triage and there has been a run of sick patients brought in by ambulance which have tied up staff. You brace yourself for a challenging consultation.

worried_mom
http://www.bestwayguides.com/

At triage the nurse has noted the baby to be afebrile and had had only one small posit typical for an infant that age. The baby has not been observed to be irritable but has been crying in the waiting room. Observations, both objective and subjective were normal.

In the following scenarios the infant is clinically well and there is no evidence of a serious bacterial illness, cardiac or metabolic problem. The mother has been concerned about the child’s feeding and some intermittent vomiting during the day.

Scenario One

 

Scenario Two

 

Scenario Three

 

Have a think about how you would approach these cases? What further information would you like and what might be the cause of the observed behaviours? What realistically is your responsibility in a busy ED?

 

Potential background to Scenario One

 

Potential background to Scenario Two

 

Potential background to Scenario Three

 

Conclusion

Presenting the cases in this way makes it obvious that a huge amount of information is available to health care professionals from the attitudes and appearances of parents and family members. The source of these emotions will not always be clear and there might not be time in Emergency settings to obtain a full picture of events. But if we don’t take some sort of history and visual examination of parents and families we are missing vital clues that will help us mange children and young people more effectively and potentially put parents and children at risk.

 

The other part of the teaching session is on communication and illness recognition. I’ve recorded a short summary of this:

 

Utilising the improvement from healthcare social movement #MedX

I am pretty sure it is impossible to change the world alone. You may be innovative, provocative, and inspirational. But even our greatest leaders will cite key influencers to their success

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Hello – My name is Damian. I am a paediatrician. I am also a father and when my second daughter was 8 weeks old she was admitted to hospital with suspected meningitis. I saw the best that healthcare has to offer patients and their families during that worrying time. Compassion, dedication and great skill. To the colleague who expertly performed procedures on Bella’s delicate veins I will always be grateful.

But I also saw the worst of healthcare. A failure of senior staff to introduce themselves, the neglect of staff not washing their hands and the public display of hierarchy for the benefit of an individual needing to assert their authority.

There are many things I wish I could change about Bella’s stay in hospital. What would you change in healthcare? If you are a patient what frustrates you most? As a health care professional, how would you like your service to be run? Sadly change can become somewhat of a dirty word.

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Max Davie, a paediatrician, once said to me, “we are fed up of change, but not of improvement

There are many things we can improve with robust research and the scientific method. The dose of chemotherapy, the type of surgery or the treatment of infections with new generation of antibiotics. But what of personal change, system change, cultural change? For these we need movements.

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Social Movements are collective actions by large, but sometimes informal, groups of individuals or organisations to carry out, resist, or undo a social change. When we think about resources for change we tend to think about economic resources (budgets, technology, individuals etc). These resources are limited and finite whereas social movements can release resources in the form of social capital which is vital in environments where monetary intervention is not possible.

Within healthcare there are many shared values, both for patients and professionals, so achieving common goals through a movement has an obvious appeal. For example, the Institute for Health Care Improvement’s (IHI) “5 million lives” campaign aimed to reduce medical harm in American hospitals. The movement generated considerable publicity and the IHI claimed they surpassed their target.

Social Movements are not a new idea. They have been occurring for centuries. However in the last decade there has been a seismic change though the accessibility and reach of social media.

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Social media is increasingly seen as credible and accepted medium by which to disseminate information, decrease the knowledge translation gap and allow professional and patient engagement in a meaningful way. It has hugely increased the momentum and motivation behind social movements. I’d like to discuss some social media derived movements I have been involved in, or aware of, and share some learning.

NHS Change Day was about harnessing the power of collective action. It was a grass roots frontline movement for improvement in health and care and 98% of the activity was undertaken by volunteers. It asked for a simple action. To pledge to perform a healthcare intervention on a single day (March 13th 2013). It became single biggest day of collective action for improvement in the history of the NHS with 189000 pledges made. Change Day has been replicated across the world and is now in its 4th year.

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Change day started with a tweet that enable a first conversation between junior doctors and an improvement leader. From that first conversation a timeline can be drawn that resulted in a national event that impacted on the lives of patients.

Change day taught me about the power of stories. My pledge in the first year to try some of the medications that I prescribe to children. One, an antibiotic, was absolutely vile. It was truly disgusting. It made me realise that this wasn’t something you could give to parents and expect them to religiously give to their child. I realised you need to provide clear guidance on how to hide the taste and encourage adherence.

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Importantly the process created a story of my experiences. The staff in my department know about my pledge. They have seen the video of the odd contortions my face made when I tried to swallow it. The narrative a powerful back drop in promoting change in others.

This year Kate Granger, a doctor, passed away having been diagnosed with a rare form of cancer. She was responsible for #hellomynameis. A social movement that clearly begins with her encapsulation of how frustrating it is when health care staff don’t introduce themselves. Her campaign started on twitter and with now 1300 million impressions continues to spread throughout the world. A powerful personal narrative with meaning for others.

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Free Open Access Medical Education (FOAM) is an international movement that has brought together people from many backgrounds and specialties. It describes the production of educational materials in a variety of forms that are openly accessible. The concept of FOAM started in a pub (much like all great innovations!). Mike Cadogan coining the term during an international emergency medicine conference. It has come to represent a focus point for critical care and emergency medicine communities in particular. The term encompassing not just the materials produced but the bringing together of enthusiasts who design and digest them. It has developed into a true digital community of practice as demonstrated by examination of the hashtag #FOAMed. FOAM, along with patient derived digital communities such as #chroniclife, are social movements almost entirely derived within social media yet have all the attributes of a community of practice with the potential benefits they confer on professional and patient outcomes.

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We are now at the beginning of a new approach to social movements. One in which anyone: pubic, patient or professional can contribute to the challenge that is change.

A very public social movement can inspire others to feel passionate about what they are doing. To do this we must:

  • Learn to tell and share stories, always keeping in mind the event(s) that prompted the initial story
  • Let these stories build communities

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I am sure it is impossible to change the world alone. But with others we can achieve great things. The 21st century social media enhanced social movement will continue to teach us about connectivity and community. I for one am very glad to be part of it.

Huge thanks to Helen Bevan, Jackie Lynton, Daniel Cabrera, Jesse Spur, Chris Nickson, Mike Cadogan and many others who have impacted on my thinking in some way. 

This is a shortened version of my presentation at #MedX 2016

Auto-update a slideshow with pictures sent in by e-mail

Craig Sayers (the genius behind the power point counter hack) created a novel way of sharing photos at his wedding. Friends and family could send photos they’d taken to an e-mail address that automatically added the photo to a slide show which was being projected onto a wall at the wedding. You can imagine the fun that ensued as the evening progressed.

The geek that I am realised this has an application in Medical Education; particularly in workshops and conferences.  You can get delegates to respond to questions by getting them to take a picture of answers or comments they have written down and display them for everyone to see.

I thought it would be useful to share this process. There will clearly be other ways of doing this but I think even the most novice of computer users should be able to put this together!

  1. Create a dropbox account. You will need to install dropbox onto your operating system as well.
  2. Create a send-to-dropbox account and link this to your drop box account (don’t worry about the funny looking e-mail address you may be given at this stage)
  3. Download photolive (links to windows/mac downloads are at the bottom of the screen) onto your operating system
  4. When you open photolive click ‘choose a folder’ and select the dropbox folder “Attachments”. You will find this in the folder “Apps’ in the dropbox folder (which should be installed in your operating system during part [1])Screen Shot 2016-03-18 at 14.44.32
  5. You are given the opportunity to change the display time of the slideshow and the transition effects.
  6. Send a picture to the e-mail address you set up in 2. You need to send a picture file (rather than a pdf etc.) and then press ‘play’ on photolive
  7. If the system works you should see the photo you sent yourself appear in the photolive display. Sending yourself another photo should add this photo to the slideshow.
  8. If the above doesn’t work check you have pictures in the Attachments folder in dropbox. If you don’t it means they are not being sent there (review the send to dropbox e-mail if this is the case). Put some photos directly in the folder and see what happens to the photolive display. If this doesn’t change you may have selected the wrong folder so review this. 
  9. If you don’t want to hand out an odd looking e-mail to your delegates you can create a gmail account with a specific e-mail address (I created basisquiz@gmail.com for the test I performed at the BASIS course). Click on settings when logged in (often found via the cogwheel symbol) and then click on forwarding and POP/IMAP. Insert your send to dropbox e-mail here.You then have to confirm to dropbox that you do own the “send-to-drop box” e-mail. You will need to go back to the “send-to-dropbox e-mail” page and in the options tab select “include HTML body” and “plain text body“. This means the e-mail gmail sends to confirm will appear in the attachments folder in dropbox. You can find the confirmation hyperlink and click on it (or copy and paster it into a web-browser) to confirm. These FAQs have further information.

If you have completed 1-9 hopefully when you press play on the photolive programme (and it is linked to the attachments dropbox folder) any e-mail with a photo you have given to the audience that links to your “send-to-dropbox” e-mail should start appearing in the slideshow!

Sadly I haven’t found a work-a-round for embedding in powerpoint or keynote . Therefore you will need to stop and open photolive if this is part of a formal presentation

I’d love to know if these instructions help or if you have a quicker way to hack this…

This work would not have been possible without Dr. Craig Sayers insight so a big thanks to him!

The Sounds of Winter: An audio-visual review of Paediatric Respiratory Disease

The leaves have turned brown, the temperature has dropped and Emergency Departments and wards are beginning to fill with wheezy coughing children. In the Northern hemisphere winter is with us…

Emergency and Urgent Care are often over-burdened by the effects of this seasonal change, which is particularly extreme in children. The predictable increase in respiratory disease this time of year should mean we are experts in its management but the combination of frequent staff turnover and challenging disease phenotypes militates against this.

Why is acute paediatric respiratory disease so challenging?

Different diseases are not only difficult to describe but may co-exist in the same patient

Asthma, Bronchiolitis, Croup and Pneumonia are 4 seemingly distinct clinical entities in children. However there is also this odd condition that exists between bronchiolitis and asthma in the UK termed viral wheeze (or as some family doctors call it: wheezy bronchitis). Finally the most common respiratory ‘condition’ that children acquire is a viral upper respiratory tract infection.

The snotty infant, off feeds with sub-costal recession and a cough, could have any one of these except asthma (although even the British Thoracic Guidance doesn’t use age as an exclusion). Ask a medical student to define asthma and I suspect you’ll get a potentially more correct answer than a doctor in the early years of training. The student may quote the patho-physiological diagnosis of reversible airways disease and bronchial mucus secretion. The junior doctor will be honed in on wheeze and prior history i.e what they see in practice. In the <1 group where bronchiolitis (breathing difficulties, cough, poor feeding in the context of wheeze and/or crepitations on auscultation [1]) is a common differential the diagnostic conundrum versus viral wheeze can cause confusion.  Practical definitions are often worthless until you see enough cases to be able to apply pattern recognition.

Croup is technically an easier diagnosis – a pattern of characteristic cough and stridor differentiates it from other respiratory conditions.

via mommy hood

However it’s not uncommon to see a child with stridor and a history of barking cough but wheeze on auscultation and a prolonged expiratory phase.  There is an association between croup and asthma and certainly a proportion of children can have mixed signs. This isn’t unsurprising as parainfluenza or any of the other viruses that can cause croup can set off the inflammatory cascade that typifies viral wheeze and asthma.

Finally pneumonia is one of those terms which is frequently used in different ways by health care professionals and the public. Lower Respiratory Tract Infections may be bacterial or viral in origin and although pneumonia (an infection or inflammation of the lung caused by nearly any class of organism) can also be either it is often used to imply a bacterial cause. Diagnosis using clinical signs is fraught with challenges (regardless of how clear the crackles are after having seen the x-ray). There is often an (unnecessary) tension to exclude pneumonia as the cause of the severity of a child’s condition in asthma or bronchiolitis. Which leads us nicely onto judgements of illness severity – a real but often unrecognised health system challenge.

Mild, Moderate and Severe Acuity Descriptors have inherent face validity but their assessment is more complex than the clinical features alone. 

Both professionals and members of the public would probably have a similar opinion on the severity of respiratory distress in this child

However we know there is large inter-observer variability in assessment. My own work has shown that experienced paediatricians differ in their interpretation of the severity of specific clinical signs.

Acuity Table from PVC Table

To be fair, interpretation of respiratory signs was probably the least variable (compared to alertness, hydration status etc.) but 40% of participants still differed in their assessment in this category. There are numerous reasons for this (blog pending on the role of gut instinct in interpretation of clinical signs) but one explanation is that specific features of respiratory distress don’t take into account previous illness trajectory. Typically a clinical feature (moderate recession etc.) will be linked to a degree of severity or a specific score. This is done in isolation of the other clinical features and doesn’t contribute to an overall impression of whether the child may be tiring or not.

How “severe” is the respiratory distress in this 8 month old child?

The child is grunting, has subcostal recession, and a raised respiratory rate (saturations were 94% in air). The underlying diagnosis could be anything from viral wheeze to pneumonia but you’ll have to take my word for it that this little guy had viral wheeze.  On a published score  relevant to the child’s age he would be at least moderate to severe. In practice an overall impression is also made on how long you think he will be able to sustain that level of work of breathing for. Part of this decision is based on experience and hence the variability of response when I show this video to different clinicians; from “wow, he is sick” to  “yes he is working hard but he is not too bad

 

Trajectory of illness is important. A child at point x may have been observed to be getting better (A) or getting worse (B). To an external person arriving to review the child there will be no difference between A and B but to the observing clinician their judgment on illness has been altered by how the child’s acuity has changed over time. There is a complicated third arm as well describing the ‘stable’ child who may suddenly improve or deteriorate (C1 or C2). Bronchiolitis, especially in neonates, often has this pattern. An experienced clinician develops a feel for the potential for sudden deterioration (although may not be able to explain why) and hence modulates their judgement on severity accordingly.

Acute Paediatric Respiratory Disease can be challenging

Every winter throws up a different severity of viral antigen producing varying intensities and complexities of respiratory presentations. There is not always a definitive best evidence approach. Considering all possible diagnoses, being aware of trajectory of illness and always listening to the parents will at least ensure you don’t get caught out.

I finish with a video of our grunting child taken 6 minutes after the original footage was taken (he received a single salbutamol nebuliser.) Please note the initial noise is from the child in the next cubicle 🙂

Thank you to the parents of these children who kindly consented to the filming and display of the video on an openly accessible site.

For those interested there are vine versions of the grunting and croupy child. Both parents were keen other health care professionals should be able to learn from them.

[1] This is taken from the SIGN Bronchiolitis 2006 guidance – although out of date the definition itself I think is pragmatic and remains credible

Paediatric Emergencies Conference: Top 10 papers 2013-15

I was asked to do a short session at Paediatric Emergencies 2015 (14th October) on the top ten papers over the last 2 years (seems like it was the week for this type of review!).

It was an interesting challenge to define ‘top’ and I took a pragmatic approach of reviewing pemdatabase.org and then checking my long list against the most cited articles on web of science (using pediatric* OR paediatric* AND emergenc* in the MESH and topic headings).

What resulted was 30 articles:

Chosen Papers

The top 10 were chosen on the basis of interest and future potential to change practice. I’m happy to be challenged and more than willing to accept further suggestions 🙂

(please click on the box itself to go to the abstracts and the link below it for my thoughts on the paper and reasons for inclusion)

Fever and Sepsis

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Slide11
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5 referral tips that won’t annoy a paediatrician #tipsfornewdocs

Paediatricians have a reputation for being ‘nicer’ than some other branches of medicine. This is probably unfair on the other specialties and more likely to represent the fact that referrals to paediatrics are almost universally accepted. This does not mean that less thought should go into a paediatric one though. In fact Paediatricians can be as unforgiving about poor quality referrals as anyone else (they just might not say so to you directly).

There are a few common bug bears that I thought would be worth sharing with health care professionals working in fields who may be referring to a Paediatric in-patient team. I do this in the context of a Paediatrician (who works in an Emergency Department) often making referral to other Paediatricians. I am sure there are many other points to add to the list but as a starter…

  1. Think before you speak

For any referral run through what you are going to say before you say it. Too often a junior after being told to refer an infant seen in an Emergency Department instantly picks up the phone and dials. This results in an incoherent story based on what the senior has told the junior about the child not what the paediatric team need to know about the child. If you can’t explain the reason for the referral in less than 15s then you haven’t got to grips with the case and probably don’t understand the reason for admission. This is a skill that requires practice and teaching. In August ask more experienced colleagues what they would say and get them to listen to you making referrals.

  1. Don’t confuse stridor and wheeze

Stridor is an inspiratory noise

Wheeze is generally an expiratory noise

Referring a child who you have said has croup but describe them as having only an expiratory wheeze is diagnostically mis-leading. There can be a mixed picture and if you are unsure – say so. During winter there will be a handful of children who it can take a while to work out the primary cause of their respiratory distress. Precision in terminology is a good sign you are able to risk assess correctly. And with that in mind…

  1. Don’t say “I’m worried this well-looking child with a non-blanching rash has meningitis

The primary concern in children with a non-blanching rash is meningococcal septicaemia. They may have meningitis as well but this is not the primary concern. While it is not unreasonable for parents to use one term to cover both a physical sign and a disease process this is not case for the medical profession.

Meningitis: Inflammation of the meninges (can be viral or bacterial)

Meningococcus: The organism Neisseria Meningitidis (a gram negative bacteria). Meningococcus in the blood is the cause of petechiae and subsequently purpura, the non-blanching rash, tested for with the glass test.

Meningococcal disease: Infections (both septicaemia and meningitis) caused by meningococcus.

  1. You may miss seeing the signs of tonsillitis but you must have at least looked for it. 

There is a spectrum of tonsillar appearance and I suspect even between experienced paediatricians there is variation in how much pus or spotting constitutes tonsillitis. In fact disease progression may mean in between General Practice referral and eventual arrival on the wards an exudate may have appeared.

However the answer to:

“Have you looked in the throat?”  should never be “no

Click here for a quick guide on how to look in the throat of a child.

  1. Always, always take a good constipation history in children with abdominal pain

Does your child have constipation?” is not taking a constipation history….

You need to define regularity of bowel habit and its appearance.

Normal‘ is not an appearance. A description is important and in my experience children old enough to speak get the giggles talking about ‘sausages’ or ‘little round balls’ which helps engagement.

Passing a motion should not be painful. It is surprising how often a parent only finds out their child has severe discomfort on the toilet when someone else asks the question. Some more thoughts on constipation on childhood here

I hope these 5 points are helpful, as I say I am sure there are more, and I hope to add to this over time. Please, please never be afraid to ask for advice when dealing with children. Thinking through the question though will always be in the child’s best interest.

All the best

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A Prof. on PROMISE

The recent PROMISE Trial has resulted in some great discussions about the impact this final part of the Early Goal Directed Therapy Trilogy will have. See Rebel EM’s  concise review and Ric Body is on top form with his analysis on behalf of st.emlyns

I managed to squeeze 5 minutes out of Prof. Tim Coat’s busy schedule to garnish some of his thoughts. As one of the authors he was able to give his reflections on how his practice will change and what the future holds for EGDT..

 

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