Category Archives: FOAM

Not ‘just’ a fever….

This case is brought to you courtesy of ASK SNIFF . We are very grateful to the family of the young boy for consenting to the video being made publicly available. We hope it will be helpful for all health care professionals who deal with children.

Presenting Complaint

A 3 year old boy presents to an emergency department (ED) with a fever.

His parents describe him has having been very miserable from the start of the illness. Following a visit to his GP, he was prescribed penicillin but developed a widespread rash. He returned and an allergy was suspected. His antibiotics were switched to Clarithromycin but there was no improvement in his symptoms. 4 days into his illness he started complaining of pain in his right foot and his parents noticed he had been walking with a limp. Today they were worried he might be dehydrated as he had developed dry lips.

Initial Features

This is the child as he presents:

What additional information would you like in the history?

 

What additional clinical information would you like?

 

Diagnosis and Management

What is/are potential differential diagnoses?

 

How would you manage this child?

 

Learning

 

What are the key features?

 

Why is it a difficult diagnosis?

 

What you may not know

 

Outcome

After initial treatment our young boy started to make an improvement

Acknowledgements

A huge thanks to the family for agreeing to universal publication of this case. We are indebted to them for being able to demonstrate the key features of Kawasaki’s Disease. The video footage was obtained by Dr. Mariyum Hyrapetian who contributed to the production of this short case and we are grateful for her support as well as that of Whittington Hospital who allowed filming to take place. This video was taken as part of the ASK SNIFF research programme. ASK SNIFF (Acutely Sick Kid Safety Netting Interventions For Families) aims to to develop safety netting interventions for families to use to determine when to seek help for an acutely sick child.

ASK SNIFF 5 - Strap

References

  1. Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, et al Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Pediatrics 2004:114:1708-33.
  2. Tsuda E, Hamaoka K, Suzuki H, Sakazaki H, Murakami Y, Nakagawa M, et al. A survey of the 3-decade outcome for patients with giant aneurysms caused by Kawasaki disease. Am Heart J 2014;167:249-58
  3. Newburger JW, Takahashi M, Gerber MA, et al. Diagnosis, treatment, and longterm management of Kawasaki disease. Circulation 2004;110:2747–71
  4. Burns JC, Shike H, Gordon JB, et al. Sequelae of Kawasaki disease in adolescents and young adults. J Am Coll Cardiol 1996;2:253–7
  5. Belay ED, Maddox RA, Holman RC, et al. Kawasaki syndrome and risk factors for coronary artery abnormalities: United States, 1994–2003. Pediatr Infect Dis 2006;25:245–9
  6. Brogan PA, Bose A, Burgner D, et al. Kawasaki disease: an evidence based approach to diagnosis, treatment, and proposals for future research. Arch Dis Child 2002;86:286–90.
  7. Eleftheriou D, Levin M,Shingadia D,Tulloh R,Klein N,Brogan P Management of Kawasaki disease Arch Dis Child 2014;99:74–83 [Open Access]
  8. Harnden A, Alves B, Sheikh A. Rising incidence of Kawasaki disease in England: analysis of hospital admission data. BMJ 2002;324:1424–5.
  9. Moore A, Harnden A and Mayon-White R Recognising Kawasaki disease in UK primary care: a descriptive study using the Clinical Practice Research Datalink British Journal of General Practice 2014; 64(625) e477-e48
  10. Harnden A, Tulloh A, Burgner D. Easily Missed? Kawasaki Disease BMJ 2014;349:g533
  11. Benseler SM, McCrindle BW, Silverman ED, Tyrrell PN, Wong J, Yeung RS. Infections and Kawasaki disease: implications for coronary artery outcome. Pediatrics 2005;116:e760-6

An introduction to Quality (for Improvement)

I recently presented at the RCPCH Clinical Tutors event on the theme of Quality Improvement. I was doing an introductory talk while colleagues Jane Runnacles and Bob Klaber provided advice for those with more experience.

I was asked by the college to place the presentation on the college tutors website but I felt the collection of pictures and minimal text wouldn’t be much use to those not at the talk therefore I have quickly done a video-cast of the presentation. I have edited some of the content and wasn’t able to embed some of the videos but have supplied bit.ly links for them.

I am by no means an expert on quality improvement but have some credibility in a few projects I have been involved in. The links to the journals I mention are below:

Paediatric Trainees and the Quality Improvement Agenda: Don’t just do another audit

Delivering Quality Improvement: The need to believe it is necessary

but I also recommend you have a look at the Archives of Disease of Childhood EQUIP series which starts with a brilliant introduction to Quality Improvement in Paediatrics and Child Health

As always feel free to comment and question!

The video cast is below

and here is the original slide-set:

and the bit.ly links

http:/bit.ly/lonenut

http:/bit.ly/bronzeagechange

The Path to developing F.O.A.M (Free Open Access Meducation) #FOAMed

I’ve often felt a slight dissonance between the world I inhabit as a clinician and the world I inhabit as part of the FOAM community. This shouldn’t be the case but the disconnect appears to persist. This is partly caused by myself, “I’m not sure anything I produce will be accepted in my workplace” and partly re-inforced by my environment, “Oh FOAM stuff! Don’t really do it. Go and talk to Damian, he’s interested in it.”

When I started as a consultant I made a conscious effort to try and avoid these stereotypes. Why can’t FOAM material be produced as part of my clinical work? So with the support of colleagues I have gone about doing this; reflected by a number of recent blogs:

Leading an Emergency Department

Listen – Look – Locate: An approach to the febrile child #tipsfornewdocs

As a result I’ve begun to notice a common trend in the way others have been getting involved in creating their own FOAM:

 

 

I have not based this construct in any form of theory, it’s much more back of the napkin type stuff.  However I think I have taken some inspiration from Mike Cadogan (who else!) in terms of how FOAM networks have been created and also some brilliant analogy on ‘blogging’ ecosystems. I also recently came across the concept of rhizomatic learning which I think is very akin to the philosophy which has sustained the FOAM community of practice.   I am hoping though those more widely read than myself will be able to apply some theory to my approach.

The idea is as follows:

 

Young girl watching a fishbowl1. Curiosity

The initial spark is formed when an individual hears a conversation or reads an article that is FOAM related (or  FOAM-esque). This may need to happen a couple of times and, more often than not, is re-inforced by knowing a FOAM-ite who can explain in more detail. Often the first leap is into a social media domain (i.e twitter/google + etc.)

 

 

2. CurationCuration

The interaction with social media and then through to FOAM resources often begins with ‘hoarding’ of content. The available information can feel quite overwhelming to begin with and so web-links of blogs and podcasts are saved religiously . This phase may be brief, or prolonged, and is clearly aided by good filing systems!

 

 

 

 

 

3.  Celebration 

As confidence grows, sharing material which has been enjoyed or has resonated with the person’s own beliefs and practice, becomes more frequent. This may simply be by word of mouth (leading to increasing “curiosity” in others) or via social media channels.

 

 

 

 

4. CollaborationColloboration

Increasingly active participation in the FOAM community then leads to discussions with that community. Sharing material naturally leads onto constructive criticism of the subject. Often many of those involved in FOAM will remain at this junction of the path. However for some ‘collaborations’ with others lead to a desire to participate further…

 

"The Beginning" Road Sign with dramatic blue sky and clouds.5. Creation

Having immersed themselves in FOAM some will decide to then produce their own content. This may simply be in the form of a blog posting, perhaps with a “collaborator” or a review article. Increasing ease of access to recording equipment has seen ever more podcasts being released and the influence of SMACC on raising awareness of PK type presentations has led to a variety of video-cast style short talks.

6. Cultivation

The development of new FOAM material is only really the beginning as its creation gives the author deeper understanding of the advantages and limitations of the medium they have chosen. New insights lead to new understanding and increased collaboration, not only cultivating others interest, but leading to new skills sets in the individual themselves.

Path to FOAM

 

 

 

I have spent time pondering whether it is a path or a cycle. It probably doesn’t really matter but as always would be grateful for feedback!

The Fun Index: What level justifies the use of trampolines?

A decade ago the number of trampoline injuries was described as an ‘epidemic’ by some commentators. In part this was based on the huge rise in injuries in the UK between 1990 and 1995 when numbers soared from 29600 to 58400 [1]

Screen Shot 2014-09-18 at 21.15.49

At the weekend my children were playing on trampolines at a country farm. I will be honest – I have mixed feelings on trampolines. Not a clinical shift goes by with there being at least one child who has had some form of injury from a trampoline (regardless of the presence of ‘safety netting’). And at least on of my colleagues agrees! One the flip side I concede they are great fun.

So how much fun do they have to provide to outweigh the trouble they cause? I was mulling this over while reading a paper on QALY’s recently and decided to have my own stab at health economics.

Lets create a theoretical ‘fun’ index.

The Fun Index

Finding good data to support further calculation is tricky. Surveys have found that 49% of  4-15 year-olds trampoline, while 23% do so regularly [2]. Working out how many trampolines there are in the UK is tricky  – in 2003 40000 were sold but I am having difficulty finding more recent figures [3]. The incidence of trampoline injuries is also difficult to quantify – US data put a figure of 160 per 100000 children in the 5-14 age group [4]. So lets do a back of the napkin calculation:

In an region with 100000 children there will be 49000 who are trampolining. Of these 160 will get injured.

The total amount of fun for those who don’t get injured (and taking a stance that most will have good fun possible) scenario is:

48840 x 0.8 = 39072 units of fun

If all children injured have little fun (again a least possible fun scenario):

160 x 0.2 = 32 units of fun.

Even if children had not much fun on their trampolines you can see the huge numbers of children who don’t get injured will always mean fun will be had!

[note though this approach doesn’t take account of multiple children on a trampoline which clearly increases the fun but also increases in the risk of injury]

I welcome challenge on this approach but only if taken in the spirit of this blog 🙂

Trampolining

[1] AvonSafe – Action for safety report 2011

[2] BBC – The ups and downs of garden trampolines 2012

[3] Bhangal K, Neen D, Dodds R. Incidence of trampoline related paediatric fractures Injury Prevention 2006;12:133–134.

[4] CBS News – Pediatricians warn against trampoline use, citing injury risk 2012

(Some serious but user friendly guides to health economics can be found here and  here)

The ice bucket challenge: The best solution to SVT

Not one to waste an educational opportunity I used my ‘ice-bucket’ challenge video to talk about another use of ice-buckets…

SVT

Children in Supra-ventricular Tachycardia (SVT) are not uncommon presentations to Emergency Departments. It’s worth remembering that infants won’t present complaining of palpitations and may just be brought in by parents with poor feeding, irritability or just not being ‘right’. There is a really nice blog post about SVT  from Paediatric EM Morsels but I want to focus on one form of treatment – ice-water. I have yet not to have a child present who I have been unable to revert by this technique (It will happen I am sure…).

The key mistakes people make are:

1) Not holding properly. Young infants must be completely swaddled and have their face held in the water. This looks dreadful – so a lot of pre-warning to the parents is necessary.

2) They don’t complete immerse the face. It is not a slight ‘dab’ – the whole face must be immersed

3) They panic at 3 seconds.

In my experience you need a good 5s (sometimes slightly longer). This feels like a very long time (and is worse than the swaddled hold!) so you must brief parents (and other staff!) extensively about it.  Another approach is to basically hold longer than comfortable, and then hold a bit a more, if you don’t feel like counting in your head.

My ice-bucket challenge was to demonstrate what 5s feels like. Believe me if you can revert this way it is A LOT better than adenosine….

(Would have been better if I had thought through in advance what I was going to say but the light was running out fast…!)

[I have donated to the MND association]

EM isn’t child’s play when it’s Emergency Maths

New starters to paediatric wards, emergency departments and general practices around the country are faced with a huge array of formulas and equations to navigate. Most are relatively simple and require only a basic revision of multiplication tables. However some calculations are required in a time critical manner and anyone experienced in treating children knows how easy it is to make mistakes. In resucitation situations there may be many drug doses to calculate using some medications which may not be frequently used by the person prescribing them.

Given paediatric pharmacy is a very ‘mass’ based subject prompt calculation of weight is an essential first step. The traditional approach taken is that advised by APLS courses:

Weight 0 -1 = (Age/2)+4

Weight 1 -5 = (Age x2)+8

Weight 6 -12 = (Age x3)+7

There is a great blog from Simon Carley on the introduction of three equations rather than just one and the problems this may cause. The key point being does having three forumula increase complexity, and therefore risk of error, especially given we aren’t really sure what amount of difference in weight is clinically significant?  Other mechanisms of calcuating weight do exist, the broselow tape for example, but I especially like this one via Dilshad Marikar

(2010 APLS weight estimation) – Talking to the hand from Paediatric Tools on Vimeo.

The Leicester Hospitals Emergency Department have been working for sometime on a drug calculator for use in Emergency Situations. I’m very grateful to Dr. Mike Pearce, Dr. Mark Williams and Dr. Steve Corry for their hard work on bringing this to fruition. In the spirit of ‘FOAM’ we are sharing our efforts, not because we think it is any better than other systems out there, but because we are sure improvements can be made.

Drug Calculator

It can be downloaded by clicking LRI Paeds Drug Calculator v1.4. It’s been extensively tested and has the approval of our senior paediatric pharmacist. As with all such calculators we can not accept responsibility for its accuracy or ensure its currency.

Please let us know what you think via comments, @damian_roland or @em3foamed

Leading an Emergency Department

August is changeover time for junior doctors in the United Kingdom and hospitals of all sizes are welcoming new staff into their departments. In Emergency Medicine it is especially important that new staff are given support and supervision as the hectic nature of our specialty can be challenging. One of the most daunting aspects for junior doctors who have progressed through training far enough to start adopting more senior roles is the task of leading the Emergency Department.

Challenges Ahead

Being doctor-in-charge requires a skill set far greater than clinical knowledge. You must be also be a good communicator, negotiator, and arbitrator. There is a neat little summary of the managerial skills required here by Rick Body from St.Emyln’s. In order to help some of our new registrars Prof. Tim Coats has discussed some of the things he does while doctor-in-charge which we thought we would share:

There is also a podcast 

Please do feedback any additions or suggestions!

%d bloggers like this: