Category Archives: Medical Education

Blogs and Posts related to Medical Education

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:

 

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 Star Wars guide to Quality Improvement

Despite being a galaxy far, far away the principles of quality improvement still hold. Here is what we can learn from some of the main Star Wars protagonists…

Yoda (The Improvement Guru)

Yoda

Yoda knows every improvement methodology in the book. Sadly like many experts his explanation of it doesn’t always  go down well with his disciples. Especially novices who often get bored and run off to try it their own way. Perhaps Yoda should read Demystifying Theory and its use in improvement. To be fair he has some great stories to tell though…

R2-D2 (Data)

R2D2As Deming said, “In god we trust, all others bring data“. The problem R2-D2 has is despite being full of information very few people are willing to listen, or even when they do, understand him. Whether a brilliant shot with a blaster, handy with a light sabre or a fantastic pilot if you don’t understand data you will never find the solution (map) to the really big problems (death stars)

 

Han Solo (The Charmer) 

Han SoloYou have read the latest improvement science literature. You have run through your model of improvement. Your PDSA templates are ready to go. And two weeks later you are still waiting for someone, anyone, to complete your new  proforma. Just as you are about to give up, Han Solo wonders into cantina, picks up a dog-eared form used by someone to doodle on and says, “this looks ok kid“. Suddenly, everyone, is using the form.

Finn (The convert)

FinnHaving  just read “Don’t just do another audit” Finn has had something of an epiphany. Jumping ship from his organisation’s normal way of doing things he finds things are a little tougher than he expected. Improvement is really hard but it’s a lot more beneficial in the long run…

Darth Vader (The Strangler)

Darth Vader

All good improvement projects meet a brick wall. Darth Vader is an especially tall and strong one. Able to silence any new innovation without even speaking Darth knows it is going to be his way.

Or his way. Or someone is going to suffer.

 

 

The above were the first 5 which I have subsequently added to. Always keen to hear more suggestions!

Rey (The learner)

Rey_Star_Wars

Very rarely do health care professionals lack passion. However like Rey you sometimes don’t realise what your actual talents are. A small improvement project can be the first realisation that you really can make a difference and not just talk or dream about it. And even more like Rey learning is pretty exponential when it begins.

Thanks to Helen Bevan for suggesting Rey

C-3PO (The sceptic)

C-3POTo some people the status quo is simply the safest place to be and trying anything new is never going to be successful.

The odds of successfully surviving an attack on an Imperial Star Destroyer are approximately…

However sceptics are often predictable and can be inquisitive enough that with a bit of persistence you may find they join for the ride (only to find something else to complain about…)

Tie-Fighters and X-wings (Design) 

tie_fighter_x_wingThere is an inherent attraction to things that look good. Great visual design is always going to improve the chance of a successful project. From observations charts to surgical checklists you want something that looks streamlined and efficient.

Lando Calrissian (The inconsistent supporter)

Lando Calrissian

A improvement project is failing when you find unexpected support from someone who comes out the woodwork to provide additional help and resources when they are most needed. Then just as you think things are back on track they side with the stranglers and the project is stopped dead. Building a team is vital but understanding their allegiances even more important. Remember though not everyone who sides with the Empire does it for ever…       (thanks to  for suggesting Lando)

Boba Fett (the mercenary) 

Boba FettHard working, resourceful and clever but really only in it for the reputation or an award. Always delivers but only at a price. Watch out for short terms allegiances with Stranglers and inconsistent supporters

(Thanks to Ross Fisher for suggesting Boba Fett)

 

Princess Leia (the deliverer)

With a determined, pragmatic and no-nonense approach to getting the job done all improvement projects need a Leia. Equally at home dealing with high level hierarchy as she is with front line staff; Leia makes sure the right processes happen at the right time. Not afraid to express her opinions but always willing to recognise the skills of others.

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

What I learnt this week: Does time make teams? #WILTW

This is the 48th WILTW 

In the most recent edition of the Emergency Medicine Journal there is an article entitled, “How familiar are clinician teammates in the emergency department” by Patterson et al. I think it is a pretty interesting study, even if you are not a health care professional (but I’m a bit of data geek so not everyone will agree!)

The authors looked at the amount of time any given clinician (by this they meant doctor, nurse or support staff) spent with any other clinician over a 22 week period. By averaging out times they calculated something called ‘weekly mean familiarity’ – the average amount of time any two clinicians would spend together. Because of the shift nature of Emergency work and a limit to the amount of shifts you can do there is clearly a maximum time you can spend in contact with a colleague. However some of the weekly mean familiarity figures were surprisingly low. For example, Junior Doctors would only spend 0.4 hours, on average, working with the same Junior Doctor per week. I’ll be honest I still can’t quite get my head around how small this number is but the maths do seem to work out.

Teamwork

This article struck a cord as I attended a lecture this week on Human Factors by Patrick Mitchell, a neurosurgeon from Newscastle. He is particularly focused on casting a wide educational net i.e you must train whole departments if you are to reduce human errors; you can’t just cherry pick the most interested individuals. One his themes was the difference between groups and teams:

Groups and Teams

Table via For Dummies 

Essentially “While all teams are groups of individuals, not all groups are teams [1]” 

These comparison tables are often seen as twee and theoretical rather than  practical. However I’m sure that team spirit being important to effective functioning of the unit is not unique to Emergency Departments. But is a component of team dynamic a function of the time they actually spend together? Given the variety of rotas in many health care organisations I think it’s important we consider how often staff do get a chance to ‘be together’. Many in medicine have complained that working time directives targets have been bad for patient care. I do not completely buy into this. I do believe though the team spirit is vital and that Patterson et al. has given me much to ponder.

What have you learnt this week? #WILTW

1. Source: Boundless. “Differences Between Groups and Teams.” Boundless Management. Boundless, 17 Apr. 2015. Retrieved 17 Apr. 2015 from https://www.boundless.com/management/textbooks/boundless-management-textbook/groups-teams-and-teamwork-6/defining-teams-and-teamwork-51/differences-between-groups-and-teams-261-4011/Teams works differently from groups.

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

What I learnt this week: Research resilience #WILTW

This is the 36th #WILTW

This week I formally received my PhD. A chance to dress up, wear a funny hat and sit with a sense of dread that you will be the person who trips up the stairs en route to shake hands with the vice-chancellor. My PhD was completed well over 6 months ago – my first graduation ceremony postponed as it ironically clashed with the presentation of my findings at an academic conference. Since then enough time has passed that I have ‘graduated’ in other ways; most notably a new consultant job with increased levels of responsibility and accountability.

Completing a PhD is a big task – the write up was painstaking and the viva a more challenging process than I had expected. The latter perhaps a sign a naivety on my part, the former an inevitably. It was uncomfortable though, in a week in which I have faced a number of challenging clinical situations, to be forced to ponder what I had gained from this academic qualification? Other than some letters after my name and a life time of, “so can we call you Dr Dr now?” of course..

Snakes and Ladders

Earlier in the week I spoke to a group of academic trainees in Emergency Medicine. I was in hindsight maybe too stark in my views of the challenges of academia. The pressure of ‘output’ doesn’t relent. You can leave what might be the most horrible shift behind but even when you press submit on your grant or paper submission you can’t relax until you find the words ‘accept’ on the email in response. This maybe months later. You have repeated tough decisions about which paths to follow, which projects to chase and which fantastic ideas to drop to ensure you have a balanced work load with adequate capacity to not impinge on your clinical duties.

I wasn’t initially sure my PhD really prepared me for any of these challenges, it certainly hasn’t had the dramatic effect on my writing style I hoped it might! What it has given me though is resilience. Despite all the negative things I could think of, some in honesty clearly over-emphasised for effect (follow @academicsay for examples), I still feel enthused and passionate about my work. For every rejection letter there is (eventually) a publication. For every day wasted on a grant application there is chance to work with some truly inspirational people and feel that you are contributing to work that makes a difference. Whether the PhD gave me resilience or just confirmed I had it I am not sure. What I learnt this week that tenacity is always eventually rewarded.

Graduating Isla 2(My daughter on her graduation from nursery…)

What did you learn this week #WILTW

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