This is the nineteenth #WILTW
A significant proportion of patients in health care services are seen by multiple health care professionals (excepting primary care and out-patients). Acknowledging some patients do deteriorate rapidly, generally there are the same clinical signs and symptoms to be observed regardless of the different staff seeing them. It is well recognised however that patients can have many clinical encounters before someone finally recognises they are seriously ill [1]. The fact that some clinicians see different ‘things’ in patients is not unsuprising. There are some clinical signs which are very subtle, such as work of breathing and fine movements, which require training and repeated exposure to be able to put into a context which makes pattern recognition obvious.
However others are more clear; physiological features such as heart rate and breathing rate being fixed signs which should not differ when examined by different individuals. To be clear I am not pondering over gut feeling here. The literature on the use of ‘gestalt‘ by experienced clinicians to recognise serious illness is substantial but this is not about subtle signs or intuition. How is it that in the same time span a patient who has clear features of illness may be recognised by one person but not by another? Experience and knowledge play a role but continued failure to recognise significant illness even by experienced professionals represents a significant challenge for the health care community.
I have a research interest in the educational use of clinical video cases. This hat often collides with my clinical practice hat when system errors occur in the recoginition of illness in children. This dilemma of why a particular patient isn’t recognised as being ill (or the converse – when someone is overtreated as being very unwell when in fact they weren’t) is an important issue as is often the root cause of communication problems between departments in hospitals.
The video below was consented for general viewing by the patients’ mother (appropriate hospital and national guidance was followed). I use it (hopefully!) as a potential grey case to highlight how the same clinical features can be interpreted differently . I’m hypothesising there maybe differences in determining which are the salient clinical signs in this case. Please feel free to leave your thoughts in the comments section (appreciating previous comments may bias you so try not to look!). Regardless of whether I’m right or wrong I hopefully will learn something I can feed back on in the future!
[Oxygen Saturations 96% – Heart Rate 170 – Temperature 36.4]
What have you learnt this week? #WILTW
[1] RCP NEWS standardising assessment of acute illness severity
With the proviso that I am adult trained (anaesthetics), albeit with 2/12 PICU. And I watched your video without sound so I’m missing any auditory cues.
Subcostal recession, ?head bobbing, ?mouth breathing/gasping. Possibly some splotchy skin (might be the video). That kid twigs my spidey sense. They do not get to go home. Equally, I’m not about to intubate them right now. I’d want them in a monitored area, ideally HDU level.
I’d be talking to a friendly paediatrician 🙂
I’d love to know what the paed trained people are seeing. And also an EM (non PEM) take on it.
Thanks FS – for taking the plunge and putting your thoughts out there!
Without the sound you miss the obvious expiratory wheeze which doesn’t need a stethoscope to pick up! There is recession yes and this child should twig your spidey sense as their respiratory rate is also raised.
They also look comfortable – an odd one this: I am telling you they are working comfortable hard? What is this man on about!
I deliberately didn’t give the background that this child had been like this for 2-3 days and was feeding very well with regular wet nappies. Parents concern was with the noise of breathing and not the work of breathing. In this context I see a child with clear signs of respiratory distress but who isn’t tired. With clear safety net advice I did eventually send this child home.
In the absence of further information however you have a child with obvious recession and as a young infant is relatively high risk. A paediatric opinion is therefore entirely justified.
What you ‘see’ requires context – a diagnosis of a ‘happy wheezer’ a cohort of children who often work comfortably hard can only be made with further information and often observation.
Your spider senses served you correctly!