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]

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, even personal injury cases (regardless of the presence of ‘safety netting’). In the unfortunate event of an injury, it’s important to consult a motorcycle accident lawyer New York City to understand your legal options and rights. And at least on of my colleagues agrees! One the flip side I concede they are great fun. In many legal cases, polygraph tests are employed to discern the truth in criminal investigations. They can be a useful tool in gathering evidence, and are often used in conjunction with other investigative techniques. Contact experts like lie detectors uk for professional services. Additionally, if your injury involves negligent medical treatment, a medical negligence attorney Spokane specializes in holding healthcare providers accountable for patient harm.

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.

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:

48840 x 0.8 = 39072 units of fun

If all children injured have little fun (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 🙂

[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)

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

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]

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.

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

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.

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!

The first Wednesday of August in the UK represents an exciting time for a cohort of newly qualified junior doctors who start their medical careers. For those commencing in Paediatrics and Emergency Medicine, or starting these specialties for the first time, the prospect of managing young potentially unwell children can be daunting.

Having to assess the “febrile’ child often results in a drain of colour from even the most confident of junior doctors. This quick presentation is centred specifically around assessing the febrile child and contains a few experiential and evidence based tips.  It is not a comprehensive guide to history taking or examination – please watch #Paedstips you won’t find in books , How to examine children, and look at the resources via Seeing kids is child’s play at St.Emlyn’s  for further detail.

If you need a framework to start with though – go no further than Listen, Look and Locate:

 

Many thanks to the SMACC team for releasing my #SMACCGold talk: Evaluating Education. The background story can be found here

The publication related to the 7I Framework can be found here

Video

Damian Roland – Evaluating Education from Social Media and Critical Care on Vimeo.

Slides:

Audio: link here

“Assessment drives learning” raises wry smiles (and occasional heckles) whenever it is mentioned. However it’s unfortunately the case that ‘encouragement’ to understand and learn comes from the need to demonstrate that new knowledge in some form of test. In Post Graduate Medical Education these tests are specialist exams which are required in order to progress to more senior stages of training. The scope of information needed is huge (and often the exams split into various sections to make them manageable!). The curriculum describing the knowledge similarly large and there is great heart ache as you scroll through 50+ pages of bullet points each starting, “the trainee will be required to know…”.

By necessity curriculum are bland but what has become increasingly apparent to me is the large blocks of ‘grey’ knowledge that appear to be missing from them. I say ‘them’, I can only really speak for Paediatrics, but I am given confidence in this assertion by the ever increasing momentum of the #FOAMed movement. Chris Nickson has previously eloquently explained why #FOAMed itself doesn’t need a curriculum. However while assessment drives learning, so does experience. It’s quite clear from the huge amount of materials posted daily on a variety of clinical topics there is a thirst for information that is not readily available by common reference sources. I’ll use the #SMACCGold conference to demonstrate this point.

Lets take the section on statistics in Royal College of Paediatrics and Child Health (RCPCH) emergency medicine curriculum.

To be fair this is clear, practical knowledge that is needed by clinicians. How does this translate into actual practice though? How will we use this to provide better patient care? What will convert these concepts into something clinicians can practically deliver? I think the answer comes from Prof. Simon Carley’s two excellent lectures at #SMACCgold. One on what to believe and when to change  and one on risk factors in ED

 

As another example Paediatricians are involved in extremely challenging situations in resuscitating seriously ill children and sometimes need to make decisions about when that resuscitation should end. Is there a curriculum that defines and aids this process? It appears not but certainly Cliff Reid’s talk at SMACC is a great example of how this topic could be approached.

Finally I scanned through the College of Emergency Medicine curriculum for “chronic pain” and struggled to find anything. However with over 1000 views so far this probably fits the bill:

 

It would be harsh to say that those writing curricula have been lax in their tasks, it’s more that some topics are not easily encapsulated. They are often hidden, or camouflaged, in between more clear cut points.

 

 

This is where #FOAMed has come to the rescue. A variety of brilliant minds around the world have been able to recognise knowledge they needed to know but just wasn’t currently available ( a recent talk is entitled #paedstips you won’t find in books!). Ultimately #SMACCgold stands as a testament to revealing this camouflaged curriculum content (and I am sure more will be revealed at #SMACC2015). It may well be the case that assessment drives learning, but perhaps those in charge of medical education may want to use #FOAMed to drive curricula…

At #SMACCGold in 2014 one particular lecture that really caught my attention. Cliff Reid talking on “When  should resuscitation stop”.

It is brilliant talk with a well pitched narrative, evidence based insights and a constant return to the human side of clinical practice that is all too often forgotten. As a Paediatrician with a special interest in Emergency Medicine the child presenting in asystole (no movement or electrical activity of the heart) is one of the hardest aspects of my job and the decision on when to stop CPR often a challenging one. It is vital that anyone who works in Emergency Medicine listens to Cliff’s talk and takes home some of his key points:

Never make decisions in isolation of each other and a blood gas should never make your decision for you

(my interpretation and not Cliff’s actual words)

The talk uses two examples, both of children, to demonstrate the huge human factors element to decision making in halting CPR. In one of the cases the child made a full recovery despite nearly being in situation where attempts to resuscitate were stopped. The cases certainly were unique  – one involving cold water immersion and the other a complex congenital heart defect. What of a potentially more common scenario – sudden infant death syndrome. These are still unique events, there is no other child in the parents’ eyes, like the child you are trying to restore a circulation to. What evidence or anecdote will you use in these situations?  Does the knowledge that one child, in one place, at one time, survived after a heroic resuscitative effort lead you to do the same? What if the parents knew that there are reported cases of children surviving after hours of down time. Could you convince them why you are stopping after 20 minutes if you think the child has never shown any signs of life? Only the clinicians in these unique situations will know the real circumstances of what made them go that extra minute or seek that extra intervention. Encapsulating their gestalt will be nearly impossible – so we are left trying to do the best we can with the information we have available. As Cliff says:

“The important thing about human life is that its about other people – it’s about connection and it’s about love. It’s about our love for other people that motivates us to do everything we can.”  

For these most complex and emotional decisions the chance to reflect before these tragic events can only be of benefit in my opinion. Cliff Reid’s talk is certainly an excellent chance to do that.