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.

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:

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])
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.

@Damian_Roland like the first email/ telegram/ SMS everyone will want to know what was sent….here it is! #QIF16 pic.twitter.com/qtsZb0LEVI

— Orlando Hampton (@Orlando_Hampton) March 18, 2016

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 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.

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

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.

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

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

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.

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]