How to Spot the Sick Child in the Emergency Department

Ffion Davies gives her take on how to spot the sick child in the Emergency Department.

Paediatric medicine is no doubt hard and can at times be scary. There is nothing worse, in Ffion’s opinion, than sending a child home who later represents to the hospital in a worse condition, or even worse, later dies.

So, how does one spot the sick child amongst the droves of children who will present with fever and vomiting.

In this talk, Ffion gives a lesson on how to spot the sick children in the ‘grey’ zone – those that are not clearly sick and not clearly well.

Ffion breaks her thinking into two main areas: physiology and psychology.

Physiology matters. Scrutinising a full set of observations/vitals (in the context of the child’s age) will help avoid the feared crime of discharging a sick child.

Ffion discusses tachypnoea as a prime example of a simple physiological compensation to raise one’s suspicion of serious disease.

Similarly, psychology matters. Ffion talks in depth as to why she considers this to be true.

Talks on Paediatric Emergency Medicine are always popular because Emergency Medicine physicians are insecure about mismanaging a child. Are children precious? Are adults just big children? Therein lies the problem.

Less knowledge, less experience and perhaps less confidence. Compounding this is the complexities of having to deal with the stressed parents when you yourself are stressed because of the situation.

Ffion continues to talk about systems of thinking and decision making. She compares Type 1 thinking which is automatic and instinctive with Type 2 thinking, which is more considered. She explains the risks and benefits of relying more upon Type 2 thinking when considering the sick child in the Emergency Department.

Finally, Ffion concludes by talking about strategies to improve your own management of the paediatric population in the Emergency Department. She discusses improving your knowledge base, using resuscitation aids and checklists and training by using stress inoculation simulations.

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1. Dr Ffion Davies FRCEM, FRCPCH Consultant Emergency Physician University Hospitals of Leicester UK Spotting the Sick Child

2. EM physicians discharge most of their patients home EM doc

3. 4 The grey zone The hard part of being an emergency physician….. W ell Sick

4. 5 Experience + learning E-learning website www.spottingthesickchild.com NHS England Re-ACT series 10 minute video https ://www.youtube.com/watch?v=N35J3NLJW_s

5. 1) P hysi ology 2) psychology

6. 7 physiology “3-minute toolkit” www.spottingthesickchild.com - a proper top-to-toe in 3 minutes + PHYSIOLOGY ABCDENTTT (ENT temperature tummy) RR, HR, SaO2, peripheral coolness / (cap refill)

7. PEWS type scores help with the grey zone

8. 9 PNEUMONIA AS AN EXAMPLE Chest wall recession x SaO2? Often normal Auscultation? Often normal Unwell, lethargic Tachycardia Tachypnoea

9. Salmonella septicaemia Small bowel malrotation with perforation Viral myocarditis………………. THE CLUE: Lessons from the coroner’s court 170 +

10. 1 WHAT ABOUT FEVER ? 1 2 3

11. Triage 1 hour < discharge

12. Psychology

13. STORY 1 Girl aged 2 ½ 4 week history of swollen face, abdominal pain, lethargy and weight loss Two days prior to admission, saw GP: Δ throat infection Rx penicillin Taken to ED as parents not happy: FBC taken, sent home FBC result rang through from lab and parents recalled to ED Hb 60g/l ; Plt 88 ; WCC 672.4 (of which 584 = blasts)

14. 8 week old baby with apnoeic episode at home “He looks fine, you can go home” 30 seconds later baby goes apnoeic , blue, floppy Crash call / code IT’S THE SAME BABY AS IT WAS 60 SECONDS AGO!! Apparent life-threatening event STORY 2

15. Psychology: what DO THESE STORIES HAVE IN COMMON?

16. MORE PsychologICAL FACTORS….

17. Parent Doctor Child Parents a re stressing me Parents a re unnecessarily stressed

18. My preciousss? “Children are precious and special”

19. Child “Adult” Elderly Homo Sapiens

20. INCREASED COGNITIVE LOAD

21. Why is thinking relevant to paediatric emergency care? Automatic thinking Non-automatic thinking

22. Automatic thinking Several tasks can be performed simultaneously Limited cognitive burden

23. KNOWLEDGE TYPE 1 THINKING (ref p croskerry ) EXPERIENCE TYPE 1 THINKING

24. Analytical Fragile if cognitive load increases eg stress KNOWLEDGE WEAK COMPLEX SITUATION Non-automatic / type 2 thinking

25. “If things start happening, don't worry, don't stew, just go right along and you'll start happening too.” - Dr Se u ss

26. Increased cognitive load in paediatric emergency care Simple skills may be difficult: Arithmetic Recall from memory Errors in critical thinking ability: “ Paralysis by indecision ” Confirmation bias

27. SCARED TYPE 2 THINKING NO TIME NO KNOWLEDGE I NEED TO ENGAGE BRAIN. HMMM…… COGNITIVE OVERLOAD ERROR: “HE’S FINE: KIDS USUALLY ARE” SEEK HELP Specialist Senior Dr Google SOP DENIAL ERROR Charts, cheklists + drills CAN’T BE BOTHERED

28. So what do we need to do? Get some PEM knowledge Use resuscitation aids & checklists Train by stress inoculation therapy (military) - regular practice drills / simulation exercises

29. 37 The grey zone 1 more top tip…. Use risk stratification W ell Sick

30. 38 Risk stratification Absolute age ( <2 months , 2-6m , 6m-2y , 2+ ) Ex - prem Cardiac disease Any chronic disease or syndrome Young parents with poor social support

31. TOP TIPS FOR SENDING THE RIGHT KIDS home PHYSIOLOGY

32. Is your mind safe? DENIAL? SCARED? TOP TIPS FOR SENDING THE RIGHT KIDS home PSYCHOLOGY

33. THANK YOU! [email protected] PSYCHOLOGY PHYSIOLOGY