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. For more like this, head to our podcast page. #CodaPodcast

1. Dr Ffion Davies
FRCEM, FRCPCH
Consultant Emergency Physician
University Hospitals of Leicester UK
SPOTTING THE SICK CHILD

3. EM PHYSICIANS DISCHARGE MOST OF THEIR
PATIENTS HOME
EM doc

4. 4
THE GREY ZONE
The hard part of being an
emergency physician…..
Well
Sick

5. 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

6. 1) PHYSIOLOGY 2) PSYCHOLOGY

7. 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)

8. PEWS type scores help with THE GREY ZONE

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

10. Salmonella septicaemia
Small bowel malrotation with perforation
Viral myocarditis……………….
THE CLUE:
LESSONS FROM THE CORONER’S COURT
170 +

12. 1
WHAT ABOUT FEVER?
1 2 3

14. Triage
1 hour
< discharge

15. PSYCHOLOGY

16. 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)

20.  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

21. PSYCHOLOGY: WHAT DO THESE STORIES
HAVE IN COMMON?

24. MORE PSYCHOLOGICAL FACTORS….

25. Parent
Doctor Child
Parents are
stressing me
Parents are
unnecessarily stressed

26. “Children are precious and special”

27. Child
“Adult”
Elderly
Homo Sapiens

28. INCREASED COGNITIVE LOAD

29. WHY IS THINKING RELEVANT TO
PAEDIATRIC EMERGENCY CARE?
Automatic thinking
Non-automatic thinking

30. AUTOMATIC THINKING
 Several tasks can be performed simultaneously
 Limited cognitive burden

31. KNOWLEDGE
TYPE 1 THINKING (REF P CROSKERRY)
EXPERIENCE
TYPE 1 THINKING

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

33. “If things start happening, don't
worry, don't stew, just go right
along and you'll start happening
too.”
- Dr Seuss

34. 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

35. SCARED
TYPE 2 THINKING
NO TIMENO 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

36. 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

37. 37
THE GREY ZONE
1 more top tip….
Use risk stratification
Well
Sick

38. 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

39. TOP TIPS FOR SENDING THE RIGHT KIDS HOME
PHYSIOLOGY

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

41. THANK YOU! ffion.davies@icloud.com
PSYCHOLOGY
PHYSIOLOGY