We’ve had some great recent posts at St. Emlyn’s on the use of ketamine and LAT gel for children undergoing procedures in the Emergency Department. In this post I’m going to discuss something quite simple, but potentially very powerful and definitely very satisfying, that will often help you to avoid going down the route of procedural sedation. I’m talking about distraction techniques for children in the Paediatric Emergency Department. I can’t claim to be an expert – far from it – but here are a few #paedstips that might help you to use less ketamine, even after you’ve started using the LAT gel!
[learn_more caption="What's going through a child's mind in the Emergency Department?"]
This is the most important question to answer. As a doctor, you have to see things from the child’s perspective. What do they understand about what’s happening? Try to see the situation from their perspective. They may have never set foot in an Emergency Department before. They might not have a clue about what goes on. Doctors, nurses and all the other staff can look like big, official, scary grown ups to children. Remember that none of this will be helping the situation. They’re going to make kids feel nervous and afraid. [/learn_more]
[learn_more caption="Remember the effect of contagious emotions"]
As well as remembering the child’s perspective, you have to consider the parents’ perspectives. What do they understand about what’s happening? They’re likely to be really worried about their child. Their adrenaline may well be flowing. They want their child to be sorted out. And yet they have to wait in the ED with everyone else – in a busy and stressful environment – where nothing in particular seems to be happening while you wait.
They may also be really worried about what’s going to happen. The prospect of sutures or another medical procedure might scare the parents as much as the child! They might be squeamish, they might be wary of how their child is going to react, they might be afraid that we’ll hurt their child. And really they just want to get home and put the whole episode behind them.
Remember that these emotions will also have an effect on the child. If parents are scared, the child will be too. You can never calm a child when the parents remain hyper-anxious! You have to work on both. [/learn_more]
[learn_more caption="Recognise your own emotions"]
So emotions are contagious – and a child will be ‘infected’ by the emotions of their parents. But they can also catch your emotions. If your own emotions are high, a child will pick up on this and you’ll make them feel exactly the same way. If you’re anxious about the procedure you’re going to do, a child will also worry. If you’re under-confident, a child will have less confidence in you. If you’re stressed, the child (and the parents, for that matter) will feel stressed.
If you’re going to treat the child effectively, you first have to recognise where your own emotions are and adjust them accordingly. [/learn_more]
[learn_more caption="Playing the perception game"]
First impressions count. Everyone knows that. So why are we so bad at making first impressions in the ED? For a start, the ED layout often doesn’t help. Our receptionists may be hidden behind bulletproof glass and sit on a higher level than the patients coming to book in, which sets up a power gradient. They may also talk to their computer screens with limited eye contact. What a way to make a first impression with anxious children and parents! There’s not much you can do about the ED layout (other than re-design it!) but it’s an important factor to recognise. Where I work (in the adult ED), we recently introduced volunteers to meet and greet our walk-in patients with a helpful smile. They are completely inspirational and they have such a calming effect. The waiting room is (honestly) usually a picture of serenity when they are on duty! The influence they have on the emotions of our patients is amazing.
If first impressions count, we have to be pretty careful about how we call patients from the waiting room. Most people simply shout the patient’s name and walk to the consulting room with patient and family in tow. But here’s a fantastic opportunity that we have to take. Next time you do this, try looking at the patient group out there and identify the patient before you shout. It’s often easier to do this with children, based on age. If you can walk right up to them, check the name and gently call them through with a genuine and confident smile, what a difference you’ll make!
The walk to the consulting room is also an opportunity. Make eye contact. Look approachable and credible. Make some small talk, try to have the patient and family laugh. I find this so much easier to do with children – they’re much easier to please than us grown ups! [/learn_more]
[learn_more caption="More on perception"]
Of course, there’s far more to perception than this. Patients and family will be forming opinions of you from the moment they set eyes on you. Your appearance is going to have to be up to scratch. You need to be presentable and look professional. You can’t seem stressed or rushed – you have to be calm. And your body language is so important – the way you stand, even the way you walk. I used to be terrible at this – but I’m getting better now that I recognise its importance. You need to look like someone who’s in control, a person that they can have confidence in.
If you do all of this well, you’re setting yourself up for a successful consultation and procedure. If you do it badly, you might as well book them in for ketamine or a GA right away. You lost, it’s GAME OVER. There’s no going back! [/learn_more]
[learn_more caption="The consultation"]
The consultation is about you getting all the information you need to make a diagnosis and then you giving all the information they need for the treatment. Right? WRONG!
Actually, the consultation is theatre. You need something out of it – sure. You need lots of information. The family also needs information. But, all the time, that family is judging you. You’re influencing their emotions. You’re gaining or losing their confidence. Do it wrong and, well, you know…. It’s GAME OVER.
What do they need from you? They need to know you’re human and that you’re likeable. They need to know that you’re knowledgeable, skilful, professional, thorough and more. This is essentially an interview! They don’t get to choose their doctor at the end but, as sure as eggs is eggs, they’ll have chosen whether to put their confidence in you. [/learn_more]
[learn_more caption="Preparing for the procedure"]
Preparation is about getting all the staff together and all your equipment. Right? I think you’ve got the hang of this by now… WRONG!
Preparation is also about having a plan, and about psychological preparation – for you, the whole team, the parents and the child.
First, the plan. This needs to be fairly choreographed. How will you take the equipment into the room? Is the child going to see a suture set? Needles? Vials of anaesthetic? Syringes? How will they react if so? You might just scare them off. Then again, if you hide everything below a mystical green sheet it might be even more scary. Ideally, you want this to be as discreet as possible – and your distraction techniques need to have started before you even bring the equipment in, so you can ideally do it without them even noticing.
Who will do what and who will sit where? It’s often helpful if the child can’t see the procedure (e.g. for suturing) but blocking it with a big green sheet or similar can be more scary than helpful. Try to use ‘natural’ barriers. For example, to suture a foot, ask a nurse, play therapist or parent to sit on the bed next to the child’s hips. Put the child’s foot behind the nurse. This assistant is then a ‘natural’ (non scary) barrier. We do that sort of thing all the time for intravenous cannulation, right?
Second, the psychological preparation. Here, you’re working on all the factors discussed above. You also want to familiarise the child and the parents with you as a person. You might, for example, apply the LAT gel yourself. Then, you might nip in to ‘check’ on it every 5 or 10 minutes. In doing so, the family is continually exposed to you. They get to know you, they feel more relaxed in your presence. Have a little chat each time – get to know the family. The child comes to associate you with some nice small talk, they build an impression of you as a ‘nice’ person. You’re not just the evil doctor who’s going to stick needles in them! This is a new technique to me. I read about it in an article by a parent – if only I could remember where I found it! [/learn_more]
[learn_more caption="The procedure"]
So, we’re finally there. We’re going to do this thing. And here’s where you need the actual distraction technique. If you’ve done all the above steps well, you’ll know a little about what your patient likes and you’ll be able to customise your distraction technique. Perhaps it’s a 3 year old who’d like a story about fire engines, perhaps it’s an 11 year old who wants to play with some app on his dad’s phone. You might even be lucky enough to have iPads in your ED for distraction! Start this well in advance of the procedure and give the child time to get engaged with it.
Then you can get down to the nitty gritty of the procedure. And that’s the easy bit! [/learn_more]
I hope this will help your practice in future. Mine has developed throughout my careeer and is still developing. Any tips from experts (or otherwise) would be greatly appreciated as comments or tweets. Use the hashtag #paedstips – it’s becoming a pretty good #FOAMEd resource!