Paediatric sepsis: The first hour. PLUS St.Emlyn’s at #Retrieval2014

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I was absolutely delighted this week to attend the first day of the Retrieval 2014 conference in Glasgow. I first came across this conference in 2013 when I followed the twitter feed which had #FOAMed gold quality tweets on all aspects of retrieval and resuscitation in general.

Screenshot 2014-04-26 14.50.24The conference is hosted by the Emergency Medicine Retrieval Service in Scotland, a fantastic group of clinicians who are really striving to deliver the highest quality care to Scotland. The geography of Scotland does mean that they have a really mixed practice and some real challenges in terms of geography, and in particular in terms of weather!

So, I had been asked to talk about paediatric sepsis, which is great as this is important although I did feel a bit an imposter as I am neither a paediatrician, have no advanced qualifications in paeds and I’m not a retrievalist. I realised this when it became apparent that I was the only person without a selfie slide of myself in a helicopter (although they do exist).

There were many highlights on the day. I got up at 0430 to get to Glasgow in time to hear @cliffreid speak. I don’t get up at that time for anyone you know……, and I was not disappointed. An excellent talk on leadership in retrieval, no slides, just a talk with authority and engagement. Many were mentioned with @karelhabig noted for his excellent qualities as a leader on many occasions.

We heard from Darren Walter (local lad to me and old friend) on the rather long gestation of UK MERIT teams. Interesting to hear how far we have come (not far enough) and how far we have to go (some way yet).

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@davidrhogg loves these

Jonny Gordon brought us up to speed on the forthcoming Commonwealth games in Glasgow. A major event with major responsibilities – I do not envy his workload over the next few months, though the level of planning already in place is clearly very impressive.

jammiedodgers

@cliffreid and @EMManchester love these

David Hogg was both tremendously engaging and also such a nice chap. His work with colleagues on Arran around resilience is truly impressive and his talk was superbly well delivered. Cliff and I agreed with absolutely everything he said apart from his assertion that Hobnobs are better than Jammie Dodgers – this is heresy, or perhaps a Scottish tradition, we could not work out which. Anyway, here’s his video demonstrating the amazing work that they do. His question on the day – how many services are in this video (there’s a lot!). http://www.arranresilience.org.uk/

 

Dave Lockey had some real insights into prehospital anaesthesia. Anaesthetists were better than EM docs in their series at achieving intubation, but the difference is small and both have very high rates of success (and surely they should be shouldn’t they?). He has moved to a one size fits all approach to drugs which I like (reducing complexity). Lots of other gold in that talk. We then heard Tim Parke talk on simulation which differentiated between ‘drills’ for procedures and full on simulation. I  like this as the former is much easier to achieve in busy EDs. Gareth Clegg spoke on more amazing work from Edinburgh and the cardiac arrest research that they do. Filming arrests gives so much information but could be medico-legally hazardous so be careful. With consent we saw some amazing work from the Scottish service in saving a man’s life.  Niall MacMahon brought us up to date with the CCP training program in Scotland using Moodle (which of course also powers St.Emlyn’s) & Richard Price shared his experiences of mobile education across the highlands and islands of Scotland (in a bus that was not a bus).

Finally I’ve re-recorded my talk and put it up on VIMEO for anyone who wants to watch. This talk is aimed at the generalist who may have to deal with children. Enjoy.

There is also a short version on the podcast site

 

I tweeted the talk as I went along (via tweetdeck) which interestingly helped spread the message but also meant that I could control the message (is that wrong??).

And lastly a mention to Lauren, Anneke & the many others who kept us going with some amazing tweets.

 

Comments

  1. says

    Wow. THIS is why I beleive in FOAMEd – a quality masterclass in paediatric sepsis (or resus in general) delivered to my laptop or tablet.

    Touched on so many things that make a difference

    – the reality that critical illness presents not to the PICU, but to the GP, the waiting room, the St Elsewhere ED….and that quality FOAMed presentations can make us better clinicians

    – the need to OWN resuscitation as a generalist. Get away from the mindset that it is somehow OK ‘not to do kids/critical illness’ and that everything will be fine somlong as you can call retrieval; rather that doing simple things well has significant positive downstream consequences

    – use of cognitive aids. The Scottish paeds sepsis flowchart with early prompt for adrenaline as inotrope is worthy of dissemination

    What I would give to see this sort of quality content available to evey rural ED in my area. Through SoMe and FOAMed, this is possible.

    …and nit a single heicopter selfie or ECMO machine.

    Nice work

  2. says

    Great post. Great talk. So useful. I’m currently doing a Paeds term in a small, busy community Hospital that has LOTS of sick kids. This is a fantastic resource to share with a few of my colleagues working there.

    Thanks You!

  3. says

    Thanks Simon

    This is a great overview – I like the way you have clearly signposted this for the health care professional who deals with children but isn’t necessarily a paediatrician. However the detail and insights are applicable to anyone managing children, regardless of their experience.

    Given we are both sticklers for detail I would like to highlight one point. You mention in the talk the problems with the initial assessment of children. Many are hot and bothered at arrival and could fit the criteria for having sepsis. You say perhaps 20% of those in the waiting room are “hot and irritable….”

    I would like to draw a subtle distinction. Without doubt many children who present to urgent and emergency care settings are hot and miserable (and maybe more that 20%!). The effect of having a temperature makes you feel grotty and I will take this opportunity to remind everyone it is this distress with fever we should be treating not the fever itself. However to me irritability is a different entity. The irritable child can’t be consoled, sometimes doesn’t even seem to recognise their parents, often holds their arms and legs out rather than drawing in and has a temperament completely out of keeping with other features of illness. Obviously the distinction between this and being miserable is not black and white. There is a spectrum which is why detection of illness in children is so difficult and why my job fascinates me so much :)

    Not point in apologising for being pedantic about this…I am being so. But recognising the difference between the hot and miserable child and the hot and irritable child is one of the great arts of paediatrics. It is by no means easy but if we are to really to improve our recognition and management of sepsis we must understand this paradigm. You don’t need to be a paediatrician to do this; you just need to think to yourself – is this child miserable or are they irritable? Just that thought my lead to a direction of travel which may save a child’s life.

    and remember in children: Observation is an investigation..

    • says

      You are (as always) quite right about the distinction between irritability and being miserable. I completely agree with you and apologise for any confusion. I think the point I was trying to make links in with my thoughts about the ability of experienced clinicians, receptionists, triage nurses, play therapists and many others to notice these differences and to take account of them (an element of their Gestalt in fact). Similarly we don’t want 20% of all children in the waiting room treated as severe sepsis either!

      In terms of language and the use of words we also need to be mindful that whilst you and I understand the distinctions and importance of the word irritable and we can agree on its use, others may not be as clear or may attribute their own values to the term. In Virchester many parents will use the word irritable to describe their child’s behaviour when I would describe it in other terms (such as miserable). Obviously I would record both in the notes making it clear who said what.

      In summary – absolutely yes – we need to be pedantic, but also mindful that words mean what people want them to mean and that there are risks in such different views.

      Humpty Dumpty had something to say on this matter in Through the Looking Glass (L. Carroll)

      “When I use a word,’ Humpty Dumpty said in rather a scornful tone, ‘it means just what I choose it to mean — neither more nor less.”
      “The question is,” said Alice, “whether you can make words mean so many different things.”
      “The question is,” said Humpty Dumpty, “which is to be master— that’s all.”

      vb

      S

      http://en.wikiquote.org/wiki/Through_the_Looking-Glass#Chapter_6:_Humpty_Dumpty

Thanks so much for following. Viva la #FOAMed