Tag: David Krieser

Aug 28 2019: Paediatric regional teaching, PIPER Go Now, and *listen*

Summary Teaching 28 /8/19
Paediatrics regional Teaching with thanks to Dr Lucy Selleck
David Krieser: A story of a complex communication dynamic between treating team and parents:
Febrile convulsions lasting a total of 40 minutes while negotiating with the parents one of whom was a GP and the other, an anaesthetist.
The anaesthetic parent wanted to perform IV access initially themselves, an IO then IV was placed by the ED consultant. A third line was performed eventually by the parent after multiple attempts.
Intubation was not preferred by anaesthetic parent, nor CT and the child was to go to CT and then for transfer to RCH.
The case highlights boundaries of practice, shared decision making and good communication.
Bindu Bali: A wonderful personal story of burn out, self -care and resilience and how to manage multiple aspects of life when your situation is too much. You had to be there for this.
Ilse Spillane: A personal story of being the mother of a sick child and communication by treating teams:
At birth her child was jaundiced, then by 6 weeks she was putting on weight however still jaundice and passing 20+ bowel actions a day. The GP, paediatrician, nurses all told her to not worry. Eventually a bilirubin confirmed hepatic failure and the child needed a biopsy for possible biliary atresia
Various learning points raised such as:
·         Don’t dismiss concerns or generalise parents knowledge
·         Listen, gain trust
·         Don’t explain costs to parents as money is no object when your child is unwell
·         Don’t insult parents by telling them their requests will harm their baby
·         Don’t promise what you cannot / won’t deliver, parents appreciate a call in the night more than finding out their child was inconsolable
·         Allow parents /patients to have their emotions
·         Set up for telling bad news properly, not in a corridor, with no time for questions.
·         Apologise and admit mistakes

·         Empathise, note their background and needs.

PIPER ICU consultant cases and learning points

·         PIPER offer consults retrieval and education with 1 consultant in hours and senior reg AH
·         50% issues are respiratory, then neuro and then miscellaneous (sepsis, DKA, bleeding)

·         Communicate in a ISBAR format so they know that the question/concern is

Note the ‘GO NOW Criteria’ online: https://www.rch.org.au/piper/retrieval_referral/go-now/

Where is it time critical, the definitive treatment cannot be done locally, what can be done whilst waiting.

Case 1: 10/12 old w Bronchiolitis D3 who arrested with large pleural effusion

Learning points: draining the pleural effusion may have helped the cardiac instability. A child can cope with 1 lung but a pleural effusion will cause a tamponade so you have septic distributive shock with now an obstructive shock.

Case 2: 9/12 old with Choking, stridor and intercostal recession

-trial adrenaline nebs with no change
-assumed to be croup however best to see what a croup child does on room air if only on 4L, if they are getting an airway obstruction with decreased sats, think outside of croup or how to manage a severely unwell child
– child intubated:
-moving down the DOPE pathway

D- displaced ETT                                check position

O- obstruction                                   suction

P-Pneumothorax                             US/CXR/decompress

E – Aetiology review                       not croup?

Tried suctioning, ETT confirmed and then bougie advanced to push a foreign body (chicken) which improved sats until bronchoscopy could be done and nebs continued for temporising measure.

Case 3: 3 y/o child with 10 days URTI and respiratory distress

-Noted Sub cut emphysema on CXR
-Worsening emphysema distorted anatomy for intubation
-likely lung disease not a fistula causing the air leak
-despite low flow o2 , accepting over 80% sats, w min pressure and trying to decompress the emphysema with sub cut needles, ECMO was required

Less is more sometimes.

Case 4:  2 y/o child with initially presumed DKA

pH 7.16, lact 6.8 HCO3 18 and BSL 16

-DKA usually don’t have lactates of over 4
-AXR confirmed a malrotated gut/dilated loops and the pt had ischemia.
If it doesn’t fit the diagnosis , don’t make it fit

Bronchiolitis and high-flow nasal prongs: audit

Thanks to Priya Shenton, Suzana Lazarovska, David Krieser and Bindu Bali for their work on this audit.




Key points:

  1. High-flow nasal cannulae have been proposed as an intervention that may supports inspiratory effort in bronchiolitis and may reduce the need for transfer to paediatric intensive care units
  2. This study did not show a reduction in transfer rate out of Sunshine hospital to the Royal Children’s hospital after the introduction of high-flow nasal cannula
  3. Reasons may include small sample size and staff unfamiliarity with a new intervention
  4. Further study is ongoing, with recruitment begun on a prospective randomized trial, managed by the Paediatric Research in Emergency Departments International Collaborative (PREDICT)