Tag: paediatric

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

Yuen’s Yap 5/7/17 – VFRAC update, clinical risk, paediatric forensic medicine, metaanalyses

For DEMT Terence Yuen – Teaching 5/7/17


VFRAC – virtual fracture clinic

Update from Becky Pile ED physiotherapist

3 months running now

VFRAC reviews all referrals next day and then funnels cases:

  • Direct to OT
  • To ‘traditional’ fracture clinic + organizes repeat imaging
  • conservative VFRAC management – simple fractures for phone management and LMO follow-up

Can manage other acute injuries eg. Achilles rupture

VFRAC needs to be booked for next day – please tell your clerk

No limit on booking numbers

Already a reduction of about 26% diverted from fracture clinic

Patient satisfaction information survey pending – being collected now


Adults only so far – no paeds


Clinical risk management and clinical governance

Dr Lucia Le Kim – deputy director with Dr Terence Yuen


Governance includes:

  • policy
  • Education
  • Clinical guidelines / protocol
  • Systems: escalation pathways / codes / mandatory competencies / credentialing
  • Audit / review / quality / outcomes / KPIs / M+M / satisfaction / Riskman / in-depth case reviews / adverse events

All clinicians as they progress through their careers should develop an awareness of wider process of healthcare delivery in the hospital context, over and above individual patient cases



  • Seen risk – eg. the patient you have seen who is unwell
  • Assumed risk –
  • Unseen risk – ie unseen waiting room patients and any patient who you have not personally reviewed



  • Assumptions: interpretation of case / interpretation of investigations
  • Interpretation of clinical stability
  • Diagnosis momentum
  • Geographical blindspots – eg. EOU / EDIS filters (clerical risk)



Eg. Chest pain: ECG to be seen by senior / EOU consultant review /


Mitigate risk by good communication

Avoid premature labelling / diagnosis


Take actions to re-stratify risk

  • Re-utilize resources
  • Reallocate resources
  • Retrieve additional resources


Victorian forensic paediatric medical service (VFPMS)

Dr Bindu Bali

See presentation here


Paediatric arm of adult forensic service

Mandatory reporting – suspicion of physical or sexual abuse; not mandated to tell the family per se

Social work / IRS support to support clinician or family / access to phone

Issues regarding confidentiality if contacted by DHHS

Safety concerns can trump privacy legislation however it is a grey area

Admission often necessary to facilitate further survey but if no further medical needs exist then DHHS is responsible for safe accommodation

RED FLAGS: household violence / heavy use of drugs + alcohol / serious mental illness / child’s vulnerability (eg premobile / preverbal)



  • Do not try to interpret
  • Describe only
  • Consider red flags : away from bony prominences / TEN – torso / ears / neck / if not fitting developmental stage


Journal club: EGDT and meta-analyses

Dr Ashley Loughman – see presentation here


Early goal directed therapy

How to assess meta-analyses


PRISM metaanalysis

  • Prospective collection to ensure uniformity



  • Theoretically pool information to get closer to the “common truth”
  • Increases external validity
  • Cons: inclusion biases / lack of negative studies / agenda driven bias / poor quality of original papers