Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

All right, good evening everybody. Um So before we begin, I just wanna check that you all can actually hear me. Ok? So if you can hear me, can you just put it in the chart saying, yup, we can hear you and we can see you. Ok. That's great. Thank you so much Alistair, right? So, hi, my name is Aaron and I'm one of the events coordinator for E UPS this year. Uh Thank you so much for joining us on a Wednesday evening. Uh We appreciate all of you for taking time out of your busy schedules to attend the very first talk in our, the world of Pediatrics Subspeciality series, which we're starting off with emergency medicine. So this talk will be delivered by Doctor Sarah Alexander, a consultant pediatrician at S Kits Edinburgh with an interest in emergency medicine. So without further ado, um I'll invite doctor Alexander to the stage to deliver her amazing presentation. Thank you very much. Thank you for asking me to come and speak to you all this evening. Um I hope everyone's had a good day and has a cup of tea or something stronger. Um Yeah, I'm a pediatrician. So I'm and I work primarily in the emergency department at the sick kids hospital in Edinburgh. Um I thought I would talk a little bit, first of all about how you can train in emergency pediatrics. Um, and then talk about the good bits, the bad bits um, of working in this field and then give you a bit of a flavor of what working as an emergency pediatric pediatrician would look like. Um So basically, there are two ways of inching P as it's known. And so you can, you can train as a pediatrician and then apply for grid training, which um is the area of the Royal College of pediatrics where you would apply for any of the specialties. So emergency pediatric emergency medicine is now recognized as one of the specialties. You tend to start applying for this kind of kind of ST four onwards. Um and it's a two year grid program for emergency medicine. So you'd have a year of pediatric emergency medicine and then six months in intensive care and anesthetics, three months in orthopedics and three months in general surgery. Um as a kind of rough guide general surgery, you might do a bit of time in the ent and plastics as well. Um And so that isn't the route I actually took. But um that is the kind of recognized training now within R CPC. And then the alternative way to do it is to um train with che So the Royal College of Emergency Medicine and um quite a lot of trainees will do ap year. So they tend to do this at the ST five level. Um And then what that would mean is they extend their training by a year and they do six months within our department and then three months in medical receiving and three months in PICU. So the department ends up, you have, we tend to have a mixture of both. Um So if you're training to be a pediatrician, at the end, you can either become a general pediatrician often. Now you can be a general ped pediatrician with like a spin module or a specialist interest. So, um and we have a couple of pediatricians who do like a morning with us and that's kind of how they've gone down this route. So they work primarily in general peds, but they do a morning in our department and then we don't have any, we have one trainee who's going through her grid training at the moment. So at the end, she will work primarily with us with a little bit of time in general peds and that's how I work as well. Most of my sessions are in a um and similarly, on the other side, we have most of our, our chem colleagues do still do adult work and they either do mostly adults and a bit with us or mostly as and a bit with adults. And so it's, it's nice in that I currently am on a week of medical receiving, um which actually I really enjoy just a bit of time out of A&E working on the wards, that kind of thing. So there you can have a mixture which is really good. And then I guess why emergency pediatrics? Um, there's lots of reasons I think one of the reasons I really like is that you see a bit of everything, like, you know, every day there's something you've never seen before, to be honest. And so you're learning all the time. So we will see tiny ex prem babies coming back just at term or we've had a baby born in the car park before and we see, so we see from really babies who are still essentially preterm, not at their due date yet, right up to the age of 16 and sometimes a bit older depending on what the underlying problem is. And I really enjoy seeing the spectrum of ages. Um, and we see medical problems, surgical problems and you know, orthopedic, lots of injuries, these kind of things, um, lots of misbehaving teenagers. And so I just really enjoy the spectrum of age that we see and being able to see medical and surgical problems. Um, and we look after the whole family as you do in any area of pediatrics and get to know families really well as often families who come to us a lot. So it's nice to know them well and be able to make it as less stressful as possible. Um It's a very practical job. You do a lot of procedures, which again, II really enjoy as well. So we take a lot of readings at the back of the years and we see a lot of dislocated patellas, which is this middle xray in the sporty teenagers. And they're always fun to put back and we have to often put them back in the car park if you can't get them out of the car. Um with all sorts of random stuff, this this later knee X ray. I don't know if you guys can see the pointer, but this is a girl who knelt on a needle, so this needle was embedded in her, in her knee. So trying to fish stuff like that. It's really fun. These are this picture of the baby foot is example of a hair to. So um babies can get their mother's hairs wrapped around digits and you trying to get them out as, as tricky as you can imagine. And we also do um pediatric pediatric sedation in the department um for all sorts of things, to be honest, mostly for manipulation of fractures. Um but I've done it for foreign bodies in strange places and that kind of thing. So a bit of anesthetics in there too, which is uh really fun. And the other thing that I love, probably the thing I love the most about an A&E department is the team ethos. Um It's a huge team actually, but it's a really, um, we are, you tend to work with sort of like minded people who, um, like the buzz and the adrenaline. Um, and being busy it's a really busy, busy job. Um, and you work really closely with nurse practitioners, which I really love and II find that there's, there's no real divide between the medics and the nursing staff. It's all just a big team, everyone helps each other. There's sort of less, much less hierarchy than in other teams, which what is something, you know, it suits my personality. Um And then also you get, there's the opportunity to be a real team leader when you're an, a consultant. Um We are a major trauma center for Scotland. Um So Glasgow's Children's Hospital and ourselves are the two major trauma centers. So other hospitals will be trauma units. And so you're taking calls from other areas to give advice as a sort of single point of contact or the spot because it's known. Um And then in resuscitations, you're very much the hands off team leader, you know, standing in the end of the bed, putting together all the information. Um and um and these kind of things, so I really enjoy sort of, it takes, it's different skills that you perhaps don't learn as a student or even a junior doctor. And then, so it's challenging, but um satisfying if you feel you've done it well and affected the whole team. And then talking about the challenges, I think it's similar to other areas of, of the NHS. But then the patient numbers that we see now in our department are extreme, I would say. Um So if you think 2020 was sort of lockdown here and you can see what a difference that made to our attendances, even though we became the COVID hub for Children, we saw far, far less Children. And then the year after that was, um, pretty much on a par with how things have been before. And then last year was um sort of one, the only word I can describe it. The winter was a bit insane. To be honest. I think the media had a lot to answer for that and that they sort of every parent thought their child with a runny nose had strep and was inevitably going to die. Um So the, the threshold for coming to be seen was much, much lower and we were slightly overwhelmed last winter. So the patient numbers are, you know, are a problem. I became a consultant in 2016. So we essentially saw 50,000 patients that year and we've had no increase in staffing numbers. And last year we saw 60,000. So you can imagine it's, it's a, it's difficult and it, it does um take its toll and I think you have to be mindful of the impact that this job has on you. And so that you kind of have good practice out of work to look after yourself in terms of mental and physical health and things. Um other things that affect us. Interestingly, the birth rate in Scotland is going down for um trending downwards and the death rate is higher. However, this our part of Scotland is quite unique in that population is rising continually and, you know, at a higher rate than in other parts of Scotland. So Midlothian and East Lothian population and is, you know, East Lot rose at kind of 1.8% when the national rise was 0.3. So people want to live in Edinburgh and they want to live in East Lothian. Um and that's having a huge impact actually on GP services which then, you know, spills into our department. If patients can't get appointments, they'll just come to me. And so it's kind of all connected. And I think due to lack of kind of government planning, it, it is causing huge stress on primary care which then feeds into stress on our department. And the other thing that affects us significantly is um the winter obviously and viruses. Um And this, I thought was an interesting, we got a very helpful email from public health Scotland to let us know that there was lots of R SV around. Um But I thought this graph was actually really interesting. So you can see the blue line is um COVID and lockdown, the dark blue line so essentially disappeared. Um RSV, the virus. So the, the big causer of um bronchiolitis in babies in the winter and then the year after the R SB wasn't too bad. And then last year, um if I picked the right lane, this dark green line, it was kind of similar as to what it was um in 2018, 19 and then the red line is this year. So the peak has just, you know, risen and at a rate that hasn't been seen before. And, you know, I turned up this morning and first thing is to be told is that there's not a single bed in the hospital, so it has huge impact on a and then subsequently in the medical wards. Um So I guess they are the real challenges, pediatrics, as you guys probably know from all your placements is a challenge in itself. Um because it's not easy, they aren't just small adults, they're very different. And so it's um it's, it is a specialty, it takes a time to learn and to have experience and sort of good clinical acumen uh to feel confident doing pediatrics. So anyone rotating into the specialty finds it difficult, which also has an impact on consultants and the amount of support that uh junior doctors need, et cetera. Um Yeah, and not just, it's just to highlight that how difficult. It is, you know, you can have your normal beings for adult uh values and it's easy to remember. And then actually when you're working in pediatrics and um somewhere as general as an emergency department, it's trying to know the norm for each different age group and that just comes with time and experience. Um and having a little chart in your pocket is always helpful too. And then the problem with peds is everything's hard. Um You know, so and then I presume in adults best, if you need a blood test, you just go take a blood test. But um, you know, in pediatrics, you need to have put the numbing cream on and then you have to wait an hour for it to work and then you have to find the vein and then the mum's crying and, you know, everything's really difficult and, and um, but yeah, there are ways around it and you get a lot of information by looking at Children and Children like really rubbish and an hour later when the C kicked in, they can look great, which is always fun. Um And yeah, distraction is key and um, if you're ever going on pediatric placements, it's worth knowing who the latest characters are that kids, kids are enjoying. So Peppa pig is still around. Um and then things like Patel, these kind of things that you can have a bit of chat with the kids. Um I put, don't forget the bubbles there to remind me to say to you guys that there is this great resource. And so it is important not to forget the bubbles. A tub of bubbles gets you out of so much trouble. Um And I was very sad when we weren't allowed it during COVID. And so the actual bubbles do do work amazingly well for distraction, but it's also a great website with lots and lots of pediatric tutorials and modules and things if, if you guys haven't come across that's worth having. Um and use bribery wherever possible, kids love a sticker. It's unbelievable what they'll let you do for a sticker. Um So I guess one of the reasons that I um or one of the things that continually motivates me to do my job and to get, you know, think of other things that we could be doing within our department or, or statistics like this. Um So it's really quite troubling to hear that Scotland has a higher mortality rate for under eighteens in most of Western Europe and, and about 300 Children and young people die in Scotland every year and trying to find sort of really up to date statistics in this kind of field can be quite difficult. But a lot of reports that I read recently suggested a quarter of deaths now, um is one in four deaths in young people in Scotland as by suicide, um which is, is really, really terrible And so I sometimes feel like in an emergency department, you're seeing people either in a crisis point for, you know, or you've missed the boat, for example. And so I like the idea of trying to use every opportunity to influence um young people when they're coming to our department. So, um adolescence is probably one of my kind of sort of favorite fields or special fields. And I did the adolescent spin module when I was a register. Um And it's a really interesting area of medicine because we're learning more and more about adolescents all the time. Um And so, you know, if you're ever, if you're interested in this part of pediatrics there, some brilliant kind of TED talks out there. Um uh I've forgotten her surname. Somebody Walker, was it maybe who does an amazing TED talk and on the adolescent brain and how we're discovering, you know, that the prefrontal cortex and, you know, it takes ages for it to mature and be fully developed. So then it's hard to override this impulsivity that young people have and they're kind of emotional areas of the brain are really hyperactive. Um It's just loads of very interesting information coming out there to sort of explain why adolescents do what they do and behave the way they do. And we know that a lot of them use an emergency department almost as for their primary care needs and also they're quite erratic. So they're much less likely to make a GP appointment and might just walk into an emergency department. Um, but they're also potentially at risk of lying about why they're there, you know, and it's worth bearing in mind that they might have come for something minor, but actually they're there to try and disclose something major. So, um, I just feel like every contact with young people is an opportunity to try and see how they're doing, to be honest. And often we don't have enough time but, and wherever possible, it's really helpful to try and, you know, use, I use statements like, oh, and while you're here, is there anything else that we can, we can help with, you know, anything you tell us. So having a confidentiality statement is really helpful. Um And you say things like, you know, anything you tell us is, is obviously confidential unless I'd be concerned that um you meant that you or somebody, you know, was at risk and it's quite an awkward thing to say. It's a sort of phrase, it's worth practicing so that when you need it, it feels more natural. Um because if a young person was struggling with their mental health, but they haven't reached out, you know, it might be that, that one time that somebody gives them the opportunity to see that, that they would say. Um So yeah, adolescence is probably my biggest passion within our age group, although I'm a sucker for a cute baby. But um yeah, so they're the, the death rates within Edinburgh's or within Scotland are pretty harrowing and, and we see a lot of troubled young people. So I find that quite inspiring to be honest to try and do the best that, that I can do within my job. Um So I'm just going to have a drink and, and succumb to r ei think, but I thought I would um give you some case examples and talk you through. Um Well, I wish was an average day in the department. It's never this, it's never as exciting as this, but this is all cases that have come through the door. But um sadly, not all on the same day, but um I will talk you through them. So you start start of your day is eight in the morning and you're the consultant on for the day. So you arrive, the nurses tell you that there are three nurses short and you'd, you'd be forgiven for thinking. Well, what's it got to do with me? But in a, in a department like hers, it's a really big deal. The nurses just keep the place running. They're so hard working and supportive. And so even the level of uh experience within the nurses can have a massive impact on the flow of the department and, and the patients kind of being well looked after. So to be three nurses short is pretty, pretty dire and you're 12 to 10 doctors called in sick and you're informed there's no cubicles in the hospital and there's no P ICU beds. And we're often told that and I often think I'm not really sure what they want me to do about that. If kids have to come in, they have to come in, but more frequently than before you arrive in the department to find those people, you know, families who slept there. And we've been having to use i in rooms as, as hospital beds. Um, so it's gonna be a tricky day, but then a school student arrives who's on work experience and they're hoping to hang out with you. The police have arrived and they want a statement from yesterday. There's a parent on one phone asking for blood results and microbiology on the other phone to tell you about a positive blood culture in a baby who was sent home. And that probably that part isn't really an exaggeration. That is often what happens the minute you walk in the door. Um, but you get used to it. It's fine. So this is actually an old photo. I didn't have time to take pictures of the new triage. So that's, I don't know if any of you are in our old place, but so this is your triage of your A&E department. Um, Tias is a nightmare. I feel so sorry for the Tias nurses, but essentially what they have to do is look at the child in front of them and measure their observations and hear the story and then label them with a number that will then affect how quickly they are seen. So it's, it's a tough, tough old job being the triage nurse, but t one is immediate resuscitation. So very rarely that does get carried through the door, which is always horrible. Um, but most of the time it would be an ambulance standby call and then T twos would be sort of Children who are hypoxic with wheeze or bronchiolitis, babies who are hypoxic or like a new DK, for example, these kind of things. And then T threes would be maybe sort of hot, hot little ones who don't look particularly well, um, or maybe ABDO pain that aren't too bad but, but they want, you know, they're quite sore. Um So T three you can imagine is a bit difficult as this kind of, um, um, in between category. But the national standard is that these Children should be seen within an hour. Um, and then T four is your kind of medically well, patients. We don't tend not to use T five or six and then T seven is minor injuries. T eight, we can send some Children to out of hours. Um, but there's very limited out of hours appointments and there are very strict criteria as to what we like to stand. So, in an ideal world, it would be a great solution for a lot of our problems. But actually in reality, it's, it's not, doesn't ease a lot of the work burden. And then T nine is patients who have been called back by any of the teams in the hospital. And that's a useful t category because we're confined to a four hour limit. So patients are supposed to be seen treated and discharged within or admitted within four hours except if they are expected patients. And then we don't have that sort of time limit on them, which is helpful because we get into trouble for anyone who has stayed a bit too long. Um So your first patient of the day has been triaged category two. And so it's a nine year old boy. His history is of two days of diarrhea and vomiting and now he's got worsening right sided abdominal pain and you watch him walking in and he's struggling to walk up the corridor due to pain. His temperature. His observations at tria, his temperature is 38.2 heart rate, 1, 30 respiratory rate, 20 his BP is 100/68. Um And what would you want to do first? Um So you can call, are you going to call for a surgeon? Are you going to request an urgent abdominal ultrasound? Would you take a full history and examination or do you, do you, do you get IV access and send some bloods? Ok. It's asking me to do it too here? You go. Ok. So 66% of you would take a full history and examination. Um, and I would absolutely agree. That's the right answer. I think. Um, if you call for a surgeon and you haven't examined the patient yet, you're probably at risk of getting a sharp end of a surgical tongue. Um, an ABD ultrasound is potentially what might be done eventually. But to be honest, if, if in a child you're clinically very convinced that they have appendicitis, then we wouldn't do an abdominal ultrasound. Um So we tend to do that when there is um when they, you know, we can't decide 100% if this is an appendicitis or not. Um And after you've taken a full history and examined the child, yes, you are going to get intravenous access and 10 bloods and then while the bloods are away, you tend to let the surgical team know um and keep the child know by mouth until the team arrive. So, yeah, I would agree full history and examination. I'm just reading the chat because somebody has asked a clinical question and I'm not sure if they currently have that child with them or not. Can I ask a question if I have a 10 day child with stats of 85 how many in liters of oxygen? There's some wheezing. What salbutamol should be given? 9 a.m. is called, but I want to treat her until paramedics arrive. So the answer to that question is give them 15 L, give them as much oxygen as you can and don't give them salbutamol, salbutamol will not help a 10 year baby and will make them tachycardic. And it sounds like they probably have bronchiolitis if you can hear wheezing. So I would give them high flow oxygen up to 15 m. Um And I would, if you have access to suction, you might want to clear the nasal passages. Um ok, so nine year old boy. Um so this is your abdominal pain, nine year old boy. So you basically, he has no other relevant history. He's had a bit of down and vomiting, no dysuria or testicular pain and he has no relevant past medical question and not on examination. He doesn't look great. He's pale, he's cruel around the edges and he's definitely sore and guarding in his right leg. And it's always really important to examine the testicles in any sort of abdominal pain and never forget it, especially in Children with learning difficulties who may seem like their tummy sore as they can't tell you. So it really important to always um have checked the testicles and I've seen it be missed before in, in a child with learning difficulties who had AAA torsion. Um So we get a lining, send off some bloods, get a urine sample just to have excluded that. Although it really doesn't sound like that's gonna be the issue. Give um him some morphine really important to treat pain in Children appropriately. And people are scared of opiates. But in somebody like this where they're, you know, in severe pain, you want something that works quickly. And so you could use intravenous morphine or intranasal fentaNYL if you're struggling to get a line, keep him know by my and call the surgeons. So it's 99 o'clock and the ambulance, uh, box goes off, radio goes off. And so they want to let you know that they're bringing in a 10 year old boy, he's been an unrestrained passenger in the rear seat of a car. The car has collided with a barrier traveling approximately 40 miles an hour and he's been thrown, thrown through the front windscreen of the car. So what abbreviation is used for a trauma standby history? Is it at mist at most thas or Misty? Ok, perfect. So 85% of you said at mist which is brilliant. Um So a stands for age of patients. So our patients, 10 years old t is the time of the injury. So at one o'clock mechanism here is thrown through the windscreen of a vehicle moving at 40 miles an hour and then I as a summary of the injuries. So um the paramedics tell you where the radio who's got an open head wound and multiple facial lacerations s is vital signs. So he's unresponsive. So we you'll have heard of the Glasgow coma score. So is a sort of abbreviated way of doing that in pediatrics. It's much easier to remember, to be honest. Um So you is unresponsive. So he is alert, he responds to voice, p responds to pain and you unresponsive. So our patients unresponsive, he's tachycardic. His BP is fine. Um But remember that it's Children will maintain a normal BP until very, very late. So a low BP in a child is a prerest sign. So a normal BP is not of not as reassuring as it is in adult patients, his rests are quite low, just 10. Um And his oxygen situations are only 89% on high flow. The treatment the crew have administered is he is immobilized and is getting oxygen and they put a pressure dressing on the scalp wound and scalp wounds can bleed a lot. So very important that they've done that already. And so basically, when you get a call like that, um when as a major trauma center, we have a team set up. So in the way that you would put out an emergency call, uh you can put out a trauma call and basically you decide on level it being level one or level two. level one is uh either a patient with suspected major hemorrhage or if for example, medic one have gone out and they have decided that it's a level one patient. So if they phone the department in advance and like and tell you it's a level one. Um, otherwise it's level two, if there's a problem with airy breathing circulation, um, or disability d so if they're concerned about a, um, neurological problem from a head injury, um, it's sometimes hard to know exactly what's the right thing to do. But in reality, if you look at the teams, so what you would do is you would phone switchboard, double two, double two state, what level of trauma team stand by you want and tell them it's in the pediatric recess. And but in reality, I think the only difference in the teams is that you get the surgical consultant for level one and you get a surgical register for level two. Um So it doesn't make a huge difference to be honest. So if, if you, if you misjudge, it doesn't matter. Um I think in our patient, he is tachycardic but um II think I would put a a level two call for him um with the normal BP and yeah, I would probably put it level two and then I can upscale it to level one if I'm concerned once the patient arrives is what I would do. Excuse me. So that's our, that's actually a picture of our old resuscitation, but it just demonstrates. So what happens is the the emergency team will gather around the bed and any of the specialties who are called to attend would be asked to stay behind this line until they're asked to come forward to the patient's bedside. And that's just as you can imagine that a lot of people attend these um resuscitations so it can be very noisy and very busy, which is the, exactly the opposite of what you want. So the specialists are asked to stay behind the line until they're called forward by the emergency team. So when you prepare for a trauma patient, there's things that you want to do that are sort of different to medical resuscitation. So you would um get the blood warm ready. So you prime it with normal saline. Um and the blood warm is always a bath and almost takes up the whole job of one person. And so definitely sort of a good plan to have it on and primed and then you might not use it and that's fine. Um The main drug you're gonna give is tram acid. Um There's no evidence that it's helpful in sort of mild moderate head injuries. But if you're worried about any um sort of intraabdominal bleeding, for example, then, you know, um or bleeding, uh long bone bleeding and bleeding in the chest, then you would give a bolus of tram acid and then you want to be, you want to be ready for managing bleeding in other places. So, um you would have a pelvic binder available on the bed and, you know, this child has been thrown out of a car so he could easily have a pneumothorax, a hemothorax, you're gonna have the chest box open and ready. And then you may want to think about getting two units of red cells on route um from the blood transfusion service. And so they are the kind of things that you think of when you're in the room preparing for this patient. And the next thing you're going to do is assign people rules. And so you tend to have nurse one and doctor one. So nurse one is doing observations. Doctor one does primary survey if any of you are interested actually on the the Lothian internet, if you go to directory and then to the our our directory home page for the emergency emergency department, there's a, the first part of our home page is that kind of teaching area and there's some videos there. So there's quite a nice primary survey video. Um or these things are available on youtube as well. Sometimes really interesting to watch the London teams do it. Um because it's what's so interesting is that the resuscitation room is essentially silent. Everybody just knows their job and does their job. And the only person speaking is the doctor doing the primary survey who feeds information back to the team lead. So it's quite amazing to watch actually how fast it is and quiet it is. And the nurse two, doctor two would be assigned to IV LINES and drugs. And then you have your team leader at the end of the bed. And depending on how many other people you have, you might have someone assigned to scribe, hopefully have anesthetics and the ODP at the airway. And we also obviously need someone to be assigned to the family. So that's a whole other person. So you need quite a big team for a recess like this, um which, you know, as a consultant can be tricky to manage. Um but quite good fun at the same time. So the different, different principles for trauma patients are you're worried about bleeding. So it's C ABCD E and the first C stands for a catastrophic hemorrhage. So places you can bleed, sort of talk about chest, abdomen, pelvis, long bones, um and then kind of on the floor. So if there's been any blood at the scene, and as I said, you can bleed a lot from uh like scalp wound, for example. Um And then you worry about airway, don't forget C spine. Um And then it's uh your B CDE as, as kind of you guys, I'm sure you'll know from resuscitation courses. Um So the management of this patient essentially, you know, the patient arrives and their G CS is um seven, which is um tells you that their airway isn't safe. So they're going to be intubated and ventilated using a rapid sequence induction, really important still to give good pain relief. Um And think about IV fluids and blood, if there's any concern and then the main thing there when you examine this patient, all you can find is, you know, the obvious head injury and nothing else obvious to find. And your main intention then is to, you know, if there has been a brain injury that is you can't change effect that you know, there will be a sort of primary brain injury. But what you can do is try and minimize the chance of a secondary brain injury by monitoring the temperature, the blood glucose and the carbon dioxide level through blood gasses. Um You're going to want to phone the neurosurgeons and then get this patient to CT as soon as possible. And the national gold standard is that they're there within an hour. Um which is actually really achievable to be honest, um especially with the kind of pre alert to calls that we do now to radiology are included in that. And so you obviously would um take, well, potentially the anesthetist actually would take over the team leadership role if your department was busy and they would take the patient to scanner. Um And this is what you see in the scanner. So it was a large extradural hemorrhage and, you know, you can see that there's midline shift. So that's something the neurosurgeons are going to have to sort out. Um So we'd phone neurosurgeons, phone theater and get the patient there as soon as possible. So that's taken up quite a bit of your mourning, um, head injuries are by far the most common trauma that we see in Children. Um, so, uh, we're, you know, it's, um, what was I going to say? It's just something you get quite comfortable with going through the motions of a head injury and getting them to ct kind of within the time frame. And so that, yeah, as I said, the trauma call works very well. So you've just gone for a cup of tea when somebody comes to find you to tell you that that's the box has just gone off again. It's now half 10 in the morning. I'm just watching my time and talking too much. So it's an eight year old girl who's coming. He's had a trampoline injury and has a swollen, painful right upper leg. Um, so you take your ATMs history, she was twisting injury on a trampoline, swollen leg. She's alert, bit tachycardic. You'd be a bit hypertensive, that's her thing. And the crew have put a splint on and then she arrives and you can hopefully see that she has got an externally rotated and shortened right leg. And this is, you know, her femoral fracture is confirmed on an X ray. And so we see a lot of femur fractures actually. Um, as I realized, I put a picture of the cast on the or the splint on the wrong leg. Um, but, uh, what we tend to do is give them morphine when they first arrive and then you want to sedate the child to then put the nerve block in. So we would put a femoral nerve block, um, or a ft Iliaca block in, um, which, you know, then provides analgesia to the whole leg and then we would put them in this, which is called a Thomas Splint. Um, and then we xray them in the splint and then get them up to the ward. And so it's actually a really common injury, um, especially with trampolines. So it's midday. Now you're saving lives left, right and center and the child gets brought into triage and by the family and it's a two year old and they've been seen to put something in their mouth. Parents aren't sure what it is. They think it happened about an hour ago. There wasn't really any color change. Um, but they were kind of gagging, kind of coughing, gagging and then swallowed. Um, mom thinks it was a coin but the child hasn't been able to eat or drink since and they're upset and dealing a lot. So they're just pouring their own saliva. So, the first thing you're going to do is an X ray. So, do you think this child has swallowed a 1 lb coin? A 2 lb coin, a button battery or a poker chip? Which is what my GP husband thought this was. Mhm. Excellent. I can report back to my GP. Has that you guys all got it. Yeah. So hopefully I'm sure you'll know. Um But it uh 46% of you guys thought it was a two pen and I can totally understand why because you'd imagine that's the silver outline and that's the gold in line. Um But actually coins don't show up as, as well as that on the next day and what this is is a button battery. Um And the reason that, you know, that is this double halo sign we call it. So if you ever see the outer line and the inner line that is a button battery till proven otherwise. And the reason it's so important to recognize that is because um once the battery comes into contact with acid, it will start to erode um and can then erode the tissue around it, leaving you with a giant hole in either your esophagus or your stomach. So it's a real kind of emergency to get these out. So what we do is immediately refer these Children to the ent team. Um And whilst they're waiting, you give them honey, which kind of cos the battery um ideally preventing it from coming into contact with the acid. The only time you have to be a bit careful is if they're under one because honey contains um botulism from the soil. So under ones can't have honey because their gut isn't mature enough to metabolize botulism. Um And then they can have botulism toxicity which would essentially render them paralyzed. And unconscious. So we can't give honey tender ones. Um, but basically this, this child would be hooked off to the theater as quickly as possible and the that you would get scoped out. Um, and then they just are admitted to the ward for kind of a close watch after to make sure they're eating and drinking and all as well. So it's one o'clock you are getting hungry now. Um, but the radio goes off again and it's a really crackly lane which again happens all the time. And every time I think it's such an odd old fashioned system that we, this is how we communicate with paramedics, but that is what we do. Um So we think they've said a five day old but a baby who's tachypneic. So that's basically all the information that the person who's answered the baby has been able to get. So you assemble the team back into research and your baby very promptly arrived straight after. So it's a five year old baby and they were, well, when they were born, they turn, but now they, today they've been noticed to be breathing really fast and they've stopped feeding. So you're gonna do an at e assessment of this baby. So, airway looks clear, there's nothing obvious in the airway, but you're only taking sort of occasional gasps and there's no sats pickup coming from the sax probe. They really tachycardic heart rate 200. But you actually can't feel any femoral pulses. And the other place, you could check for essential pulses in the umbilicus if they've still got a kind of stump of cord. If you're struggling to get into the femoral area. B is definitely drowsy, they sort of slightly respond to pain, but gen generally are kind of unresponsive and they've got cold, dusky hands and feet and you can't record a temperature. So this is a bit of a nightmare, isn't it? This baby makes you feel it definitely puts your heart rate up to about 200 as well. Um There, this actually, I think I did take this from the, don't forget the bubbles neonatal nodule. Um And it's useful to a point. I think I put it in just to kind of. So you guys would have seen it and been aware of it. It's a suggested approach to thinking of um the potential reasons why you might get be faced with a collapsed neonate. The reason I don't like it hugely or I like it, but I it tends to, I think basically that you should focus on three most common things and then have the rest of it at the back of your mind. So, sepsis is always first in babies and then cardiac for me would be second. And then the third thing you're going to think about is metabolic. And then I think if you've excluded those three things, then go back and look at this and try and work out what else it could be. Um, and that we did have a baby the other day who had a, I think a sodium of 100 and 17 or something. And it turned and they were quite drowsy and it turned out it was a formula issue that dad just thought the milk seemed too watery. And so was adding a couple extra scoops of formula and completely messed with the high isotonic. The formula was and the baby came with really abnormal sodium. So the the other things do happen. But if you can bear in mind sepsis, cardiac metabolic as your kind of top three differentials for a collapsed baby. And actually, this baby is the classic story of um a duct dependent heart lesion and the thing that's going to point you to that is the absence of the femoral pulses. So essentially at birth, um you are or sorry prior to birth, you are shunting a lot of blood directly to the systemic circulation through the the ductus arteriosus because you don't need to oxygenate the blood uh when you're in utero. And then after birth, this duct will start to close. I mean, most of the time it kind of 24 to 40 hours, it starts to close. Um and then it will slowly kind of close more over that first week of life. Although I have seen babies with really complex cardiac conditions whose ducts have closed at six weeks actually, they've kind of collapsed at six weeks. Um But definitely in that first week of life, when you get this kind of story, it should really make you think of a duct dependent heart lesion. And so if you look to this diagram, you can see that there's this real narrowing here, um which is called a a coarctation and this narrowing of the aorta. And actually, this baby has been managing because it's been able to shunt blood through the, the duct. But as soon as that duct starts to close the amount of blood that's getting to the systemic circulation is really compromised. Hence, very difficult to feel peripheral pulses. The problem you're going to have with these babies is getting access um because they're not perfusing their body. So that can be really difficult. Um And never, you know, remember to think about things like IO access and what you want to do is reopen the duct and the drug we use for that is prostaglandin or prostin. And prostin is amazing in that it works really quickly, but it's half life is very short. So the minute you stop giving it, it stops working. So the worry there is that if you lose your access, you're, you're potentially in a lot of trouble. But so yeah, we're gonna get access in this baby, start prostaglandin and try and get an urgent echocardiogram. Um They're gonna go to intensive care and then we're, they'll be discussed with Glasgow and transferred there. Um I will um needles in Children that can be really helpful. We most commonly try and put them in the proximal tibia, but you can put them in the distal femur and you can put them in the proximal humerus as well, really difficult in babies actually. Um And sometimes you resort to using the old, slightly older fashioned cooks needles as opposed to the easy IO drill just to give you a little bit more control. Um But there are other things never to forget in babies. So if the ideal baby is still going to have an umbilical stump, so you could take a slice of that stump and try and get a line in the umbilical arteries or veins. So if you put a line in the umbilical vein, that's a central venous line that you've got right there. Um So it's worth sort of remembering. That's an option and the other place to never forget. And these babies is scalp veins. Um So it's difficult because potentially their airways being supported, but the one place they are probably still perfusing is their head and neck. Um So I've been in situations where there's just been a room full of people, none of whom have been able to get any access at all. And you would, you just try every vessel in that baby's scalp until you get one. because you just need to get the prostin going and then you'll be able to get lines in other places. So, don't ever forget scalp bes. Right. It's definitely lunch time. But while you're having your lunch, the nurses come to tell you there's a, an eight year old boy with a very deformed forearm at triage. There's also a one year old baby with a non blanching rash and there's a 12 year old who says that they are, um, they can feel their heart racing and they're feeling a bit short of breath. Um, so you've not had lunch, but neither have any of your team. So, um, what are you gonna do? What order are you going to see those patients? You're going to go see your baby first? Then the deformed arm, then the SVT or I should have said sorry, a nurse has done an ECG if she has, which shows that this patient is in SVT. Are you going to go baby S CT arm S CT, baby arm, arm SVT baby? Or don't be ridiculous? You're going to get some help. Bye bye. Oh, it's quite split this one. So, yeah, half of we think don't be ridiculous. Um, or you're changing baby arm CT is 8%. Baby Act arm is a third CD baby arm, 15%. And don't be ridiculous. You're gonna get help. It's interesting. Actually, I'd like to know what consultants, how consultants would answer this question. So, in the exit exam and you'll, you'll get scenarios like this where you're given a kind of, you go to the evening hand around the night shift doctor and you have to decide what order you're gonna do things. And, um, I, so what would I do? Well, I'll tell you what I'll do. But, um, so I would, first of all, stick my head in the door of the baby and you very quickly see this baby sat in mom's knee watching Blue, which I can highly recommend if none of you have ever watched Blue is absolutely brilliant TV, for adults as well as Children. Um and the baby sat me watching Blue eating snacks and you can see from the door that this looks like what's called HSP, which I'm not kind of bore you with just now. So as you're leaving the room, you ask the nurses to set that baby up for urine and then on your way to the SVT, you look at the in the room of the boy with the arm injury, he's upset, pale and sore. So he definitely needs seen. So you ask the nurses to start getting intranasal fentaNYL ready and to go and find someone who can see this patient and prescribe this for you. So essentially that's getting help, I guess and then you then reach the room of the child with likely SVT. So that's probably how I would do it just depending. Um but I looked out there so the baby with the rash had HSP and not meningitis. So I would have been a bit, a bit stuffed, I think. Um, but yes, so we see quite a lot of CT actually, um, in our department and there's different things you can do. I don't think I've ever managed to get it to go back with carotid sinus massage. Kids have a little stubby, little fat, little necks. I don't know if that's part of the reason. Um, but what does work really well is the ice bucket challenge. Um And then you can try things like maneuver um or blowing in syringes. But um obviously, it depends on the age of the child and how cooperative they are and all these kind of things. So it can be a little bit tricky, but ice tends to work really, really well. Um because I think we see so many Children who get albut it's often the thing that will tip them into SVT because it puts your heart rate up so much. So, yeah, we get a lot of SVT actually. Um but anyway, your ice bucket challenge this patient and, and beautifully get them back into sinus rhythm. Perfect. So you're just gonna keep an eye on them for a bit longer and then you check on the boy with a sore arm and he's had his fentaNYL, he's had his xray and it shows, you know, a very angulated forearm, fracture radius and ulnar. So this again is a really common thing in our department. So basically you would measure kind of the degree of angulation. Um But as a rough guide, if you look at that and think that needs to be straighter, then that tells you it needs a manipulation. So we do lots of these now to stop kids having to go to theater. Um and kind of taking up the cpod list. So we would tend to give them fentaNYL propofol in the department and get them nice and sleepy. And then the orthopedic register would get this a bit straighter and then they go in a cast. Um, and it works really well. Uh So if you're ever in our department, definitely try to come in and see a manipulation if you can do. It's very staff heavy. So it depends on the staffing, but um it works well and then you're just sort of having a breather and then the radio goes off again. And I just put this in as a brief mention because this was a call that we did once, get on the radio to my friend and I had calling and I had just taken the handover at half past four ready to start the evening shift. And the paramedics shouted on the radio scissors in brain, I repeat scissors in brain. And I think everybody got the giggles actually. And then we kind of looked at each other and thought, well, they're not actually going to be in the brain though. You know, because that's ridiculous. And then this is the scan of the patient who subsequently arrived being wheeled into the department. She was sitting upright looking at everybody. Um, but because you can see the outside of the scissors, you could very clearly see that the scissors must be in her brain. And she had been sitting at her desk at home, uh, crafting and had led to get something and just missed misjudged and had toppled and the desk had toppled. And that just by total freak chance she had landed on the scissors. Um, but they had, um they had inserted themselves into her brain at just where the frontal and temporal lobe kind of meet. So right down that tract there and um she was alert and completely unfazed and her mother, as you can imagine was in pieces as was the whole waiting room as she got kind of pushed through the department. Um And so she went up to theater and then one of the um O dps came down about an hour later and asked us if they could borrow some medicine called Keppra, which is for seizures. And I kind of said, oh, well, she obviously she had a ct scan person in theater and I never MRI this obviously or she would get stuck towards the magnets. Um But yeah, they came down to get some anti seizure medicine and I said, oh, no, is she fitting? And they said, oh, no. They haven't started yet. She's asleep. But every time they go to pull out the scissors, they lose their nerves. So everyone's just standing around trying to decide what to do. Um, because it was, you know, she was completely fine. So the worry is you're going to do damage by taking them out, essentially. However, they managed to dissect the scissors out of her brain and I went to see her on the ward the next morning, she was just completely fine. It's, it was incredible, but I just, it will never leave me the scissors and brain. I repeat scissors and brain message. So it's next thing, the nurses come and find you and shove this in your face and ask you what to do. So it's a 13 year old girl who's come to the department by herself with abdominal pain and she tells, she told the nurses that she's not sexually active, but they've got a urine sample of her anyway. And she is 100% positive for being pregnant. But the good news is it's five o'clock and it's time to hand over and somebody else is gonna have to deal with that. Thank the Lord. So yeah, that's an average day in a pediatric emergency department. Um So you get a, you get a bit of everything and uh you are about to go home for some well deserved wine after that shift. Um So I think basically we've probably got time to open up to any questions. I'm just having a little look at the chat from a social standpoint. How would you approach a trauma case of suspected child maltreatment, including direct or neglect and the parent are present? Um, ok, so that's an interesting question. So I guess if you're seeing significant, well, so what I would say is that there are things to be suspicious of. So if there's ever been a delayed presentation or to the department, then that raises concerns or if you ever see an injury that's not in keeping with the story that you're being told or if the story changes a bit, um, or you, um, you know, you're seeing an injured child and sometimes it's just that your spidey sense isn't, isn't happy and you look on their, their computer records and, you know, there's concerns in the past or for example, a long bone fracture in a premobile child, these kind of things. So there are times when you become very suspicious that there might have been, um, that the child's been mistreated. Sometimes it's bruising, unexplained bruising that comes up. Um, these kind of things, sometimes it's a child with an injury and you're being told a story and the story is so crazy that you sort of think it must be true, but it still sounds a bit crazy. Like the one that I can think of is a boy who's and had a coat hanger in his bottom and and the story was that he'd been jumping on the couch and there had been a coat hanger wedged in between the two cushions and he had just landed on it. But um, so it can be very difficult. I think the first thing you have to do is just treat the child in front of you and the parents are there and present and allowed to be there. Um And then what you have to do, for example. So if you, I'm trying to think, you know, if it's a baby who's upset, unknown reason and you examine this baby and think one of the legs is swollen and then you actually the leg and that confirms a fracture, then you're going to have to go and tell that family that you are going to have to involve in child protection. So there are doctors who in Edinburgh, this is different in different health boards, but in Edinburgh, how it works is we have a child protection team who are on call and we would speak to them and they would raise what's called an I RD. So an interagency referral discussion. So that means that the, the concern is always shared by social work, health and police. And what's really important is to tell the family that you're going to do this and that why you're going to do this. And so that can be quite difficult. You get very mixed responses from the family often if it's families who are, who have social work and involvement previously and they will get quite anxious and angry about it. Um And they often the hardest families to manage, even if, you know, they haven't essentially done anything to this child, but they will get very angry that you're involving social work again. Um And when it has been legitimately accidental, most families are pretty upset that the process is happening but understanding, but it's still very stressful and traumatic for them. Um But you can't, you wouldn't ever stop the parents and being with the child unless for example, the mom was accusing the dad of something and it was all getting very kind of heated and emotional and then you may need to get the police to the department, that kind of thing. But I've never, I don't think had anything like that. Um But most of the time it comes out through a sort of police investigation that uh who the kind of perpetrator was and then it, it is dealt with social work in that way, but in the actual moment where everyone's in the department and you know, the parents are, are kind of welcome to be there. You don't know who it is, that's done anything to this child, but you have to be open with them. Explain the process that you're about to go through. Inform child protection, tell them that that will lead to social work and police involvement who will want statements from their child. Um, so, yeah, I hope that answers your question. I don't know if there's any other questions at all. We deal with quite a lot of child protection to be honest. Um, so you can kind of get used to having difficult conversations with people. Um, yeah, I think that's the only question at the moment. Ok. All right. Thank you so much, Sarah for that wonderful presentation on pediatric emergency medicine. That was really insightful. I certainly enjoyed um specifically the walk through of all the interesting cases. Um It seems a bit overwhelming. Um But thankfully, those are made up into one single day and I believe you would agree that those were interesting cases as well. So we're just gonna give everyone a couple of minutes to ask any more last burning questions this Sarah they, they might have in the chat. But for those of you that don't have any question and um want to leave for maybe dinner. Kindly help us to kind of fill out our feedback form and you receive a certificate of participation for the event. So I'm gonna be putting the feedback form in the chat so you guys can access that. Um And just remember that if you manage to join all the Talks in our Subspeciality Series, we will generate a separate certificate of completion for you at the end and don't forget to look out for our social media platforms and medal as we'll be having our diabetes and endocrinology talk in exactly two weeks time and we hope to see you all there again. Um So we're just gonna be around here for a bit in case any of you have any more questions, if not. Uh Thank you so much for joining this talk on pediatric emergency medicine.