Minor musings on a Major Incident 

This week, London experienced the type of incident some would say we have been anxiously dreading, having watched our European neighbours in Paris, Berlin and Nice suffer similar senseless violence in recent months. A vague unease that ‘something might happen here’ suddenly became realised, the picture pulled into focus as an anticipated nebulous threat materialised into a set of concrete events.

Five people (at the time of writing) have lost their lives. Many others have suffered unimaginably; some lives will never be the same, and it is impossible to say where the ripple effects of this incident will stop. What shone though the chaos, though, was the calm, professional response that demonstrated how well prepared our emergency services are to step up and respond. This is what we train for and it shows.

The following thoughts are a few reflections on being (very) peripherally involved in a professional capacity – some notes to myself to keep filed away in memory for a future disaster that hopefully won’t come.

Read. Your. Major. Incident. Plan. Like they told you to at induction. One day, you might need it at short notice.

Look after yourself. If you are concerned that friends or family may be involved in an incident, make a quick phone call and check they’re OK. You won’t be able to concentrate on your job – and you won’t be doing the best for your patients – if you are preoccupied with worry.

Look after each other. No one came to work today expecting this; everyone is working outside their comfort zone. Be on the alert for people struggling.

Keep off social media. The media are instantly on the hunt for facebook quotes and tweets from anyone medically involved. And if you answer the desk phone to someone asking for information (journalists try this trick) – politely direct them to the hospital website or communications team.

Waiting… is the worst. Nervous energy is contagious in the calm before the storm. Where we were, one of the consultants did an impromptu teaching session on the history of the triage system – which not only kept everyone’s mind busy, but stopped us from pacing the department waiting for patients to arrive.

Stay informed… one screen with a reputable news source for live updates. Don’t speculate, and remember ‘fake news’ spreads fast. If media was graded like evidence based medicine, anonymous twitter sources would be sub-level 5.

What are the patients seeing? In paediatric ED, children are normally carefully separated from the adult waiting room to shield them from what can be very scary sights and sounds. If the department ‘flow’ has to change as patients are triaged to different areas, how will you shield vulnerable patients from seeing things they shouldn’t have to?

Be the small cog in the machine. A department which runs smoothly in a crisis is as much (if not more) down to the people reliably performing the simple day to day tasks, than those who are sprinting from one code red to another. The baseline workload is still there and still needs to be seen to safely.

Thoughts of solidarity, sympathy and respect to patients, families and colleagues affected by the events of this week.


Minor musings on a Major Incident 

This week, London experienced the type of incident some would say we have been anxiously dreading, having watched our European neighbours in Paris, Berlin and Nice suffer similar senseless violence in recent months. A vague unease that ‘something might happen here’ suddenly became realised, the picture pulled into focus as an anticipated nebulous threat materialised into a set of concrete events.

Five people (at the time of writing) have lost their lives. Many others have suffered unimaginably; some lives will never be the same, and it is impossible to say where the ripple effects of this incident will stop. What shone though the chaos, though, was the calm, professional response that demonstrated how well prepared our emergency services are to step up and respond. This is what we train for and it shows.

The following thoughts are a few reflections on being (very) peripherally involved in a professional capacity – some notes to myself to keep filed away in memory for a future disaster that hopefully won’t come.

Read. Your. Major. Incident. Plan. Like they told you to at induction. One day, you might need it at short notice.

Look after yourself. If you are concerned that friends or family may be involved in an incident, make a quick phone call and check they’re OK. You won’t be able to concentrate on your job – and you won’t be doing the best for your patients – if you are preoccupied with worry.

Look after each other. No one came to work today expecting this; everyone is working outside their comfort zone. Be on the alert for people struggling.

Keep off social media. The media are instantly on the hunt for facebook quotes and tweets from anyone medically involved. And if you answer the desk phone to someone asking for information (journalists try this trick) – politely direct them to the hospital website or communications team.

Waiting… is the worst. Nervous energy is contagious in the calm before the storm. Where we were, one of the consultants did an impromptu teaching session on the history of the triage system – which not only kept everyone’s mind busy, but stopped us from pacing the department waiting for patients to arrive.

Stay informed… one screen with a reputable news source for live updates. Don’t speculate, and remember ‘fake news’ spreads fast. If media was graded like evidence based medicine, anonymous twitter sources would be sub-level 5.

What are the patients seeing? In paediatric ED, children are normally carefully separated from the adult waiting room to shield them from what can be very scary sights and sounds. If the department ‘flow’ has to change as patients are triaged to different areas, how will you shield vulnerable patients from seeing things they shouldn’t have to?

Be the small cog in the machine. A department which runs smoothly in a crisis is as much (if not more) down to the people reliably performing the simple day to day tasks, than those who are sprinting from one code red to another. The baseline workload is still there and still needs to be seen to safely.

Thoughts of solidarity, sympathy and respect to patients, families and colleagues affected by the events of this week.


PEM Review 022 – NEW FOAMed // LISFRANC INJURY // TEG // TRAUMA // BRUEs //

foamcross           PAEDIATRICFOAM.COM

Firstly, an unashamed plug for a new project I am excited to be involved with. The London School of Paediatrics is venturing into the FOAMed world, and our new site is launching this month – you can see it here http://www.paediatricfoam.com. Take a look at @jround999’s brilliant ‘Inotropes made simple’ or this post by yours truly on Kawasaki Disease.

lisfranc.jpg   DON’T PUT YOUR FOOT IN IT…

A Lisfranc injury is an injury resulting from fractures of bones of the midfoot, or rupture of ligaments. (Eponym fans – Jacques Lisfranc was an 18th century surgeon who described this injury in soldiers falling from horses trapping their foot in a stirrup, and dislocating the midfoot). On X ray you’ll see a widening in the space between 1st and 2nd metatarsals. The patient must be strict non-weight bearing, and orthopaedics need to see ASAP. @CoreEM are here with a short podcast to explain more.

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teg-report TEG

Major haemorrhage in paeds trauma is not common – so when someone clever asks for a TEG (thromboelastogram) in the middle of a paeds trauma call, the more paediatric orientated amongst us are left blankly staring at a colourful diagram hoping it will miraculously reveal its meaning. Luckily @EMdocsdotnet are here to help with a guide to interpreting the TEG – a point of care test which provides ‘an assessment of near real-time, in-vivo clotting capacity, providing information regarding the dynamics of clot development, stabilization, and dissolution’.

Bonus: Characteristic TEG waveforms (TEG for dummies):

teg

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top-secret1          FOAMed CONFIDENTIAL

We live our lives online, and increasingly for some doctors, this includes work life – with huge potential learning benefits but also big risks if confidentiality is not respected. @EMdidactic has a piece of essential reading for consumers and creators of FOAMed, dealing with confidentiality and de-identification of patient information.

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brue         TROUBLE BRUE-ING?

Listen to this two-part podcast on Brief Resolved Unexplained Episodes on @pedscases (which are NO LONGER called Acute Life Threatening Events or ALTEs, take note!) then test yourself on your knowledge. Good for anyone new to the paeds ED.

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hernia  TIME IS TESTICLE

Learn how to reduce hernias in babies – it is not OK to ‘wait for a surgeon’ to try, and you will do more harm by waiting than having a go (the swelling increases fast and venous obstruction is a real possibility). Thanks @stemlyns for this first piece in a series of paeds surgery topics.


PEM REVIEW 021: WINTER IS COMING: CROUP // BRONCHIOLITIS // CRP ESR // FRACTURES // ANATOMY // SICKLE CELL

With coughs and sneezes aplenty in the paediatric emergency department (and that’s just the staff) it’s high time for a winter PEM FOAMed review:

cough   BRONCHIOLITIS BARRAGE

Winter just wouldn’t be winter without an influx of bronchiolitic babies. If you are one of the few in the FOAMed world who hasn’t read @sailordoctor’s incredible piece about bronchiolitis vs viral wheeze (and why salbutamol is useless in bronchiolitis), please do spend some valuable minutes doing so. If you’re looking for a podcast to get you up to speed on RSV, look no further than @EMtogether ‘s offering found here.

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seal   CROUP CASCADE

From RSV to parainfluenza: check out @TREKKca ‘s summary of glucocorticoids for treatment of croup. Bottom line: ALL kids with croup should get a dose of steroid, which should improve symptoms within 6 hours, lasts around 12 hours, and shortens hospital stays by 12 hours.

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sicklecell SICKER SICKLERS

In patients with Sickle Cell disease, Acute Chest Syndrome is a potentially devastating complication not to be missed, and not to be confused with pneumonia (although there can be an overlap.) Find out more in @first10EM ‘s review. See also, from @TheSGEM: which febrile children with sickle cell should get a chest XR?

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bottles   CRP, ESR, WTF?

If you don’t know how to interpret an investigation, you shouldn’t be doing it. This goes for EVERYTHING but I think the most common situation this applies to in the ED is ordering a CRP or ESR… ‘because I’m doing bloods anyway’ (cue rage of nearest consultant). @TamingtheSRU gives us some biochemical background on the acute inflammatory markers – CRP, ESR and procalcitonin – and while it might seem particularly nerdy to know the half life of CRP, it might make all the difference in how you interpret your result in the context of a particular case.

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finger   NAILING IT

@AndyNeill’s ever enlightening anatomy podcast series features the anatomy of the fingertip. If you have seven minutes to spare, watch his video and ‘nail’ (sorry) your next fingertip injury referral to Plastics.

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cast2   SPLINT FINISH

Few things are more satisfying in the ED than applying a really professional looking backslab splint to a fractured arm (and this will also earn you massive brownie points with your nursing team!) Pick up some pointers in this brief video by @PEMtweets.

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nsaids   DOGMALYSIS

‘NSAIDS can delay healing of fractures’… I have to admit I was personally unaware of this particular piece of dogma, but if you have been letting it influence your practice it might be time to stop withholding such a useful analgesic. @LWestafer has crunched the literature and found there is a real lack of evidence of harm in otherwise healthy kids with fractures. There may however be room for caution in those on long term steroids, with osteogenesis imperfecta or with other systemic risks for fracture non-union.

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entsho  ENTSHO

And finally a plug for an excellent ENT website, which is written by UK ENT registrars. It has a wealth of advice regarding most problems that we see frequently in the ED – so if it needs referral, at least you can get further management started before the ENT registrar arrives!


On refugees, in crisis 

This piece of writing has one thing in common with its subject matter – it doesn’t really belong where it’s ended up. It has no direct relevance to paediatric emergency medicine, so if you are here as a doctor please forget that for a moment and continue to read as a human, for it has every relevance in this respect.

I am not a martyr or a humanitarian of any standing. This piece has been written after a measly ten day stint volunteering in what is by all accounts one of the ‘nice’ refugee camps out of the hundreds – hundreds! that exist in Europe. A woman I met who had been working in the camp for several weeks (and before then, at many other camps in other places) said she doesn’t like to use the term ‘volunteer’ – with its hint of condescension and connotations of privileged gap-year tourists. She said she was there ‘to participate’.

Everyone – every refugee and every volunteer in the camp – is a participant. There is an equality in this way of thinking that acknowledges that we are all humans living through this time in history. Everyone has travelled miles from their homeland to be here but the circumstances of that travel and the decisions made could not be more different. For some, choice had vanished long ago and fleeing was imperative to survival. For the luckier ones amongst us, choices were made and questions were asked: should I go at all? Do I really want to do this? How long should I stay?

Those who have travelled with autonomy and made an active choice to participate are merely unfathomably fortunate that history did not play out in a different way. This could all be the other way round. Any possible number of forks in the road that fate did not take could have led you and your family to be the ones sleeping in a wind whipped tent on the concrete banks of a disused European port.

What is it like? There are over three thousand people and two thirds of them are children. Syrians, Kurds, Iraqis, Afghanis, Lebanese, Yazidis. Most have been there more than eight months, and there is no telling how much longer they must stay. It is flat, grey, dusty and litter strewn. Hot, windy, suddenly cold at night. Beautiful sunsets over the sea. There is tension, anger, boredom, fear and uncertainty, and there are unexpected moments of joy.

Dusk falls and a knife is pulled out as a fight escalates. Nearby, a giggling group of girls carries on their playground game regardless (haven’t they seen, or does this just not register on the scale of violence they have witnessed?)

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A curly-haired four year old in mismatched sandals walks – alone – across the whole camp to come for her daily bath in one of the NGO cabins. She sees one of the workers outside, starts running and falls over laughing as soon as she is over the doorway.

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The teenage girls have a dance session in a meeting room (six tracks on repeat, but no sign they will tire of these any time soon). The rhythmic sound of their feet drowns out the noise of the rocks the boys are hurling at the door out of sheer boredom.

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You walk past a group of young men sitting on the gravel floor, smoking, and they shout to you to come over. A split second reflex of fear will make you feel ashamed as moments later, one of them releases doves he is keeping in a makeshift coop, and you all watch them whirl in circles.

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After searching through all the clothes in stock, a mum regretfully hands over her toddler’s dirty but newish trousers and in return has to settle for a clean pair a fraction too small, with a hole in the knee. This is the clothing exchange, where you never own the clothes that in any other circumstance you would never choose.

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Two girls who you taught to make friendship bracelets recognise you from afar as you walk through camp to take dirty clothes to the laundry. They run over the broken concrete yelling ‘sister, hello sister!’

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A wild eyed boy with scars on his arm uses a corkscrew to scrape furiously at a newly painted wall. A new volunteer tells him to stop – he thrusts the corkscrew in the direction of her face and she bursts into tears. It’s her first day here.

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A smiling, university educated young man is celebrating because his friend successfully flew out of the country yesterday, travelling on a fake document. The assembled group baulks at the price – 4,500 Euros. ‘Yes, but for a new life…’

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Five years old but looking younger, with an earring in one ear and a grubby face. This scrappy boy, who speaks good English for someone who has never been to school, fights with another small child and runs away crying. Later he brings you a government-handout bread roll, which he calls a cookie, and insists you keep it to eat for your lunch.

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A woman in a headscarf is visibly stealing baby clothes from the charity store. You are equal parts pissed off that she would steal from others in need, and pissed off at yourself that your first reaction wasn’t one of pity in this desperate situation.

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If I was expecting to go and use my medical skills, on this occasion I would have missed the point (medical services were provided by a different organisation). If you can hold a paintbrush, if you have arms to lift and carry, if you can kick a football, if you can smile, sort, tidy, clean –  I think this is the ‘participation’ which the woman was describing. Tiny, tiny things, but somehow, perhaps not insignificant. Drops in the ocean.
While I was there, a camp nearby was attacked three nights running by an extremist right-wing terrorist group with petrol bombs. Tents burned, police stood by, then arrested thirty refugees.
Coming to work the next day we were weighed down with shame that fellow humans in the same country could act with such hate. Nobody from the camp mentioned it, but what must they have been feeling towards our society, where they have come to seek safety, that could allow this to happen to people who have already fled unimaginable trauma?

My unrealistic hope is that all who are currently existing in that place will one day be able to forget the entire miserable experience and move on to have happy, productive and peaceful lives wherever they end up. If they are unable to erase the bad memories, then I hope that amongst these jagged pieces there will remain a fragment reassuring them that not all Europeans wished them harm, and that some came to participate.

Donate to, (or volunteer/participate with) A Drop In The Ocean: http://www.drapenihavet.no/en/home/