Be in it to win it – Textbook of Paediatric Emergency Medicine Competition

The editors of the third edition of Peter Cameron’s Textbook of Paediatric Emergency Medicine want to hear from you. And there’s a prize of a free copy up for grabs (see how to enter below).

We asked Simon Craig, one of the editors (and also a favourite of the DFTB team) some questions about the next edition:

 

What areas of PEM do you think have seen the biggest changes since the last edition of the book?

The last edition of the book was published in 2012. Since then, we have seen a number of big changes in the practice (and knowledge) of paediatric emergency medicine. Personally, the highlights include:

  1. High-flow nasal cannula oxygen therapy. This has become incredibly popular for everything from premature infants to adults, however, there isn’t that much “evidence” to support its use. It will be interesting to see the results of current studies in this area
  2. Ultrasound. Although high-flow seems to work for most things, ultrasound seems to be needed for everything else… It is certainly a big help for some procedures. However, I’ve seen papers on bedside diagnosis of everything from fractures, pneumonia, intussusception, appendicitis, ingested foreign bodies and raised intracranial pressure. I’m waiting for a paper that demonstrates the utility of either high flow or ultrasound for gastroenteritis – it’s only a matter of time!
  3. Multi-centre collaborative research, not only in Australia and New Zealand, but internationally and globally. There are now a number of productive research networks across the world, producing high quality studies that will contribute to knowledge and inform our practice in the future. Recent high-profile examples include the THAPCA trial (therapeutic hypothermia in paediatric cardiac arrest), and the FEAST study (mortality after fluid bolus in African children with severe sepsis). Locally, PREDICT has conducted large studies on head injury and bronchiolitis, and is currently undertaking studies on convulsive status epilepticus, high-flow nasal cannula therapy, and other topics. There are plenty of fantastic researchers all over the world doing really interesting things, and it is a great time to be involved in PEM research.
  4. FOAM. What more can I say? So many excellent resources for everyday clinicians, and plenty of places to go for those coming up to exams. It seems to be impossible to keep up with all of the blogs, tweets, podcasts, and videos.

What journals do you read?

I try and keep up with a number of journals including many of the various EM journals (Annals of Emergency Medicine, Academic Emergency Medicine, EMJ, Emergency Medicine Australasia), Paediatric Emergency Care, local and international paediatric journals (Journal of Paediatrics and Child Health, Paediatrics, Archive of Diseases in Childhood, etc), as well as the “big” journals (NEJM, JAMA, BMJ, Lancet). Again, it’s impossible to read everything, so you have to be selective!

What chapters are you most looking forward to updating?

I don’t think that any particular chapters will be “more exciting” to update than any others…  There’s plenty of new knowledge and practice, and I’m looking forwards to hearing what people are doing and thinking from all over the world.

How to win a copy of the book:

The editors want your feedback, so that the new edition is even better than the last. Just fill out this survey and you’ll be entered into the prize draw – one lucky DFTB reader will get a free copy of the new edition.

https://www.surveymonkey.com/r/DFTB_PEM_textbook

Sitting on the Couch, Talking Evolution

I’m seated here, in upholstered comfort, with two questions. The couch is a dreadful, shameless pun, which I will explain in a moment. The questions though, are real.

Both questions relate to the relevance of evolution in emergency medicine. The first is how does our current understanding of evolution help us be better clinicians? The second question is what do we not yet know? Or, in other words, what is the depth of our ignorance? (Please don’t answer that. It is a rhetorical question*).

Evolution. To briefly recap the last three and a half billion years (give or take), it started when a few basic molecules chunked themselves together. Amino acids assembled into proteins – monomers to polymers, folding themselves into proteinaceous origami. DNA formed. Pretty quickly this had the remarkable idea to split and produce an heir. This was the real miracle of life. Twitches of biological advantage then produced, amongst other things, a wall to box in the carbon-based bits and bobs forming cells – units which then really got the hang of division. They did this over and over. For a while things bided their time. These bacterial grade debutantes swum round in a vicious, blistering stew for two billion years, at the end of which they realised it was time for an upgrade. By this point they had oxygenated the planet, and some serious evolution could occur. Then any hiccoughs that might produce a biological advantage were passed on, creating more and more complex organisms. Finally humans popped up with their hardly conceivable physiology; their countless internal interactions and stupendously complex responses occurring every single second. Go on, try it, just for a moment, think about what your body is doing, simply sitting and reading. Seriously. It is too cool for words (certainly far too cool for mine).

But what does this sublimely elegant sequence of events have to do with emergency medicine? Sepsis – 3. That’s what. We were discussing the new terminology in teaching. qSOFA. (SOFA, get it? I am sorry. I really am). Sepsis has to be one of the most complex disease processes around. It is a rampaging, blazing blizzard of swirling chemicals; a genomic, metabolomic monsoon. Distressed mitochondria signaling for help, agitated endoplasmic reticulum producing misfolded proteins in panic, redundant cascades sparking up and looping back on themselves. The entire organism in disarray. All of the responses interconnected and surprisingly unique to each individual. Here at the pointy end of evolution, human pathophysiology in full-flight is an event almost too wondrous to behold. And we reduce it down to a respiratory rate, some confusion, and a 3 digit number. I fully appreciate that qSOFA is designed as a descriptor of organ dysfunction in response to infection, and is neither meant to describe, nor diagnose (I am preparing myself for the reader backlash here). But, certainly in ED, it feels so far removed from this complex and individualised disease that it hardly seems to raise an eyebrow of interest.

Rafts of guidelines we use have similar problems. How does one grind down an almost infinite array of interactive cellular combinations and permutations into a simple guideline or diagnostic algorithm? Artificial Intelligence is on its way, we are told – Holmes and Watson machines that will replace most of a doctor’s diagnostic work. Well good luck to them, I say.

To return to the original question, how does an understanding of evolution make us better clinicians? Well we can start by respecting the complexity of the response humans have to disease, and how little of it we truly understand. This way we are less likely to be prone to dogmatic statements, more respectful of the individual presentation in front of us, and more considered in our therapeutic decisions. It also helps us to understand why much of current research, on single interventions, produces small, if not no, gains (and many results seem to be simply the outcome of number-exploitation, rather than true effect).

We are the privileged few. Sometimes one can only appreciate the terrifying complexity of something when it goes wrong. We get to see it, and we are thus are not condemned to a life of sleep-walking, never appreciating the magnificence of evolution and what it means to inhabit a human body with all of its labyrinthine convoluted function.

Our second question is what is it that we don’t know? The other 99%, I would hazard a guess. Like the fact that we have just discovered 1200 new exoplanets, nine of them potentially habitable, all of these possibly with carbon, hydrogen, nitrogen, maybe even oxygen, all dancing around and thinking about getting it on. There is so much more for humans to discover. It’s an incredibly exciting time to be open-minded about new discoveries, both without and within, and be prepared to drop rigidly held teachings when we learn more. For us, it’s glycocalyces, hidden chemical messengers, brand new communication cascades, and so much more. And we are here, in medicine, taking part. We are, surely, the lucky ones. More wonder, I say. More wonder.

*A rhetorical question may not be what you think. Although the standard teaching is a question for which one already knows the answer, this is not quite true. The Greeks and Romans, who bestowed upon the world the flamboyantly wonderful figures of rhetoric, had dozens and dozens of terms and classifications for rhetorical questions (none of which they could actually agree upon. Sadly, their empires crumbled before they had a chance to tidy up the definitions). Some of the examples of rhetorical questions are: apocrisis, antiphora, epiplexis, subjectio, and epitemesis, amongst many others. Mine was an example of hypophora. I did not want you to answer it (knowing full well the extent of my own ignorance). Instead I intended to answer it, however lamely, in the remainder of the text. Those Greeks were onto something.

The post Sitting on the Couch, Talking Evolution appeared first on LITFL: Life in the Fast Lane Medical Blog.

Nurse sent home for wearing black shoes.

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This is a guest post by Nurse Y.
As nurses we experience plenty of WTF moments during our interactions with the organisations we work for. This is one such moment….

 

I had an ‘incident’ (I guess you could call it) Friday that has been playing on my mind all weekend.

Whilst I was outside enjoying my morning coffee on the balcony, my nursing agent called and ‘begged’ me to do a shift for her (at an Aged Care Facility) a few suburbs away.
I haven’t worked in Aged Care on a morning shift for probably 5 years, despite nursing close to 14. Whilst currently re-studying at university for a Law degree – yes, I know – it is a ‘massive change’ – I am still fortunate enough to have had already established a career in nursing to help pay the bills while I study. I certainly couldn’t do it in retail! I digress. As I ask her how ‘desperate’ we’re talking, she assures me ‘very’. I’ve been in the business a little while now, especially with agencies including what the 67 different levels of desperation are.

I took the job 1: Because she has been a fabulous agent, and found me an amazingly well-payed, Uni-friendly part-time gig in GP nursing (where I’ve found my love of nursing the last 5 or more years), and because, well, 2: The desperation was a good 30-ish.
Besides, I do love our oldies – excuse me – ageing population and what’s a few pills, wounds, paperwork and pushing a 5KG drug trolley around a place you’ve never stepped foot in before, right? I’ve done it more times than I’ve had hot dinners. Easy-peasy. Like riding a bike. I pick my uniform out from the washing basket, take a quick sniff [1] (all good; I’d only worn it the day before) and make my way out.

Once I get to the facility and welcomed as I am usually as an agency nurse, with a touch of gratefulness, a pinch of relief and a comfortable amount of silent praying that I won’t need too much orientation. As always, I’m ridiculously relaxed and ready to get in, do the job, and get out, and all – usually – with a smile on my face. I’m directed towards the area where I’m ‘in-charge’ to be greeted by a visibly agitated, but very polite young Asian nurse.
I notice that she too is from an agency, although different from mine. She quickly sits me down at the nurses’ station to give me a handover, and to tell me that the facility had asked her to leave because she wasn’t wearing the appropriate footwear. She could stay until someone replaced her – me – but then she had to leave and drive back home after only 3 hours of work.

Her English was perfect; she was well-groomed; short and fit, but wearing black runners with her uniform. Because she had – wait for it – just been diagnosed with osteoarthritis in one of her joints. Her ‘runners’ were actually specifically designed to help facilitate her walking and alleviate her foot pain. Perplexed, I asked her if she had explained this to the manager, to which she said she had and that they had still asked her to leave.

At this point we both look down at my feet. Yup. I was wearing runners. Nice ones albeit, but still runners because they were comfortable and have a hot pink trim. No other reason. They weren’t those foul-looking leather ’81-inspired closed-in “nurses shoes” I own 95 pairs of, but they were covered. Well, they were covering my entire foot. But policy and policy.

She gave me a thorough and kind handover, and had already done the bulk of my work. All morning pills, PEG feed, insulin, BGL’s and DD’s. I told her to get (the hell) out, gave her a tiny touch on the shoulder and reassurance that her agency would still pay her for the 3 hours of (might I add) very efficient [2] work she had already done.

And this is where my black heart broke. As the other ‘in-charge’ nurse and I were running through mandatory orientation paperwork, I could see my agency friend on the phone and gently tearing her pay docket into pieces. I stopped listening to frantic agency nurse orientation and asked my friend in pink what was wrong. Voice crackling, and a visible lump in her throat she tells both myself and nurse Frantic that her agency was not going to pay her.

This woman had drove for half an hour to get there, had done her job and was ASKED to leave. She didn’t walk in and decide nurse Frantic and her team were visibly tired, busy and short with their answers nor that it wasn’t worth her day or time; she was more than prepared to stay. She also gave, in my opinion, a very valid reason as to why she couldn’t wear shoes not covered by their policy and procedures/ OH&S issue, but alas, she went home after working 3 hours, getting up at BS O’clock to accommodate their staff levels/ ‘desperation’ AND all for naught.

I did end up finishing that shift – mostly through a heavy heart and gritted teeth – all whilst looking down at the ground. But not because I felt sad and was worried about what I might say if Pink Nurse was mentioned, but because I was busy.

Busy making sure my runners were visible to everyone, especially the pink trim.



  1. Stop there Judgy McJudgy – we’ve all re-worn our unwashed uniforms (provided we haven’t been giving incontinent patients shower trolleys all shift).  ↩
  2. She didn’t miss one signature in the drug chart, or miss a pill.  ↩

 

If you have your own story or reflection you would like to share on theNursePath please email it to ian@thenursepath.com.

Sepsis

Collaborate on Slack You are asked to review a 47-year-old male in the Emergency Department with hypotension that has not responded to rapid infusion of 2 litres intravenous crystalloid. On examination his temperature is 40C, he is warm peripherally with a respiratory rate of 24 breaths per minute, an arterial oxygen saturation of 98% on […]