Children are just little adults. SMACC2013. St.Emlyn’s

Here at St.Emlyn’s we like a bit of #dogmalysis. We like to challenge established thinking and perhaps to look again at what we all know to be true.

One such dogma is that ‘Children are not little adults’.

This is embedded into our training from undergraduate level, through postgraduate training and it’s one of the most common (and quite frankly the laziest) lines to appear at the beginning of any paediatric text.

Now, there is much to be said for paediatrics and paediatricians. I work with some absolutely amazing paediatricians on a regular basis and frequently use their skills, knowledge and experience for kids in the ED. In my current hospitals it’s a great symbiotic relationship that works well, but in my training and travels this has not always been the case. When we stop and think about sick kids, and I mean really sick kids we might perhaps need to think again about whether the expertise lies in a job title, or in a skills set. In terms of resuscitation should we ask ourselves a dogmalysis type question….

In the resus room are children really just little adults?

The following talk was delivered at SMACC 2013. A great conference that excelled at getting clinicians to think and challenge what we think we already know. My contribution is designed to be the antidote to the established dogma around children and as such I’ve designed the talk to be delivered as a challenge to established thinking.

I wanted to do this talk from the perspective of a general emergency physicians who deals with kids as I believe this to be the norm in the UK. Most sick kids will initially be seen by a general EP and whilst I think some paediatric specialists in the UK believe that this should change and that adult and child emergency medicine should split apart, that’s not my belief and for much of the country it will not be practically possible. So, for the foreseeable future we need to ensure that our EPs are mentally prepared to engage with paediatric resuscitation in the same way that they do for adults. That, I hope, will be the outcome of this talk.

All the cases are illustrative and not real cases. For confidentiality reasons I’ve made the main case up based on an amalgam of past events and experiences over many years. The docs mentioned are essentially hypothetical (see note on cases on St.Emlyn’s below). They are included to illustrate the principles discussed and show a chain of events that can take place through procrastination resulting from a fear of intervening in sick kids. I should also clarify that when I say (in the talk) that cases such as these are not uncommon – that refers to the delay in intervention. I don’t want to give the impression that children are dying on a regular basis! The vast majority of kids are treated well in the UK, but it is not infrequent to see delays manifested in the resuscitation process that we would not expect to see in adults.

The views are designed to promote debate and are based on my personal thoughts and experiences. They do not represent the opinions of my colleagues, my employer or students. In fact I may be the only person in the world who thinks this……but I don’t think so. We recently met Joe Lex here in Virchester and he attributed the following (I think) to Rosen (previously said Tintinalli – thanks to Chris Nickson for correction)  ‘the last thing a sick kid needs to see is a paediatrician’, and whilst that is a far more provocative statement than anything in my presentation there may be some truth in the statement. Let’s go for an amendment ‘a sick kid should not ONLY see a paediatrician’. Hopefully that statement will make more sense after listening to the podcast.

If you like this I would strongly recommend that you also listen to the talks given in the same session. Matt O’Meara doing a great job on the FEAST trial, the very impressive Mary McCaskill on neonatal nightmares, and Andrew Numa on futility in paediatric care.

Matt O’Meara on the FEAST trial.

Mary McCaskill on Neonatal nightmares

Andrew Numa on defining futility.

Finally, I have always worked in hospitals that see kids and I think it’s a really exciting and rewarding part of practice. Like everyone else I am not immune to errors and many of the lessons in this presentation are…., as Casey Parker might say Hard Learned.


[learn_more caption=”Cases on St.Emlyn’s”] Case studies on St.Emlyn’s We do present hypothetical cases on St.Emlyn’s. These are based on the experience of our team as educationally active emergency physicians. For centuries doctors and nurses have used stories to teach and learn from each other. However, we are careful not to break any patient confidentiality rules.
As a result if we present a case then it will always be fictional and not relating to any specific case or patient. For example if we present an (anonymised) X-ray or ECG we will create a clinical history that is compatible with the radiological/ECG findings but which does not relate to a specific time, location, patient or circumstance. Whilst it may be argued that this detracts from the clinical learning we believe that patient confidentiality is more important in these matters.
We will create time, date, age, sex, details of the patient and their circumstances etc. Our cases are therefore an amalgam of different cases and experiences.
Any resemblance to patients treated by us now, in the past or the future is entirely unintentional and accidental. Our cases are presented to help us all reflect and learn, in that way we might become better clinicians for our patient.
Vive la FOAM! (Free Online Medical Education).[/learn_more]

 

Posted by Simon Carley

Professor Simon Carley MB ChB, PGDip, DipIMC (RCS Ed), FRCS (Ed)(1998), FHEA, FAcadMed, FRCEM, MPhil, MD, PhD is Creator, Webmaster, owner and Editor in Chief of the St Emlyn’s blog and podcast. He is Professor of Emergency Medicine at Manchester Metropolitan University and a Consultant in adult and paediatric Emergency Medicine at Manchester Foundation Trust. He is co-founder of BestBets, St.Emlyns and the MSc in emergency medicine at Manchester Metropolitan University. He is an Education Associate with the General Medical Council and is an Associate Editor for the Emergency Medicine Journal. His research interests include diagnostics, MedEd, Major incidents & Evidence based Emergency Medicine. He is verified on twitter as @EMManchester

  1. Hi Simon
    Fantastic talk – that really set the scene for the Paeds plenary at SMACC.
    Thanks to the magic of the Internet, I’ve finally got to hear it!
    Small point – I pretty sure the quote you attributed to Judy Tintinalli actually belongs to Peter Rosen.
    Cheers
    Chris

    Reply

    1. Thanks Chris – now sorted with attribution 🙂

      Reply

  2. this was freakin awesome talk and so glad I am able to hear it today through the power of SMACC2013!
    Simon , I have heard much of the concepts you talk about previously but the way you speak and present them in this podcast was brilliant, regardless of slides! I listened to it whilst flying today and perfect measure of inspiration and education for me today.
    WOW what can we expect in 2014!?

    Reply

  3. Without seeming like too much of a creep….. this is brilliant boss. I think we all will have a similar anecdote. Seems many of us (myself included) are prone to a this cognitive error, where we would act quickly and decisively in an adult, but are happy to delay when its a child. My new question for the juniors (and myself) is: “What would you do if an adult looked like that?”

    Reply

  4. Dr Ffion Davies July 22, 2013 at 12:13 pm

    Spot on Simon! Couldn’t have said it better myself. (Sorry – has taken me a month to get around to listening to this!) Tried saying the same thing at a paediatric conference a few years back – went down like a lead balloon but hey ho!

    Reply

    1. Thanks Ffion, I am delighted that you share the same principles. I am a great believer that PEM must take the best from the many specialities that interact with sick kids and that we, as resuscitationists, play a key role in making things happen in the resus room.

      Many thanks for your comments and thanks for reading.

      S

      Reply

  5. […] isn’t another argument about why children aren’t just small adults – the report actually contains data which supports this […]

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  6. […] lot about seeing paediatric patients in the past; about how seeing kids is child’s play, how children are just little adults (controversy from Prof Carley as ever!), and even given you some paediatric tips you won’t […]

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  7. […] I am lucky enough to work in both paediatric and adult trauma centres in Virchester. I think this is a good mix as really nasty paediatric trauma is rare but adult trauma is not. This means that we can transfer our expertise gained from frequent exposure to severely injured adults to the much rarer severely injured children. Such cross fertilisation of protocols, ideas and therapies is (in my opinion) a good thing. Check out the smacc talk from 2013 if you want to know more about the rationale for sometimes treating children as little adults. […]

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  8. […] relatively less injured and with a different trauma pattern. Children are not small adults. And yet the reality is that assessing a child clinically in the same way you assess an adult clinically will…. Administering airway support, fluid and analgesia in the same way as one does to an adult will […]

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Thanks so much for following. Viva la #FOAMed

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