Having attended the ICEM2016 conference in Cape Town a few days ago, I came across a new concept championed by PEM physicians from all over the world: the Paediatric Marketplace. If you do not know what this is, the best way to describe it is like a speed dating event where the delegate wonders from stand to stand to be quizzed or tested on multiple areas of paediatric emergency medicine like paediatric rashes, sedation, paediatric ECGs etc., recognising that we can find it tricky to look after children well in the ED.
This concept was new to me though I hear it had already been run at the previous ICEM meeting in Hong Kong. It was really great fun and a good colleague of mine described it as a professional bazaar where one can shop for old and new items (or knowledge if you prefer).
I came across a stand that particularly caught my attention and certainly triggered some reflection: the children’s rights champion stand.
I have to reference the Child Rights International Network group (CRIN) here and the website where this originated from. It would be unfair and unethical not to do so. I also suggest referring to it ad nauseam as there is extensive material available for free for you to browse at your leisure.
At the stand, you were asked to tick three boxes out of ten promises you will try to keep in the near future when attending children during the course of your work. You then had to sign the declaration to bind you somehow to your own promise.
I would like to go through some of these as I felt they are worth discussing for beginners and non-beginners alike. In the fast-paced, often stressful environment of our EDs/PEDs, it is so easy to forget these essential pillars of good practice.
1. Help children feel safe and welcome
Emergency departments are scary places for both children and parents. Chances are that the day they attend your workplace (where you are likely to feel comfortable) is going to be one of the worst (if not the worst!) days of their life. It is therefore essential for you make the utmost efforts to make them feel welcome and safe regardless of the reason for their attendance. This might not be easy due to the volume of patients we see or the speed at which you have to whizz from one patient to the other. It is important however for you to remember that any little effort can make a huge difference to the experience your patient and their relatives will have in your PED.
2. Greet children by name
We often make pledges to introduce ourselves by our (first) name but would it not be fantastic to greet every single paediatric patient by their first name too? This is easily feasible as most patients book in and get triaged before you see them. You would often have a wealth of information about them even before you start seeing them. It ties in with the first point I made about making the patient feeling safe and welcome.
3. Allow caregivers to accompany and support their child
I do this invariably and it is great to have parents to assist comforting their own children. I often allow this to happen during complex procedures like procedural sedation. I however ask the family to leave before we start the planned intervention that required the sedation. I just find it is too many things to concentrate on having the parents present too (situational awareness – but this would merit a full blog on its own!). Does anyone approach this differently? I know that some of my colleagues allow parents to stay in during the whole procedure but you should be doing what you are comfortable with.
4. Learn how to communicate with children of different ages
Now this sounds like stating the obvious but is extremely important. I know one thing for sure that a big reassuring smile and caring attitude will translate across all age groups to both children and parents.
5. Use play and distraction to reduce stress
In Virchester, we have a great member of the team who is play therapist and provides cover for most of the day helping us with this. Her input is extremely valuable, as she knows how to use different distraction techniques at all age levels. She is a great asset to use during cannulation, suturing, plastering combined with the appropriate analgesics/sedatives. Natalie May gave a great talk about this at the EuSEM conference last year in Turin and wrote a blog on the topic, you can read it here.
6. Inform children about their emergency care
Engaging children (and parents) into their clinical care will achieve gaining their trust and cooperation. Remember to use simple words and most importantly do not lie! Saying to a child that that a painful cannula insertion or injection of local anaesthetic will not hurt at all will only destroy any trust you have built up so far. You will be unable to re-establish this easily after you lost this.
7. Listen to children and take them seriously
This is not only professional courtesy but also empowers your patients in making their own decisions. After all, there must be some true in the saying “children always tell the truth”. Very important clues in your patient history will guide your working diagnosis and the investigations you will organise.
8. Respect children’s dignity, privacy and confidentiality
Toddlers might be shy about their belly button and teenagers might be reluctant to show you that inguinal hernia. It is up to you to find that fine balance when you involve the parents (and which one?!) before you intrude into what your patient will regard as his/her personal space. So be patient, explain why it is important that you have a look at this or that (sometimes with mummy or daddy but always with a chaperone for intimate examinations). Also remember to ask permission before touching. After all, your patient’s body belongs to him/her only!
Should we try to make three pledges a week from the above non-exhaustive list?
It is not only good practice but I am convinced it will make that day in ED a better experience for your paediatric patient (and of course his/her parents)!
I would be grateful for any of your comments…
@baombejp on Twitter
Further reading and references:
- https://www.crin.org The Child Rights International Network’s work is grounded in the UN Convention on the Rights of the Child.
- https://www.crin.org/en/home/rights/convention/text-convention Learn more about the Convention on the Rights of the Child
- http://www.unicef.org.uk/UNICEFs-Work/Our-campaigns/Become-a-UNICEF-UK-Childrens-Champion/ Unicef UK works to make sure the UK Government delivers on its responsibilities for children
5 thoughts on “Making ED Visits Easier for Children”
Love this Janos! Informative, but also really well written.
The techniques that you discuss are almost common sense but can so easily be misplaced in the chaos of the department. Particularly so when we feel stretched and under pressure to ‘get things done’ as quickly as possible. In reality, this is counter intuitive.
Taking the time to make the child feel relaxed and settled in the environment, in the bigger picture, is time saved. They are much more likely to co-operate rather than resist. I am also a big advocate of honesty with both the child and parents. Telling a child that a cannula without local anaesthetic cream is a ‘little scratch’ or that they ‘won’t feel a thing’ when you are attempting to remove an unbaked bean from their nose breeds mistrust. It makes the current procedure challenging, but also each subsequent contact with medical services.
GREAT post! I also encourage caregivers to empower children with decision making when possible. I.E. We can’t ask “Can I look in your ears?” as this is a necessary part of the exam and not optional… but we can ask “Which ear should I look at first?” I find this makes a big difference at establishing and maintaining rapport!
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Thanks for posting this, Janos. I’m really please to see that so many of these points crop up in my Paeds Tips talk from smaccGOLD (http://www.stemlynsblog.org/paeds-tips-wont-find-books-_nmay-smacc-gold/) – it’s always good to hear that people agree with what you’re saying! This is a great call to clinicians to prioritise experience for children in PED. It’s important for future ED experiences too, well into adulthood – a worth investment!
Very well written article