It’s changeover week, so across the country trainees are moving up a grade in their career ladder. There are new doctors, just finished medical school. There are senior registrars becoming consultants. There are ST2s who have woken up as an ST3. This is a bit of a scary day for most, as for the latter group, and many other trainees in all specialties, they went to bed as what we would have previously called a senior house officer, and they have arrived at work today as a registrar.
This also means that having finished my ACCS training a few days ago, I’m now an ST4, which means I will be the most senior doctor in the department at certain points. I think I’m going to go back to bed and pretend it’s a bad dream. (Ed – Or alternatively all your dreams coming true and your hard work and knowledge being rewarded!)
In part 1 of this introduction to ST3 blog series, I wrote about the portfolio, some of the assessments that needed to be completed, and some top hints and tips to make sure you’ve got everything on your ARCP checklist in time. It feels like a tickbox exercise, but using forms correctly, especially the ESLE, can really improve your knowledge and skills, so don’t just dismiss them.
This second part contains just a few pieces of advice that I received that really helped me this year, so hopefully some of them can help you too. As in the last post, whilst this is tailored to emergency medicine ST3s on the paediatric aspect of the year, it will be relevant to all grades of trainees in most specialties.
- There are generally three types of children
In the paediatric ED, children mostly fall into three categories – those who are obviously well, those who are obviously unwell, and those who are somewhere in the middle. It’s pretty easy to spot those in the first two categories, and just watching them come in from the waiting room can give you some big clues. The kids that are unwell can get very sick very quickly, so get some senior help and don’t feel like you need to manage these kids on your own.
The children in the middle are tricky. They’re not well enough to send straight home, but equally they’re not unwell enough that they definitely need admission. So what do you do? Sometimes it might be necessary to do investigations, but often the best thing is to just watch and wait.
- Observation is the best tool you have…
If you’ve ever worked on a paediatric ward, you’ll know that they admit a lot of kids just for observation, and maybe to give them some paracetamol and a sandwich. It’s stuff that could be done at home, but it’s reassuring for the parents that we’ve done nothing special and yet their child has gotten better and is now tearing the place apart, eating everything in sight, and passing on their bugs to all the new friends they’ve made in the waiting room. Here in the paediatric ED in Virchester, we have a specific paeds clinical decision unit, where we can admit children that are likely to go home, but just need a bit extra time to make sure they are getting better. It’s a great little ward and means that we can take ownership of these patients without being bound to the usual 4-hour target. It provides good continuity of care for our slightly unwell/head injury/major trauma patients, and also aids our learning as in most other hospitals you’d admit them and then never find out what happened after they left the department.
It’s definitely okay to put a child back in the waiting room, and reassess them in an hour, so don’t be scared to do it.
- …but distraction is also pretty good too
Whether it’s bubbles, toys, or some dubious glove-balloon-animal-puppetry, distraction can really help you to assess a child properly, or perform procedures. Don’t rush into an examination. Take the time to talk to the parents, play with the child, sit down and do some colouring to get them on your side. You could even download some apps onto your phone or your department tablet (if you have one) to distract the child instead – The Association of Paediatric Anaesthetists of Great Britain and Ireland has a great list of apps you can try. Distraction really helps, particularly if you need to examine the abdomen, or a sore arm. In a crying child, it’s near-impossible to determine which bit of the arm needs the X-ray, or if there’s any tenderness in the tummy, because everywhere you touch seems to hurt. The nurses are usually awesome at distraction techniques if you need a hand, or if you’re lucky enough to have play therapists, even better. If the child is comfortable with parents but not with you, you can ask one of them to feel up and down the arm/leg and watch the child’s face.
This post by Nat gives some great tips on using distraction for procedures, as well as some other fantastic information on pain and sedation.
- Learn how to hold a child
If you don’t have children, and you’ve not had much paeds experience, it’s possible you’ve never held that many children. Indeed if they don’t belong to you or someone you know, outside of a hospital setting it’s pretty much frowned upon. However, picking them up and holding them can give you so much information, does the baby settle in your arms, do they remain irritable, do they have good tone or are they all floppy. Does that toddler seem miserable or are they reaching for your stethoscope and badge and trying to eat them? This article gives some good tips on holding young children. Just be confident.
Important note – children do reach an age where picking them up is no longer appropriate. However, in the much younger children, I really do feel holding them, with the parents’ permission of course, can help you greatly in deciding if this child is well or unwell. (Ed – I always note “handles well” in my examination of the neonate, provided they do, of course!)
- Ask the parents
You’ve seen this child for maybe 15 minutes. The parents have been with them for their whole life. People don’t like bringing their children to the emergency department, and whilst their child may look well to you, there’s something wrong, something different, that the parents are worried about. Make sure you ask them what that something is. As an emergency physician, when you see a child, your job isn’t just to make sure the kid’s ok, but also to reassure the parents. This is extremely hard if you don’t know what their concerns are, so ask.
Top tip from the brilliant Liz Crowe – if parents are very anxious about a very well child it may be worth asking how things are going at home (particularly with neonates – a difficult time mentally and physically for new parents), or if have previous experience with hospitals. Bereaved parents are anxious parents, so bear that in mind.
- Listen to the nurses
While you’ve been running around searching for different rashes on popular online search engines, and trying to persuade the radiographers to do ‘just one more X-ray’, the nurses have been looking after the kids. They’ve been taking their observations, playing with them, giving them medications, talking to the parents, watching how they run around the place, or how they’ve just been sat there not talking or eating. They’ll have a gut feeling about each patient. And they’re often right. When you start off, before discharging a patient, just tell the nurse that’s what you’re about to do, and ask if they have any concerns. They might have picked something up, something medical, something social, some safeguarding concern that you didn’t.
The nurses were there before you started working in the ED, and they’ll be there after you’ve moved on to someone else. They know how things work, they know where things are kept, they often know what you need before you know yourself. Listen to them, work with them, bring them cake, be good to them, be polite, look after them, and they will look after you.
This also applies to housekeepers, domestics, receptionists, health care assistants, practitioners, play specialists, porters, and anyone else that might work in the ED.
Equally, if a nurse tells you they’re worried about a child, or asks you to see a child, go and see that child.
- It’s ok not to know
Particularly in children, it’s quite often we can’t make a diagnosis. They’ve got some kind of rash, some kind of viral illness. A good amount of paediatric emergency medicine is about saying, “I don’t know exactly what it is, but it doesn’t look like it’s anything serious”, followed by some superb discharge and safety netting advice to reassure the parents that they can represent for medical advice if something changes or they’re concerned. But at the end of the day, we’re still trainees, we’re still learning, so if you’re not sure about something, ask for advice.
- Say hi and make friends
Your first interaction with specialty teams should not be a referral. If you see them in the department, say hi, ask them how their shift is going, whether their take is busy. If they look busy or stressed, offer them a drink or show them where the sweets are (there are always sweets in the ED…).
Have an attending friend who brings fruit and hands any angry consult resident a banana. Starts entire convo off better. https://t.co/XOA4ZeRuXa
— Jenny Beck-Esmay, MD (@jbeckesmay) June 28, 2017
Healthier than my mini-snickers offering but I don't wait til they're angry – and now they vent TO me, not AT me #dasSMACC https://t.co/p3Km5lX4nb
— Natalie May (@_NMay) June 28, 2017
And make friends with them, extend your team to include them. After all, you are really all part of the same team, to make the patients better, and a good working relationship with your inpatient specialty teams can go a long way.
- Look after yourself
We’re all such conscientious people, and often we find it hard to tear ourselves away from our patients (particularly if they are sick children) to get a coffee or a bite to eat. We often stay late as “we don’t want to trouble anyone, and besides, the blood tests should be back in the next fifteen minutes”, and it can feel bad to leave the department if there’s a big wait to be seen. We get so busy at work, and with poorly kids it can be emotionally draining, so it’s important to keep a good work/life balance, and to make sure you’re having fun and keeping healthy outside of work.
Liz, Janos and Nat have posted some fantastic blogs on topics such as clinician wellbeing, sleep hygiene, preparing for your night shifts, and eating hygiene. These posts say more than I ever could and I would encourage you all to read these. It’s so important to also ensure you make time for things you enjoy, whether it’s cycling, running, going on holiday, musical interests, seeing friends and family, or just relaxing on the sofa with a bottle of beer and a really cheesy movie. Make sure you take all of your annual leave, and try to take the maximum amount of study leave you can, in order to enhance your body and mind. Leave on time, hand your patients over, and take your breaks. You’ll be a better and happier doctor for it.
- Be awesome to each other
I still maintain that if we could all just remember these two things patient care and our own work lives would improve hugely. #dasSMACC pic.twitter.com/VMI95IkLY9
— Iain Beardsell (@docib) June 28, 2017
A mantra for life. As a new ST3 doctor, you and all your new ST3 colleagues are in this together, working alongside each other to be the best you can all be. I was so fortunate to have some wonderful friends to work with at Virchester PED this year, they’ve really inspired me, taught me so much, and made me a better doctor, and I’m really going to miss the ones that have taken a break from the programme to go off and be awesome somewhere else for a bit. Be good to each other and look after your team.
Well that’s all from me on moving up the EM career ladder into ST3. I really hope you’ve found the two posts useful. Don’t forget to go back and read part 1 – on the portfolio if you haven’t already. Please also check out and contribute to the hashtag #TipsForNewDocs on Twitter, and contribute below or on Twitter with any extra advice you have.
Good luck for ST3, or whichever grade you’re headed to on whatever specialty you’re doing! You’ll all be amazing.
All the best,
Please also read this blog post on ALTEs/BRUEs by PEM supremo Nat May. Particularly the three Rules of May – definitely ones to follow. The post really helped me when assessing newborns having funny do’s, and there are some great videos of children doing strange things which are useful to know about before you see it in front of you.
Janos’ post on how to make visits to the ED easier for children is another must-read.
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