PEM Tips from Someone Who Knows – PEM Induction

Author: Kate Dear / Review & Questions: Sarah Edwards/ Codes: / Published: 12/09/2018

RCEMLearning asked Kate Dear what her tips for new docs in the PED are. Kate is an excellent Nurse Consultant/ANP, and if there is someone who knows, it’s her.

Starting in the PED might be quite a scary thought for some of you, while for others who have had some paediatric exposure it may be the opportunity to gain more experience and refine your skills. I just want to share some thoughts and experience that I have and that my fab Paeds ED nurses have to make your life a little easier and less scary.

We all appreciate that paediatric EM is not everybody’s favourite flavour and whilst I love it with a passion for some it’s just anxiety creating and hard work. The marmite of Emergency Medicine. I guess the first thing to say is that kids are usually honest –  if they are sick they are sick. They rarely have pseudo fits or feigned unconsciousness (as a rule) and if they are well they are running around the waiting room eating Quavers. However, kids can be a tricky subset of patients in that sometimes they look well when they are quite sick and conversely they can look really sick and miserable and actually be clinically well.  Parents know their kids better than you ever will, if a parent says, “this is not normal for my child”, believe them, dismissing parental concern will come back and bite you. Have a flexible approach to your assessment, they won’t allow you to follow the textbook examination format. Listen to chests when you can and if they are crying use that opportunity to look into the back of their throat. Sometimes if they are sleeping when I go in I will listen to their chest immediately and then start taking a history etc. as they may wake up screaming.

Make the examination fun, “I’m going to listen to your tummy to see if I can hear what you had for breakfast/dinner/tea”, or, “Mr Mouse is looking for potatoes in your ears, what shall we do if we find one”, that kind of thing.

Distraction Distraction Distraction !!!! iPad, baby shark, paw patrol, Peppa Pig, bubbles, singing, stickers. Get really good with knowing what ages like what things. Have a supply of party bag bubbles and stickers and Baby TV on your phone or a department iPad (most places have these now). If you have a play specialist use them, they are amazing.

The nurses are the most precious commodity in a PED. LISTEN to them. ALWAYS ask the nurses what they think as they have a wealth of experience and knowledge, top tips and practical solutions to most of your problems. They know the pathways, the safeguarding pitfalls, the options available to you and they know when a child is well and when they are sick. ALWAYS and I mean ALWAYS check with the nurse before you send a child home, for several reasons. They may have additional information such as safeguarding that you are not aware of, they may not have done the child’s repeat observations in the past few hours, they may know that a child needs admission even if you don’t. PLEASE communicate with them they will absolutely save your bacon all day every day. They have saved mine countless times.

I asked my Paediatric Nurses for some top tips and this is what they said:

  1. Speak to the nurses before seeing the child
  2. Keep the nurses updated after seeing a child
  3. Don’t put paracetamol and ibuprofen on a prescription unless you really feel they are unable to get any from the chemist/supermarket
  4. If it’s super busy please feel free to do your own set of observations/take a cannula out etc.
  5. Know where to restock tongue depressors/ear pieces if you find they have run out
  6. Read the nurses notes and paramedics notes for vital information such as BM, urine dip results, safeguarding concerns
  7. Don’t be scared to ask for help or ring the paediatricians for advice it’s not a competition on who can send the most kids home. Stay safe, the most experienced clinicians ask for help, that’s what makes them good.
  8. Don’t feel the need to wait for a temp to go down if you have a source of infection and the child is well

Safety net when sending a child home, explain all the relevant red flags and advise them when to return to the ED, make them feel like they can come back as this is very important. My standard dialogue when I’m discharging a child home is to discuss the red flags and say:

The really sick child

Do a rapid ABCDE, give them high flow oxygen and get help. Doing those few things makes ALL the difference.  Offer to help the ED senior clinician by running a gas, helping to prepare IV fluids, writing a time line of observations and actions/interventions. Gathering important information such as previous attendances, ringing for paediatric support, putting an emergency call our for anaesthetics, ordering a chest x-ray, these all help .

Find out about the Paediatric critical care Transport service for your area, in my area the North West/Wales area, this is the NWTS service. If you are in a DGH this amazing team offer PICU support at the patients bedside for a critically unwell child in the ED. They are also available for telephone advice. The senior clinician often needs to speak to this team but its invaluable that you know where to locate their contact details. This specific team have a crash call drugs calculator which will calculate doses of emergency drugs and you can print it off. If you know how to find it and do this, it will be an enormous help in an emergency.

Have an aide-memoire for WETFLAG and reference values for observations laminated and in your pocket at all times as this makes life so much easier when a parent rushes in with a peri-arrest 3 year old and you haven’t had time to prepare.

Finally ask for help, any experienced clinician would much rather you sought them out for advice and support rather than take a risk as kids can be tricky and sometimes a second pair of eyes and a senior review can make all the difference. Your senior clinicians and nurses want to support and guide you as we recognise it can be tricky and we all still need support and advice from a friendly more experienced clinician.

Finally, enjoy! Paediatric Emergency Medicine is fun and really rewarding. There’s so much more I could say but hopefully I’ve covered some of the main things to support your venture into the world of PEM. Good luck!

If you can’t get enough advice, Edward Snelson has an excellent blog here.

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