Welcome back to the WREN blog!

It has been a tough first month for many of us, whether you have been redeployed to adult services or are soldiering on through this never-ending lockdown!

If you do find time to read our blog, and you enjoy it, please share it far and wide! 

Take care and above all, keep safe!






ATAIN: Avoiding Term Admissions Into Neonatal units 

Celyn Kenny, ST4

With March fast approaching and job change on the horizon new challenges may be facing some trainees. A daunting role is that of starting in a tertiary Neonatal Unit. E-learning for health offers an online e-learning course on avoiding tem admission on the Neonatal unit. A great refresher on basic Neonatal medicine, post natal ward case scenarios with the addition of empowering us on our role to minimise term admission and keep babies with their parents. 

WREN Christmas Quiz
Davide Paccagnella, ST4

The days are shorter, the wards are busier, but on the bright side…Christmas is approaching!
Take a quick break from work with something light, like a statistics quiz! (there is also some trivia in there, don’t worry)
There is often more than one correct answer, as you will see. It all comes down to perspective.


1. How might confounding factors be avoided?
a. They just can’t be avoided
b. By matching individuals in the groups according to potential confounders
c. By mixing all the data together
d. By clarifying everything beforehand

2. A study where neither the patient nor the researcher knows which treatment the patient has been randomised to receive, is called a:
a. Good study
b. Single-blinded study
c. Double-blinded study
d. Not a clue study

3. What is the “number needed to treat”?
a. 42
b. 1537
c. Depends on the circumstance
d. Depends on how much the researcher wants to get published

4. How can the confidence interval be calculated?
a. By using the standard error
b. By asking a statistician for advice
c. By subtracting your own confidence level from the level of confidence you have in the Health secretary
d. It does not matter, so it is not worth calculating

5. Likelihood ratios can be multiplied by pre-test odds to give post-test odds. True or false?
a. False
b. True
c. Neither
d. Likelihood ratios are an old-fashioned concept and, frankly, irrelevant.

6. Sensitivity...
a. measures the proportion of true positives that are correctly identified by the test
b. measures the proportion of false positives that are incorrectly identified by the test
c. Is often undervalued in Medicine
d. Is always a waste of time, according to some people

7. Type 1 error can be defined as...
a. The first error a researcher makes
b. The incumbent US president’s interpretation of the election result
c. The rejection of a true null hypothesis as the result of a test procedure
d. The content of this entire quiz


Answers:
1 – b; 2 – c; 3 – c; 4 – a + b can both be true; d – may be true, if you are that kind of person; 5 – b; 6 – a, c, d may all be true depending on your views; 7 – you should know this, but I will respect your opinion.

Dear colleagues and friends

The WREN blog is back!
As we all get ready to face a tough winter, let us learn to be kind to ourselves, and practice resilience.
Let's start by reading about AWEN (All Wales Wellness and Education Network), a brilliant initiative that has allowed trainees to remain connected with one another, and share knowledge on a virtual platform.
The second piece is a thoughtful and inspiring personal reflection, with practical advice on how to overcome stress and trauma.
Finally, we have included a brief reflection on the Digital Asthma Masterclass from September.

We hope you enjoy the read!

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All Wales Wellness and Education Network (AWEN)

Andrea Misquitta, ST8
On behalf of the AWEN team

We really hope you have heard of AWEN by now- if you haven’t where have you been!! We are the All Wales Wellness and Education Network - a group of trainees and consultants hoping to improve your educational and wellness needs. We were born during this pandemic, when it became apparent that paediatric teaching had been put on the backburner in many places. We felt this was unsatisfactory for our training needs and so using the London School of Paediatrics as our inspiration, we launched AWEN. The trainee group is comprised of Tom Cromarty, Sarah Myers, Eve Bridgeman and me from the South and Jemma Wright and Kim Hallam from the North. We also have Assim Javaid on board as our ideas guy and Stacey Harris, who along with Sarah and Jemma is one of our wellness champions. We have tried to make this a trainee led initiative as much as possible, but it wouldn’t work without the support of the LPD’s in many trusts and our fantastic educational lead Pramodh Vallabhaneni.

We wanted an all Wales teaching programme to share out the load of teaching and enable us to ensure that teaching is happening 5 days a week, which is so exciting and something I’ve never experienced before and I’m almost at the end of training! Obviously due to COVID we are not able to congregate in our handover/seminar rooms as before to access teaching, so it is all being done virtually – however this is not such a bad thing and provides so much more flexibility, you can even tune in pre/post nights in your PJ’s from the comfort of your own sofa/bed if you want! It also allows those currently not working due to maternity/paternity leave and OOPE’s to stay in the loop.

We have been busy beavers behind the scenes, setting up the timetable, ensuring it is always updated with the latest links. Sending out a whole host of messages on WhatsApp to remind you of what’s happening. Trying to think about interesting topics as well as finding presenters (along with the LPD’s) or presenting ourselves. We have also been collating your feedback for the presenters. Not to mention trying to get our heads around the virtual teaching world and all the other "techy" stuff we have had to get to grips with – admittedly easier for some of us than others!!

Now what we really need is a little help from you – please attend the sessions when you can and participate if needed (it really does make a difference if people join in). We have had good numbers so far so please keep it up. Please complete the feedback form - the presenters are giving up their time to teach us and it is so important that we can give them something back in return. It also gives us a record of how many people are attending and what’s working and what isn’t. If 30 people actually attend teaching but only 10 people complete feedback, we don’t have an official record of actual numbers, which makes it really difficult for us to put forward a strong case for keeping this going in the long term. Please consider volunteering to be a facilitator, it will really help us make these sessions run smoothly and allow the presenter to just concentrate on teaching.

We have had some excellent sessions so far, including formal teaching, journal clubs, case discussions and excellent Friday grand rounds. Wellness Wednesdays have also been well received with lots of exciting things in the pipeline, including poetry, crafts, Makaton, and diversity. Neonatal teaching has been extremely popular too. We have heard that you are really enjoying being able to access teaching in areas you are not currently working. We are working on allowing you to catch up on sessions. Unfortunately recording hasn’t always worked and some sessions are not yet being shared due to confidentiality. The ones that have been recorded are on our Dragonflix YouTube channel and the links to them are on the archived sessions page of the timetable. If you subscribe to Dragonflix and request notifications, you will get a message when new videos are added. Some videos are added as unlisted so you may not see them on the channel page.

This is our teaching programme and it’s not often that we are in the driving seat, so we want to hear from you:

• If you think something is great – we will try to get more of the same for you
• If you think something is not so great – we can try to fix it
• If you want to present – we would be delighted, we want to get more trainees involved. You can do a case-based discussion, journal club, more formal teaching, a quiz, anything you can think of – we are open to suggestions
• If there is a specific topic you would like to have teaching on – we can try to facilitate this
• If there is a session you missed, and a catch-up video is not available on YouTube – we can ask if the presenter can share their slides

Most of all though, please tune in and enjoy!

Links and contact details:
https://bit.ly/AWEN-Timetable
https://bit.ly/AWEN-Feedback
https://bit.ly/AWEN-Wishlist
https://bit.ly/Dragonflix

Contact us via WhatsApp - Numbers available on Welsh Paeds Trainee Comms
Contact us via Email - AWENPaeds@gmail.com

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Overcoming stress and trauma:
​an idiot’s guide for junior doctors

Stacey Killick, ST8


Life is good. Life is bad. And life can be mediocre in the middle with nothing to moan about. As doctors, it is well recognised that we are strong people, determined and resilient and able to deal with a variety of stressors in our professional fields. But what about when it all gets too much? When the stressors are in both your professional and your personal lives and you feel that even the most ordinary of days can be a struggle, what then?

This year has not been my year. Not that it has been anyone’s year. But as far as years go, I can only liken it to falling down the stairs, over a banister and landing crash bang into a wheelie bin of clinical waste. The bad kind. I was doing specialty training as part of my HDU spin at a local tertiary hospital. I had had fertility treatment and had successfully fallen pregnant. Things were busy but things were good. Then all of a sudden, things changed fast. I went from having some lower abdominal pain to going to my local DGH and being diagnosed with a ruptured ectopic to going into full on haemorrhagic shock and being rushed into theatre. A tummy full of blood and one necrotic tube with blob later, I was kept in until my obs were better and then off I went home. Problem solved. No follow up I was told by the Obs and Gynae registrar, as all had been sorted.

I didn’t cry for 3 days. I was determined to get home. And then once there, I was determined to carry on like nothing had happened. And that was ok. Until it hit me. It wasn’t just the loss of a pregnancy, the loss of some of my fertility and emergency surgery. I had nearly died. It was all new I told myself, a few weeks of staying at home and then I would access all the help I needed. It seemed sensible at the time. And then COVID happened. I was then stuck at home, isolated from my family and friends, unable to see my GP, unable to access any counselling and unable to get any sense of normality back in my life. I was off for 3 months in total, and I used my time off to try to acknowledge and overcome the loss and trauma that I had gone through before returning back to work. To accept the order of events, the emotions and difficulties they have caused, and to get back into a good place. Since returning to work, I have been looking at the various sources of advice on how to cope with stress and trauma, how to cope, how to be more resilient etc. And the advice is fairly repetitive. Sleep for 7-8 hours a day, eat healthily, avoid/minimise alcohol and caffeine use, exercise regularly. If these things were so easy, wouldn’t we all be strutting around like Joe Wicks with a six-pack, a stethoscope, a big smile and a smoothie??

So. This is what I have learnt.


1. Learn to say no
This is a hard one for us as problem solvers and as dedicated workers, but do you know what? It is ok to just do your basic job for a period of time and not take on any extra if that is what you need to do. There are times when we can do revision, take on extra projects and prepare lots of teaching. But equally there are times when you can’t. And to say “I’ve got a lot on over the next few months and I feel a bit overwhelmed so I am looking to just do the basics for a while and then start doing extras” is just fine. I’m not good at saying no, but giving yourself that bit less to do when already feeling overwhelmed is priceless, it has really helped and we are absolutely justified to ask for that.

2. Assess and adjust your social media
The internet can provide us with so much: forms of contacting others, sources of news, amusement as well as teaching resources and revision aids. Professionally, you only find what you access. But personally, such is the way that through the likes of Facebook and Instagram, there is so in the way of political ranting, new issues and concerns from our fellow professionals as well as those that pose their breakfasts for photos and brag about their wonderful lives. It can make us feel intruded upon our time off away from work, and it can make us feel inadequate, and even sometimes resentful. So have a good think: do I need all of this? What in the words of Marie Kondo ‘brings you joy ‘? Select what you want. And the rest, either delete or take time out from. Being off during COVID, I found myself reading the news endlessly, worried about my colleagues and feeling guilty for not being there. I also found myself looking at others, their stressing about what seemed absolutely minute and also seeing pregnant women and baby adverts everywhere I went. So I gave myself a 2-month social media holiday with minimal reading of current affairs. And it gave me the time I needed to focus on me and not worry about the rest of the world and nor to feel judged by it. Worth a thought.

3. Speak to those at work
You will not be the first person to struggle and you will not be the last. Have a think about your team, who you know and decide who would be best to speak to. Naturally, we identify mentors that suit our own personality, who we are and how we work, and it may be that they would be the person that you would find it easiest to first speak to. It would be good to let your educational supervisor know too, but perhaps in the interim, having somebody who can help you is better than no one. They may be able to re-assure you, to guide you, to advise you. Or perhaps even just listen if that is what you need. Acknowledging the struggle is one of the hardest things to do, so even this first step is massive. Do it.

4. Consider additional sources of support
Within our jobs, we have access to Occupational Health. We have access to the PSU (Professional Support Unit). And we also here within Wales have access to HHP. This is Health for Healthcare Professionals. It is a free and confidential service that you can access (www.hhpwales.co.uk and 0800 0582738) whereby you speak about the issues that you are having, and they can arrange various types of support. You explain a bit about you, you are put in touch with someone close to where you live and as it is for health professionals, they work into the evenings and around your rotas and the waiting time is minimal. Priceless. CBT for me has been one of the biggest game-changers. It is not for all, but through this my perspectives have changed and I feel a lot stronger to tackle what life throws at me. Think about it. Try it even. What have you got to lose?

5. Look at your time management
It is easy to fall in to the trap of doing work related things on your days off. To finish a weekend on call and to have a week day off only to realise you have a list full of rubbish jobs to do that will take up a lot of the day, resulting in you returning to work and not feeling as though you had a break. I went to a course last year, and they chatted about time management and it made me think, could I be more constructive with my time? And the answer was yes. I now make a list of crappy jobs and I allocate one or two things to every weekday. Can I on a Tuesday just reply to that one email, ring the dentist and put the washing machine on? Yes I probably could somewhere throughout the day. The result: you mostly CAN squeeze these things in, and then when you have an off day, it is free/a lot more free having cleared throughout the week what would have taken a decent bit of time all in one go and ruined your day. The same can be with work related things also, max out your working days and squeeze in to enjoy your off time. The equivalent of the boy at school who did his homework whilst there and then went gallivanting in his own time. It can help and it gives your mind-set that feel of time that is free and is yours to do with as you feel. It won’t work for all, or perhaps entirely, but give it a go, I was surprised myself.

6. Consider speaking to your GP
I say consider because it won’t be for all. But consider it. We are doctors, but we are also patients. And it is worth thinking about if we too need help medically. We preach about mental health, about the associated stigmas, about accessing help if you need to. Well, practice what you preach. If you need help, there is no shame in it, no one needs to know about it and if seeing your GP and considering additional forms of support or even medication helps your quality of life, why would you not. It is an option to not be ignored.

7. Speak to your friends and family
It sounds basic I know, but we don’t always do it. There is the fear of feeling as though you are whinging, or one of my favourite sayings, having a ‘pity party for one’. And yes, we all know people that are worse off than ourselves and situations more dire than our own. But that does not take away from the stresses or the struggle and the fear in our own lives. And although we carry on and perhaps bottle it all up, it is good to just let it out and just rant sometimes. To have our own five minutes. Do it. You would listen to others without judgement, so let them.

8. Do something you enjoy each week
I was on a leadership course and there was a retired matron who had gone into management talking about resilience. Crazy. Loved her. She spoke about resilience being like a reservoir. And that if it was 80% full, you would have room for a bit of rain and even some heavy rain. But if it was 95% full even at the beginning, how would manage if any extra rain came your way? It made sense to me. About looking at life and deciding to get less worried about things, to clear areas of concern up etc. And then came question time. And someone asked her what she had learnt that was the most useful and that she wish she had realised earlier. And she her answer was to do something you love. To keep up with something that you enjoy no matter what, because to have that small fragment of happiness and to be that person that you are is so important. One hour a week she said, just one hour out of the 168 hours in a week. So I thought about it. I love reading; always have, and I kept books for the time that I had annual leave. Yet the rest of the time, I didn’t allow myself to read because I was too busy and it is a distraction. Yet I love it, the escapism it offers. And so I now read at least once a week. I also, when writing/typing during night shifts and in the evenings when cooking, listen to old albums that I love, ones that I can put on and know all of the words and sing to. Even if it is a Vengaboys album. It is small, it is meaningless, yet it is so easy and it makes you happy.

9. Reward yourself
Life was so much more straightforward when you were 12, being given your pocket money to spend on yourself, spending hours on choosing which sweets and CDs to buy from Woolworths. Perhaps even £5 if you had a good school report. And then life got real. Before you knew it you were holding numerous bleeps with a less than fully staffed team, bills coming out of your ears, exams to revise for, 2 audits that you’ve been asked to do and that’s without any issues in your personal life. So I ask: when did you last treat yourself? Genuinely spoil yourself for doing such a good job in adulting just by trying? Go for it. A spa day. Some new clothes. That drum-set that you always promised yourself that you would buy when you were big and had the money. Life is tough. And it isn’t always that kind. Why not treat yourself as recognition of how hard you work and how hard you try? Me; I have bought lots of books to read, some expensive face cream (not getting any younger) and also a few pieces of jewellery just because. Finish some night shifts from Hell: breakfast of your choice and some pointless houseplants from Sainsbury’s on the way home. Finish an essay: buy that jacket that keeps cropping up on Instagram. Every now again in between all the big things, we deserve to treat ourselves and pat ourselves on the back. Did you know Amazon do 3 kg bags of Haribo? Well they do….
​
10. Look at your perspectives
An easy statement. And not so easy to do. But by changing your perspectives you can change your whole outlook on life. One of the best things I got told was to look at what was bothering me: could I change it, was it something so great that I needed to worry about it or change it? And if not, let it go. I am much more decisive about what to worry about now.

I don’t pretend to be a shining example. I still have sad days, I still have bad days and I still have the odd day where I just need to take time out. But these were the things that I found the most useful. No one wants to end up stressed or struggling or in a bad place, but it is life and just sometimes we do. My suggestions won’t be for everyone, and that is ok. I just wondered if anyone would benefit from reading something that is honest, genuine, practical and pre-tested. I hope this offers some help and I wish you all the best.

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DIGITAL ASTHMA MASTERCLASS 2020:
New frontiers in children's and young people's asthma
4th September 2020
@LondonPaedResp
Davide Paccagnella, ST4


This event happened a while ago, but it was too good not to share.
All virtual, but so compelling that I felt like being there in person.
The variety of speakers and topics made for an excellent learning opportunity, even for medical students or non-medical professional. This was because even the more complex themes were explained and discussed by extremely knowledgeable people, who were able to make them accessible.
Asthma is one of the most common paediatric presentations - I’m sure most paediatric health professionals will feel comfortable dealing with an acute exacerbation, and many others will have experience in chronic asthma management.
Prior to attending this event, I felt a degree of confidence when thinking about asthma management – but I soon realised that there were so many more elements to think about, so many more issues to address, so much more to understand, when faced with an asthmatic child.
It would be difficult to summarise the day – every speaker was truly excellent. So I thought I’d share some of the topics that specifically caught my interest and gave me food for thought.


Dr Mark Levy spoke about the Global Initiative for Asthma (GINA) 2019 recommendations that might significantly change the way we manage asthma. Have a look below, and if you’re interested you can read the article in full: https://erj.ersjournals.com/content/53/6/1901046?fbclid=IwAR08fRes-HOveXiSx3RBqK3kVFP2sp34AfwXgUG7myIlaWpmZsdQtrDwWKM 
​

With ARCP around the corner naturally the portfolio panic sets in. With the current pandemic, many face to face courses as well as the RCPCH conference have been cancelled. We have all witnessed a big drive in virtual meetings and also online focused learning. Zoom is now our new found best friend! 
 
We are fortunate in our Welsh Deanery with the development of an interactive and variable weekly teaching schedule with the introduction of AWEN (All Wales Wellness & Education Network) set up by trainees for the trainees. A big thanks to Andrea and her team for keeping us going with ample opportunities to learn and also reflect to ensure our curriculum needs are met for the ever nearing ARCP. https://docs.google.com/spreadsheets/d/e/2PACX-1vSAJDgw2xhvpCmkz5fipUqOh-ZhXTFKmXtBFldFiRXuv3utP4UGUPXOOFCnSdi2MK2Hs33iKg-DUJim/pubhtml

 
On the RCPCH website there are lots of online e-learning opportunities to ensure we as trainees are up to date as well as keeping us engaged with training needs. Through Compass we have the access to many different online courses with a big variety of topics. From Safeguarding to Acute Paediatrics to Prescribing. There really is something for everyone. This also includes Foundation trainees who have an interest in Paediatrics; plenty of CV building ideas to keep you in the game and strengthen your future application. 
 
​
 






Imaging in cases of suspected physical abuse in children 

Celyn Kenny ST3
 
When it comes to managing children, who have experienced suspected physical abuse, ensuring correct imaging modes for that specific case is crucial in enabling effective investigation of complex cases. Recently, we have seen a change in the modalities of imaging used in a Safeguarding medical with the role of Skeletal Surveys now being the gold standard. 
 
This online course aims to provide an overview of the principles behind the guidance used in imaging when it comes to cases of suspected NAI. With the use of practical demonstrations and advice it informs us on how to obtain the best possible quality images within the necessary timeframes
 
 
Aimed at Radiologists, Nuclear Medicine technologists, Radiographers and of course Paediatricians. Thus, raising the question of how good is our understanding, as budding Paediatricians, to the reasoning behind why we request these imaging modalities and can we improve and expand our knowledge and create a better working partnership with our Radiology colleagues. The RCPCH also encourages A&E staff, community-based health professionals, safeguarding lead professionals as well as all individuals involved in the imaging process to complete this e-learning.  
 
 
The course itself has five modules which are very easy to work through. Module number one is an introduction, giving us a flavour of the modules and highlighting the importance of the understanding and reasoning behind specific imaging modalities. The second module looks at the process of making the referral for imaging. Here we learn what are the requirements and information necessary to ensure the correct images are taken within the necessary timeframes. Producing the images is discussed in the third with a strong focus on ensuring necessary images are taken with minimal possible radiation exposure and of course patient distress. The fourth module focuses on the role of the Radiologists in reporting the images and stresses the importance of how findings should be documented. Follow up is the focus of the fifth and final module and how we can play an active role in ensuring this does not get missed. 
 
 
 
Was it useful?
 
Completing the modules was informative with a nice flow and not time consuming. I have learnt the importance in the reasoning behind images and their importance in certain age groups. What I have found most useful is how important key parts of history is on requesting the appropriate investigation. This aids the reporting process for the radiologists and the ability to make a clearer picture in deciding is this injury caused by NAI or not. What was useful about this course was it had areas focused to the role of each member of the MDT within the process of investigating NAI and how important a collaboration is with your colleagues in complex cases. 
 
Would I recommend?
 
I did find there was a lot of guidelines from the Royal College of Radiologists and the Society and College of Radiographers which were wordy and heavy on occasion and may be too in detail for what we need. However, on the whole it was very straight forward to work through and I have learnt and reflected on the importance of knowing which modality is needed when and why. This can only help in completing future child protection medical case reports and also boost my confidence when it comes to the dreaded discussion with Radiologists. To add to this there is a lovely certificate on completion that can be uploaded straight away to your portfolio!
 
 
 
 
 
 
 
 
REVIEW: E-learning ‘Paediatric Prescribing Principles 2016’

 https://www.rcpch.ac.uk/resources/paediatric-prescribing-principles-online-learning

By Dr Gemma Ford – Foundation Trainee with interest in Paediatrics
 
What is it?
The Paediatric Prescribing Principles e-learning is a succinct, three-part e-learning resource that takes you through the fundamental aspects of prescribing safely for children and young people. Each module is said to take 20-30 minutes; however, you are free to work through it at your own pace. 
 
1stPart - Drug Metabolism: This, for me, was the longest module of the course. It is split into five sections, each full of useful physiology, pharmacology and worked clinical examples. It is rich in science, and I shamelessly enjoyed being taken through the detailed pharmacology. It acted partly as revision, and partly as a great foundation to paediatric physiology, and introduction to the rest of the course. I spent over an hour on this section, but I am a junior doctor who hasn’t done paediatrics since medical school, therefore enjoyed taking my time with it. 
 
2ndPart – Adverse Drug Reactions: This part was much shorter, taking me about 30 minutes. It started with the physiological changes from neonate to adult, and why children are at increased risk from ADRs. It then worked through some specific examples of common ADR’s in paediatrics, their physiological explanations and clinical presentations. 
 
3rdPart – Prescribing in Paediatrics: This section was shorter again and gives you the chance to practice prescribing for children whilst familiarising yourself with the BNFc. The content was mostly generalised good prescribing guidance and therefore not exclusively relevant to paediatrics – therefore a useful revision for any speciality. 
 
Is it easy to work through?
Yes.

• The software it uses is very accessible and easy to work through. I am not in the least way technical, and I managed it with no problems whatsoever. 
• You can enter and leave the course as much as needed, so no issues getting timed out while putting the kettle on.
• It saves automatically – so no danger of losing where you have got to, or having to re-do sections that have been deleted. 
• The design is colourful and the teaching is interactive, but not overwhelmingly so.

 
Who is it useful for? 
 
Medical Students – The content is very accessible and would be useful for anyone learning or revising paediatrics, neonatology, or revising for the PSA.
 
Foundation trainees – As mentioned, I am a foundation trainee with an interest in paediatrics, but have not yet had a paediatric job. I can honestly say I feel more confident going into my paediatric post having done this course, as prescribing for kids is not something I have done much of previously, and paediatric physiology seems like a semi-distant medical school memory. PLUS – you get a nice certificate to add to the portfolio. 
 
GP trainees – New to paediatrics or starting a GP job having spent the last years in adult medicine? This would be a great refresher and safety check, prior to assessing and treating children. It is not hospital specific and therefore applicable to anyone that treats children day to day. 
 
Paediatric trainees – As I am not one (yet?!), I am unsure of how much of this is bread and butter to you who do this day in, day out. However, I can imagine that revising pharmacology of the drugs that you commonly prescribe, and enforcing good prescribing principles, is never a waste of time?! 
 
How do I find it?
 
If my rambling has not put you off and you are keen, as I was, to have something other than loaves of banana bread, to show for time spent in lockdown; go to the RCPCH website àeducation and careers àcourses àonline learning and podcasts àbrowse or search for ‘Prescribing’. 
 
RCPCH e-learning is with Compass, which is free to access for members, and can be accessed by non-members as explained below.

Stay safe and happy e-learning! 

​I recently spoke at the Cardiff and Vale SAS (Speciality, Associate specialist and Staff grade) staff forum. The forum was attended by about 15 current SAS doctors and their day included talks from the medical director, amongst other leaders in the organisation. I concentrated on the medical engagement work I had done last year as a Welsh clinical leadership fellow. As a part of that year I conducted a Survey of current medical engagement levels. My aim was to include any non-consultant doctors who would not been previously included in the medical engagement survey conducted in 2012 and 2016.
 
I wrongly considered all non-consultant doctors to be labelled as “junior doctors”. This was more than just an error in nomenclature, as it highlighted my ignorance in understanding the important roles of different medical staff working in the organisation. SAS doctors are neither Consultants nor Trainees, but a separate and highly important group. Paediatrics has a large number of SAS doctors supporting the service in both ward, outpatient and community settings.
 
The numbers in Cardiff and Vale (CAV) Health Board:

They are one of the most diverse branches of practice in the health service, make up 20% of the workforce in some areas, and play a pivotal role in the provision of hospital services.
 
I, like many others at all levels of healthcare organisations, had neglected to understand or recognise the incredible work and experience SAS doctors have gained through their distinguished careers. Specialty, Associate Specialist and Staff Grade (SAS) doctors are a key part of the paediatric workforce but are often undervalued and are reducing in number. SAS doctors are senior clinicians with at least four years training in paediatrics, are not a consultant and are not currently in specialty training. This new report from the RCPCH outlines the latest workforce data on SAS doctors in paediatrics and gives recommendations for how employers and workforce planning bodies can better support this essential group (1).
 
 
SAS doctors are an important part of the paediatric workforce with nearly 800 whole time equivalents working across the UK. Most work in community child health, many in key roles such as Named Doctors for Looked After Children and Medical Adviser for Adoption. Furthermore, there is an average of one SAS doctor on every general paediatric rota in the UK – vital for the maintenance of services and reducing gaps.
During my session on medical engagement, we had a number of really interesting conversations on the causes of SAS disengagement as well as potential remedies for improvement. I was interested to hear that many of the doctors in the room had > 20 years’ experience in their respected specialities. Many of these individuals felt under-appreciated and undervalued. Most of my recommendations to improve medical engagement generally, focus on organisations and senior leaders creating cultures where all staff:
 
                                                                      1.  Feel valued

                                                                     2.  Have a voice

                                                                   3.  Are listened to!
 
One of my favourite questions to ask anyone about medical engagement (if not about most things in life) is;
 
“If money was no object, what is one thing would you do to improve ……. SAS engagement?”
 
When individuals are not constrained by the normal instinctive barriers which inevitably suppress innovation and freedom of thought, individuals and teams come up with some fantastic ideas. The interesting part is that many of these do not require much investment at all. E.g.
 
                 “I would make sure that the clinics that I run (and have done for 10 years)
                                            are in my name instead of a consultant”
 
                       “I would make sure that SAS doctors are given the accreditation
                                 and recognition for the work they have done”
 
“I feel like I have a huge amount of experience in the speciality, can contribute to the decisions being                       made on a strategic level and just want to have my voice heard”
 
                 “I would really love healthcare staff to stop thinking I’m not a consultant,
                                      therefore, I cannot be experienced!”
 
SAS doctors often fall victim to ‘Gradism’– facing lack of recognition, higher levels of bullying and, in some cases, being denied the development opportunities and incentives given to other branches of practice (3)
 
The same themes came out of the discussions with SAS doctors as those from discussions with Foundation Doctors and Trainees; “We want to feel valued” and for organisations to really show this ‘Actions speak louder than words!’. Forums, where different groups are represented, encouraged to speak, listened to and then those views acted upon, can make massive positive steps towards creating a culture of improved medical engagement.

                   To see the ‘Full Engagement Survey Report’ click here or this link
 
                  To see the Summary and Recommendations click here or this link

For more information on SAS doctors: check out these two excellent articles

                                     The Hidden Heroes of the NHS (2)

                                     RCPCH: Supporting SAS Doctors (1)
 
The report recommends a number of measures for workforce planners and employers including:

• Reintroduce the Associate Specialist grade
• Implement The Charter for SAS Doctors
• Ensure SAS doctor involvement in local services, including training and supervising trainees and other staff
• Implement the minimum number of SPAs in the SAS doctor contract
• Provide opportunities for SAS doctors to develop special interests and work as independent practitioners
• Increase the number of SAS doctors in the UK by about one third

 
Although the charter was published in 2014, a 2017 survey revealed that 53% of SAS doctors were not aware of it and 65% didn’t know if it had been implemented by their employer.
 
References:
 
(1)https://www.rcpch.ac.uk/news-events/news/supporting-sas-doctors-our-new-report
 
(2)http://secure.rcem.ac.uk/code/document.asp?ID=3793
 
(3)https://www.bma.org.uk/features/whoaresasdoctors

  
 
.
 
​

​
​COVID – 19
 
Celyn Kenny ST3 
 
A very unsettling time has fallen on us as trainees. The Coronavirus has arrived with its crown and we have many uncertainties facing us. What will happen to our training? Will we be deployed to the dark side of adult medicine? And a question we never thought we would be asking ….. what about Kaizen?
 
The RCPCH has written to us with many a letter stating that our wellbeing and safety is what is paramount to them and they will support our training needs in these times. We are all human and with some of us experiencing cancellation of exams, START assessment and the fast approaching CCT the anxiety is almost expected. However, the clear message from the Vice President of Education and Training at the college Dr David Evans is DO NOT WORRY ABOUT YOUR TRAINING. We all have many unanswered questions on the months ahead however we must continue to support each other and work through these difficult times. Dr David Evans is working very closely with the trainee committee in minimising the effects Covid-19 will have on our training and we must be reassured by this. Current updates can be found at  https://www.rcpch.ac.uk/resources/covid-19-rcpch-trainee-progression-uk-through-2020.
 
Despite the uncertainties we are facing with the Covid Pandemic one certainty we have is our colleagues! Our wellbeing is of the upmost importance over the coming few months and even though we will be expected to be robots, working in places we are not used to or even working a rota we are not used to, we need to recognise more than ever that its ok to not be ok. Wellbeing will be a big thing over the coming months, with heightened anxiety, overwhelming and upsetting circumstances, we do need to reach out to our colleagues and support each other.  As NHS workers, we have access to many a self-care app* and also the Intensive Care Society has pulled up useful self-care advice**.  Not forgetting our very own Stacey Harries who’s created excellent top tip reminders focusing on our well-being and Huw Davies’ Covid care and me website***. Thank you both.
 
*https://www.nhsemployers.org/news/2020/03/free-access-to-wellbeing-apps-for-all-nhs-staff
 
** https://www.ics.ac.uk/ICS/Education/Wellbeing/ICS/Wellbeing.aspx
 
*** www.covidcare.me
 

 








  




In these coming few months our focus in work has changed to clinical facing medicine however it is very difficult to escape from the cloud of Kaizen which hangs over us. Our priorities are ever-changing as are our working expectation which adds to our stresses. Work based assessments, reflection and keeping an up to date portfolio is lower now on our priority list. However, the RCPCH is encouraging us to think outside the box when it comes to work based assessments and have stated that modifications will be made at ARCP. The RCPCH team has provided a ‘Quick fire’ guidance for us on how to reflect on our experiences while meeting various aspects of our progress curriculum. In addition to this our portfolios now contain Service – Experiences Development log where we can add these reflections. 
 
As well as being mindful of our own well-being we also more than ever need to mindful of our patient’s well-being. Children are not as affected by Covid-19 as adults however are going through many uncertainties and changes themselves from school closures, being away from friends and families and also being aware of their parents worries of the Pandemic. More than ever we must not forget the mental health and well-being of children and young people. We must be honest with children and empower them of the vital role they have to play in self isolating and protecting their elders. 
 
The next few months will be tough and our resilience will be put to the test. However, we have protective mindfulness strategies that we should and can purposefully engage in daily to help our mental wellbeing. The RCPCH send us weekly updates keeping us up to date and at Cardiff and Vale the daily updates from our CEO is helping moral by keeping us informed. There is a Welsh saying that I tell myself daily during this time “Daw eto haul ar fryn” the sun will shine again.
 
 

 
 

Welsh National Student Paediatric Conference 2020 – WREN Paediatrics

Alexandra Richards, 4thYear Medical Student 
 
The first Welsh National Student Paediatric Conference took place on 1stFebruary 2020, at the University Hospital Wales. We hoped that we could encourage students to consider a career in Paediatrics and support a brighter future for paediatrics in Wales. It brought together healthcare students and foundation doctors from all over the UK alongside several inspirational paediatric healthcare professionals.
 
The day started with our first guest speaker, Professor John Gregory. John, who trained in Dundee, is a Consultant Paediatric Endocrinologist and leads Paediatric Endocrine Training in Eastern Europe, Nairobi and Lagos. He introduced academic paediatrics to our delegates and shared several lessons that he had learnt from patients around the world, including a baby orangutan(!). 
 
Then we listened to some oral presentations, giving students and healthcare professionals the opportunity to show-case their research in Paediatrics. We saw a range of talks highlighting topics from the “opioid epidemic” to ketamine use in the ED. Dr Chris Dadnam also introduced a fantastic opportunity for Foundation Trainees and Clinical Fellows interested in experiencing Paediatrics through taster days at the Children’s Hospital for Wales. 
 
After being re-fuelled with tea and coffee, we were introduced to our second guest speaker, Marcus Wootton. Marcus manages the RCPCH programmes in Myanmar and Cambodia. He led an absolutely hilarious (and eye-opening!) talk about Global Paediatrics and the need for healthcare professionals around the world. Following this it was time for lunch, networking and poster presentations!
 
Once fed and watered, the delegates then had the opportunity to rotate through four interactive workshops relating to PEM, Neonatology, CAMHS and the future for Paediatrics. The Paediatric Emergency and Trauma Workshop was led by Drs Jordan Evans, Tom Cromarty and Assim Javaid. This workshop was highly interactive giving delegates the opportunity to decide on management decisions. One delegate shared that they “had learnt more about emergency medicine in that one workshop than 4 years in Medical School” - Well done PEM Team! 
 
Our Neonatal Workshop was led by Drs Matthew Pickup and Joanna Webb who introduced the career pathway and opportunities in Neonatal Medicine. Drs Fiona Astill and Jenny Williams led a beautiful introduction to the sensitive subject of CAMHS. Talking about mental health is not easy but is becoming increasingly important within Paediatrics. Last but not least, the future for paediatrics… led by Dr Pramodh Vallabhaneni and Judith Van Der Voort. Will Alexa be able to diagnose patients in the foreseeable future? 
It was then time for the Q&A panel highlighting research, education, training and opportunities within Paediatrics. Jordan Evans and I were also able to introduce our new research initiative: World CUPS. This supports both undergraduates and paediatricians with clinical research and QI projects. If you would like to get involved or would like some support with an on-going project, please email us on worldcupsresearch@gmail.comnow…
 
To end a fantastic day, we hosted a networking event where healthcare professionals from various paediatric sub-specialities were able to meet and inspire the future generation. Thank you to all the generous support and time given from paediatricians in Wales!

The annual St Davids Day conference was held this year at the centrally located Marriott Hotel. The conference was dedicated to the Wellbeing and Health of the child in Wales. With a program as exciting and varied from talk to workshops and a whole host of guest speakers it is clear to see why it was a sell-out. Huge congratulations to our very own Tom Crom on getting such a program together. 
 
This month’s blog post is dedicated to the St Davids Day conference. It has given us as trainees a time to reflect on the health of the child in Wales and the importance of the role we play here as well as remembering why we chose the Paediatric specialty. With the conference closing with the PAFTAs the day was also a chance to celebrate our achievements and successes throughout the year.
 
Dydd Gwyl Dewi Hapus i bawb now let’s hear from our trainees…
Celyn Kenny
ST3
 
A chance to be inspired

Any healthcare professional who looks after children on a regular basis, knows that treating a physical illness is often only a temporary measure. Children living in poverty are, on average, much more likely to contract physical and psychological illnesses, whilst almost always lacking the means to improve their living standards. This is true for children living in Wales today, where it is estimated that 29% of children and young people live in poverty (a significantly higher proportion, compared with the adult and elderly population). It is also true that the gap between the richest and poorest is widening. 
These figures were no surprise to me. I have worked in Paediatrics for nearly four years, both in England and Wales, and have looked after countless children, whose parents did not have sufficient money or education to give them the care they deserved. It is therefore essential, as Professor Viner clearly highlighted, that we all have to take small steps to address health inequality, and be advocates for our children in any way we can. We have a voice and it is time for that voice to be heard. Isn’t that the reason we decided to do what we do? 
The St David’s Day conference this year was a brilliant chance to network, socialise, and learn. I am extremely grateful to all the speakers for inspiring us, and giving us food for thought; needless to say, the organisation was excellent.
 
Davide Paccagnella, ST3 Trainee
 
A byte-size snapshot 
​
Well, blow me down, that was a brilliant conference! So many excellent speakers on a range of whole range of topics! Perhaps for me, the best thing about it was just how approachable the speakers were. Stacey Harris and I managed to catch up with pretty much every speaker (apart from a couple who had to head home early) and interview them for Dragon Bytes. Turns out you can be the Chief Medical Officer for Wales or a famous television presenter and still be the most down-to-Earth people ever. It was lovely discussing the talks further with such renowned speakers, getting additional insights into their areas of expertise. Also, the PAFTA event after the conference was fabulous! I’ve never been so proud to be a Wales trainee. Hats off to both Tom Cromarty and Hannah Davies for doing so much hard work for this event!
Hope that's alright! Let me know if you need more.
Assim Javid 
ST4
A celebration 
I really enjoyed the St David’s Day conference in the Marriott. It was a great experience both to learn more on the topics discussed and to have the chance to speak to others trainees who work in different hospitals or departments. It was uplifting to have a segment on celebrating trainees and to see it having defined area of the day. It is so common to hear about how bad things are in paediatrics especially with rota gaps, trainee unhappiness, high number of patients. However, it was very enjoyable and amazing to see all of the good things that current trainees are doing and to see this being celebrated!
 
Lizzie Sharpe 
ST3 
 
Being a Welsh Trainee
Having done my 8 years of Paediatric training across three deaneries, I've always had the fortune of recognising what a special, wonderful place Wales is for paediatric training.
 
Smaller hospitals, tight knit professional communities and a fabulous network for training, learning and providing patient care are at the centre of it. 
 
But also, Wales is a fascinating place - culturally, linguistically, geographically and in terms of its pathologies and medical system. I came here is 2012 and was hooked in weeks.
 
The St David's Day Conference is central to that, with both social and educational benefits. It's wonderful to work in a system with real local Accountability, proximity to policy makers and experts and the opportunity to be among friends in similar circumstances. So many of the people I work with every day are an inspiration. The quality of the work we do here is astounding, supported by our training infrastructure (thanks, Dr Body!) and other networks, such as WREN.
Kate Burke ST8 
Inspiration from our colleagues 
 
This was the first year I was able to attend the St David's Day conference and so I was looking forward to it greatly. The programme was exciting with current topics such as childhood obesity and use of screen time. A highlight for me was the talk from Dr Jennifer Evans and a previous patient of hers, Mercy. The talk was engaging and interesting, hearing the challenges of managing a chronic condition from both perspectives. I found it very inspiring to hear the exceptional doctor- patient relationship that can be made and how that positively impacts on management of a chronic condition. It was quite emotional hearing how much Mercy thought of Dr Evans, and how they had both impacted each other’s lives. 
 
Not only were the talks a great part of the day, but the opportunity to catch up with colleagues was brilliant. It reminded me how lucky we are to have such a tight knit deanery where we all know one another so well. As an ST3 approaching the daunting step up to registrar, it was so lovely to have such encouragement and advice from colleagues and friends. We in the welsh deanery are exceptionally lucky to have such support in one another, which ultimately contributes to making training here in Wales so great. It was lovely to acknowledge this by finishing the day with the PAFTAs. It was wonderful to hear so much praise and recognition for our tutors, peers and allied health colleagues. 
 
The St David's Day conference was educational, enjoyable and highlighted the fantastic family feeling trainees here in Wales are lucky to have.
 
Caitlin O’Donovan  
ST3
 
 
 
 
 
The PAFTAs
 
I had the pleasure of organising the Wales PAFTA awards this year.
 
The response to the survey was incredible!
It was amazing to see the volume of votes for so many inspirational wonderful people. 
 
We are so very lucky in the Wales paediatric deanery. It’s a very inclusive, welcoming and supportive environment. It made me realise we aren’t just an academic body but more of a family who champion each other’s journeys and achievements.
 
The comments highlighted academic success and messages or acts of support. It was a real eye opener to see that even little acts of kindness/inspiration go such a long way in the sometimes very harsh medical environment we work in daily.
 
It was very important to me that all of this year’s nominees received an email notification. Without everyone’s amazing contributions, large or small, our experience in the deanery would be very different. 
 
This year’s winners were presented their awards following the incredible St.Davids day conference In Cardiff. The atmosphere was one of incredible positivity... which may or may not have had something to do with the prosseco wall! 
 
I hope all those who attended or received a notification felt their contribution was valued and that the positivity helps us strive to make 2020/21 an even more successful inspirational year.
 
Hannah Davies
ST4

​Considering how often we refer to the CAHMS team as Paediatric trainees we have very little opportunity to work with the service and more importantly learn from the service. What better way to learn than from an integrated joint CAHMS and Paediatric study day.
 
The study day was held at the brand new CUBRIC building at Cardiff university which was as modern as they come! You really could see how the University is now up and coming within the research world from its facilities. The programme for the day was varied and the topics diverse with up to date evolving research especially in the Neurodevelopment world.
 
What better way to start the day than with a talk given by Kate Burke, who has the talent of making the most complicated of topics understandable and interesting, that topic being Genetics. Kate gave us an update on genetic testing for children and adolescence and how it’s now becoming part of mainstream medicine especially with the Neurodevelopment pathway.  More children are having genetic testing done as there are more test available and also there is now a greater scope of phenotype. Requesting a CGH array has now become a normal part of every working day within Community Paediatrics and Neonatal medicine. They are very easy to order however we learnt that awaiting the result can take up to a year with the increasing demands on the genetic services. Kate also gave us of the brief different types of genetic testing available and why we use them.

This was then followed by Safeguarding cases. In small groups we worked through four different cases and focused on how we would take the history and manage the patients. As an ST3 trainee I found this very useful as it gave an overview of how to manage different Safeguarding topics from a child in need, to Munchausen by Proxy, Sexual Exploitation and the importance of when a Section 47 is indicated.
 
 
Safeguarding tips:
 
Section 47:
A Section 47 Enquiry is initiated to decide whether and what type of action is required to safeguard and promote the welfare of a child who is suspected of, or likely to be, suffering significant harm. The enquiry is carried out by undertaking or continuing with an assessment in accordance with the guidelines.
 
 
Sexual exploitation:

• Contact duty social worker who will then contact the police
• Complete a SERAF (sexual exploitation referral assessment framework)
• Forms available in all A&E departments

 
 
Fabricated induced illness:

• Form a chronology
• Speak to and involve as many members of the wider MDT as possible
• Involve the safeguarding officer and social services
• Use the RCPCH document - Fabricated or Induced Illness

 
Following some coffee and cookies the next talk was given by Dr Joanna Martin a research fellow in Child and Adolescent Psychiatry. Dr Martin spoke of her recent research work in ADHD and sex differences. It is well documented that boys are more likely than girls to be affected and diagnosed with ADHD; every 3-7 boy to every one girl. Most studies have found that ADHD symptoms and impairment levels are similar in diagnosed girls and boys however girls may in fact have more inattentive difficulties. This raising the questions are there sex specific symptoms? Girls may show their ADHD traits through social interactions and impulsivity whereas boys have more of classic ADHD symptoms. Research is emerging that girls displaying traits of ADHD may be missed as they have genetic protective factors; and if picked up correctly and commenced on medication these patients may respond better. These girls are more likely to get diagnosed with anxiety and depression in future. I found this talk interesting and eye opening and will make me more open minded for future cases.
 
After lunch came a Neurodevelopmental Update. In Wales, this essentially encapsulates Autism and ADHD however it should be seen as impairment in growth and development of brain. This includes ADHD, ASD, intellectual disability, tics, specific learning disorders, motor co-ordination disorders all are part of developmental trajectory which presents in childhood. Statistics from the ND steering group showed that 80% CAMHS workload is related to Neurodevelopment. The funding from 2016 of ‘together for children and young people’ was spent in forming a national pathway for ND, with guidance for assessment, autism toolkit, ADHD toolkit and how to do assessment – a very useful and practical resource which can be found on 1000 lives Wales website. ‘Together for children and young people’ finished in October and is now moving to more integrated whole-systems approach. every team now has single point of access (now have data for referrals, accepted and rejected). Over the next few years we are likely to see expansion in these services…… watch this space.

This then led nicely into a talk on Autism in females and other aspects of variation by Consultant Community Paediatrician Cath Norton. The female phenotype is now recognised as being camouflaging by hiding unwanted autistic behaviours and or explicitly using more socially acceptable behaviours. When it comes to social relationships they are interested in making friends but do not quite get it right and may be more interested in relational objects e.g youtube, animals, reading. They have internalising difficulties. There are mental health implications for camouflaging and sadly one of leading predictors of suicide in autistic adults.

We then learnt from work conducted by Rutter in 1996 on the “Quasi autism”; autistic type symptoms seen in children adopted following an early experience of institutional care and who also can get deprivation linked ADHD which can be pervasive. There is a higher prevalence of ASD and ADHD in LAC population (as well as prevalence attachment issues, trauma, neglect etc) and maltreated children more likely to be hypervigilant. The term attachment disorder likely overused, and possible presumed due to this social background. A useful resource is the Coventry grid when looking at autism in LAC children as they may have different attachment needs. In the future, there is going to be more training to look at a holistic approach assessment of these children i.e. no further unilateral diagnoses or doing autism and not ADHD. The work from steering groups in this development is working towards integrated services with education, families and social services. And the hope is to adapt national IT systems so there is a place the information can all be pulled together forming a ‘clinic profile’. The information in one place, including what families are hoping to get from their experience. To finish we learnt of the integrated autism service who do the assessments in people over 18 years and is where we refer patients when they transition. This service cares and provides for older children with neurodevelopmental variation and functionality in college and workplace.

The last topic of the day was about ACEs, a topic we are now getting more familiar with and used to recognising. Public health Wales Adverse Childhood Experiences study back in 2015-2018 which looked at traumatic experiences in childhood and their impact this included child maltreatment and indirect trauma from childhood household e.g. parental separation, DV, mental illness. It is know well known that ACEs increase individuals risks of developing health-harming behaviours (high risk drinking, unintended teenage pregnancy, smoking, prison and interestingly from recent American studies also affects academic potential and contributes to developmental delay. We discussed a case of a 14year old whose parents had been exposed to many significant ACEs which has subsequently affected the nurturing environment for the chid to grow up. This encompasses that ACEs are vicious circle and interventions are required for both child and parent. 
​
To close we touched briefly on attachment disorder, an emotional and physiological dysregulation and how it can present clinically. These children often have a poor self-concept and a fragmented sense of self (i.e. child doesn’t have a sense of their own body so doesn’t recognise hunger etc), poor social interaction and sensory processing difficulties. With attachment, the intervention will depend on developmental stage of child. There is a lot of focus on something called ‘theraplay’ which is based on helping the carer enjoy the relationship with the child. It is clear that in order to make an impact we have to help the child and the parents to help build their relationship to create a therapeutic environment.
 
Reflecting on this study day it really was a whistle stop tour into the work done by our community colleagues and as a current ST3 community trainee and excellent crash course to consolidate what I have seen and learnt over the last few months. I would like to thank the organisers for a very interesting and diverse day, I highly recommend attending!
 
Celyn Kenny
ST3 

​The Wales Neonatal Network Annual Audit day took place at the Life Sciences Hub in Cardiff Bay on 9th January 2020. The Wales Neonatal Network was established in Autumn 2010 and brings together NHS health professionals and partners from other organisations, with the aim of ensuring equitable, high quality and clinically effective neonatal care is available to babies and their families in Wales. The Annual Audit day is an opportunity to share experiences and changes in practice from across the network, to learn from other good practice, and to identify areas for future development.
 
The programme this year was again full of interesting topics covering respiratory care, neurology, National Neonatal Audit Data for Wales and transport to name a few. Particular highlights came from Dr Lucy Perkins, Consultant Neonatologist at Singleton Hospital, Swansea. Dr Perkins was sharing her units experience in optimising the early respiratory management of preterm infants, and the quality improvement project that had been undertaken to reduce the rates of intubation and mechanical ventilation. This talk fitted in well, as it followed a presentation by me on the ongoing audit into the management of Respiratory Distress Syndrome in Wales, which has been a very successful WREN project. Having the opportunity to discuss these two initiatives together showed how practice can be positively changed by sharing ideas and information.
 
Another exciting innovation came from Dr Kate Burke, Neonatal Grid Trainee, who shared her ongoing work with creating a Hypoxic-Ischaemic Encephalopathy Care Protocol and ‘Passport’ that would help to standardise care and assist information sharing across the level 2 and 3 neonatal units in the network. There were also updates from the units in Newport and Swansea regarding the introduction of General Movements Assessments at 3 months of age for those infants at higher risk of poor neurodevelopmental outcome, and how this new assessment was helping to identify and target early intervention for those babies showing early signs of neurological impairment.
 
The day rounded off with an update on CHANTS (Wales’ Neonatal Transfer Service) activity from the past year, and how Wales were performing on the NNAP programme (which overall was quite favourably!). I would recommend the audit day to anyone who has an interest in neonatal care, either at level 2 or level 3 units, as an opportunity to hear the latest news in the care that the units in the Wales Neonatal Network are offering. It is also a fantastic opportunity to present your own project data to a receptive audience and help to shape clinical care. The network are actively looking to undertake multi-centre projects and are in discussion with WREN as to how we can take these new initiatives forward, so if you’re keen to get involved, please get in touch!

​Professor Ronan Lyons (Professor of Public Health at Swansea University) then highlighted some of the amazing Public Health work that he has been involved with, focussing on the SAIL Databank (over the past 10 years) and current developments such as Health Data Research UK (@HDR_UK).
 
The Secure Anonymised Information Linkage Databank started in 2009 and is continuing to collect data which is then 'de-identified' so that it can be analysed by researchers across the world. This data from patients in Wales combines health and population data for >5 million people, so far creating 26+ billion rows of data.

SAIL Datasets

​Privacy is absolutely paramount, meaning that this is the only dataset that is globally accessible as long as researchers meet the criteria of being safe and accredited. Every project proposed must also meet some strict inclusion criteria, such as ensuring that the research’s purpose is to protect people and it is in the public interest, etc.
 
This resource of ‘big data’ has already enabled a number of research projects which have guided policies and public health advice to families across Wales. Many of these projects have involved Paediatrics:

• Gestational Age, Birth Weight, and Risk of Respiratory Hospital Admission in Childhood. DOI: https://doi.org/10.1542/peds.2013-1737. Showing differences in hospital admission rates between babies born at 39 and 40 weeks’ gestation at a population level.

 

• Change in alcohol outlet density and alcohol-related harm to population health (CHALICE): a comprehensive record-linked database study in Wales. Showing the link between alcohol-related harm and outlet density. Therefore helping to guide policies and the regulation of alcohol outlets in a given population.

 

• Population data also showed the positive effect of the Welsh ‘Warm homes NEST scheme’. This provided evidence of its impact on the health of the population and helped secure continued funding at a time when austerity saw many other public schemes discontinued. 

HealthData Research UK (@HDR_UK) is aiming to do the same as SAIL in Wales but across the whole UK with a larger data set.
 
Ronan made it clear that we are coming to a tipping point with the vast amounts of health data that is being collected. This gives huge potential for positive impacts if used safely and correctly. There are exciting innovations such as the ‘Personalised Genome’ enabling personalised medical interventions, whilst wearables (and other technology) can encourage the self-monitoring of health and disease. The challenge is to reduce inequalities in health without reducing gross disparities in wealth.
 
The public are rightly concerned about the security of their data, especially with the data security scandals of various social platforms in recent years. Public trust needs to be built and earned. SAIL has a consumer panel, composed of members of the public. These individuals are involved with the accreditation of certain projects and often help them throughout the research process.

The whole lecture will be available to view on the BMA website in due course.

Check it out!
​
​If there are any questions then please get in touch.

Dr Fiona Astill, Leadership Fellow

Leaders in Healthcare is a conference in association with the Faculty of Medical Leadership and Management (FMLM). It was a huge event with hundreds of attendees. Additional to the plenary sessions, much of the groups were workshop-based with themes around self, team, organisation and systemto choose from.
Personal highlights included:

1. Lord Victor Adebowale - possibly the most down-to-earth Lord I’ve ever seen who marched on to the stage and promptly announced he was here to “gob off at us” for a while! His speech was discussing the challenges that faced the health service and felt these were equity, access and technology. He talked about leadership not being about just your own organisation but that we have a duty as healthcare professionals to consider population health, and the need for a credible team. There is no right way to lead:

• Be like you. People are led by humans. Be human first
• Be open about your vision
• You are your values and values are what you do.
• Additionally a fish rots from the head (slightly disturbing image, and I’d imagine made some directors in the audience a little uncomfortable!)

2. Military leadership – an interesting discussion from senior ranking officers in the army and the RAF, regarding the concepts of leadership and followership. Their advice for leadership and followership:

1. 1. Learn from yesterday
   2. Focus on today’s capability
   3. Address the customer’s/service user’s hopes for tomorrow
   4. Invite internal holding to account
   5. Invite external holding to account
   6. Work collaboratively
   7. Set measures of success   
      

3. Forum theatre – this started off with us feeling a little apprehensive that we might have to get up and act. Luckily, actors were provided and the initial scene played concerned a conversation between a medical director and a chief registrar. The scenes were initially played, followed by discussion with the audience as to why what they had done did or didn’t work. It was quite enlightening to watch the situation play out and I think we could all remember a time when we’d been in a similar situation with a dismissive ‘leader’. Changing one’s body language, speech and attitude made a big difference to the conversation and ended with both parties satisfied. 

‘Problems only exist in the absence of the right conversation’ Werner Erhard

4. Seven Transformations of Leadership – what differentiates leaders is not their personality, management style or leadership philosophy but their internal ‘action logic’ – reacting to their environment and challenges. http://hbr.org/2005/04/seven-transformations-of-leadership in case you were interested in finding out more about your current style?

5. Speed coaching – the FMLM organised a series of short sessions that attendees could sign up to, to discuss a problem or barrier in their own leadership style. Of the fellows that went I think we all found this valuable to an extent, and a current theme of this year is definitely to question yourself, and to be more aware of your own strengths and weaknesses. 

6. Wellbeing – lots of workshops and talks around this topic. ‘Doctors as Second Victims’- in a room full of people 86% have had personal involvement in a near miss or adverse event. Of those 70% felt this affected them personally and professionally. We need to encourage open and transparent conversations about errors, without the blame. We need to be compassionate towards our colleagues and supportive.

Dr Davide Paccagnella ST3

​WREN study days are best described as a regular opportunity to do exactly what we are all about: meet, make friends, network, and learn from each other. If you are new to Paediatric Training, or have recently moved to Wales, they happen twice a year and are an essential component of the work we do. 

This autumn, we had some excellent speakers. Making a start was John Watkins, statistician working at Cardiff University and well-known in the world of medical statistics. It would be unfair to say that he taught us the “basics”, as I found myself reading up on quite a few statistic-related topics over the following days. What he managed to give us, however, was a very thorough overview beginning from the core elements of data analysis, all the way up to statistical tests and multivariate linear regression. In a word, intense! I cannot recall having been taught “Statistics” in a 2-hour session when I was at university. And it was not always easy to keep up, but my neurons enjoyed the early morning stimulation!

Next up, it was time to hear updates from ongoing projects around Wales. There is truly no limit as to what can be achieved if you put your mind to it. Multicentre trials have recently been completed in cooperation with PRAM (Paediatric Research Across the Midlands) and PENTRAIN (Peninsula Trainee Research Audit and Improvement Network). Details are on our website, and you can have a look to see what other trainees are up to elsewhere in the country – www.wrenpaediatrics.com;www.pramnetwork.com; www.pentrain.org.uk– exciting projects, trainee-led, getting national and international recognition!

Following on from this, Alex Richards, Cardiff University Paediatric Society (CUPS) president, introduced a new project – called WORLD CUPS (Working Paediatricians Overseeing Research Led and Delivered by CUPS). This is based on the idea paediatric professionals can request help from interested students, and vice-versa. Jordan Evans, ST8 Paediatric trainee, is the CUPS liaison and has already got multiple projects going. Involving students in research is vital, and I wish my medical school offered me anything that was even remotely similar! Interestingly, the Welsh National Student Paediatric Society Conference will take place on Saturday 1st February 2020 at the University Hospital of Wales, Cardiff. Paediatric professionals are needed to share experiences with students, and promote our specialties! What better chance to meet people and network? Have a look at https://www.facebook.com/events/788342174927002/

New projects and ideas are coming up all the time. And the potential to transform your idea into a multi-centre trial is always there. If you attended the study day, you might have heard about some of these projects. The best way to get involved, if you have a new idea, or data you have already collected, is to speak to like-minded people and get the ball rolling. We can help with that, especially if you are struggling to find enough people to take your project on at a local level.
To close off the day, we had the privilege to have two great lecturers. Firstly, Dr Martin Edwards, Consultant Paediatrician at UHW, provided us with a practical guide to systematic reviews and meta analyses. Personally, I came to the realisation that performing a systematic review does not have to be regarded as a complex, unachievable task. Certainly, it requires patience, and knowledge of how to research and analyse evidence. But it did not discourage me from thinking that yes, it could be done. Just think how often we, as clinicians, base our decisions on evidence from meta-analyses – all the time, I would say. It is therefore imperative that we develop a good understanding of how it all works, and contribute to this essential area of research.

Last but not least, Dr Ian Wacogne, the edition editor of Archives of Disease in Childhood – Education and Practice, and consultant paediatrician in Birmingham, very kindly visited us in Bridgend for the afternoon. He talked to us about “how to write”. And what a talk it was! Firstly, he engaged us all in an honest discussion about the type of readers we thought we were. So think about it: are you a systematic reader (do you read in a structured, organised manner)? Or perhaps you are a “just in time” reader (if you manage to extract the information you need at the last minute); you could also be an “on the bus” reader, and enjoy taking in small amounts of information at a time. When we write, it’s good to know who we are writing for – what is our target audience? Most importantly, do we have anything interesting to say, and would we enjoy reading what we wrote? Those of you familiar with the journal edited by Dr Wacogne will know that it can be a pleasant read in a number of different situations, and that it has something for everyone. So why not write? Submitting an article can seem daunting but there is plenty of guidance on https://authors.bmj.com/

In conclusion, I hope I have convinced you to attend the next WREN study day, which will take place on 19thMay 2020!

Dr Celyn Kenny ST3

This year’s Autumn WPS clinical meeting took place on the 8th of November at the famous Celtic Manors sister hotel, the beautiful, Coldra Court Hotel. I can see why its described as a ‘Celtic convenience’, located at the gateway between England and Wales, the Coldra Court Hotel is close to glorious Welsh countryside and is situated just off the M4 motorway at Junction 23 and really is a hidden gem. ​

WPS meetings are recognised and renowned for their educational presentations, from medical students to consultants, and as a great way to network professionally, and of course socially, with our Paediatric Colleagues. They also bridge the gap between Hospitals not only on the M4 corridor but also with our colleagues in the far away land of North Wales. This was even more evident this year as we were also joined by our Paediatric Anaesthetic colleagues, making it an extra special multidisciplinary networking event. As said by the chairman himself Dr David Tuthill “It is a meeting that appreciates Junior Doctors on their journey through training from medical student to higher training”.
 
 
The day started with a welcome talk from the president that then led into the introduction of the first guest lecturer Dr Hannah Gill. Hannah, who originates from Wigan, is a Consultant Anaesthetist at Bristol Royal Hospital for Children. She moved to Bristol to work on an RCT administering Xenon to term babies born in poor condition and completed a PhD studying the dose-response relationships of Xenon and volatile anaesthetics in immature rodents. How refreshing it was to hear a talk titled Anaesthetic neurotoxicity: does it exist, in such a strong Wigan accent. 
 
 
Then the presentations began.  The first session saw a range of topics from post-operative analgesia to medication errors then to respiratory distress in the newborn. Focus was given to the experienceof introducing minimally invasive surfactant therapy on a neonatal unit; theuse of MIST which is interchangeable technique as LISA therapy and how numbers of intubations and oxygen requirements have been reduced following this introduction on a Neonatal Unit; this in turn may lead to the reduction of BPD. This talk led nicely to Chris Course’s hard work on re-auditing the Improvement on the management of respiratory distress syndrome in preterm infants across Wales. Chris has done so much for research projects across Wales and should be commended for all his hard-work and dedication. Following this it was time for coffee and the mingling with colleagues began!
 
 
Following the caffeine ingestion, the presentations continued and again a great variety of topics were seen. A focus was given to Paediatric Palliative medicine, an area I would definitely like to learn more. Fran Norris presented on Advancing access to advanced care plans which was very informative and she was commended by going on to win one of the WPS awards. Safeguarding also featured heavily with our very own Assim Javid presenting his work on burns which he completed during his academic ST3 year. Assim spoke of the influence of causative agents and mechanisms of injury on anatomical locations of burns from scalds and contact burns in children less than 5 years old. This age group is recognised as when most burns happen and he opened our eyes to when safeguarding concerns arise. Enthusiastic and engaging to his audience Assim rightly went on to win the trainee award. Well done Assim!
 
Before lunch the second guest lecturer was Dr Jayne Sutherland, an Anaesthetic Trainee in the Wales Deanery (ST6) with an interest in global health, medical education and paediatric anaesthesia. ‘Take a deep breath and open your eyes’, a talk focused on Jayne’s year in Zambia as part of her out of programme experience. She told us some frightening figures of how 5 billion people lack access to surgery world-wide and that 143 million additional surgeries are required annually to meet this demand.Zambia, a low economic country,is facing an uphill struggle with an expanding population. Jayne worked with theZADP charity and told us of her role with the charity; teaching, initiation of mentorship, battling to get the basic services required and learning all this through the politics and hierarchy. What she gained from this experience was a greater understanding of the politics of safe surgical provision, a bucketful of experiences, huge job satisfaction, new perspective, new coping strategies and the importance of taking time to stop and disconnect. Following this was our time to stop and disconnect for lunch!
 
 
Following a fantastic buffet lunch with choices aplenty there was no post prandial lull as Mr Oliver Jackson, Consultant Paediatric Surgeon at the Noah's Ark Children's Hospital for Wales, took to the stage.  He moved to Cardiff in July 2018 and since his arrival has been at the forefront of Paediatric Surgical advances in Wales and the services now offered to the children of South Wales. A talk entitledHidden Surgery, Visible Results – How laparoscopic paediatric surgery in Cardiff is helping our patients; Mr Jackson took us on a journey of the evolution of laparoscopic surgery. The talk started withthe question “who are the Surgeons?” and was a great introduction to the new surgical team at UHW. We then learnt of the new services offered at the Children’s hospital and how the transferable skill of laparoscopic surgery has led to the surgical advancement of these services. A laparoscopic technique is now being offered for procedures such as pyloric stenosis, inguinal hernia repair and even Neuroblastoma. This talk was so inspiring it made me reconsider my career path and channel my inner Meredith Grey (for a total of five minutes!)
 
Then came the third set of presentations and it was clear to see that wellbeing would play a big role. A presentation which stood out for me was one given by Fiona Astill on the Evaluation of burnout in paediatric staff. As Paediatric trainees we could take so much from this,69.2% of staff in Wales at risk of burnout,what can we do to improve our work-life balance? Protective factors are key to help reduce this risk with supportive colleagues and good managers playing big roles. In a world, full of shortages and increasing rota demands we really must remember the importance of these factors. 
 
This led nicely onto the final talk “The three emotional systems” by Dr Nicole Parish, a Clinical Psychologist working within the Noah's Ark Children's Hospital for Wales.She started with a game of ‘stand up’ where we stood up if we had felt certain emotions or experiences at work. Then Dr Parish went into the main body of her talk which was describing the three emotional regulatory systems. The first, the threat system, where we get our motivation and strong physiology. However, it can make us more likely to recognise negative behaviour even in a room full of positive, and jump to conclusions because of this threat system. This goes back to the primitive part of brain and its often easy to get stuck in this threat system. Next came the drive system which is related to evolutionary need to forage and our need to hunt such as pursuing our goals. Which is highly relatable to us within medicine as we strive to achieve our goals. However, this can get exhausting which led into the importance of the third system, the soothing system. This is our feel-good system and the need to be relaxed and calm that leads to the feeling of being safe and content. Within the context of hospital medicine, we will see a lot of threat and sometimes are unable to think of things in a constructive way and are more likely to be angry and critical of ourselves.  Dr Parish highlighted the importance of balance and the need of all three systems for this as they all are beneficial in their own way. It is important to think if there is an imbalance how we can help each other through and it is often the soothing system that’s missing. It is a necessity that we take time to stop, think, reflect and show gratitude to ourselves and reinstate this balance.

 
The evening was brought to a close with a three-course meal and a much needed social! A fantastic day full of variety and wonderful topics from medical students to Consultants and of course with our Anaesthetic colleagues adding to it. The next meeting has just been confirmed May 22nd2020; who will join me in making the journey to The Quay Hotel in Deganwy, North Wales?! 

​

Dr Annabel Greenwood ST5

​​When a flyer advertising the Welsh Paediatric Cardiovascular Network (WPCN) Autumn Meeting popped up in my inbox, I jumped at the chance to attend in the hope of broadening my (somewhat limited!) paediatric and neonatal cardiology knowledge.  I’m sure many fellow trainees would agree with me when I say that the subspecialty of paediatric cardiology can at times feel a little overwhelming and complex, so any additional learning opportunities in this field are certainly invaluable. 
 
This year’s Autumn meeting was held at the Radisson Blu Hotel in the centre of Wales’ capital city, and was attended by a range of representatives from the paediatric multidisciplinary team with an interest in cardiology.

The principal theme of the day was pulmonary artery hypertension (PAH), and the morning session was particularly neonatal-focussed, emphasising the relationship between prematurity and PAH.  To set the scene, the day began with a case presentation of an ex-premature baby with chronic lung disease and a patent ductus arteriosus who subsequently developed PAH.
 
Then followed a talk on cardiovascular outcomes in chronic lung disease (CLD) of prematurity. Professor Kotecha, Consultant Neonatologist at UHW, discussed the effects of CLD of prematurity on the left and right sides of the heart independently.  With regards to the left-side of the heart, he considered the theory that those born prematurely will have higher systolic blood pressures later in life.   This was based on the concept of arterial stiffness, and that prematurity and low birth weight are inversely related to arterial stiffness, and also that lung function is inversely related to development of arterial stiffness.  However, he then went on to discuss the results of an ongoing respiratory study, the ‘RHINO’ Study, (Respiratory Health Outcomes in Neonates), whereby children aged 7-12 years, born prematurely at <34/40 gestation, were assessed in terms of their lung function, including spirometry measurement pre and post-bronchodilator therapy.  The study found that there was no significant difference in peripheral systolic BP between those born prematurely with CLD, those born prematurely without CLD, and term controls.  There was, however, a significant difference in peripheral diastolic pressure (higher in preterm CLD patients).  This difference could perhaps be explained by measurement error or even steroid use.  
 
As for the right-side of the heart, pulmonary pressures increase in those born prematurely, but the key point to note is that by improving lung function and a child’s overall general health, then pulmonary pressures won’t be such a major issue. 
 
Dr Kevin Poon, Consultant Neonatologist at Royal Gwent Hospital then took us through the echocardiographic assessment of PA pressure.  He highlighted the echocardiographic parameters used to assess PA pressures, and also surrogate markers of raised PA pressure.  

The following measurements can be used routinely to assess PA pressure:

• TR jet – provided there is a good envelope, no RVOT obstruction or large VSD, and good RV function
• PR jet 
• PAAT:RVET ratio (PA Acceleration Time: RV Ejection Time) – in addition to TRJV, or if unable to obtain good TR envelope
• TAPSE (Tricuspid Annular Plane Systolic Excursion)
• LV eccentricity index - when septal flattening or bowing seen 
• Myocardial velocity – if you have a tissue doppler package

These are measurements that I am on the whole unfamiliar with, given my limited exposure to performing echocardiograms, however, it was very useful to learn more…and of course, the key message was to ‘leave the fancy stuff’ to the cardiologists!


After a brief refreshment break, Karina Parson-Simmonds, Children’s Cardiology Nurse Specialist at UHW, presented about the ‘6 Minute Walk Test.’  This is a test to determine the distance a person can walk at a constant, uninterrupted, unhurried pace in 6 minutes, and is widely used to assess exercise capacity of paediatric patients with CV disease.  It can also be used to monitor disease progression, to evaluate patients’ exercise tolerance pre/post-operatively or to measure response to an intervention, and can provide longitudinal data for a patient if repeated at intervals over a period of time.  It is not however ‘gold standard,’ as this remains the cardiopulmonary exercise test, and the BORG index score (rating of perceived exertion) is subjective, possibly causing discrepancy in results. 
 
 
 
Continuing with the multidisciplinary theme, Dr Lena Thia, Paediatric Respiratory Consultant at UHW, then discussed the respiratory management of the child with CLD and PAH. There are a number of respiratory causes of PAH, all associated with hypoxia;  

• CLD
• Pulmonary hypoplasia (congenital diaphragmatic hernia, single lung)
• Chronic interstitial lung disease
• Sleep disordered breathing 
• Severe airway malacia with hypoxia
• Severe CF with end stage lung disease
• Neuromuscular disease with night time hypoventilation

Co-existing cardiac disease predisposes to developing PAH in CLD, and infants with Trisomy 21 with or without structural lung or heart disease are at increased risk of developing PAH.
 
Key investigations to consider are;

• CXR

• Blood gas – how much compensation? How high is the CO2?
• Overnight sleep study
• Lung function tests (spirometry, transfer factor)
• Exercise testing with saturation – evidence of desaturation when exercising 
• CT chest, CTPA
• Bronchoscopy 
• VQ scan
• Lung biopsy

With regards to optimising respiratory management;

• O2 for any daytime or night time hypoxia
• Ambulatory O2 for exercise
• Supplementary O2 for air travel
• O2 for emergency use at home
• Treat infections promptly – annual influenza vaccine, palivizumab, prophylactic abx
• Safe feeding assessment, and management of GORD

​The final session of the morning was an impromptu session by Dr Dirk Wilson, Consultant Cardiologist at UHW, as the planned speaker was unable to attend.  This was a fantastic session on ECHO interpretation of common structural defects (ASD, VSD, AVSD), with the use of ECHO videos to enhance learning.
 
Unfortunately due to on-call commitments, I was unable to stay for the afternoon session, however, Dr Maria Mendoza (Neonatal Clinical Fellow at UHW), has kindly provided us with a great summary…
 
"The afternoon was a fun, interactive session amongst all participants of the meeting to culminate everything we learned during the day. Each table consisted of a multidisciplinary team of consultants, trainees, nurses or cardiac physiologists where a well-informed discussion was made possible. Different cases were presented and each team was able to analyse the case together, view the different imaging results available such as ECG, Chest X-ray and Echocardiogram findings and come up with a diagnosis and subsequent management. Some of the cases were Hypoplastic Left Heart Syndrome, Possible Noonan Syndrome with Pulmonary Stenosis, Atrial Septal Defect and Hypertrophic Cardiomyopathy. We also discussed the risk of acquiring RSV especially during the winter season and which babies are at risk and need RSV prophylaxis. Overall, it was a very high-yield discussion of different clinical cases with many learning points."

​

Dr Tom Cromarty ST6

Earlier this month I travelled to Barcelona with the EU funded TALK Debrief research project. This is part of the Research and Innovation Staff Exchange (RISE) programme, where Medical staff from Cardiff (Wales), Barcelona (Spain) and Stavanger (Norway) visit each other’s hospitals to learn and help with the implementation with TALK debrief, as well as experiencing other healthcare systems.
 
TALK is designed to guide structured team self-debriefing after any learning event in clinical environments. The Structure can be seen in the figure below, with more information and FREE resources are available at TALKdebreif.org
​

​Whilst on my latest placement in Barcelona, I was able to attend the only specific Children’s Hospital in Barcelona called Sant Joan de Déu (SJD). This large tertiary referral hospital is mostly public funded and is going through a series of renovations. I was fortunate enough to visit the brand new PICU which in Spanish is called the Pediatric UCI (Unidad de Cuidados Intensivos), and experience the innovative Simulation centre. I was particularly impressed with the Simulation team which was created and lead by José María Quintillà Martínez. Over the past 15 years he has been incredibly passionate about simulation in healthcare, starting off with a very low fidelity mannequin and no support, to now having an integrated simulation service.
 
José and his team were incredibly enthusiastic about Simulation, ensuring that the focus stays on the intended output and the methodology, rather than the expensive shiny technology. After developing a relationship with the world leading Boston Children’s Hospital Simulator programme, José and his team have developed a Simulation service that has the backing of the hospital board and is fully integrated with the hospital, rather than a stand-alone medical education tool.
 
Other than Simulation courses, which they run on >150 days of the year, the majority of the time for hospital staff, the team was recently involved with the architectural planning of the new PICU. Having created a mock bed space in the Simulation centre, they replicated the clinical scenarios which would need the most people and equipment, such as an unwell patient requiring ECMO (Extra Corporeal Membrane Oxygenation) or Dialysis. They modified the design and size of the room, from the location of sinks, equipment & monitors, to establish the optimum environment with the floorspace available.
 
Once the ward renovations had been finished, they again brought in the Simulation team to practice common procedures and daily routines. This meant that the teething issues which inevitably come up, were corrected without a patient in sight or put at risk. This forms part of the SIMTest function of their integrated Simulation Program which can be seen below.

​
​SIMTrain is the traditional work of Simulation in Healthcare, however the team in SJD aim to develop personal and team skills, as well as training patients and families. Trainers from the Boston Simulation programme visit the hospital to train a multidisciplinary group (Doctors, Nurses and Physios), forming a core Simulation faculty who can practice and train others in their departments. The PICU had five nurses and five doctors trained up, who would run a two-hour scenario on three occasions every Thursday. The simulation philosophy is so embedded, that any new department being renovated (including PICU and NICU) has a separate ‘Simulation’ room (see below), specifically reserved and always ready for use. This also enables teams to put rented equipment and new protocols to the test before investing in them and practicing on patients.

Permanent Simulation room on the PICU unit

José’s team have used the Kerr-Patrick education model to validate learning from Simulation, currently working on levels 3 and 4 to demonstrate changes in behaviour and patient outcomes. The backing they receive from the organisations leaders has enabled them to hire an innovation team, subsequently creating the 3D4H (3D for health) unit. After a complicated oncological surgery was abandoned due to the challenging anatomy, the team used imaging to create a 3D version of the patient’s head. This meant the surgical team could make an accurate surgical plan and even practice the surgery as many times as possible. By saving money on theatre and anaesthetic time, this method saves time, money and makes the procedure safer for the patients.
 
As the specialist centre for MPS (Mucopolysaccharidosis) in Spain, they receive many referrals for management and perform up to fifteen maxilla reconstructive surgeries per year. These patients have complicated upper airway anatomy, making the intubation difficult. 3D4H printed a number of typical MPS heads with accurate upper airway anatomy and put this onto a traditional high-fidelity mannequin for simulations. This enabled anaesthetists to practice this complicated skill a number of times, demonstrating their proficiency before the patient had even arrived.
 
The 3D4H team have developed been used in a number of other ways.

• Tracheostomy’s: They have printed multiple versions of anterior necks with tracheostomies. They then run simulation scenarios for ‘blocked Trachy tubes’ for staff and parents to practice their skills and improve their confidence.
• Skin: Various printed skins help staff practice suturing, wound management, accessing tunnelled central lines and USS guided cannulation. Much cheaper than buying the material from external companies.

Simple 3D printer

Trachy and various skins printed from 3D4H team

​Integrated Simulation is a new way of designing and improving medical environments, teams and the care they provide, by exploring and learning from reality before it happens! I was completely inspired by the number of functions which their Simulation team performed as an integrated service with the hospital, and the incredible number of cost-effective uses for 3D printing. 3D printing is being used more and more in medicine, with the materials becoming cheaper and technical printing skills advancing every year.  
 
How could you use Simulation or 3D Printing where you work? Perhaps Barack can inspire you?

​As always feedback or questions are always welcome.
Twitter. @tomcromarty
Email. Thomas.Cromarty@wales.nhs.uk

Davide Paccagnella, ST3 Paediatric Trainee

​When I attended the 4th Annual Paediatric Medication Error Prevention (PMEP) Study day (which took place in Morriston Hospital, on 8th October 2019), I already knew that it was going to be a great experience!
For the past four years, Morriston has achieved great results in the field of medication error reduction and prevention. They have done this by forming a revolutionary tripartite alliance between Paediatrics, Nursing and Pharmacology. It all makes sense – by nature, prescribing, administering, checking and supplying medication is a multi-disciplinary exercise, and improving the safety of these processes can only be achieved by working together across different specialties.

This annual study day has become increasingly popular, year after year, with almost 100 registered attenders this time around. Which meant that, on the day, the lecture theatre was nearly full, making me feel like I was attending a national conference as opposed to a local study day!

The morning was kick-started by Professor Philip Routledge, CBE, from the All Wales Therapeutics and Toxicology Centre. His keynote address provided us with a global perspective on drug manufacturing, testing and marketing. When it comes to prescribing, I did not know that the largest avoidable cost, worldwide, is non-adherence to prescribed medication!  Prof. Routledge also highlighted important steps (often taken as a result of tragedy) that helped make drugs safer over the course of time. Some of these stories were very moving and sobering. Overall, it was a brilliant lecture, and I’m certainly hoping that Prof. Routledge will consider returning to Swansea to inspire us all, again, next year.

​

We were privileged to have Alana Adams, Principal Pharmacist from the Welsh Medicines Information Centre, and Dr Alison Thomas, Medical Director of YCC Wales, who came to give us an overview of the Yellow Card Scheme. Perhaps unsurprisingly, it turned out that not many audience members had filled a Yellow Card out before – this lecture was therefore a necessary reminder of just how important it is to provide this information, and what reactions need to be reported.

Dr Davide Paccagnella

​When I submitted an abstract to the 2019 Europaediatrics conference in Dublin, I knew little about it. As my abstract was accepted for poster display, I started reading about the European Paediatric Association (EPA), and got more and more interested. But no amount of reading could really prepare me for the experience of going there – so I thought I’d share a few thoughts with all of you. If you’re interested in going to a great conference, make connections, perhaps display/present a poster, and (last but not least) learn some pearls of wisdom from professionals on top of their game, please read on…

 ​The European Paediatric association is, in their own words, a “pan-European scientific association, whose main objective is to encourage scientific co-operation between not-for-profit National European Paediatric Societies/Associations and between European paediatricians working in primary, secondary and tertiary paediatric care in Europe, in order to promote child health and comprehensive paediatric care.” It was founded in 1976 in Rotterdam, and now represents 50 National European Paediatric Societies and Associations.
So far, 9 Europaediatrics Conferences have been held. The one I’ve been to was held in Dublin, between the 13th and the 15th June 2019.

1. The topics – it would be virtually impossible to list all the topics covered at the conference. From neonatology and critical care, to adolescent medicine and health promotion, from local issues such as social media and obesity, to global child health concerns, such as increasing migration and ongoing conflicts, all interests were catered for. Although I was only able to attend a handful of lectures and workshops (as most of the sessions ran contemporaneously), I felt excited, stimulated, impressed, and humbled by many of the accounts and experiences that were being shared. 
From a “paediatric trainee” perspective, I particularly enjoyed a “Meet the Expert” session on the diagnosis and management of seizures by leading experts Sophia Varadkar and Mary King, as well as a heated debate between Professors Chiarelli and Viner (both Diabetes and Adolescent Health specialists) on whether childhood obesity should be considered a form of abuse. 
I learnt a lot and made quite a few useful notes by attending some of the satellite symposia on allergy (desensitisation therapies) and Duchenne muscular dystrophy.
And the truth is, I wish I’d had more time to attend all of them! Whether the topic was educationally relevant to me at the time, or whether I learnt about global child health and how the world works, I left feeling more hopeful about life in general!

2. The speakers – Where do I start? Some of the very best of Healthcare professionals from all over Europe (and the World) seemed to be there. If I was to name them all, you might be reading on for a while...
But just to give you a flavour, the president of the International Paediatric Association, Zulfiqar Bhutta, spoke about Child and Adolescent Global Health Challenges.
You may have met or listened to our former RCPCH President, Neena Modi, or our current one, Russell Viner – well, they both delivered powerful and moving speeches.
And the list goes on...It would be fair to say that everyone I have listened to presented a topic they were not only competent at, but also interested in sharing with the audience. This made every lecture/workshop that I attended stimulating and interactive.
Finally, I had a moment of wonder – the Health Minister of Ireland gave a speech at the Introductory Plenary. Although elements of his speech were, by nature, political, I was deeply impressed by his manners – he came across as knowledgeable, humble, and respectful of the medical profession.  Made me hopeful that a few other Health Ministers across the world may do the same.

3. The atmosphere - I’d never been to Dublin but I can only recommend it. It was a busy couple of days as I was also preparing for an exam, so I did not fully enjoy all that Dublin could have offered. The venue was spectacular (by the river, with great views over the city and the Wicklow mountains). I met a few colleagues from Ireland with whom we chatted about a variety of things ranging from politics to travelling (and medicine). I also spoke to a few Italians about paediatric training and the differences between our systems – which made me really appreciate the structure of our curriculum and the opportunities we get as members of the RCPCH.

​I felt that more could have been done to allow professionals whose first language was not English, to express themselves in their full capacity.
Although everyone had prepared presentations in English, the quality of the translations varied significantly. It just seemed a shame that highly-knowledgeable professors should struggle to express complex concepts in a language that wasn’t theirs. I understand that having translators would have been logistically complicated (and perhaps not justifiable), but I think it would have made a positive difference to both speakers and audience.
Otherwise, it is difficult to be objectively critical of anything – hot food would have been nice (but the sandwiches were acceptable) and better velcro to attach posters may have come handy, although I should probably blame my fabric poster for that (which was, by the way, a good investment, as I could fold it and pack it in my luggage without incurring Ryanair fees).

​Yes – simple answer. Expensive (450 Euros) but good value for three days of excellent opportunities for learning, networking, and much more.
I ‘m glad I went, for all the reasons I explained above, but mostly because it gave me a boost of motivation and hope for the work we do as Paediatricians.
If you’d like to attend the Conference in 2020, have a look at the links below.
 
http://www.epa-unepsa.org; https://www.europaediatrics2020.org/
 

Dr Thomas Cromarty ST6

​Session delivered by:
Sara Hughes – Speciality Reg in Paediatric Dentistry,
University Dental Hospital Cardiff

​Earlier on in the month I was able to attend an incredibly enlightening session on Oral Health in Paediatric patients. Aside from teaching me how to brush my own teeth properly at the age of thirty-five, there were some really useful nuggets of information. Especially for questions which my friends who are parents ask, starting “You’re a Paediatric doctor, you should know this” (Spolier..often I have no idea). Well when it comes to kids and teeth, now I do, and in 5 minutes so will you. I thought it would be easiest to go for a Q&A format, so I’ll jump straight in.

Turns out that apart from the Natal Teeth which you sometimes see whilst on the Post-Natal ward (check it’s not loose and airway obstructable, then send to a dentist):

• The first teeth usually come through at 6 months.
• You get a full set of primary teeth (20 teeth, EDCBA,ABCDE) by six months
• The full rack of secondary gnashers (32 teeth, 87654321,12345678) by age twelve.

BabyCenter – Baby Teeth Order of Appearance
​

 Eat sugar -> Bacteria in the mouth use the sugar to produce acid -> Acid then demineralises the enamel -> Hole is formed. Think of it like the “Battle of the Bouche”, with protective factors versus destructive factors. On the good side we have Saliva (buffers the acid), Fluoride (strengthens enamel) and a healthy diet (low sugar, coarse food cleanses teeth). On the bad side there are caries causing bacteria, xerostomia (low saliva levels) and poor diet (high sugar).

​Actually No, the bacteria which are implicated in causing caries are acquired, and usually from adults that can transfer the bacteria to the child. So please don’t recommend doing that.
 
“Yeah, the baby teeth aren’t in good nick, but we’ll sort out his teeth cleaning when the adult teeth come through….we cool?”
 
Decay and Caries in the baby tooth can track down to the adult tooth and affect the development of the crown, making it more likely to break down and need extraction. Also, if baby teeth need to be removed prematurely, adult teeth then drift in and either can’t erupt or erupt abnormally, causing “crowding” of teeth. Sometime adult teeth to be removed as well.

Figure 1. The baby tooth above the adult tooth (circled) was removed so hasn’t erupted properly due to drift of the tooth to the right.

​Answer: Frequency is worse than Total amount

​The ‘Stephan Curve’ (above) shows that after sugary foods/drinks, bacteria use the sugar which makes acid (lowering the pH). When the pH in the mouth is below the ‘Critical pH’ of 5.5 then tooth decay happens. The longer cumulative time the mouth’s pH is in the ‘critical zone’ then the worse the decay. So you can compare a day without sugary snacks Versus a day with sugary snacks! (below).

 
How big is the problem? What are the REAL stats? (UK data from 2013)

​8 year olds: 46% have ‘Obvious evidence of dental decay’
Socio-Economic Inequality:
57% (children who qualified for free school meals)
45% (did not qualify for free school meals)
 
12 year olds: >30% had obvious decay in the permanent teeth
15 year olds: >40% had obvious decay in the permanent teeth

​Dental Health DOES impact on General Health!
Children with decay and tooth pain who are not used to visiting the dentist are scared, so don’t tell their parents and suffer in silence. Some of these effects can be seen below:

​ Sugar Smart app: This breaks down daily recommendations into sugar cubes rather than grams, which is much easier to understand.
NHS food factsis useful: Maximum Daily allowance of sugar in children is 4-7 cubes (each cube is 4g sugar)

​Drinks!Fizzy drinks, Fruit juices.
Hidden sugars:Tomato Ketchup (not so bad when consumed with a meal). Petit Filous (1.5 sugar cubes each)
Dried Fruit:Lots of sugar and sticks to teeth as well

• Reinforce key messages
• Brush Twice a Day
• Use fluoride toothpaste
  1. If child <3yr – 1000ppm fluoride
  2. >3 – 1350 – 1500ppm fluoride (adult concentration
• Spit! Don’t rinse.
• Do not eat or drink after brushing at night

 
2. Give Tooth Friendly Advice:

• Keep foods and drinks containing sugar to mealtimes only
• Drink only milk or water between meals
• Do not eat or drink after brushing at night
  • No bottles of squash or juice in bed to sleep
  • Cut the top off the teat, off to transition off bottles
• Stop bottle/breast feeding from 12 months – Use expressed milk in a free flow cup
  1. Breastmilk does have lots of sugar so try to avoid giving breastmilk as going to sleep. Milk will be left on the teeth and increase chances of decay. Drink breast milk then brush teeth. (Milk in the day much safer!)

”Bottle Caries” where milk sits on the teeth overnight (and saliva reduction is low)

​Remember: Sugar free squash  or just no added sugar

3. Recommend  safe snacks

• Raw Vegetables
• Fresh fruit
• Savoury foods

4. Encourage regular dental visits
Ask the question as part of your regular history taking E.g. Who is their Dentist?  - Just asking the question can be enough
“How often?” - depends on risk level, 6/12 to 18/12.

​Unflavoured & Non-foaming (SLS free) for children with autism. (e.g. OraNurse)
DO NOT Recommend: Fluoride-free toothpastes, Toothpastes containing baking soda (stains only), Charcoal toothpastes.

​Check that the patient has a Dentist. Otherwise can register with NHS Direct.
Other Options:

• General Practice
• Community Dental Service – can do domiciliary check-up.
• Hospital Service – Check if there is an electronic Referral System?

If there is significant swelling or severe pain, then contact Max Fax

Dr Chris Course, ST6 Neonatal GRID Trainee

The 3rd Congress of joint European Neonatal Societies (jENS) took place between 17th-21st September 2019. jENS is  jointly organised by the European Society for Paediatric Research (ESPR), the Union of European Neonatal and Perinatal Societies (UENPS) and the European Foundation for the Care of Newborn Infants (EFCNI) and occurs on an alternate-yearly basis. It is one of the largest neonatal conferences in Europe, and around 2,000 delegates attended to hear the over 120 speakers discuss the latest scientific advances in basic, translational and clinical research, as well as latest clinical guidelines and recommendations in patient centred care, all within the field of neonatology and perinatal care.

​jENS is a perfect conference for anyone with an interest in neonatology. I think as a new GRID trainee it was really inspiring to hear about all the latest developments in the field and see what treatments and management strategies we may be employing in the next 5-10 years. I suspect the programme is probably too intensive care/tertiary neonates-focused for anyone within higher level general paediatric training, but for anyone more junior who is still deciding on later career aspirations, it certainly gave a good insight of the ever-evolving field of neonatology.

​The main conference ran over 3½ days and the programme was mainly centred around 4-6 concurrent sessions running simultaneously with different themes, covering nutrition, lung, neurology, cardiovascular and other topics. A mixture of poster walks, poster presentations and oral abstract presentation allowed delegates to also present their work, in addition to the invited speakers and plenaries. The whole conference then came together in the main auditorium at the end of most of the days for some diverse and thought-provoking plenary sessions, with a broad range of topics including integrating and undertaking research within daily clinical practice (Prof. Neena Modi, great to listen to as always), how to grade the quality of evidence (Prof. Roger Soll, head of the Cochrane Neonatal Group and Chair of Vermont-Oxford Network, making a dry-sounding topic really engaging and relevant) and how do we make end-of-life care decisions ethically and also involve parents and families actively in our decision-making process. There really was something for everyone!

​I also had the opportunity to share some work I’ve been involved with through WREN on improving the management of Respiratory Distress Syndrome in Wales. I was quite nervous leading up to the presentation, but the audience were friendly and supportive (and didn’t ask too many difficult questions!). It was a fantastic opportunity to do some CV-building and gain some experience presenting to some really eminent neonatologists who are leading their field. 
 
It also meant I was eligible to apply for and be awarded an Educational Bursary (courtesy of the charity Bliss, funded by Chiesi) which made the conference more financially viable for me to attend. The opportunities for funding to attend these big international meetings are out there, but often not well advertised to trainees – it’s definitely worth asking around (and talking to relevant pharmaceutical reps and companies) if you’d like to attend any of these big meetings. I find it enthuses me about my speciality and I can really recommend trying to attend whichever conference would be relevant for your interests.

​The conference was also an opportunity to visit Maastricht, a place I knew nothing about and would never have visited otherwise. Maastricht is a beautiful, historical city, and walking around in the morning and evenings, as well as finding some great little Dutch restaurants, was a lovely way to relax around a packed conference programme.

​The 4thjENS Congress will be taking place in Athens from 14th-18thSeptember 2021. I plan on attending again and look forward to discussing some of the ideas and new knowledge I’ve gained with my colleagues in NICU on my return from this trip!

​More information:
www.jencongress.eu
@JENS_Congress

Dr Siwan Lloyd ST5

Action for children Family Intervention Team: supporting children in the community
 
I am coming to the end of my community paediatric placement and have learnt a huge amount about the way that vulnerable children and families are supported in the community. Whilst sitting in on MDT referral meetings, I realised that I previously had very little understanding of the huge team of allied professionals, charities and agencies offering support out in the community. I therefore made it a PDP to increase my understanding and awareness of the way that the wider community supports children.

I was over the moon to be invited to an Action for Children Family Intervention Team (FIT) team meeting. The team had a psychologist and family intervention workers who all had their own caseload. The team discussed their active case-load and I was really inspired to hear about the support that they provide for children living in very difficult circumstances (e.g. living with parental mental health disorders, acrimonious parental separation, children struggling with issues surrounding gender identity, children presenting with behavioural challenges, children displaying sexualised behaviour, children living in households with domestic violence, children displaying anger and aggression etc.). The team usually perform an initial assessment and then work with a family for 12 weeks.

Many of the children had received support from their Wellbeing project (a project funded by Caerphilly families first and run by Action for Children) which supports families suffering from low motivation or low mood, anxiety, depression, social isolation or traumatic life experiences. The aim is to build resilience, improve emotional wellbeing and support for families to feel more positive and confident. The process is provided by a family support practitioner delivering engagement sessions followed by either group sessions or individual support. They work on confidence building, self-esteem, regulating emotions and feelings and preventing social isolation.

I was particularly impressed by the way the team discussed a safeguarding issue of a family who would not engage with any other service (e.g. paediatrician, social services) and who were withdrawing and becoming socially isolated but this family had built a trusting relationship with their action for children family intervention team case worker. The team discussed the way in which this was so important in maintaining this relationship and slowly getting the family and child to trust professionals.

I was also impressed by the way the team highlighted each child’s wellbeing as their utmost priority but always discussed this in the context of the wider family. There have been many times in community paediatrics when I have seen a child presenting with behavioural difficulties when it is evident that the family environment is affecting them. This team is able to provide support to the wider family and by doing so improve the life and mental health of the young person which is an invaluable resource. Action for children can arrange Family Therapy which can work on issues such as building consistent parenting.
 
I learnt about some of the psychological techniques that can be used to support parenting for example PACE – “playful acceptance, curious and empathetic” a form of parental psychotherapy developed by Daniel Hughes that can be undertaken in groups or 1:1 and works to support forming secure attachment and encourages parents to give children vocabulary for discussing emotions. There was also discussion about ACT “acceptance and commitment therapy” which can be offered to parents struggling with difficult circumstances to allow them to accept these things that they have no control over. There was also discussion surrounding teaching and supporting parents to use NVR (non-violent resistance) as a technique to manage difficult and aggressive behaviours.

I was embarrassed to admit that I had no idea how many sources of support there are for families that Action for Children can signpost and refer to (for example “Confident with Cash” is  a resource led by families first and the citizen’s advice bureau that can give advice on benefit entitlements, consolidating debt and managing household budgets to families that are struggling, TYFE (targeted youth and family engagement) is a group led by families first that take children out to participate in group activities aiming to build their social skills, confidence and self-esteem).

The team also discussed referrals on to other agencies as sources of support including Llamau (e.g. “domestic abuse children and young people outreach”), Caerphilly Council’s Youth Respect programme (a Supporting Family Change project for young people who show early indications or abusive, aggressive and controlling behaviours), NYAS (National Youth Advocacy Service – a confidential independent service that supports children and young people by helping them to be heard and exploring their views, wishes or feelings on a particular issue or circumstance), Barnados (e.g. “confident parents, stronger families” – aims to assist development of parenting skills and increase parental capacity offering support with things such as routines and managing behaviour).
​
This team works with families who are reaching crisis point and struggling to cope and I firmly believe that the vital support that they offer is likely to reduce child neglect, child emotional and physical abuse and supports the child’s overall wellbeing. It was truly inspirational to see the way that they provide support for these families (and I was so inspired I was briefly tempted to change careers in order to become one of them!).

​Image: https://www.actionforchildren.org.uk/what-we-do/parents-and-families/
 

Learning points:
​

1. When meeting vulnerable children and families always remain aware of local charities and agencies that can provide support and offer a referral to families if appropriate
2. We as medical professionals are really only a very small part of the jigsaw in supporting the wellbeing of children and young people in the community
3. There are a large variety of agencies available that we can turn to for advice and support when we encounter vulnerable children and struggling families

I hope to be able to attend further team meetings or shadow other agencies in order to continue to increase my understanding and awareness of their valuable work e.g. Barnados, Supporting Family Change. I would encourage every paediatric trainee to take every opportunity to increase their awareness and understanding of these sources of support for families in the community.
 
For more information about the work that Action for Children undertake see - https://www.actionforchildren.org.uk/. I would be very happy to share contact details with any trainee who is also interested in using some Study Days to attend an Action for Children Team meeting.
Other resources:
https://www.barnardos.org.uk/
https://www.llamau.org.uk/
https://www.nyas.net/

Dr Ciara Duggan ST4

The Professional Support Unit (PSU) was created in 2008 and aims to provide support to all doctors and dentists in training in Wales. At the recent deanery study day we had a workshop from the PSU to let us know what services are available to support us throughout our paediatric training.  They aim to support trainees early with confidential, targeted support they have a number of different resources and services available to them in order to do this.
 
Either trainees can self refer or supervisors can recommend referral to the PSU. Initially when the PSU was first set up they were primarily getting referrals from supervisors or following an undesirable ARCP outcome. However self referrals are increasing year on year as trainees have become more aware of the services available.  The PSU also has a presence on ARCP panels in order to support trainees and also offer additional support to any trainees with an outcome 2 or 3.
 
The PSU can provide an initial meeting where they explore the support needs and the best options for that trainee.   They provide health support, discussion about career options, eportfolio/ARCP support and help with those struggling with exams. They have links to a counselling service which trainees will be able to access within 24 hours of referral and they will try and link trainees to services as close to home as possible. They try and identify trainees who need adjustments for health or disability in advance so that each job can be prepared prior to the trainee starting.
 
I was interested to hear about the exam support which they can offer to trainees. They are seeing more and more trainees accessing their services for help surrounding passing postgraduate exams and the anxiety that these exams can cause. They can help with revision techniques and planning, dealing with the anxiety surrounding exams and dyslexia assessments where this is appropriate leading to extra time or support during exams.
 
Part of the workshop highlighted the success of the PSU in helping trainees. They show an increase in exam passing rate after input, an increase in outcome 1 at ARCP and a high level of satisfaction from the trainees who have been supported. All in all the session highlighted this resource, made it sound accessible and useful and I think it ties in with the recent push from trainees talking about our own wellbeing in work. The link is below if any one would like to access the PSU you can call them or email.
https://psu.walesdeanery.org
​

The Wales Deanery recently organised a study day themed around health policy and practice in Wales, and our role as Paediatricians in influencing these policies.

Below we have two separate accounts of the day, one from a trainee perspective, and the other from the Head of Monitoring at 'Positif' - Wales' largest public affairs company.

Dr Lucy Deacon ST1

How much do you know about the structure of Welsh Government? Would you recognise a photo of our Health Minister? Why does it even matter?

I have to be honest, I had no idea about any of these things before I went to regional teaching a few weeks ago. At the start of the afternoon session I didn’t know what to expect, mainly because I knew so little about the National Welsh politics. It was, however, one of the steepest and valuable learning curves for me in training this year- I am left feeling both educated and empowered as a Welsh citizen and member of the medical profession within Wales.

Twenty one areas of government are devolved to Wales. Within those twenty one areas is Health and Social Services and together they receive half the budget given to Wales to spend. The Welsh Government really does care about Health.
​
The training, delivered by positif, was engaging and relevant. We learnt about which departments are devolved to Welsh Government and who the big names are within the Welsh Assembly. Knowing this structure and then how policy decisions are proposed, debated and approved equips us as medics to be able to influence health policy within Wales. We learnt about choosing who to write to and how to start a national conversation about the issues that matter to us. Creating a conversation comes not only from research, and published articles and papers, but from making the relevant people, in power, aware of these findings, joining working groups, responding to national policy documents in consultation and identifying champions to join us in fighting for the change we want to see. And timing. Timing is important and very relevant to writing this piece because, now is the time to be writing to Assembly Members. The election cycle means now is the time to be making proposals, ahead of parties writing manifestos next year, this is the time to be raising our questions and lobbying the government to discuss them. Questions for the Health Minister can be oral or written and he answers questions every 4 weeks on Wednesday. Asking for more money is what everyone does but proposing solutions is what is listened too.
 
We finished the afternoon planning and presenting our ‘Lift Lobbying’ pitches. Individuals came up with an issue they wanted to change, among them – rest facilities for junior doctors, what to do with the national report on Adverse Childhood Experiences, making CAMHS a 7 day a week service for children in crisis and having a drug and alcohol service for children in need of support. We were challenged to think ‘what is it you are actually trying to do?’ The room became impassioned as we worked on compressing the proposals into a 2 minute pitch you could give if you found yourself in a lift with Vaughan Gething.
 
So, I left at the end of the day, having been involved in lively debate and feeling better informed about how health policy is formed within Wales. But more importantly I left feeling a sense of privilege and of responsibility as a doctor because now I knew how to get my voice heard on the issues that matter to me. It was clear from our pitches that as junior paediatric doctors we wanted better services for the children we care for and that we are uniquely positioned to identify the issues as they confront us in work on a daily basis. What we see every day is the health of our nation, and indeed our nation’s future, so safeguarding it is in the Welsh Government’s interests. There are routes to get our voices heard and knowing more about how policy decisions are proposed, empowers us as doctors to influence discussion and debate.





​

Rhodri ab Owen
Head of Monitoring,  'Positif'

​A common misconception is that you need to be “in politics” in some way to have a political impact and influence. You do not. This was the biggest take away I wanted to give a group of paediatricians who came to a session at the Princess of Wales Hospital in Bridgend on how to influence politicians and key stakeholders.
 
Context is the key to successful political influencing. It is about talking to the right person, or an influencer on the right person, in the right way, about the right things, at the right time. Politicians in Wales are much closer to the people than in other parts of the UK, and it is far easier to influence and organise a meeting with Assembly Members, than other politicians across the UK. Most policy development and legislation have come from an individual or a group of individuals influencing politicians. For example, the system of presumed consent for organ donation came about after several years of campaigning from a cross section of interested organisations. Kidney Wales may have led the campaign, but it was actively supported by others with an interest in increasing organ donation rates such as the British Heart Foundation and the Cystic Fibrosis Trust. It also gathered support from the British Medical Association, which provided additional gravitas in making the case.
 
While discussing allies as part of the context, it is also perhaps worth reflecting on who your opponents might be. You might not think you have opponents but every interest group chasing the same pound, or every organisation seeking attention to their policy asks, is potentially an opponent. Even those you might assume to be allies are not necessarily so – UK Transplant was one of the most lukewarm organisations in respect of a policy of presumed consent for organ donation in Wales.
 
The legislation for presumed consent in Wales which reached the statute book in Wales in 2013 began six years earlier with the building of a coalition and an information gathering exercise. This helped establish the context of the campaign. Data and statistics were gathered, best practice examples were observed in other countries, and a bank of knowledge was created to ensure depth and consistency. From this firm foundation, not only was political action taken, but steps were taken to create and shape the context of a wider public discussion. This included becoming part of Welsh Government working groups, inputting into consultations, and publishing articles in newspapers. All of which elevated the issue and gave it clear context to support the campaign and its key asks.
 
TOP TIP: Make sure you have spent a decent amount of time planning, evidence gathering and sounding out potential allies before you embark on any campaign, especially if it is impactful or high profile in nature. Getting things right from the outset can avoid problems and disappointments later down the line.

Dr Assim Javaid ST3 

Provider: Bristol Medical Simulation Centre

Course Length: 1 day
​
Cost: £85 (Free for Peninsula and Severn Trainees)

A one day course aimed at dealing with paediatric emergencies that can happen on the ward, in ED or on an admissions unit. It’s aimed at level 2 trainees and provides more difficult and challenging simulations than seen in other simulation courses. There’s a mix of resuscitation and communication scenarios aimed to push junior registrars out of their comfort zone and to make senior registrars think harder about their leadership styles. 

​The Bristol Medical Simulation Centre, if you’ve never been there, is fantastic. There are a number of beds, made to simulate the ward, theatres and side rooms, and this, alongside an excellent range of mannequins, really help to minimise a lot of simulation artefact by making the scenarios feel that bit more real. The faculty are friendly and approachable. They also provide a really good debrief session, which I find the most useful part of simulation.

​Bristol is a bit of a nightmare to get into! But that’s always been the case and something you’ll just need to factor in when making your way there. Other than that, the only other downside is that the vast majority of the attendees will be Severn trainees. They’ll all know each other relatively well and, unsurprisingly, will take to working together in simulations easily. If you come from outside this deanery, be ready to be the unknown factor in the group. That’s not necessarily a bad thing but it’s worth being aware of beforehand.

​In a word, absolutely! The scenarios are challenging (I won’t say what they are as that would defeat the purpose) but in no way unfair and closely related to our practice. The focus is very much on gauging and developing how you work as a leader of a team in an emergency and this is the best course I’ve been on for developing that aspect of our professional behaviour. Though there is a cost for Welsh trainees, it’s certainly nowhere near as high as other similar courses and I think the value for money is excellent.

Oliver Walker ST6, Neonatal GRID Trainee

Preparing for consultant interviews may feel like a very distant problem in the early years of paediatric training.  However, thinking early about what you’d like your future consultant job to be and how to get it can help guide your priorities in the last years of your training.  For many of us this may well be the first interview we have had since applying for paediatric training.
 
Dr Helen Jeffries and Dr Rachel Rayment gave an instructive talk on consultant interview skills at the recent junior doctor leadership session at UHW.  They talked from personal experience of being both the interviewer and interviewee. A key message was the importance of preparation well in advance.  As well as building your CV in the later years of training, try to demonstrate an interest that will be a selling point to the panel, be it an area of clinical expertise, management experience, research or education.  
​Look online for consultant interview scoring criteria and identify areas of strength as well as weaknesses that you can address in advance.  When looking for jobs try to think carefully about whether it is right for you, remember that consultant jobs are often still a career long position.  Dr Jeffries and Rayment told us that if you feel the job doesn’t quite fit your needs (e.g. you have a research interest you’d like to pursue) you can discuss any specific changes with your future employer.  They suggested that this should be done early in the process as once you are appointed renegotiation can be very difficult.
 
Once an interview has been offered, visit the department, make contact with and ideally meet as many members of the interview panel and department as you can.  This will give you a valuable insight into the priorities of the department and likely interview questions.  It is as important to meet non clinical as clinical staff.  Visiting will stop you being an unknown quantity at interview.  Make sure you are aware of local issues and practices - this can be especially true if moving regions or countries.  For example, NHS England has a very different structure to NHS Wales with different bodies for service commissioning and service delivery and this alters an organisation’s priorities.  Look at the values of the trust or board you are applying to, try to see what the its plans for the future are and how you complement these.
 
When preparing for the interview practice as much as you can with friends and especially consultant colleagues who can offer valuable feedback.  There are also services that provide professional advice and training for interview skills.  
 
Dr Jeffries and Dr Rayment emphasised that clinical skills are taken as a given - it is how your other skills and experience will fit the needs of the department that really matters. 
 

Dr Christopher Course ST5, Neonatal GRID Trainee

The first South Wales & West BPD/CLD Symposium took place at the Holiday Inn Cardiff North on 12th June 2019. The day aimed to update delegates on the latest topics on the prevention and management of chronic lung disease of prematurity (CLD), also known as bronchopulmonary dysplasia (BPD). We attracted nearly sixty delegates from a multi-professional background from across the South Wales and West Country regions.
 
The morning session focused on hot topics in the prevention of CLD. It started with an overview of the current trends in management of respiratory distress syndrome of prematurity, presented by Dr Chris Course. This talk highlighting changes in practice since the introduction of the Wales Neonatal Network RDS Management Guideline in 2016. Progress has been made in mechanical ventilation support and supportive care, but the data highlighted the ongoing need to optimise early care in the delivery room and aiming to stabilise on non-invasive respiratory support.

This was followed by Professor Sailesh Kotecha (Cardiff University) presenting his groups ground-breaking work on the influence of pulmonary microbiome on the development of CLD, the negative impact of ureaplasma colonisation, and potential therapeutic interventions. ​

​Dr Malli Chakraborty  (NICU, Cardiff)followed with an overview of the current evidence base for different mechanical ventilation strategies in preventing CLD, stressing the importance of minimising duration of mechanical ventilation, gentle ventilation modes (such as Targeted Tidal Volume mode) and future directions for support, such as NAVA (neutrally-adjusted ventilatory assist). The morning was rounded off with Dr Lieve Boel (NICU, Cardiff) giving an update on the latest research in antenatal and postnatal steroid management, discussing the emerging role of early postnatal hydrocortisone, and potential advances with intracheal instillation of steroids.
 
The focus of the afternoon then shifted towards the management of CLD and the longer-term outcomes of CLD and premature birth. The afternoon started with a discussion on the role of palivizumab in reducing RSV-related morbidity and mortality for those babies with chronic lung disease, and the possible expanded role it may have for late preterms, who still have a higher RSV-related morbidity. Dr Aung Soe, (Medway Hospital Kent) Topic Expert for the NICE guideline on Specialist neonatal respiratory care for babies born preterm (https://www.nice.org.uk/guidance/ng124) highlighting some of the challenges of the NICE review process and summarising the recommendations. 

​This was followed with a moving talk from two parents, whose daughter had been born extremely preterm and suffered with CLD. Their experiences were vitally important in bringing all of the science and guidelines discussed so far during the day to impact it really has on families. We rounded the day off with Dr Martin Edwards (Consultant Paediatrician, Children’s Hospital for Wales) presenting his research on the long-term respiratory outcomes of premature birth, stressing that abnormal lung function and increased respiratory morbidity persists through childhood and into adulthood, highlighting that if we can optimise their early respiratory care, we can have a positive impact on their health for the rest of their lifespan.
 
We would like to thank Abbvie ltd for their help in supporting the day and we hope to organise a similar symposium next year – please stay tuned to the WREN twitter feed and website for more information.