‘The Palliative Care Journey: Managing Uncertainty’
Guest blogger Dr Tim Warlow
All Wales Paediatric Palliative Care Network
Following the success of last years All Wales Paediatric Palliative Care Network Conference, the team are excited to introduce the much anticipated 2018 conference. This year we will be exploring the palliative care journey from the perspective of the child and family. Hearing from the families themselves, the day will follow their journey from diagnosis through to bereavement. Some of the questions we will be asking include:
• When should palliative care be introduced and how do I raise the issue with families?
• How do I support families whilst making difficult decisions about their child’s care?
• What are the spiritual needs of families at the end of their child’s life?
• How do I manage difficult and unfamiliar symptoms at the end of life?
• How do I approach uncertainty and grief?
• How can Ty Hafan Children’s Hospice help me to provide holistic care to families?
When working with families of sick children, many of the most challenging issues we face are also the most rewarding when done well. This day aims to unveil those daunting aspects of care, provide ample opportunity for discussion, and hearing from the expert parents and professionals as to how we can serve our families better.
The morning will focus on introducing palliative care and decision making, especially relevant in light of recent high-profile media cases. We will consider how we can involve children better in decisions relating to their care, collaborating with families to ensure they feel listened to and valued whilst navigating legal and ethical uncertainties.
Next we will hear from families of children with life limiting conditions themselves. What were the most challenging times, and what actions of professionals were key to their palliative care journey? What was helpful, what was harmful? We will consider how each professional on their journey played a key role in ensuring excellent holistic palliative care and what we can learn from one another.
Finally, the afternoon will include a series of breakout groups to provide opportunity to really get stuck in exploring an aspect of the palliative care journey that is a priority for you. There will be time to discuss and ask questions in a smaller group setting. Topics include supporting children and families at the end of life, managing difficult symptoms, supporting grief, bereavement and spiritual care, and how to support staff including debriefing.
Last year’s conference was booked up quickly and over 100 delegates had a fantastic day. Now in its fourth year we have built on the lessons of previous years, responded to your feedback, and produced a day which promises to be challenging, rewarding, and a fascinating insight into the lives of our patients and families through their own eyes.
Here is some feedback from last year’s conference as a taster of what delegates took away:
“Learnt many new things. Was challenged on preconceptions and pre-existing myths of Palliative Care. Enjoyed the professional, but personal element for some speakers / discussions.”
“ Excellent day from start to finish, sessions we interesting, informative and thought provoking.”
“I was hooked from start to finish”
“The case studies/discussion groups with the panel of different professionals involved with the neonate and their families’ journey were excellent and thought provoking. These were great for learning about how processes can work well and can adapt along the way.”
We look forward to you joining us in October
Date: 18th October 2018
• Location: Park Inn by Radisson Hotel, Cardiff City Centre
• Cost: £32 per person (£16 subsidised tickets available for students and upon individual request)
• Bookings and information: firstname.lastname@example.org
9th-10th July 2018
Dr Rebecca Broomfield
The Patient Safety Congress aims to transform the UK’s approach to delivering high quality care. It champions patient safety as the organising principle of a healthcare system which is truly efficient, effective and able to offer the best experience to patients and carers.
I was lucky to be able to attend the Conference in Manchester in July. Prior to attending I had minimal experience with the Health Service Journal who sponsor the event and although clearly focusing my training and clinical work on optimising patient safety I knew very little about this movement within healthcare. The HSJ run awards and publish a journal purely focusing on and publishing patient safety initiatives and ways which can all make out practice patient focused and as safe as possible.
The conference was busy and if I am completely honest the timetable when I first looked at it was completely overwhelming. There was key note lectures which drew the participants together and then 5 streams running throughout the 2 days which you could dip in and out of to cover the sessions which most interested you and met your personal learning needs. Along with an exhibition centre and poster presentations focusing on 9 different topic areas.
Unfortunately due to childcare compromises (working parent problems!) I wasn’t able to travel up to Manchester until the Monday morning so missed the opening keynote speakers which I was reliably informed were excellent and predicted the exit of The Right Honourable Jeremy Hunt from his health secretary post, but unfortunately the predicted replacement Dr Kevin Fong turned out to be less accurate!
When I arrived I set up shop in the Human Factors stream. The streams for day 1 were: Human factors, Delivering quality improvement on the frontline, Driving a culture of patient safety, Improving patient safety through governance and compliance and finally Bridging the gap: policy and clinical Practice. The human factors stream was chaired by Martin Bromiley OBE (@MartinBromiley) of medical “Just a routine operation” fame https://www.youtube.com/watch?v=JzlvgtPIof4 – if you don’t know who he is or his story as a healthcare professional then you really should so click on the youtube link and learn about it.
What is human factors?
As defined by NHS England Human Factors for healthcare are: “Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings”.
Essentially it is about
Making it easy to do the right thing
The stream started well and I very much enjoyed hearing from 3 speakers talking about how they had introduced human factors within their areas or work and outlining the importance of doing do. Dr Shelly Jeffcott (@drjeffcott) spoke first about the importance of human factors and outlined some goals.
She emphasised designing the systems so that it is easy to do the right thing and the importance of integrating human factors training in the medical workforce. Education for Scotland have developed an e-learning package on human factors. It is easy to create an account and access this at:
Next up in this session was Mr Simon Paterson-Brown (@spbsurgery) he spoke about the use of training within a surgical environment to develop non technical skills. His sessions Non-Technical Skills for Surgeons have international acclaim and have been widely published. Finally the session ended with Professor George Youngson (@ggyrach) whop focused on thE impact of bullying and discrimination in care systems. Bullying is a huge problem in the NHS and this was outlined during this session Professor Youngson identified that it is still a problem and has done work proving its detrimental effect on patient safety. He encouraged us to speak up for safety and ensure that bullying was addressed in our departments.
The stream then moved onto the nudge theory and how we can use this within the NHS.
Helping people to make the right decision at the right time thus improving patient safety. During this session there was talk about the noble prize winning book “Thinking fast and slow” by Daniel Kahneman looking at the way people make decisions and how the nudge theory exploits this. By understanding how people behave we can design better policies and systems to improve patient safety. The EAST framework was suggested here: Easy, Attractive, Social and Timely. Any change in behaviour should fit into this framework. And where there is variation in practice it offers a good target for change.
After lunch I remained in the Human Factors stream and the session delivered by Abbie Coutts and Professor Bryn Baxendale (@gasmanbax) focusing on situational awareness. During this session it was the first time in this conference that I was exposed to a patient story being used to demonstrate a learning point. This is something which was utilised through the conference, across many different streams and had a truly powerful impact. Abbie Coutts presented her father’s case and observations on why errors occurred.
She has used the errors in care which happened to her father to teach the health board which cared for him about human factors. She suggests that this should be taught by people doing the job and understand why errors happen in order to address them rather than just how they happened. Professor Bryn Baxendale then spoke about balancing acts and how to embedded key skills and behaviours into practice. Both speakers focused on normalising excellence and doing the simple things well.
The fourth session in the human factors stream again used a patient story presented by Kathryn Walton https://www.youtube.com/watch?v=r7gk1AvZKZA We heard from the patient, the healthcare worker and what happened afterwards. I would encourage everybody to follow the link about and listen to the story. This was an exceptionally emotive story and emphasised.
The final breakout session I attended was delivered by The GMC within the Driving a culture of patient safety stream who presented a discussion on the GMC survey and understanding this data in relation to patient safety. The keynote to end day one was delivered by Professor Alison Leary (@alisonleary1) and focused on the fact the “Hope is not a plan” and within medicine what we can learn from other safety critical industries. Professor Leary presented an the fact that the very structure of the NHS is significantly different to other safety critical industries in that we place our most junior inexperienced staff at the front line closest to the operational risk, with the experienced workforce behind the scenes. This is in contrast to other industries who use their experienced work force next to the operational risk and use them to allocate selected work to the junior teams. In the NHS we need to be focusing on rewarding frontline experts to stay where they are on the shop floors rather than moving them further and further away into managerial positions. We need to use good policy and education where the expectations are clear and safety is mandated alongside clear credible leadership. Her closing statement was particularly poignant and a quote from Dr Tracy Dillinger NASA “People defer to hope, but when failure is not an option, hope is not a plan”
We went out for dinner in Manchester as a group of leadership fellows and I can 100% recommend The Alchemist for cocktails because they are fantastic, and for those based in South Wales one has just opened in Cardiff (yay!).
Back to the conference ...!
Day 2 opened with the prize giving for the poster competition. I entered 2 posters and this one won its category of ‘Education and Training’ Proof that if you do an interesting improvement project then it’s always worth popping it into a conference because you never know how far it might go.
The keynotes opened with Dr Bill Kirkup presenting themes which happen when things go wrong and how we should use these to make sure that as organisations we do not get into situations where things go wrong. He identified the follow themes:
- Failure to learn
He ended with 5 key points for maintaining patient safety:
- Listen to the patient, they are telling you the answer
- Honesty not reputation management
- Investigate and learn – not suppressing bad news and learning from others mistakes
- Dismissing and denial leads to a slippery slope which is harder to stop
- Do NOT think “It will never happen here”
The second keynote was also focused on investigations but from the Healthcare Safety Investigation Branch and what we can learn from the investigations which they have already processed. It is worth reading the summary documents of these investigations as it is different from a root cause analysis which will take place internally. They look at the route cause but also ask “why?”
Again day 2 was split into streams. The 6 streams on day 2 were: Collaborating to achieve patient safety, Delivering improvement on the frontline, Using research to solve the big challenges, Prioritising safety for vulnerable people, workforce the crucial ingredient for safety and Bridging the gap: Policy and the clinical practice. I attended Leading from the top: New research on trust level leadership under the using research to solve the big challenges stream. I left this session feeling quite negative. The panel presented learning which they felt had happened since the Frances Report. Which seemed to be, in their opinions, very little. They appeared to feel that this was a continuing problem with variability in quality and consistency of leadership practises. I feel (esp. as a current leadership fellow) that the Wales deanery is actively promoting and encouraging learning about clinical leadership. And I would signpost anybody to the FMLM website if they want more information on clinical leadership. https://www.fmlm.ac.uk/
I then attended the LEDER program, http://www.bristol.ac.uk/sps/leder/, focusing on what needs to change for people with a learning disability in order to ensure their safety, under the Prioritising safety for vulnerable people. Again this focused on a patient story presenting the experience of the family of Oliver McGowan. (@PaulaMc007) They are campaigning for mandatory training for healthcare professional in how to adapt for patient with autism and learning difficulties. They want to work on preventing these stories and raise awareness for people to make reasonable adjustments. They encourage communication, an overriding theme from this year, with the patients, and their families as they know the patient best.
Then, before lunch I moved into the Workforce stream to hear from Leigh Kendall (@leighakendall) Again this presentation focused on a patient story presenting Hugo’s story focusing on preventable harm within a maternity setting. Hugo was born after Leigh suffered from HELLP syndrome at 24 week gestation and lived for 35 days. She is working on improving bereavement information and including bereaved families in the quality improvement processes, alongside communication between healthcare professionals. She again encouraged communication and stated something which will stick with me “You can’t upset us anymore because the worst has already happened” Don’t be afraid to speak to bereaved families they can give you vital information and want to have a voice. Mr Edward Morris then presented the work of the Royal College of Obstetricians and Gynaecologists on Each baby counts (@EachBabyCounts) again focusing on patient stories and human factors to encourage a focus on communication and preventing harm. https://www.rcog.org.uk/eachbabycounts
After lunch the conference was again brought back together for keynote sessions. The CQC Chief inspector of Hospitals, Professor Ted Baker, presented an evidence based argument for how Inspections can help us with patient safety. He encouraged us to engage and empower frontline staff to really focus on patient safety and put patients at the centre of what we do. He reminded us to “relentlessly focus on leadership and culture” but also to recognise that healthcare is a high risk area and we have to accept the implications of that fact. He believes that with backing the inspection process can be used to drive forward a culture of patient safety.
The Right Honourable Jeremy Hunt MP was due to present next in his role of Secretary of State for Health and Social care, but as he had been relocated and Matt Hancock (@MattHancock) had been in the job for less than 24 hours Professor Bruce Keogh and Dr Aidan Fowler from 1000 Lives stepped up to be part of a panel for the next steps for patient safety.
The conference closed hearing from a panel about how their organisations overcame safety challenges. The overriding themes were again all about culture, communication and mindset. If you can get this right then you seem to be on the right track!
The Patient Safety Congress was a fantastic, engaging conference and if you get a chance to go I really would. The use of patient stories to focus the attendees was a really useful tool and one which I will take forward with other presentations in the future. It was a really important reminder that we do have the opportunity even as trainees to focus on patient safety and improve outcomes.
Guest Blogger Dr Jordan Evans
N Engl J Med 2018;378:2275-87.
If there’s one thing we all know about manging diabetic ketoacidosis (DKA), it’s the importance of being extremely cautious with fluid management due to the risk of causing iatrogenic cerebral oedema right?...Wrong! Once again, like John Snow, we unfortunately ‘know nothing!’. When will the childhood lies end, Father Christmas isn’t real, the Easter bunny’s not real and now this, the most painful blow yet.
In this PECARN (Pediatric Emergency Care Applied Research Network) study, published in the New England Journal of Medicine, Nathan Kuppermann et al investigated the influence of intravenous fluid administered on the rates of neurological injury in children with DKA.
What was the reason for the study?
Brain injury occurs in the region of 0.5% - 1% of DKA presentations. It presents with sudden neurological deterioration. Patients without a marked neurological deterioration may have more mild neurological impairments e.g. memory / cognitive impairment. As all of us were likely taught, brain injury in DKA has long been thought to be iatrogenic, secondary to fluid administration causing cerebral oedema due to osmotic gradients. The evidence for this school of thought is however lacking and evidence has emerged actively disputing it. Alternative explanations have been proposed that there may be something about being particularly unwell with DKA that leads to the neurological injury, possibly inflammatory or vascular changes. The more unwell the patient is the more likely they are to require fluid resuscitation and therefore an association between severe DKA with brain injury and fluid administration could be mistaken as causation. Remember that association is not proof of causation! Oedema may develop secondary to the brain injury itself as it does in other mechanisms of injury such as trauma.
Where did the study take place?
The study was conducted across 13 centres in the United States.
Who did they include ?
Children aged 0 – 18 years with a diagnosis of DKA (pH < 7.25, glucose > 16.7 mmol/L. Children with GCS <12 were excluded two years into study (due to concerns of treating clinicians).
What did the investigators do?
Children presenting to study centres with DKA were randomly assigned to one of the following four groups;
1) 0.9% saline fast administration
2) 0.9% saline slow administration
3) 0.45% saline fast administration
4) 0.45% saline slow administration
The fast group were given a 20ml/kg bolus which was then followed with replacement of a 10% fluid deficit with the first half of the deficit volume being replaced over 12hrs and the rest over the next 24 hrs.
The slow group were given a 10ml/kg bolus which was then followed by replacement volume for a 5% deficit which was given over 48hrs.
The primary outcome was a decline in mental status (GCS <15 on two occasions within first 24 hours of treatment. Patients and parents were blinded but not the clinician.
Secondary outcomes; clinically apparent brain injury (neurological deterioration leading to clinical decision to treat for raised ICP, intubation or death), short term memory, memory & IQ at 2 months and 6 months.
What were the results?
4912 patients met the inclusion criteria. Due to the complexities of the study of these there were a total of 1389 episodes of DKA included in the study (from 1255 different children). There was a fall in GCS in 3.5% of these epsiodes (48 episodes). There was clinically apparent brain injury in 0.9% (12 episodes). There was no difference between the two groups for any of the outcomes. (Some of the raw results favoured the fast fluid administration group although none of these results reached a statistically significant level).
Kupperman et al. rightly concluded that ‘Neither the rate of administration nor the sodium chloride content of intravenous fluids significantly influenced neurologic outcomes in children with diabetic ketoacidosis’.
Take home message for practice in Wales
1. We no longer need to be as anxious about giving fluid too fast in DKA
2. If you need to give a bolus for shock do so without fear of causing cerebral oedema, this study provides evidence that it’s not harmful.
3. With regards to the fluid deficit replacement although this study shows we could safely give it a little faster stick to current practice of the Wales DKA protocol as it doesn’t show any improvement in outcomes for the faster administration of IV fluids.
4. It’s worth remembering that there is good evidence for using 0.9% saline for maintenance IV fluids in children (to prevent hyponatraemia) so it’s not clear why they chose to have arms in this trial with both 0.9% saline and 0.45% saline.
Guest blogger Dr Sandheeah Ramdeny
Over The Wall, is an amazing activity camp which is free for children, teenagers and family who are living with serious health challenges. It is a national charity which provide support to kids who are faced with seious health challenges through transformational residential camps across the UK. There are different camps which take place at different times of the year some of the camps focused mainly on the kids living with serious health problems some on the siblings and some on the families. These kids who lives with their health problems are mostly affected by their illness and are unable to participate in fun activities normally enjoyed by their friends and peers. Consequently, these kids then have a reduced self-esteem and self-confidence which can negatively impact on their growth and their development.
The main purpose of Over the Wall, is to tackle these issues to allow a transformational change to occur in a safe environment with medical professionals being around to provide the medical care that they need so that the campers return with a new sense of their abilities and ambitions and improved self-confidence.
I choose to take part in the health challenge camp which was mainly focused on the kids with serious health challenges which took place in Strathallan, a really nice boarding school located in Perth, Scotland with breath taking landscapes. The medical team were named the ‘Beach Patrol’, which consisted of 5 paediatric Spr, on GP, one paramedic, two nurses. The camp lasted for a week and the first few days were mainly centred around simulation scenarios to deal with the different cases which could arise whilst in camp as well as becoming familiar with the medical condition of the campers and to learn about their individual management plan. There were around 60 campers with a wide range of medical condition ranging from Type 1 diabetic, ALL, sickle cell disease, cerebral palsy, medical condition requiring bowel washout, Haemophilla, Marfan syndrome, Noonan’s syndrome, DiGeorge syndrome, kids with heart failure, patients on daily chemotherapy. Our normal day would start at 07 30 am in the morning and end around 2230 with 2 of us taking turns to do a night shift to provide cover each night. As the medical team, we were involved in giving the campers their medication before breakfast, during lunch and dinner time and accompanying the campers whilst they were carrying out their activities such as ensuring the young Type 1 diabetic would have their blood sugar level monitored and insulin administered accordingly. Each one of us would be closely attached to a camper who could potentially become sick so that we would be able to keep a close eye on them and we would accompany them to all the activities.
Most of the activities were based on the campus of the boarding school. For instance, each day would have activities planned such as archery, music, drama, swimming, arts and crafts. These activities would be focused to allow them to realise their potential and us trying to make them believe in themselves and go beyond what they can do. The evenings were based mainly on Talent night where the campers would do an interesting act, play, dance or music to demonstrate each of their talent.
There was one day, when the whole team went to Edinburgh to go to the international climbing arena. This was an excellent opportunity to allow campers to reach beyond their capabilities. For instance, on the camper in my group, a lovely 8 year old girl, who was afraid of heights and did not want to attempt any climbing. However, when she saw the other kids having so much fun and me being by her side telling her that I would be here and she could just attempt to climb and that she didn’t have to go too far. She was initially reluctant but the finally agreed. When she started climbing., she realised that she wasn’t scared anymore and was able to climb. When she got down, she was very emotional as she was now able to do something that she could not do. She said that she would never forget this experience.
Some of the statements of the campers from Over The Wall, “It is no exaggeration to say that my experience with OTW was on the best weeks of my life. It Is true what they say.”
To me, I do believe that Over The Wall provides an amazing opportunity to allow seriously ill children to go beyond the boundaries of their illness and have a positive impact for the rest of their life.
For more information go to www.otw.org.uk
NH Gent Belfort Hotel, Ghent, Belgium 22-24th June 2018
Annabel Greenwood ST3 Trainee, Wales Deanery
The 4th INAC was held in the beautiful and charming city of Ghent, Belgium. The INAC was established to provide a global platform for neonatologists and budding-neonatologists across the world to come together and share their work on the recent advances in neonatal medicine.
This year’s meeting was hosted by the Belgian Society of Neonatal Medicine, led by their President, Professor Filip Cools. An exciting programme was awaited, packed full of brilliant talks delivered by highly esteemed neonatologists, and included a showcase of diverse abstracts from all over the world. Delegates attended from over 50 countries across five continents.
The conference itself was perfectly situated, set upon a quaint cobbled street, running alongside the iconic canal that winds its way through the vibrant city.
From a personal perspective, I was extremely excited to present my work on organ donation on an international stage. Organ donation in neonatal medicine remains a fairly new concept, and I felt privileged to have the opportunity to fly the flag for organ donation, raising awareness and sharing my knowledge and experiences with others at such a prestigious event.
I was fortunate enough to be joined by my colleague and friend, Dr Chris Course, on the trip, who was presenting the WREN Project we collaborated on with Dr Zoe Howard, on postnatal antibiotic use across Wales. Our project fitted in perfectly with one of the principal themes of the conference, namely antibiotic stewardship.
There was a particular emphasis on neonatal neurology over the course of the weekend, and it was fascinating to learn of the latest developments in such a complex and challenging field. Professor Jose Honold discussed the concept of a ‘Neuro NICU’, a collaborative approach between neurologists, neonatologists, radiologists, neurosurgeons, neurophysiologists, and specially trained neonatal neurology nurses, using specialised equipment to optimise the management of conditions such as high grade IVH, meningitis and encephalitis, seizures, HIE, and those with congenital cerebral malformations.
Another highlight was learning about the recent advances in neonatal lung ultrasound by Dr Luigi Cattarossi, to help guide the diagnosis and management of a number of lung diseases including RDS, TTN, pneumonia and pneumothoracies. This quick and focused bedside diagnostic approach has been shown to be as reliable as CXR in demonstrating lung pathology, resulting in less exposure to radiation for the neonate.
It was also of great interest to learn about the challenges faced in neonatal medicine in developing countries, and demonstrated the importance of the implementation of simple interventions e.g. bubble CPAP, in making a huge difference in the survival of preterm infants with respiratory distress.
Aside from the conference, there was plenty of time to relax and explore the local delights of Ghent. The city was electric as fans set-up camp in the square to cheer-on their country in the Football World Cup! I certainly enjoyed sampling the local delicacies, Belgian waffles being a particular highlight!
As the weekend drew to a close, I reflected on what had been a truly fantastic conference. The INAC 2018 provided an excellent platform for learning and certainly inspired new project proposals and ideas to take back to Wales! Next year's conference is planned to be in Tijuana, Mexico with a pre-conference in San Diego, so a little further afield, but another couple of top destinations for sure!
Dr Rebecca Broomfield
As a member of PERUKI and a representative for WREN I attended the update day at the RCPCH London office on June 4th 2018.
What is PERUKI?
Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI) brings together clinicians and researchers who share the vision of improving the emergency care of children through high quality multi-centre research.
PERUKI also takes an active role in encouraging and mentoring new investigators in the acquisition of research skills, regarding this as a key area for the sustainability of PEM research going forward
Why is it important?
Paediatric Emergency Medicine,Can strengthen their research activities by working together across the nations. Enabling co-ordination of research activities, and focus on common goals and agendas will help to achieve stronger outcomes.
Large scale robust multi-centre clinical research will be developed and delivered over time, and translation into practice will be achieved throughout the health regions.
Can I become a member?
If you are interested go to the website (http://www.peruki.org/) and complete the sign up form.
What is going on?
So much fantastic research in a variety of states. Some studies have completed recruitment such as the ECLiPSE study (http://www.eclipse-study.org.uk/) which we were involved in at the University Hospital of Wales - I have never been as excited about research as when I managed to randomise the first patient we recruited.
Others are established and ongoing such as the CAP-IT study which we are also involved in recruiting for in Wales. Even more are just about to begin such as the FORCE study on Torus fracture management by Mr Dan Perry (@DanPerry), the NOVEMBR study on the use of non invasive ventilation in Bronchiolitis, Paul Macnamara and the SCIENCE study.
But the day was also to present problems and potential research ideas. Professor Steve Cunningham presented the problems with research into pre-school wheeze and need for clarification of the grey areas between the ages of 2-4 years and the conflicting evidence base which we currently have.
We had a reminder from Dr Tom Waterfield (@DrTomWaterfield) about the importance of establishing the clinical features which make a child with a non-blanching rash and a temperature more likely to have a meningicoccal sepsis than another illness. The rates of meningitis are falling - do we need to act now and progress this research before we miss the opportunity to capture this information. Which features make the child more likely to be unwell and which can differentiate those who are sick with those who are not.
Information was presented on the HEEADSSS tool and discussion led by Dr David James (@DrDaveJames) about the definition of adolescence - should it be defined as the ages 10-24 years? and they would rather be 'young people'. Young people presenting to the emergency department are a big group, and this is increasing. As emergency paediatricians can we do something for this group of the population and should we be. The HEEADSSS tool (Home, Education, Eating, Activities, Drugs, Sexuality, Suicide, Safety) is useful but only if you know what services are available in your area and how to signpost people to them.
Could we also utilize PERUKI to reduce variation in practice? An example discussed on the day was the use of metal detectors for ingested objects. There was no consistency about the level of training which people had to use the equipment as well as the areas of the body which were scanned. Also there was an inconsistency about what people did with the information when they used the equipment.
There was also discussion about findings elsewhere which have not been replicated in the UK data. For example the rotavirus vaccination has been associated with a reduction of seizures elsewhere but the data from the UK does not show this. Why is this? We use a different vaccine could this be the reason or are we not collecting the right data. This demonstrates to me an important feature of research which is to know what is going on and be able to pick up trends in data and potential secondary outcomes which may be unexpected.
Is bright! We've taken a few ideas forward for projects within UHW and I am excited to hear the results of the ECLiPSE study.
If you are interested; become a member, follow the twitter feed and attend an update day for more information. If you have any interest in collaborative working, getting involved in research or providing the best care for your patients I would suggest it's worth a look.
Princess of Wales Hospital, Bridgend, Friday 8thJune 2018
Annabel Greenwood Paediatric ST3 Trainee
Broadly speaking, I feel our exposure to safeguarding training in the early years of paediatric training is limited.
Before you know it, you are the registrar on-call, out of hours, contacted with a complex child protection referral. As a junior paediatric trainee about to transition to middle-grade training, I will inevitably at some point, be faced with this scenario, and if I’m to be completely honest, the thought has previously caused a slight degree of tachycardia, hyperventilation and perspiration on my part, at the uncertainty of such a situation!
I therefore searched for a way to dispel my fears and came across a child protection simulation course set-up by Dr Emily Payne, ST8 Community Paediatric Trainee in Wales. This fantastic one-day, multiagency simulation course has certainly enhanced my confidence in the management of child protection cases and I would certainly recommend the day to my fellow trainees.
The course facilitates approximately 6-10 trainees, a perfect sized group to allow plenty of opportunity to ask questions and share our experiences with each other.
The day began with a couple of short lectures, setting the scene for the day, addressing some key safeguarding principles, including the rights and responsibilities of all doctors, and an outline of the child protection process. We also discussed the ‘ACE’ (Adverse Child Experiences) Study, which has demonstrated that for every 100 adults in Wales, 47 have suffered at least one ACE during their childhood, and 14 people suffered 4 or more events. ACE are stressful experiences occurring during childhood that directly harm a child e.g. sexual, physical or emotional abuse, or effect the environment in which they live e.g. domestic violence, mental health, parental separation. It has been shown that ACE impact across the life course, e.g. affecting neurodevelopment in the early years, potentially causing social, emotional, and cognitive impairment, and perhaps leading to the adoption of high-risk behaviours and crime later on in life.
Later in the morning we divided into pairs for 3 workshop sessions focusing on physical, emotional and sexual abuse respectively. These informal, small-group workshops were based on a clinical scenario and provided an excellent opportunity to voice any queries or concerns we had regarding the different categories of abuse.
In the afternoon, we worked through a number of simulation child protection scenarios with actors playing the role of the child’s parents, making the situation as realistic as possible. At the end of each scenario we re-grouped to provide feedback and discuss the case in more detail. I felt that this was a completely safe environment to practice leading challenging safeguarding scenarios, and found it extremely useful to receive constructive multiagency feedback, from doctors, social workers and the police.
The day was brought to a close with a simulated strategy meeting, and we all played the role of a different member of the multiagency team. This provided a fantastic insight into the role of each member of the team, and demonstrated how everyone works together to collate the evidence in order to generate an accurate account of events, to ensure the safety of the child.
I thoroughly enjoyed the course and feel that I will now make the transition to middle-grade training with enhanced knowledge and confidence to manage challenging safeguarding scenarios.
For further information, please contact Dr Emily Payne on Emily.email@example.com
22nd June 2018, Swansea Marriot Hotel
Gill Smith, ST4 Paediatrics Trainee, Wales Deanery
The spring 2018 WPS meeting was held in a very sunny Swansea. The sun shone down on the beach next to the Marriot hotel which provided a beautiful view during breaks between some excellent presentations and some very thought-provoking talks.
The morning presentations were on very varied and interesting topics, which included audits and quality improvement projects from medical students, paediatric trainees and consultants.
Presentations from neonatology to general paediatrics meant that there was something for everybody. I particularly enjoyed the presentation by the co-host of the WPS meeting, Dr Carol Sullivan who spoke with enthusiasm and wit about writing a student textbook in paediatrics. It looks like it will be a hit. Just before coffee, we were delighted to see Dr Peter Dale adorned in a bright pink wig and pink cape to highlight and talk about the approaching change to the RCPCH curriculum-progress. He went pink for Progress. Details can be found on the RCPCH website. More fantastic presentations ensued after coffee and the morning session was rounded off with a presentation on the problems encountered by babies born in the late pre-term period. Often thought to be close to term that physiologically they would be similar to those babies born at term. Evidence suggests this is not the case and is certainly gave us food for thought prior to lunch.
A brilliant and tasty selection of food was available for lunch, finished by coffee and a chance to chat with the exhibitors. The lunch break was also a great opportunity to pop outside and enjoy the glorious sunshine and beautiful views overlooking the mumbles.
After lunch we were kept from any thoughts of postprandial sleepiness by another set of wonderful and stimulating presentations. The first lecture back, presented by Dr Sheena Durnin was perfectly timed about of the use of paediatric pain relief practices in emergency departments in the UK and Ireland. These practices were evaluated across 40 hospitals in the UK and Ireland. It found a wide variety of practices in terms of analgesia used, timing of analgesia policies, and availability of play specialists to name a few. Dr Durnin earned the award of best presentation. Congratulations!
Next up, another award winning presentation by Dr Rachel Morris who spoke so eloquently and with such passion about the implementation of family integrated care in a tertiary neonatal unit. The results were encouraging in that since the introduction of Family integrated care there had been an increase in breast feeding rates and a reduction in the length of stay and an anecdotal feeling that parents felt more in control and were ready for discharge sooner. Dr Morris won the best trainee award and this was thoroughly deserved.
Following another round of superb presentations, the mid afternoon session was rounded off with an absolute gem of a talk from invited speaker Dr Mark Stacey, consultant anaesthetist and Associate Dean in Cardiff and Vale NHS Trust. The talk entitled ‘A Bakers’ Dozen Resilience Skills’ got us up and thinking. We had to write ourselves thirteen points to aid us in our resilience at work and life and included sleep, meditation and taking care of yourself. Some very important points and recommendations made. This talk left many feeling invigorated and gave us something to talk about during the afternoon tea break over coffee and cake before the late afternoon session.
Fuelled with caffeine and carrot cake we had a further four short quick fire talks and the day was completed with a guest lecture from Dr Michael Farquhar, Consultant Paediatrician in children’s sleep medicine at Evelina Children’s hospital. His talk entitled “Rounded with a sleep: Why We Need To Talk About Fatigue” discussed the importance of sleep and gave a convincing argument for the need for all of us to sleep well. Night shift workers are encouraged to take power naps as this will improve our senses, judgement skills and general wellbeing. This talk went beautifully well with the Resilience talk and is definitely something we should all try and think about. Driving tired can be as bad as if driving after drinking alcohol.
We made our way to the beach to enjoy the rest of the sunshine before a delightful dinner with colleagues and friends. A lovely end to a fantastic day.
Once again the WPS conference was a great success, showing a very talented bunch of people. It was thought-provoking and inspiring and a great way to meet up with colleagues and brilliant guest speakers. I’m off to get some sleep before the winter meeting (I prescribed it to myself)!
Guest post from Dr Laura Potts, Clinical Leadership Fellow, Paediatric Trainee, Wales Deanery
The Medical Women’s Federation (MWF) was founded in 1917. They aim to advance the personal and professional development of women in medicine, to change discriminatory attitudes and practices and to work on behalf of women patients and their families.
This year’s spring conference in Cardiff covered a broad range of topics affecting women from living and working with a disability through to antenatal screening and management of HIV.
The first talk ‘Prenatal testing ; risks or certainty’ was given by Dr Annie Procter, Consultant clinical geneticist. She discussed the evolution of antenatal testing and its future directions. The potential scope of antenatal screening is vast, especially with the introduction of fetal DNA analysis in maternal blood, but routine screening is currently limited to the three major trisomies. This thought provoking talk advised caution; should we test for everything we can, just because we can? It also highlighted the importance of managing families expectations effectively.
Dr Olwen Williams spoke about the progress in HIV and AIDS management in recent years. Huge advance have been made and are now close to enabling affected women to have normal deliveries and breastfeed. Women are however, still presenting with late disease and later in life, with and opportunistic infection and Kaposi sarcoma. She also reinforced the results of the recent PARTNER study which showed that in those with an undetectable viral load, transmission to their partner did not occur. There is a new public health initiative promoting Undetectable = untransmissable.
There were also a number of abstract presentations. Of particular interest was the work being done at Singleton neonatal intensive care unit on family integrated care (FiCare), presented by Dr Rachel Morris (ST5 Paediatric trainee and trainee representative for the MWF in Wales) .
Family integrated care is centred around four main themes – staff education, parent education, creating the right NICU environment and providing psychosocial support. The concept originated in Estonia and was developed by Professor Lee and colleagues in Toronto. It has been shown to reduce length of stay, retinopathy of prematurity and infections and increase breast feeding rates. Singleton have already had a lot of success, receiving excellent feedback from families and demonstrating reduced length of stay and increased breast feeding rates.
During the afternoon there were a number of workshops. I attended Dr Cora Doherty’s session on wellbeing and the healthy team. For optimal team effectiveness and performance mind, body and spirit must be considered, that is to say the team needs a clear vision, good morale and trust and have their physical needs met. The concept of the ‘fitness’ of team members to be part of the team was also considered and how we as team members and leaders have a responsibility to protect our own wellbeing and that of our team.
During the remainder of the afternoon there was an interesting talk titled ‘menopause behind the headlines’. Whilst not particularly relevant to our patients it was a delightful insight into what some of us have to look forward to!
Dr Clarissa Fabre, President elect of the Medical Women’s International Association (MWIA) shared the results of the most recent MWIA members survey. This included some worrying statistics such as 57% of respondents felt that they had been discriminated in their career, with 41% reporting that they had experienced sexual harassment or bullying in relation to their work. Unfortunately younger doctors reported lover job satisfaction, more sexual harassment and bullying and a higher incidence of stress and burnout.
The conference ended with the Dame Hilda Rose lecture, given by Dr Sally Davies, focusing on the importance of stories such as Dr Frances Morgan’s. She was the first woman to receive a doctorate in Medicine in Europe and the first female doctor registered in Wales. She was a pioneer in medical practice and social reform, working all over the world as well as working as a General Practitioner in Wales.
These stories demonstrated how far women have come in achieving gender equality but that there is more work to be done, as highlighted by the recent MWIA survey. The MWF work hard to fight discrimination against women in medicine, for example, challenging Jeremy Hunt on the lack of impact assessment for the new junior doctor contact in England and helping to tackle the gender pay gap. An interesting quote was offered at the end of her talk, ‘good practice benefits all, bad practice affects women more’. I wonder what you all think of this?
The key messages from this lecture and the conference in general were that huge progress has been made by women in medicine and in women’s health and that we all have a responsibility to report and challenge bad practice and behaviour, and make looking after ourselves and each other a priority.
For anyone interested in finding out more about the MWF their website can be found at www.medicalwomensfederation.org.uk
Dr Tim Warlow, Paediatric Palliative Care GRID trainee, Wales Deanery
Few of us can forget recent cases in the press of Alfie Evans and Charlie Gard. Such tragic cases of breakdown in relationship between families and care teams. I’m sure that alongside my own cries you have had the thought ‘Surely things didn’t have to get to this!’ These cases bring into stark clarity the importance of our skills of communication and our ability to put into practice the ethical and legal duties to involve of families and children in decision making. These cases are nightmare scenarios, but at some points in our career we will face similar challenging situations.
Aware of these issues, the All Wales Paediatric Palliative Care Team received £20,000 of Welsh Government funding to improve the skills of paediatricians in these areas. Our response was to organise a series of free workshops exploring issues of ‘communicating difficult news’, decision making and advanced care planning in paediatrics. April 2018 saw the first of these workshops in the fantastic Copthorne Hotel, Culverhouse Cross. Within a month we had filled all our places and the response on the day from delegates was fantastic.
The truly multidisciplinary event was attended by consultants, community nurses, therapists, trainees and hospice staff, all of whom engaged amazingly in communications skills breakout groups and seminars. There was time to explore advanced communication skills, read and use the Paediatric Advanced Care (PAC) Plan, and consider the views of families and young people in planning. The highlight of the day was without a doubt an interview with one of our parents whose son sadly died under the care of our service. She discussed the value of good communication, of doctors being prepared and sensitive, and the benefit of early and co-ordinated planning.
The good news is that there are several further days being organised, one for each of the health boards in Wales. The next of these is in Swansea where Dr Griffiths will be using trained actors to facilitate what will be an exhilarating day of interactive learning together with other professionals. Please contact firstname.lastname@example.org further information about upcoming days and to sign up. All workshops are free of charge and are in great venues with food provided.
If doing a good job of communicating and parallel planning with families excites your interest, these days are for you. If you want to run a mile, these days are even more for you!
Let’s get to grips with the really difficult stuff of paediatrics, lets help families to live well and for those whose lives are cut short, to live well right to the end.
Dr Rebecca Broomfield