Norwich PEM go to DFTB19: Day 1
Having long abandoned any pretence about being a total paeds/medical education nerd, to say I was excited about the arrival of Don’t Forget the Bubbles 2019 to London was an understatement. After following the previous two conferences on Twitter, I was extremely excited to get to attend, and with a slate of my favourite speakers from the FOAMed scene speaking, it was sure to be a hit. So, here are some highlights from my first day at DFTB19
Morning Keynote:
Mary Freer (@freermary) on The Hard Work of Showing Up. Mary spoke about Ichi-go ichi-e, a Japanese phrase, translated in several ways, but essentially revolving around the idea that individual moments are unrepeatable, and that those moments should be treasured. This provided a good moment of reflection for me. Moments happen hundreds of times a shift. What is insignificant for me, could be one of the most significant moments in the life thus far for a worried parent. “Your baby is fine, there are no signs of sepsis, and we are happy to discharge them”. How many times does that happen a shift for me, and yet for the parents, they’ve spent the last 48 hours with a potentially life-altering diagnosis hanging over their heads. Whilst individually I may not treasure each and every one of those moments, they will likely be treasured by someone, and there needs to be realisation and respect for that.
Shweta Gidwani (@Global_EM) on Changing against the grain. Shweta spoke about her experiences in emergency medicine in India, and the difficulty of working in a specialty that was not even formally recognised until a few years ago. She spoke passionately about those that believed in EM in India, and forged ahead, despite serious barriers, to make their departments exceptional, and how that ethic had impacted on her practice
Kim Holt (@DrKimHolt) on Blowing the Whistle. Kim’s talk centred around Haringey, being brought in post Victoria Climbie, and working in a toxic environment, battling with management and deep seated institutional issues. The fallout from the Baby P case rocked Haringey, and it took a tremendous amount of personal and professional integrity to fight, and to keep fighting the system, not because it was easy, but because it was right, and it was hard. An inspirational talk on not only the impact that bullying from senior figures has on staff on the ground, but also on the culture of a service within the NHS
Walter Eppich (@LearnThruTalk) on Wielding the Reflective Retroscope. An exceptional talk on language and it’s impact on teams’ performances. All centred around a case of a crashing child, Walter spoke about the importance of inclusive leadership, inclusive leader language and team reflection. One thing I will personally take away is the phrase “Am I missing anything here?”. Verbalising your thoughts, making the implicit, explicit in a high stakes environment encourages your team to collaborate and work together significantly more effectively.
1st Breakout:
I opted for “Beedle the Bard’s expert physical examination. In this, Nikki Abela (@NikkiAbela), David Kreiser (@kriesed) and Alun Grayson (@DrAlunGrayson) spoke about getting back to the basics when examining children.
Nikki spoke on examining dehydrated children. Although we all feel very confident about examining for dehydration, our actual ability to spot dehydration based on clinical signs is between 21 and 75%, depending on the paper. So certainly a long shot off where we would want to be. The clinical signs with the highest specificity are respiratory rate, capillary refill time and normal skin turgor, however, their use to rule in dehydration is only about 50%. The take-home message for me was: clinical signs in isolation are extremely poor. Clinical signs with reference to the child as a whole are better, and trust your instinct, as dehydrated children “just have a look about them”.
David talked us through respiratory examination, and his “Look, Listen, Feel” approach to the child with respiratory problems. My lessons were 1) take a second to REALLY look at the child in front of you. Not the monitors, not the staff, but the child. They are telling you almost everything you need to know about themselves, but good observation is needed to understand what they are saying, and 2) it can be easy to explain away grunting, especially in a crying child. Be careful about simply dismissing the noises the child is making as “just crying”
Finally, Alun touched on examining for sepsis. Many excellent tidbits here, but the most striking for me was that everyone will send a child with a viral illness home, that comes back in with sepsis. If you haven’t, you just haven’t examined enough children. For me, this hammered home the importance of a good safety net, and this was repeated in the talk. A repeat attendance isn’t a failure on your part, it’s a success of your safety net, and we need to flip the script on this.
In the second breakout, I opted for the PEM Choose Your Own Adventure. An ambitious project with live polling, dipping into the evidence behind the treatment of bronchiolitis, penetrating trauma, viral induced wheeze, myocarditis and long QT syndrome, the take homes were more than I can put to paper right now, but please visit the Trello link below for full references from the talk.
The final speaker I want to talk about was Simon Carley (@EMManchester). I will openly admit I was extremely excited to hear he was at the conference speaking, having very much enjoyed his views and content on the St Emlyns website over the years. Simon spoke about proceduralism in acute medicine. There were many parts to the talk that I want to write about, but it’s late and I’ve already written more than I was planning, so I’m going to focus on his last point. Mike Tyson said “Everyone’s got a plan until they get punched in the mouth”. Similarly, you need a plan when your procedure/resus gets punched in the mouth. If you feel like you are losing control, think about how to get control of three things: self, team, and environment. Self control can be as simple as a focussed breathing exercise, like square breathing, to bring yourself back to the moment. Team control is all about cognitive offload – when you are overwhelmed with ideas and decisions, offloading some of those tasks/decisions to a team member helps you regain control of that situation. And environmental control is about thinking about people, space, equipment and position. If you have failed a procedure, and your plan for your next attempt is just the same as the first, but with more gusto, then you will likely fail again. Step back and take a second to optimise your environment, and your second attempt is significantly more likely to succeed.
That’s all I’ve got from DFTB Day 1, I hope you’ve enjoyed, and I’m looking forward to Day 2!
For links to papers and other resources from the talks today, please check out the DFTB Day 1 Trello Board set up by Ian Lewins (@IanLewins), the link is here