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News: 10 ‘Out-of-the-Box’ Lessons for Pediatric Emergency Physicians

Saptharishi, Lalgudi Ganesan MD, DM

doi: 10.1097/01.EEM.0000450247.96357.0d

Dr. Saptharishi is a senior pediatric critical care resident pediatric critical care at the Post-Graduate Institute of Medical Education & Research in Chandigarh, India.



The task of guiding and educating junior and senior residents in pediatric emergency medicine became a welcome addition to my job as I began my training in pediatric critical care at one of Asia's most respected pediatric hospitals. Being able to do that required a conceptual understanding of the principles that guide this relatively fledgling specialty. The following 10 lessons are just the tip of the iceberg, but sometimes seeing the tip is all that is required to avert a catastrophe.

  1. Time is gold. Don't waste time on a child with complete severe upper airway obstruction/status epilepticus. Each minute in the ED is a life saved.
  2. Assuring ABCs is worth a million dollars. Nothing else matters besides airway, breathing, and circulation in the ED. This is not to underplay the importance of other aspects of emergency care, but it is always airway and breathing first in children.
  3. Children are not small adults. Let us not even dream of directly extrapolating adult management protocols to the pediatric emergency. Most centers worldwide have been burned on this.
  4. Lack of evidence for an emergency intervention does not equate to lack of clinical efficacy. You cannot do a randomized controlled trial on many aspects; sometimes it may not be ethically justified. But you cannot wait till one appears in print in certain areas. In others, the numbers to achieve statistical significance may be so huge that it becomes practically impossible. Similarly, all published studies with huge effect sizes may not translate into results in the settings in which you work. Check the applicability before you put something into practice.
  5. Newer, fancier therapies keep coming out, but unless they stand the test of time, they should not figure in your protocol. It takes years for a new intervention to become standard of care. Remember the hew and cry about activated protein C at its launch? Everyone prescribed it until it became evident that it does not work and, in fact, never worked.
  6. Do not get so close to the trees that you lose sight of the forest. You may be torn in 10 different directions with each problem taking you along a new path, but it is important to come back to your diagnosis every single time to see how the problem fits in context. Chasing individual problems and ignoring the bigger picture is often the difference between a novice and a pro.
  7. There is no place for dogmatic and emphatic thinking in emergency medicine. Though history and clinical findings drive the majority of treatment, pediatric emergency is full of surprises. Every now and then, a child stumps even the brightest of emergency physicians. Never hesitate to take help from colleagues of other specialties.
  8. It has never been about one magic bullet. It is usually a set of interventions that work when applied together. Checklists in every aspect of pediatric emergency care should be the future.
  9. The time of the “one-man army” is long obsolete. Despite all theoretical expertise (knowledge and skills), success would be a distant dream without effective team dynamics and good communication among emergency care providers. A combination of good management principles and adequate motivation among staff would translate to exponentially better patient outcomes.
  10. Bridge the gap. The numbers are clearly out there. Any effort toward improvement of pediatric emergency medicine outcomes must focus on the lesser-developed regions of the world for it to be truly meaningful. A situation where a few irreversibly ill children are kept alive on highly advanced life support measures is in stark contrast to situations where millions still die of pneumonia and diarrhea for lack of adequate emergency care and stabilization. Unless this gap is bridged, any further progress would remain lopsided.

These lessons are applicable well beyond the realms of pediatric emergency and critical care medicine. An understanding of these principles can help us remain focused on saving the lives of our smallest patients.

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