Paediatrics - better communication in emergencies

Dr A is a consultant in paediatrics, working in the emergency department of a teaching hospital. Here he reflects on the need for better communication in emergency situations.

What's the issue you reflected on?

Tell us about an incident/situation/feeling that gave you cause for reflection

A 4 year old child with established epilepsy came to A&E following a prolonged seizure and was admitted to the paediatric ICU following a respiratory arrest. I was the consultant on call that weekend and arrived in A&E about mid-way between the child’s arrival in A&E and their respiratory arrest.

What made you stop and think?

It became apparent later that they had received 4 doses of benzodiazepines prior to a loading dose of intravenous phenytoin, the latter of which quickly stopped their seizure. It also transpired that one of these benzodiazepine doses had been doubled in error. In the melee of the situation neither I, nor anybody else, had fully appreciated how many doses of benzodiazepine they had already received until after their respiratory arrest.

It was later agreed that the likely cause of their respiratory arrest was secondary to the number of doses of benzodiazepine they had received across a number of settings: at home from the family, in the ambulance from paramedics, in A&E from casualty doctors and nurses and again in A&E from attending paediatricians.

They needed a short period of intubation and ventilation but fortunately made a full recovery.

There are many ways to reflect - how did you do it?

I discussed this with colleagues in A&E and in my paediatric unit.

I reviewed the literature on the management of status epilepticus independently.

What did you do?

I flagged this as a “near miss” incident in our hospital safety system.

I reviewed the latest literature on the management of convulsive status epilepticus. I ran an update on the status epilepticus protocol for the junior staff in my own paediatric department and A&E, emphasising the correct doses, pathways of medication use and the importance of a timeline.

I asked my nurse colleagues to review the “emergency care protocol” for all children with epilepsy on emergency buccal midazolam so that it was clear how many doses of benzodiazepine their child could have. Families were asked to give a copy of this protocol to the ambulance crew should this be necessary.

We reviewed the communication pathway, how information is gathered on medication and recorded in an acute paediatric “resus” setting.

Tell us what you took away or learned from this experience?

I could have made more stringent enquiries about the number of doses and quantity of doses of benzodiazepine he had already received when I arrived in A&E myself.

This emphasised the importance of team work in this acute setting.

It also emphasised the importance of good communication between parents, ambulance staff, A&E clinicians and paediatricians in an acute, high pressure situation.

How did it change your thinking or practice?

I also took away the importance of good communication. Asking the right questions in the “heat of the moment”. Ensuring my team knows about the appropriate management of status epilepticus.

What have been the effects of your changes?

Has it improved your practice and outcomes?

Over the next 6 months, we will audit the number of doses of benzodiazepines a child receives from community through to hospital should a child be admitted with a prolonged epileptic seizure.

I will consider running some simulation exercises with my colleagues to test how well our status epilepticus protocol works in our hospital. This will test knowledge of the team within my unit – and also be a learning exercise for myself.

Top tips

What top tips would you give to doctors in your specialty about how to get the most from reflection or thinking constructively about a particular problem?

  • Put aside time to reflect. Record it as something you need to address and remember to complete your reflective notes when this is finished.
  • Discuss the situation with your colleagues.
  • Look at the literature and any clinical guidance to further inform you. Reflect on how your team functions in addressing a problem.
  • Act on what you have learned.
  • Communicate what you have learned with your colleagues.