The Procedure Paradox
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A 14-year-old boy fell from a height and was brought to the emergency room with a Glasgow Coma Scale of 14, no IV access, and possible pneumothorax and abdominal injuries. The document discusses how medical procedures like ketamine, cannulation, chest drains, and thoracotomy would be perceived differently by the patient, children, and parents, ranging from "awesome" to "dead/nearly dead." It also reflects on maintaining honorable intentions, the challenges of emergency medicine work, and finding balance between self-care, teamwork, and caring for the environment.
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The Procedure Paradox
- 1. How it felt Simon Carley @EMManchester
- 3. 14 yo Fall from height GCS 14 No IV access Possible Pneumothorax Abdominal injury
- 5. excitement
- 7. Intervention Me Children Parents/Carers Distraction Bubbles :-) Bubbles :-) Bubbles :-) Ketamine Awesome Wheeeeee Trippy Pulled Elbow Watch how cool this is Ow, but thanks! Wow! Cannulation I’m good at this NEEDLES!!!!!!! PLEASE get it in 1st time Chest drains Love them Aaaaaaargh!!!! OMG Thoracotomy I am the Resurrection Dead/Nearly dead. No words
- 8. Intervention Me Children Parents/Carers Distraction Bubbles :-) Bubbles :-) Bubbles :-) Ketamine Awesome Wheeeeee Trippy Pulled Elbow Watch how cool this is Ow, but thanks! Wow! Cannulation I’m good at this NEEDLES!!!!!!! PLEASE get it in 1st time Chest drains Love them Aaaaaaargh!!!! OMG Thoracotomy I am the Resurrection Dead/Nearly dead. No words
- 9. Intervention Me Children Parents/Carers Distraction Bubbles :-) Bubbles :-) Bubbles :-) Ketamine Awesome Wheeeeee Trippy Pulled Elbow Watch how cool this is Ow, but thanks! Wow! Cannulation I’m good at this NEEDLES!!!!!!! PLEASE get it in 1st time Chest drains Love them Aaaaaaargh!!!! OMG Thoracotomy I am the Resurrection Dead/Nearly dead. No words
- 10. Intervention Me Children Parents/Carers Distraction Bubbles :-) Bubbles :-) Bubbles :-) Ketamine Awesome Wheeeeee Trippy Pulled Elbow Watch how cool this is Ow, but thanks! Wow! Cannulation I’m good at this NEEDLES!!!!!!! PLEASE get it in 1st time Chest drains Love them Aaaaaaargh!!!! OMG Thoracotomy I am the Resurrection Dead/Nearly dead. No words
- 11. 2
- 12. 2 Need
- 13. 2 Want Need
- 16. It’s not going well
- 17. a
- 29. Final thoughts
Notas do Editor
- Thanks This is a talk about procedures from the perspective of the operator. Over the next 20 mins I want to challenge you about some of the ways we think about procedures and perhaps ask us to reflect on what it feels like to do some of the things that we do, and what the impact of the interaction of those feelings and the procedure. Both on ourselves and those around us. As you may or may not know, I am an emergency physician working in Manchester which is roughly about 200 miles NW of where we are right now. I work in both adult and children’s emergency departments which are separated by a distance of about 250m in one of the largest hospitals and trauma centres in Europe. the reason I tell you this is that much of what I am talking about is based on my experiences of working in EM/PEM and although I think they are relevant to all the sub specialities of paediatrics and critical care it’s important that you interpret this conversation through the lens of your own practice.
- So let’s start with a case, but before that, let’s just take a quick safety check and ask that for the next 20 mins we are are going to ask ourselves some tricky questions and that we are in a safe space to do so. I want us to go into this in the knowledge that we are good people, the people around us are good people and that we are all working in the best interests of children, their families and the societies that we work in. Regardless if what we discuss and whatever we think, hold onto that thought and use it as an anchor point. Anyway. It’s a quiet shift in the PED and you’re managing to talk through a few cases and do a bit of just in time education when the standby phone goes off. You are notified that there is a 14 year old boy coming to the ED. It’s a trauma call. He has been stabbed in the left chest and abdomen. He has a suspected left sided PTX and may be bleeding into the torso. A- patent B-RR 24 SaO2 94% on high flow O2 C- P 141 BP105/60 D- AVPU pupils normal E- BG normal 2 stab wounds. One in ant ax line 5ICS, one left upper quadrant. No external bleeding. IV access has not been obtained despite 3 attempts. No fluids have been given. 5 minutes And……..pause. Close your eyes and imagine that this is you. The nurse in charge puts down the phone, turns to those assembled around the standby phone and says put the trauma team call out, sounds like this one’s probably need an IO, blood, lines and a chest drain. Let’s get prepped. Put yourself in that room or another similar environment and think about that moment. Close your eyes and imagine yourself there and then ask yourself what do I feel.
- So let’s start with a case, but before that, let’s just take a quick safety check and ask that for the next 20 mins we are are going to ask ourselves some tricky questions and that we are in a safe space to do so. I want us to go into this in the knowledge that we are good people, the people around us are good people and that we are all working in the best interests of children, their families and the societies that we work in. Regardless if what we discuss and whatever we think, hold onto that thought and use it as an anchor point. Anyway. It’s a quiet shift in the PED and you’re managing to talk through a few cases and do a bit of just in time education when the standby phone goes off. You are notified that there is a 14 year old boy coming to the ED. It’s a trauma call. He has been stabbed in the left chest and abdomen. He has a suspected left sided PTX and may be bleeding into the torso. A- patent B-RR 24 SaO2 94% on high flow O2 C- P 141 BP105/60 D- AVPU pupils normal E- BG normal 2 stab wounds. One in ant ax line 5ICS, one left upper quadrant. No external bleeding. IV access has not been obtained despite 3 attempts. No fluids have been given. 5 minutes And……..pause. Close your eyes and imagine that this is you. The nurse in charge puts down the phone, turns to those assembled around the standby phone and says put the trauma team call out, sounds like this one’s probably need an IO, blood, lines and a chest drain. Let’s get prepped. Put yourself in that room or another similar environment and think about that moment. Close your eyes and imagine yourself there and then ask yourself what do I feel.
- If you like you can tell the person next to you what immediately came to mind in that moment. Depending on your past experiences, profession and training there will of course be differences, but I put it to you the amongst us here, and within ourselves even there is a mix here. So there will be a mix. Some of you will be scared, terrified even (and perhaps you should be). Some of you here will straight into planning and prep mode. Cold thinkers like Spock, anticipating every possible angle as you visualise what is about to come. But let’s be honest here, some of you here will be excited, thrilled, aroused even in the anticipation of seeing something cool. And perhaps even doing something cool. I know this for lots of reasons. When the standby phone goes off in the department people area attracted to it like some sort of honeypot of resuscitation. Model of call coming through - 86 year old red flag sepsis Model of call coming through - 14 year old fall from height, head and neck injuries ? abdominal bleed. Admit that these stories induce different feelings in yourself and that for at least some of you here it will be a frisson of excitement. You;reabot to get your hit in your addicted state. Maybe that child does come in. Maybe they do need the IO placed and you get to do it. You’ve practiced a few times and you get your chance and it goes in. Awesome! You’re so pleased with yourself. You get your WPBA signed off and high five your colleague on the way out. That night, you tell your partner about the day and how you managed to help in the resuscitation of a critically injured patient. You feel great There is only one problem. Daniel dies two days later. His family is devastated and never really recover. A year down the line his parents have split up on the background of mental health issues and his younger sister is falling behind at school. The family is a mess and never recover after that awful day when Daniel fell from the tree. On the other hand we got to do the IO!!!
- Restraining children To provide treatment for children, it is sometimes necessary to restrain them. How can this be done lawfully? Restraint In all cases, it must be noted that restraint must be necessary. Restraint merely for the convenience of the clinician is unjustifiable; it must be used only where it is necessary to allow clinical management to be provided. Furthermore, the least intrusive type and minimum amount of restraint to achieve the specific treatment must be employed; the minimum amount of force for the shortest possible time. Finally, the least restrictive option should be used. If a simple splint allowing intermittent access to a cannula will suffice, then this will avoid parents and clinicians holding the struggling child down periodically for the same purpose. In England and Wales, you become an adult on your 18th birthday. Children who are 16 and 17 years are considered as ‘young people’, and this distinction is important, since young people are covered by the Mental Capacity Act 2005 (MCA), and this gives guidance on restraint. Restraint of young people lacking capacity must therefore be necessary, proportionate and using the least restrictive measure, as set out in the paragraph above. Restraint of young people with capacity will be a rare event, and if at all possible should be agreed to by their parents. Unlike adults, young people do not have an unfettered right to refuse treatment which is necessary to save their lives. We know this because no English court has permitted a young person to choose to die rather than accept life-saving treatment. On the other hand, young people refuse treatment for non-life threatening illness on a regular basis in the NHS. For this reason, unless restraint is immediately necessary to prevent the patient’s death or permanent harm, it should not be employed to allow treatment. Nevertheless, it is completely acceptable to restrain a young person who is at risk of causing himself, clinical staff or bystanders a new injury by his behaviour. As before, restraint in these circumstances should be necessary, proportionate and using the least restrictive measure. Children younger than 16, to whom the MCA does not apply, are divided into those who have capacity and those who do not. It is the latter group that is most easily dealt with, since parents provide consent for (and usually assistance to) restraining small children for the administration of medicines; for physiotherapy; for injections and cannulas. Equally parents provide consent for their child to be restrained for similar procedures even in their absence, although to do so is undesirable and should be avoided if possible, since the child needs the support of her parents’ presence. In the same way, parents provide consent for an anaesthetic to permit imaging in a motionless child. Clearly, restraint in the absence of parents remains permissible if unavoidably necessary for the immediate welfare of the child. Older children under 16 who have demonstrated their capacity may still require restraint at times. This is a more difficult situation, since their capacity to make a decision when calm may evaporate due to the coercive effects of fear or distress. In this situation, provided parents remain willing to provide consent for the envisaged procedure, restraining their child remains lawful. However, if you encounter a child who retains their capacity and refuses treatment, what happens next will depend on the circumstances. Only if the proposed procedure is immediately necessary to save life or limb will restraint of the competent refusing child be the correct approach. The vast majority of children in such an extreme clinical state will lack the capacity to make decisions, let alone be in a state to resist the intervention. If you encounter a child who continues their competent resistance to life or limb saving treatment in a dire emergency, bear in mind the presumption that life is preferable to death; restrain and treat them. As with the slightly older group, it is completely acceptable to restrain a competent child who is at risk of causing himself, clinical staff or bystanders injury by his behaviour. Again, restraint in these circumstances should be necessary, proportionate and using the least restrictive measure. A child of any age detained under the Mental Health Act 1983 (MHA) may be restrained on the basis of this act to enable treatment for their mental illness to be given. Interestingly, s63 of the act allows us without consent to treat physical manifestations of mental illness in a detained patient, so self inflicted wounds can be sutured; and the immediate steps for liver protection taken after a paracetamol overdose. Otherwise, restraint for treatment of coincidental physical ailments in patients is dealt with as above, according to their age group. Compulsory detention For children needing inpatient treatment under the MHA, their detention in hospital can also be authorised by this act. There is evidence from the European Court of Human Rights that parents may be able to consent to the deprivation of liberty of a competent child with mental illness, providing they are acting responsibly and in good faith on the basis of expert medical advice. This will need to be tested in English courts before we can be certain it will be accepted. The Deprivation of Liberty Safeguards (DOLS) used for adults who lack capacity may not be used to detain either children or young people in hospital. The Court of Protection would need to authorise the compulsory detention in hospital of a child who lacked capacity but who was not detained under the MHA. In the meantime, the High Court could authorise the detention of a competent child, in the absence of detention under the MHA. Robert Wheeler Department of Clinical Law
- So let’s take a moment to think about perspectives here.
- So let’s take a moment to think about perspectives here.
- So let’s take a moment to think about perspectives here.
- So let’s take a moment to think about perspectives here.
- Everybody has a plan until they get punched in the face.
- Cognitive offload
- Offload decision points and hard points to others. Mention loss of situational awareness
- Equipment Space Access Facilitate change of approach
- This was about feelings and procedures At the heart of what we do there is a tension and perhaps a paradox in our approach to procedures. That’s something we come to live with over time, but we should never forget the profound impact procedures have on children, families and staff. Despite the paradox we do need to perform procedures and for most of us this will be a positive experience, right up until the point where it goes wrong. We are often time pressured and in public view which adds to the stress. It’s easy to lose focus and situational awareness in those circumstances and so it’s important that we maintain control of self, team, environment to get ourselves back on track . Finally we’ve thought about whether there really is a paradox and whether we really are awful people that enjoy doing things to people that might be painful, uncomfortable and on some occasions even dangerous. What do I think? Yes - you’re a bit weird, but if my children are sick or injured I hope that they are treated by a weirdo like you, like me, like us who is trained, interested and enthusiastic enough to get the job done well.