In Situ ED, General Surgery & ITU Simulation - Paediatric acute abdomen (in shock)

Learning Objectives

Learning objectives - Non clinical

• Communication skills with both a parent and child
• Crowd control and role allocation when you have a lot of people in a small room

Learning objectives - Clinical (Medical)

• Assessment and management of the shocked child
• Using IO access
• Choice of appropriate imaging
• Appropriate involvement of specialties (local: 2222; SGH: PICU)

Learning objectives - Clinical (Nursing)

• Assisting with IO needle/using IO
• Supporting parent
• SORT calculator and dose calculation

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Faculty - Alex Belcher, Ben Short, Paul Sykes & Ben Atkinson

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RCEM Curriculum Coverage Topics (SLOs)

SLO 2 - Support the ED team by answering clinical questions and making safe decisions
SLO 5 – Care for children of all ages in the ED, at all stages of development and children with complex needs
SLO 6 – Proficiently deliver key procedural skills needed in Emergency Medicine
SLO 7 - Deal with complex and challenging situations in the workplace

FICM Curriculum Coverage Topics (HiLLOs)

HiLLO 5 - Doctors specialising in Intensive Care Medicine can identify, resuscitate and stabilise a critically ill patient, as well as undertake their safe intra-hospital or inter-hospital transfer to an appropriately staffed and equipped facility.

HiLLO 6 - Intensive Care Medicine specialists will have the knowledge and skills to initiate, request and interpret appropriate investigations and advanced monitoring techniques, to aid the diagnosis and management of patients with organ systems failure. They will be able to provide and manage the subsequent advanced organ system support therapies. This will include both pharmacological and mechanical interventions.

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The Case

• 2 year old Cristiano has been ‘not right’ for last 1 day
• Not eating then vomited 2 hours before attendance.
• Clingy and miserable.
• He has been brought in by his Dad (Mum at home with newborn).
• Rapid deterioration with shock, poor access and acute abdomen.
• Focus on gaining access, getting paediatrics, surgery and intensive care involvement.
• Discuss appropriate imaging.

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• Refractory hypotension despite several fluid boluses and antibiotics
• PICU referral made but likely an hour before arrival
• Decision to contact ICU consultant to help with RSI before transfer

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• Decision to start vasopressors before RSI then transfer to PICU

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PICU referral process

• Simulated call made to retrieve the child
• Standard SORT form used (see below) to give information of the referral
• Referral information process can be found here

Take Home Points

• Consider delegating a person to take history/communicate with parent if emergency presentation (so can concentrate on team leading/assessment)
• IO access important skill to utilise, and not to delay use (timely use in this scenario)
• Can utilise 2222 even if not arrested: very useful when need lots of expertise quickly
• Use PICU as central referral point: they can advise and also do any liaison for you

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Latent Threats identified

• Ultrasound machine not charged
• Some equipment not readily available: paediatric HMEF, paediatric capnography line, multi-lumen CVC, paediatric FONA pack
• Phone not in room
• LP box cluttering up airway trolley

Some comments from participant feedback from own reflections:

• To be more familiar with the kit available
• Teamwork. Closed communication. Early escalation
• Prompt decision making and action before decompensation of a patient
• Importance of teamwork and human factors

Suggested improvements from participants:

• More sessions

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Final Year Medical Student Reflection on the Case

During my attachment in the Queen Alexandra Hospital’s Emergency Department, I had the unique opportunity to witness a paediatric simulation. 

Despite not being a direct participant in the simulation, it proved to be an invaluable learning opportunity and a great insight into the ways to continue education once I qualify.

The scenario allowed me to see how the team would handle a child with intussusception. However, a myriad of learning points were gleaned from the session such as:

• The medical management of intussusception/a sick child
• Effective team working and utilising other specialities/members in the MDT for the benefit of the child
• Effective handover 
• Ensuring the relatives of unwell children are informed and reassured
• The equipment needed in an emergency setting and ensuring these are available
• Utilising the SORT tool
• Contacting another hospital for transfer and organising a transfer

It was an extremely conducive learning environment and the organisers ensured the scenario felt as real as possible by displaying observations, making equipment and staff available and allowing those in the scenario to make phone calls in real time.  

Whilst I was given the opportunity to learn by watching the simulation take place, those that took part in organising and doing the simulation were very open to teaching and, during the debrief, answered all my questions about what I had seen or did not understand in an extremely non-judgemental way. The atmosphere in the room meant it was easy to ask questions for my own learning despite being very junior to those involved in the simulation.

It was an incredible experience that came with a great deal of learning. I would encourage any students or visitors to ED to observe these simulations if they get the chance. 

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By Osasere Osayimwen

Final Year Medical Student – University of Southampton

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Faculty Debrief:

• Good to do another paediatric simulation
• Uncertain if not as much ‘buy-in’ to the sim this time: aim to create pre-brief cards to use for those arriving after the start
• Need stickers for future sims but also lanyards for faculty
• Work out how to put the isimulate monitor in place of normal monitors in future

Future sessions:

• Planned next simulation December 2022
• SAU session in New Year