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Rapid Responses: Rapid Responses published:
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Were there any deaths in the series?
- Oliver R Dearlove (10 December 2004)
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Improving the resuscitation of children in mixed Emergency Departments
- Dr Joseph Y S Ting (11 December 2004)
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Oliver R Dearlove, Consultant Anaesthetist Royal Manchester Childrens's Hospital M27 4HA
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I was interested to read the article on paediatric resuscitation Various points arise. I am surprised first, that my comment is the only comment. Sick children are received in most casualties and Emergency departments in the country, with varying paediatric cover. Anaesthetists have shown an unwillingness to attend these cases (1) if they are rusty or do not anaesthetise children regularly for fear of criticism of practising beyond their competences, which the GMC says they must not do. A paediatric resuscitation is therefore a threat to every adult anaesthetist’s licence. The article implies what a bad job even the experts are doing, and focuses on a wholly negative side of resuscitation – what they are doing wrong. The article itself was trailed on the e-cover of the BMJ under a banner: ‘Medication errors during paediatric resuscitation’. I know in modern marketing, there have to be lurid tasters to get doctors to open the cover of publications that are thrust on us as a consequence of our subscription of the BMA. All the “patients” in the study were plastic resusci-babies of the type you see on ER. Therefore the banner is misleading as there were no errors in resuscitation of [sick] children. There were no un-needful deaths, and no litigation and no suspensions – all consequences of botched resuscitation in this age of naming and blaming – and suing. This of course raises issues of relevance of the article in discussing issues that are already current – see above. The doses in paediatric resuscitation are not agreed, or do not stay agreed but vary with time. When Carapiet (2) was testing knowledge in paediatric resuscitation, what was correct in 1992 was wrong and excessive in 1999 by a factor of five. For a further example, atropine has inched out of the algorithms. There was no evidence for its inclusion anyway. When I attended one of my very rare out-of-hospital adult arrests, I pointed this out –just to show that I was hip and up to date in adult things, just in case any interested by-stander challenged me as a paediatric anaesthetist as to when I last resuscitated a 55 year old. I was told by the others “Oh we know all that- everyone still uses it.” The point of this paragraph is that a few years ago, using atropine would have been appropriate and this year it would have counted as a ‘wrong’ drug. Oh Heavens! The wrong drug given at an unsuccessful resuscitation! The lawyers rub their hands with glee at this sort of thing as everyone knows that guidelines change faster than the law. Therefore guidelines would not be incorporated into law: they should stay as guidelines and not become tablets of stone. I note that the weights of the plastic ‘patients’ were announced as part of the resuscitation scenario. This is of course never what one sees in a casualty. No-one comes in, holding a child saying, my child is 11 months and weighs 10 kg. Then the resuscitators were judged according to doses to the given weight. This part was hardly life-like where guessing the weight is part of the resuscitation and in which the Broselow tape can be very useful. Rolfe (2) has published useful information on the “can’t add- can’t prescribe” scenario. They showed what everyone knew, paediatric doses are hard to calculate and need practice. Drugs errors do occur. Their perceived significance when there has been no harm, varies with numerous factors including whether the speaker is trying to get on television again or not. Resuscitation has to be timely in order to be successful. The drugs have to be given quickly and there is as yet no thought or publication on the effect of delay whilst the drugs doses are checked and rechecked –just to be sure – and then certified and signed for. Accountants would call this time-discounting. There is some trade-off between a completely consistent dose against weight in favour of quick resuscitation giving a better outcome. If I were going to be resuscitated which is more than a possibility since I have passed middle age, I would want drugs given in a timely fashion, with someone clearly in charge, using doses the doctor in charge felt I needed, without an impromptu para-medic committee pitching in saying “Golly that’s a bit large – does anyone agree with me? Do you really want it? – it’s not in this year’s algorithm, you know.” Still less would I want someone who had tried hard to get my heart beating again to be told at an inquest what a bad job he had done. By the way, I weigh 100kg. Oliver R Dearlove FRCA Ref. 1 Tomlinson A, Anaesthetists and care of the critically ill child', Anaesthesia 2003; 58: 309-11. 2 Carapiet D Fraser J Wade A Buss PW Bingham R Changes in paediatric resuscitation knowledge among doctors Arch Dis Child 2001 84 412-4 3. Rolfe S Harper N Ability of hospital doctors to calculate drug doses BMJ 1995 310 1173-1174. [Full text] Conflicts of interest – these views are the author’s own. They do not reflect the views of his employer nor of the Council of the Royal College of Anaesthetists. Competing interests: as script |
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Dr Joseph Y S Ting, Staff Specialist Emergency Physician Mater Public Hospitals, Raymond Tce, South Brisbane 4101, Australia
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Dear Sir, That medication dosing and administration errors occur relatively frequently during paediatric resuscitation even when led by highly trained and/or senior clinicians in tertiary paediatric emergency medicine centres1 is concerning. Although I was unable to find published evidence for this, I suspect that clinicians in mixed (adult and paediatric) Emergency Departments are likely to fare worse in such a study due to fewer occurrences of, and therefore less familiarity with, paediatric resuscitation. This is an important issue as not all children who require resuscitation have access to paediatric emergency medicine and critical care services at tertiary level such as that was studied, 1 at least during the initial stabilisation phase. The level of care in mixed Emergency Departments is likely to improve with increased uptake by health care workers looking after children of paediatric life support courses, although skills and knowledge maintenance may degrade over time.2 Pre-hospital emergency practitioners3 and junior medical staff 4 may not be as well trained as medical and nursing staff at tertiary paediatric emergency centres in the initial management of critically unwell children, and therefore be more prone to making errors (including that of clinical judgement rather than just drug dosing or administration) during paediatric resuscitation. This has implications for the resuscitative care of children in isolated communities facing prolonged transport times to hospitals and smaller communities who have access to only junior doctors. The feasibility of regular paediatric mock code practice may be less practicable and effective in these settings than having staff members attend Advanced Paediatric Life Support courses, 5 including refresher courses. References: 1. Kozer E, Seto W, Verjee Z, et al. Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department. BMJ 2004; 329:1321-5. 2. Durojaiye L, O’Meara M. Improvement in resuscitation knowledge after a one-day paediatric life support course. J Paediatr Child Health 2002; 38: 241-5. 3. Gaffney P, Johnson G. Paediatric prehospital care: postal survey of paramedic training managers. Arch Dis Child 2001; 84: 82-3. 4. Tuthill DP, Hewson M, Wilson R. Paediatric resuscitation-by phone. J Paediatr Child Health 1998; 34: 524-7. 5. Phillips BM, Mackway-Jones K, Jewkes F. The European Resuscitation Council's paediatric life support course 'Advanced Paediatric Life Support'. Resuscitation 2000; 47: 329-34 Competing interests: None declared |
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