☎️ “2-year-old, blue lips and reduced conscious level but still breathing.”

HR 90 bpm, RR 5 bpm, Sats 84% in air, CRT <2 seconds, Temp 37.4°C, BP 90/67 mmHg, GCS E2, V2, M4 = 8/15, AVPU P (responsive to pain).

It was a cold winters morning and a sluggish start to another shift in the Paediatric ED, so we pull the BUZZER ALARM in cubicle 10. Time for an in situ sim to warm everybody up!

The Scenario

The staff rush in: two doctors & two nurses. The team snaps into action, one doctor begins an ABC assessment, another assumes team leadership, the nurses are applying monitoring and one speaks with what turns out to be the babysitter.

Such situations are very disorientating. This is (1) an unexpected emergency, (2) in an unexpected clinical area and (3) with staff who have barely warmed up into their shift. It is easy to feel a degree of brain fog (speaking personally). However, for the benefit of this simulated patient, the mist quickly cleared…

The team quickly recognise they are dealing with a 2-year-old male with a decreased conscious level. They apply oxygen and provide bag mask ventilation effectively. The cyanosis abates and the chest rises nicely. Then, in a moment of clairvoyance, the leader considers this could be a poisoning. A child who has no signs of illness, no signs of injury and no prior history. A child who is cardiovascularly stable but with slow shallow breathing and pinpoint pupils.

Of course, rather than being clairvoyant, my esteemed colleague had a gut feeling. On speaking to the babysitter she breaks down in tears saying she is a methadone user and thinks the toddler might have gotten to her pills when she was distracted.

The team takes off the trolley brake and rushes this toddler to the high-dependency bay. Here, with ABC stabilised (albeit temporarily with effective bag mask ventilation and now also a Guedel airway), help is called for and intravenous access is sought. Bloods are sent. Naloxone is prescribed. But after 15 minutes their time is up…

The Debrief

After apologising to the team for their rude awakening and providing promises of coffee – we debrief. Learning points discussed and later considered are as follows…

How to maintain performance when you’re not at your physical best?

1) Recognise your fatigue

Tired? Thirsty? Hungry? Not at your best? Simply recognising this is an essential first step.

2) Maximise your resources

Call for help: easily said, always known, but not always done. “A problem shared is a problem halved.”

Use teamwork: with or without additional help you and your team work better together. Be efficient with role allocation. Be specific with task requests. Be concise with communication.

Bulletin of The Royal College of Anaesthetists (2008)

The ’10-seconds-for-10 minutes’ principle is a good example, where every 10 minutes at least 10 seconds is spent re-orientating the team and vocalising where the resuscitation is at and where it is going. This helps focus minds, helps reduce stress and helps coordinate care.

Move your patient? Consider your setting and equipment. “Is it easier to move your patient to a higher resource area or to bring the resources to you?”

3) Minimise your demands

Avoid overload: “Get the crash trolley, size the Guedel, provide bag and mask ventilation, get intravenous access, call for the anaesthetist, prepare for intubation”.

Listing tasks can be helpful to vocalise but beware of disorientating your team, overloading an individual and losing focus. Prioritise tasks, chunk up the workload, take one step at a time. “Ok, I’ve got the airway… now I’m team leader, we need to…”

Some people can multitask. Some people can manage the airway and team lead. Personally, I wouldn’t recommend it if alternative team setups are possible. Respect that each task, however automatic, and each role, however experienced, is demanding. Where possible share and delegate. You don’t and shouldn’t have to do everything.

Ensure offload: there are many strategies for cognitively offloading in difficult circumstances. For a sample please see the following excellent infographic.

4) Recharge

As soon as possible recharge. Take 5 minutes before your next patient. Get that toilet break. Get that cup of water. Plan your rest break. So when the next case comes in your neurons are cared for and your reflexes are sharper. Leave bravado at the door.

How to assess a child’s conscious level?

I’ll make this one short, use AVPU. It provides a rough guide to GCS but crucially provides you immediate easy to understand information that guides management. By all means, use the paediatric amended system for GCS, but if you’re like me “keeping it simple stupid” is often best…

RCPCH Decreased Conscious Level pathway poster (2015)

How to assess a child with decreased conscious level?

A decreased conscious level is a neurological emergency mandating a rapid and methodical approach to evaluation and treatment. Here, ABCDE is as ever the solid starting point. But for a more thorough in depth approach see below…

A rough but helpful comparison of the two scores is as follows (NB: from adult studies) where median GCS scores of 15, 13, 8 and 3 corresponded to A V P and U respectively. Remember, if a child is only responsive to pain or worse yet unresponsive begin preparations for intubation as your plan B if not your plan A.