Thursday, 7 January 2016

The Trouble with Training (Easter egg - when to do a Chest X-ray in children in the ED or General Practice)

I remember well how difficult it is to stay up to date across the thousands of clinical scenarios that face the General Practitioner.  When I was faced by something not in the top 100 weekly problems, I usually had to think back to my training.  That works well as long as what I recalled was accurate, and was best practice at the time and remained so.  What are the chances of all three being true even five years post-training?

Accurate recall (keep taking that thiamine) aside, the first issue is whether one's training involved the demonstration of standard care.  I was recently pulled into a twitter conversation about whether children with pneumonia required a chest X-ray (CXR).  The person facilitating the discussion was one of the local GP trainers who had himself been asked by one of the GP trainees here in Sheffield.  The trainee felt that they were getting mixed messages and wanted to know the right answer.  Of course a complete answer doesn't fit in a tweet.  Also, tweets are transient unless they are the kind that get you fired.  So a GPpaedsTips post seems to me to be the best place for a proper answer.  Since the question was about acute paediatrics, I can legitimately put a foot outside of the Primary Care remit of this site, but it seems the ideal opportunity to also address the question of when a CXR might be indicated for a child in a General Practice setting.

Continuing with the theme of see one do one, lets start with children with pneumonia in a secondary care setting in the UK.  The British Thoracic Society guidelines for community acquired pneumonia in children are, in my opinion, very good.  Their recommendation that "Chest radiography should not be considered a routine investigation in children thought to have community acquired pneumonia" is based on the old principle of 'if it doesn't change your management don't do it.'  Putting that into practice requires a little step back and for us to ask the question, 'what is a CXR for?'  I used to think it was needed to diagnose pneumonia.  That is a fallacy, since X-ray changes will have a time lag and a CXR can be a false negative.  So, is it to show the severity, or what kind of pneumonia it is?  No, the severity is a clinical assessment and the type of chest infection is determined by a combination of the clues in the assessment and the response to treatment.  According to the BTS guidelines, CXR in the ED or paediatric assessment unit should mainly be used for the cases which are a little bit different from the routine LRTI.  This might be repeated LRTI, a child who is severely unwell or a number of other reasons.  That doesn't mean find a reason.  It means find a good reason.  In particular, if you think the child is well enough to treat as an outpatient, BTS recommends never doing a CXR.  Never is a strong word but it's a good place to start and puts the GP CXR question in context.

Adults, with their risk of lung cancer, are different.  In children, signs and symptoms are usually all you need when making decisions about treatment or referral when it comes to children's respiratory problems.  In my opinion, doing a CXR for a child in primary care should be for a situation where the X-ray could give information that allows treatment to be given or a referral to be avoided.  I can't think of any situations where the CXR would do that but a history and examination would not.

I understand that one reason that CXRs are done for children in Primary Care is to reassure parents or clinicians.  I would be very wary of that plan.  CXRs often have findings on them, especially when a child has a viral illness.  A finding is not the same thing as a clinically significant abnormality, but it is not very reassuring either.

Then there is the possibility that a CXR might be done in the belief that one would be done for the same patient in a hospital setting.  That is also tricky since practices change.  The trouble is that they may change slowly and inconsistently.  I believe that the safest approach is to avoid second guessing what tests someone else will want.  I either ask them or leave them to request their own investigations.

So then there is the challenge of being up to date.  I would like to use this opportunity to tell all my secondary care colleagues how stupidly easy we have it in this regard.  The environment we work in continually provides us with updates and learning (if you are surrounded by the kind of clever yet pragmatic clinicians I work with).  I remember how General Practice is a relatively isolated learning environment and how difficult it is to keep abreast of changes in so very many areas.

That's the trouble with training and keeping up to date: these things have the tendency to look fun and manageable but actually have the tendency to expand exponentially and take over.  Meanwhile, we all have a ship to run. The solution: Cling on, outsource your troubles and let FOAMed give you the answers.

Snelson out

Disclaimer: I need reassurance too. I'm just not sure where to find it any more.

BTS guideline for Community Acquired Pneumonia in Children

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