Thursday, 9 April 2020

COVID Questions No 5 - How can I help? (Introducing the Zombie Apocalist)

As we enter the depths of the COVID-19 pandemic, most of us are asking, "How can I help?"  Regardless of our trepidation, we recognise the gravity of the situation.  I myself anticipate that over the next few weeks and months, my personal and professional comfort zones will be most likely obliterated.  I cannot expect things to be business as usual.

However, this crisis also presents a unique opportunity for front line clinicians.  We have an urgent need to be pragmatic in our practices.  This need is driven by several factors.
In Paediatric Emergency Medicine, many of us are looking at ways that we can safely achieve a more pragmatic approach to a variety of situations for the benefit of staff, children and their families.  Because COVID-19 has dramatically changed the risk/ benefit analysis for what we do, it is an opportunity to consider what is low risk and low benefit in our usual practice, and find ways of reducing the times when we might previously have observed, investigated or referred.

As it happens, I have had an opportunity to explore this question prior to the COVID-19 pandemic.  I do a great deal of face-to-face education with a variety of clinicians who work in primary care and emergency or acute paediatrics.  In those sessions, I often hear that there is a great deal of variation in practice for certain clinical scenarios.  The clinicians involved make different decisions based on their experience, confidence and the environment in which they work.  It is inevitable for example that a GP working in a remote setting is going to have a different view about referring a patient than someone who sees a similar patient in a city with easy access to a secondary care setting.

As a way of exploring the fringes of clinical practice, I sometimes ask the zombie apocalypse question.  It goes like this: You've just said that you would normally refer this child for a secondary care review.  Now imagine that something has happened that means that there is a risk to the patient from going for that assessment (e.g. zombie apocalypse).  Would you still ask for that further assessment or would you feel that it is safer for the patient to be managed outside of hospital?

Whenever the answer is no, the condition goes on a list of things that need referral no matter what.  In such cases, (e.g suspected meningitis) we are saying that there is a clear need for that referral.  If the answer is that we felt that the change in the risk/ benefit analysis would lead us to a different decision, the condition goes on the zombie apocalist.

Here's a list of the things that commonly end up on the zombie apocalypse list, based on the consensus of the clinicians at various educational events. (Note: all are specific to patients who are children or young people)
[For more detail on the safe assessment and management of each scenario, click on the problem for the link.  If there is no link yet, it will be covered in a post in the near future.]

There are a number of reasons why people are referring or otherwise taking an over-cautious approach to these situations
In each of the situations on the above list, the question that we should ask is, "What will observation, referral or investigation add?"  If any of these actions is primarily intended to add a sense of reassurance for the clinician, we should question that practice in the light of COVID-19 risk.  When I say we, I mean both primary and secondary care clinicians.  If over-caution exists, it can only do so due to a lack of functional teamworking between primary and secondary care.

So when we're asking how can we help with the current crisis, it may not be a case of re-deployment but of adaptation.  One change that could have a significant impact is a renaissance of pragmatism.

My next task is to give a bit more flesh to the pragmatic approach to each of those clinical scenarios.  The posts about each will follow over the next few weeks.  I hope you find them useful in removing the reasons for possible over-caution listed above.  Alternatively, they may simply validate what you are already doing or have always wanted to do but didn't know that it was acceptable practice.

In the meantime, all of the potential drivers of over-caution can also be remedied by a case discussion with an experienced paediatrician.  You should find that your secondary care colleagues welcome the opportunity to allow you to safely manage these scenarios in a pre-hospital setting where appropriate.

Edward Snelson