(upbeat music) - Well, hi everyone, welcome back to Clinical Conversations, the podcast for Paramedics and really anyone involved in out of hospital care that is critical, urgent, or unplanned. It's produced by the ambulance Victoria Office of the Medical Director. I'm James Oswald, I'm a Paramedic and a Clinical Practice Guideline Specialist here at AV. - And I'm David Anderson, AV's Medical Director. - Well, David, 10 years ago, 10 or 15 years ago, I suppose, if I wanted to speak to a more senior paramedic doctor, a specialist in some area, outside of a couple of niche applications, we didn't really have the systems to do that, but probably more importantly, if you'd put that question to me, what if you wanna ask a second opinion, I would have probably said, why would I want to? It's my job to make clinical decisions, and if I can't do that, then I need to study more, I need to train more, I need to reflect more, but outsourcing clinical decisions, I mean, isn't that a sign of a bad paramedic? I probably would have said those very words. 10, 15 years have gone by now, and my tell-of-health and remote consultation have absolutely changed the way that we do things. Of course, listeners will know that the COVID-19 pandemic was a major catalyst for that change. And today, we've got a really quite amazing range of capabilities compared to 15 years ago. So the technical side is now no longer really a major barrier to asking for help. But I wonder if people still feel a bit like I did 15 years ago, deep down are we still resisting the idea of consultation? - I think we are, and I think we need to collectively just get over it. Paramedics are our journalists, by the very nature of paramedic, and we are generalist healthcare providers. We have an area of a niche area of clinical expertise that no one else has, which is the assessment management and transport of patients. And I know there's a bit of a professional push towards paramedics being separated from ambulances, which is entirely appropriate, but at the end of the day, that is our thing. If you're a paramedic who chooses to work for a jurisdictional ambulance service. I am also a generalist as an intensive care physician. I have, there are things that I know that other people don't know as much about, like ventilators, but most of what I do is generalist medicine. And that means every day in my clinical practice, I consult widely, and that is just a normal part of practicing as a generalist healthcare professional, whether you're a doctor, a nurse, a paramedic, a physio, whatever. Knowing the limits of your knowledge and your understanding, and knowing when to call on specialist expertise is an important ability for a paramedic. And you, I think, appropriately reflected on a journey that a lot of us have gone through about, you know, if I don't know the answer to this question, that means I need to find out so that I don't need to ask next time. Actually, if you don't know the answer to that question, it just means you need to ask someone who does, and because they're right there, and that is the advantage that technology has bought us. And a really good example of this is what we're going to talk about for the rest of this episode, which is pediatrics. So as a paramedic, about 10% give or take of the patients that you see will be children. Only a very small proportion of those will be really sick, but a number of them might be sick. And how would you know unless you are an expert or a specialist in assessing children? Even experienced pediatric clinicians understand that a very sick child can be very difficult to spot, with obviously devastating consequences of that child is not transported to hospital or discharged from the emergency department with a well-meaning, generalist clinician having made an assumption that they aren't as sick as they actually are. Yeah, so in this episode, we're going to try and bring these two threads, these two ideas together and talk a little bit about the care of the young child and trying to better understand where we can help. And when we need to draw in other expertise that ensures that the care we're giving is as safe and as effective as it possibly can. So we're going to talk about the importance of consultation more generally. But then look at some of the complexities, the conditions that are hard to identify in with a particular focus on young infants. We're here from a VVAD pediatric specialist and then we'll talk a little bit about the ambulance VVAD, Victorian Virtual Emergency Department interface. David, you alluded to this already. You're an intensivist. You have areas of expertise, obviously. But you must come across like a quite wide range of diseases, medications on which you're not an expert. So can you tell us a little bit more about what the role of consultation is for you? Absolutely. And so as I've already mentioned, you know, a good example. Last weekend, I was working in the general part of our ICU. So most, most big ICUs these days have specialist areas. So we have, you know, heart transplant and fancy machines, ECMO and VADs. We have burns. We have lung transplant. We have trauma. And then we have other. And that's, that's fun. But it's also challenging because every patient's got something different wrong with them. So not only do I have to manage the intensive care aspect of things, every day, I have to talk to an oncologist and a general surgeon and an orthopedic surgeon and a respiratory physician and an a phrologist and an infectious disease physician. And in fact, an hour ICU and indeed in many ICUs, we've standardized a lot of that. So we've, you know, every day after the war ground, I have to talk to a microbiologist and justify every antibiotic prescription I've made. Oh, wow. And that has just become a normal part of our practice. We have a pharmacist on the war ground with us. So every day, I will say to the pharmacist, and maybe this is a sign of how old I am or how much reading I need to do, I will say, I don't know what that drug is. I will usually say, I'm not sure I can remember what that drug is. You know, I'll try and save a bit of face. Or what does that one do again? That is me consulting with an expert in drugs because there's, you know, since I've finished med school, there's entire new classes of drugs that I'm just simply never going to be as familiar with as I am with the ones that were around when I was studying. And, you know, we have nurse consultants in our ICU who are specialists in areas of patient care that I am not specialist in. So it's not just about consulting a medical specialist. It's about consulting a different health professional about an area of expertise that we don't have. And that has become a routine part of my practice. And the other thing that as a paramedic, you may not see, because I think something that paramedics miss out on is not being able to have an understanding of the inner workings of the hospital sometimes and have a bird's eye view of how that works. There is other health professionals. You generally come up through the hospital system and you see other professionals and other teams and other clinicians interacting with each other. I will most days go and grab the intensivist in the next pod and say, can you come and have a look at a patient with me or what do you think of this or what would you do in this situation? That's, I mean, I don't know what to do. I've probably already made a decision about what I would do, but it's a weird situation or it's something I haven't dealt with for a while. So I just want to get a second opinion from someone who's just not me. I still remember, I think I've told this story before, on my first day as an ICU fellow, so I was in this kind of in between phase where I technically finished my training but hadn't been appointed to a consultant job yet. So I was in a, I was on the consultant roster, but still, you know, not fully ticked off. And the consultant in the next pod was probably the intensive care physician in the unit that I respected the most in terms of his, his knowledge, his judgment, his clinical ability. He was the person that you would want looking after you if you were sick. And he came and tacked me on the shoulder and said, hey, can I talk to you about a patient? I just need a second opinion. And I actually looked over my shoulder to see who he was talking to in a realized that was me. And he was just, he had that degree of, of, of humility that he knew I wasn't his experience as him, but he also knew that I'd just pass my exam. So my knowledge probably was greater than his in terms of fact, but I didn't have the experience. So I was still someone useful for him to talk to. So I think the key for me is it was always going to be someone who knows something more about something that you do and you can use that to, to benefit the patient. Because that's what it's all about. It's all about providing the best, most up to date, most evidence, best, most appropriate care to the patient. And if asking someone else a question allows you to do that, then why wouldn't you? A common criticism when we talk about consultation or as it sometimes perceived, getting paramedics to ask the permission of doctors to do things, water is down the roll of paramedics. It dilutes clinical decision making and impacts the future of the profession and the abilities of the workforce. Is there any truth to that, do you think? Not in Australia, I don't think. There isn't some.
places. I think it is a fair concern for people to have, but I hope that for paramedics working in a system like ours, Australia and New Zealand, the UK, it's less of an issue. In fact, it's not an issue, I would argue. In other places, particularly North America and Asia, I think it is an issue. And to give you a good example, we are having an increasing relationship with paramedics in Japan. And so I've been learning a lot about how paramedics in work in Japan. And paramedics in Japan are trained to a very similar level as paramedics in Australia. They do a paramedic and degree. They have a pretty broad scope of practice. But because of a combination of legislation and culture and probably more culture, they have to ask a doctor for permission to do literally anything. And until relatively recently, that included shocking someone who was in VF. So you drop up to a cardiac arrest and see someone in VF and you get on the phone to the doctor and hope that they didn't go into a system while the phone was ringing. And that's not an exaggeration. That's a story I've been told a couple of times now by experience Japanese paramedics. So things look that's no longer the case. But that's something that hopefully will evolve with time. In Australia and New Zealand and the UK, we are well beyond that. If we ever even had that situation of that, that, or so-called online medical direction, we have always had protocolized care that has evolved appropriately over time into guideline-based care. So I don't think you ever need to worry about asking for permission to do something. All that you're doing is, in most cases, I reckon you're probably sharing a decision that you've already made with someone who has more expertise, more experience, more knowledge in that area just to make sure that it's the same thing that they would do. Or is there something that they know that you don't, something that you might have missed some bias that you might have? For example, in pediatrics, are you inappropriately applying adult knowledge to a pediatric setting? You know, well intention, but that may not be appropriate for that specific situation. So I would argue that consultation is just that you are consulting someone who has a different set of knowledge to you, to seek their opinion. And what you do with their opinion is kind of up to you, although something you learn very early on in medicine is you shouldn't ask for someone's opinion if you're not prepared to follow it because that can lead to extreme embarrassment and obviously also potentially patient harm and you're having to explain why you didn't follow the expert's advice. Yeah, it's an interesting topic. We'll have to go after a podcast or all of its own on that topic. I'd go on further and say not only does it not not only does it not water down experience in decision making, but usually you learn something every time that adds to your practice. I would say it has and it actually has been official rather than rather than attracting. Oh, I am a better doctor for having a pharmacist on the wardroand and having the microbiologist talk to me every day because exactly that you I do it see it as me being as the system seeing I don't know how to prescribe antibiotics. I see it as a safeguard and an educational opportunity every day. Interestingly, one of the ways that we are safeguarding one of the ways that we're introducing that consultation and decision support is through the Victorian virtual emergency department. We're going to go on to talk about the role of the VVD in paediatrics in particular, but firstly, I think a little primer on VVD for listeners who are not from Victoria. So the Victorian virtual emergency department is well, it's a real emergency department. It's just it's online. So the VVD allows for anybody to get in contact with emergency specialists, emergency doctors, nurses via video call and just like a physical emergency department has a front door. Members of the public can can walk in can seek their advice just like they would in a physical emergency department and paramedics can go in the sort of back door if you like to seek the advice of emergency specialists about patients that they're with. It's available 24/7 for every of charge. It's an amazing resource. It's start by emergency specialists. As I said, they have the ability to provide treatment plans, provide advice, prescribe medications, arrange for pathology, imaging. They have virtual awards for monitoring patients. It's a brilliant resource and it is in terms of the number of patients seen one of the busiest emergency departments in the state now over 250,000 I think it's I think it's the busiest in the country now. Yeah, that wouldn't surprise me. And the obvious benefit is that this can get the care that people need without a trip to a physical emergency department. That means less pressure on ambulances, less pressure on the hospital system by achieving a better standard of care for patients. Yeah, it's it's an incredible concept. I still remember the first time I was briefed about VVD. I nearly fell off my chair when when it was explained to me and what it was and what it could do. I remember just thinking why hasn't someone thought of this sooner? This is just incredible. But as you've alluded to before, we needed the catalyst and the catalyst was COVID. And now that we've got it, the sky is the limit that there's you know, there are more and more and more things that in partnership with VVD or with a virtual emergency department and ambulance service will be able to do. And we will see an evolution in the scope of practice of of paramedicine as a result. So perhaps yet another reason that that you needn't to be afraid if you're a paramedic who feels that now you have to ring a doctor all the time to ask for permission to do stuff because you're now in that in a more of an interprofessional inter disciplinary relationship with a physician and our practitioner, a physio, whoever happens to be at the other end of the line, you end up becoming to a degree. They're hands and eyes and ears and and it allows you to expand your own scope of physical assessment treatments. You're able to provide in consultation. I just think it's so exciting and there's there's there's things that used to keep me up at night. There's clinical problems that used to keep me up at night that now I am not bothered with at all because I know that we have that that safety mechanism that that that fallback of of the VED it really has been a game changer. Okay, so to set the scene a little on the topic of VVD and pediatric assessment, I'm going to now bring in our alternative services lead Sam Piot who spoke recently with VVD pediatric emergency medicine specialist Aritha O'Roei. Now when we come back we'll look further at how paramedics who are actually with a patient can then utilize VVD most effectively. Very fortunate to have you here today, Arith. Thank you for joining us. Obviously the majority of your career up until this point has been medicine in person but now such a large part of what you do is the virtual health space which obviously we sort of had thrust upon us in recent years and during COVID times and obviously just technological advancements that we see now. How do you find telehealth impacts your ability to care for patients, assess patients, particularly pediatric patients? We can be challenging at the best of times. I think it was hard in the beginning, especially because it was another thing and I was a bit, oh how is this going to work? And it was a huge learning curve to actually get into it and be comfortable using it. As you say like we work in the physical environment, it's easier where you can get your vitals, you have other people looking at and feeling and checking patients. This is a bit different but it does have its pros too because you are assessing a child in their natural environment so they're a bit more comfortable so they don't have the stranger anxiety. They are actually a bit more interested because who's this person talking to them from the iPad or something and they're all the phone and they close it so many times they have to let reconnect again afterwards. But this is again this is just one way of how we see patients in DVED because we have different streams so we have the self-registered, we have urgent care and we also have the AV patients. So from the self-registeration pathway, the ones that as I say in their own environment that's comfortable but then I don't get the obvious things that I need but I just have to use my clinical judgment then. But with the where there's AV or there's urgent care centres I do get other things. I don't get the familiarity of the environment but it's a balance and as everything else is always a balance in there. Yeah and that's such an interesting point and I know that from a paramedic point of view and I'm sure it's probably similar for yourself. A lot of what we do when we're looking at paediatriases, making yourself as unintimidating as possible. We often keep it at distance, utilize parents where we can familiar toys and things. Obviously technology is such a big part of a lot of young kids' lives these days that they're probably quite happy to try and engage with you in that way. Rather than being scared they almost want to engage. Is that fair to say? Yeah, 100%. Yeah. You do get like the occasional shakit who just doesn't want to be involved and you kind of have to work your way around it. But most of them are kind of like you know that you mostly get the siblings or somebody else like going in the background saying, "Oh, and then maybe they'll be like sibling rivalry and then the other sibling, the real the patient wants to be involved in too.
Now for paramedics out there we as I said we do a lot of our assessment Just by observing we keep our distance and we're looking at general appearance their conscious state We try and have the parents expose them once in so we can observe and see that work of breathing also see their perfusions for their skin and get a bit of an idea of their circulation We also might use techniques like capillary refill. Yeah Those types of things and that obviously gives us a large amount of information Rather than trying to get in there with a blood pressure cuff and stuff It's quite a different approach to how we would look at adult patients and then once again depending on their patient Pediatric patient age group might change it as well Is there any other techniques that you are able to deploy when you're looking at a patient? What do you look for in a patient when you just got the screen what techniques do you get the parents to do? You know what other you know tips of you picked up along the way. Yeah So we use exactly what you said about the general inspection and try to see as much as you can from the chest the limbs and And you know and we do like an ABC approach as you just mentioned But there are other things that we we can use too so we use the parents as there are extension because One of the things that this limiting with the telehealth is you only have your two senses You can see and you can hear but you can't feel so that's where we use the parents So they can you tell us what do the periphery feel like did they feel warm? Did they feel cold? We can actually teach them to do a cat pre-force I did it on the screen and they show us what the cat pre-force looks like if it's a rash for example Can you feel it? Can you press on it? Does it can it is a bumpy? Can you press it? Does it branching? Does it feel like if it's red does it feel warm? Does it you know those things that we can't actually do ourselves obviously because we're in a virtual environment? But one important thing that I would I when people join you and I tell them to use and also maybe for avitos is to get the patient to walk If the patient can walk that tells you so many things is that you know They're refusing their brain after they can walk if they're walking in a in a normal pattern That's also reassuring. They're not they haven't got a limp If they've got abdominal pain and they're walking that's reassuring from a tiny side of thing if you get them to jump again So that's also reassuring from a from an abdominal thing. There's nothing major in the abdomen going with it if you're able to jump and you able to walk that's that's reassuring for us But and I'm sticking on the abdomen We also get them to parents to palpate the abdomen and if we see if they've got an area of tenderness or it feels hard Then that's telling us our this person needs to be sick physically. This is something more sinister But I know that something that we do with adult patients with very day Really good to hear that it's actually not necessarily too dissimilar with pediatric because we do look at them like they are such different types of patients You know with the adults we say can you stand what your postural blood pressure that type of thing and you're really just Replicating that to see how do you go about normal life and then kind of I assume you get the parents input like how are they seeming now? Is that is that quite a big feature for you in tally health and Suppose another part to you know the parental worry is how do you manage if you really feel that there is not a lot wrong with the patient But the parents level of worry is showing a much bigger sign than that What do you take into account you're looking at? Is this your first child? Yeah, what's your level of experience with around kids this age and illness? How do you approach the parental worry? I try to break it down I see what the worries are and then we go with them one by one so if they can list what the worries are and then I try to address them one by one So you know if it's this well say well this is happening if it's that this is happening and I guess if if they're reassured by my answers then then that's Helpful if not then I can guide them to where the best place they can see so not a lot of parents know about the Ppp pp cc's or the ucc cc's around them and so we can't try to help guide them in To what the most appropriate facility that's close to them that they can use by just like putting their postcode then and finding it I would imagine that paramedics will come to VAD with patients and they've got Parents who are reasonably quite concerned about their child and that's something which we take very seriously Do you find that just introducing you not only as a second opinion but your your level of experience? I think is you know reasonably afforded to you that that you would provide some fairly hefty reassurance that if you're quite happy with the child Is that something you find that paramedics bringing patients to you getting that second opinion? They know that they've been saying by a doctor with a great amount of experience that that really eases the parents worry I feel like I'm just going on like the last year occasions I've had with interactions with A.V. on on the screen. I think it's actually the opposite. I think they've already been reassured by A.V. And so the ones that I've seen that the parents you know they call and I said why did you call A.V. And then they said oh because this and this but I'm so much happier now and they've already been reassured. So I'm just you know Wouldn't say I'm the cherry on the cake, but I'm just Helping you know confirming with with my colleagues then I said like they've done a great job and then and Reassured the parents. There is always going to be limitations for what VAD can do In the previous episode we're talking about limitations for managing the elderly patient those either at home or in aged care facilities And just appreciating that things like waiting a week for blood results is not acceptable Depending on how the patient presents What are the key limitations that you find when we're talking about pediatrics that have a higher rate of still requiring transport Just because we just can't manage it completely and safely in the virtual space So I've actually asked one of my colleagues a mandor about which the ones that had actually you know after a consult that needed to be Transfer to hospital and the the figures were really good in fact that AV is really good at selecting the right patients because only like the average of one a day will actually need to be doing that So I think you know the patient selection has been great on your side The the commonest ones that are looking at the list that I got were I put it in an ABC point so A an airway thing so group was the commonest one That needed transfer so you know the moderate to severe groups that were not going to respond just to like one dose of dex They needed something a bit more like an opulizer joint and not something though those are the commonest ones The second comments was asthma So again not responding to a burst and then they needed a bit more management that was the second one And then the last one was seizures or syncopy those are the ones that kind of had limitations that needed to be Physically assessed and because they needed more monitoring. Yeah, and I think that that pretty well checks out with what I would have imagined You would say as well But also knowing that we we do also have really good success in in VD Imagine patients at home with that cohort as well. It's just that few where it's like Most of these features are pretty good and pretty consistent with what I've seen before But there's just these other couple of ones that are worrying me and they're probably going to worry VD as well But then the the seizures syncopy one that's all that's always Gonna present its own risk and the first presentation on machining is probably more of the concerning one How do you um find if you were presented with a first presentation suspected febrile convalesion How is that looked at from a VD perspective in general? I know there's a that's a broad question As you said, I mean like we will we will go with a ABC we see how the child looks I guess time of day also affects how you manage these And and also have parents are comfortable or not comfortable with managing it So if it's a second presentation or third they're much more comfortable than than the first one and and also The local facility what is where where do they live? What's their local hospital? How far away is it? There's lots of factors as you say that are kind of Involved in making decisions with that But we are making lots of CPGs currently with virtual ED We have different so we have one for asthma we have one for a bunkulitis We have one for head injury so we're going getting eye through lots of things so Watch the space Yeah, nice you talk about time of day impacting is that meaning that Night time being more complicated time less things available that's more likely to mean transport might be needed especially with the parents and and their level of concern and And how they can monitor their child at that time. So yes, I know that with the adult demographic There is now VD wards Which allows for care over potentially multiple days with frequent check-ins and Applying prescribed medications often as well. Is that something that exists within the pediatric space? Yes, it does. I think we actually started at first so we with the It's called cave owl or the kids virtual observation ward has been there since the end of last We've had we have a few things that present And we look after patients and they're so chronic condition. Well, I guess like a flare of asthma For example is one of them some of the gastros that you just want to make sure that they're actually being hydrated Abonculitis kid That needs you know parental reassurance making sure they're hydrating well and monitoring. So yes, it does exist We think once again within the adult space which we're quite comfortable with as it's um I believe it's something around about 80 to 85% of the patients that paramedics refer to VAD Adult patients and only about 15 or 20% of pediatric patients They're epic the emergency physician in charge is is a concept that we're becoming more and more familiar with Particularly as someone that we can use to get a second opinion or just include in
a more complex decision-making of how we're going to manage a patient. Is that something which also reaches within the pediatric space? Yes, it's called the PEMIC, the pediatric emergency medicine in charge. So there's always a person allocated to that role who is your person that you wanted to ask about, maybe like an AV referral or someone in urgent care, because there's a big team in the kids' waiting room. We have doctors who have nurse practitioners and also the three-arginers. So the PEMIC is the person that they try to ask questions of the old answers from. We're talking about the idea of the virtual wards for pediatrics. You said that sometimes for like asthma flare-ups that can be something that can be used. How else can VVD support patients and chronic conditions, often chronic conditions is usually more associated with the old cohort, but there are things such as asthma or diabetes or ADHD, things like that. How can VVD assist with those types of patients? So let's go back to the asthma one. So if it's a person who's known asthmatic who's had viral induced wheeze before, those ones that we can help, because most of them have the education and have asthma action plans and we can help guide the parents with the treatment and observe how the treatment is administered, but also the effects of the treatment. So as I mentioned earlier, we have CPGs for managing asthma and one of them is the asthma CPG, as I said. So for the mild moderate exacerbations, we can already need to start a burst, we can start the burst, and we can monitor and see how the child is responding, and we try to stretch them while we are observing. And then if they fit a certain criteria, they can actually be admitted to our virtual observation ward. We observe them to a certain amount, and then we have a ward round in the morning and review them again then. If they have stretched sufficiently and they've approved, there's another service called virtual, Victoria virtual specialist clinics. So one of them is a pediatric asthma clinic that we can refer to afterwards that they parents are very happy to be seen by a specialist in pediatric asthma, and then they get looking at their plans and what management they have and so forth. With diabetes, there's a diabetic nurse practitioner, and they're also, I know they're in that adult world too. So again, they can help people with those types of things, and there's also clinics that they can follow up with them too. This has been an incredibly valuable podcast for me, and I'm sure for paramedics, we'll be listening as well. Can I just ask, if there is one piece of information from your experience within VA Day, or also within Royal Children's and just your whole professional career in general, what is the one thing you would really like paramedics to know? I think from virtual and with AV, I think I'd like them to know that we working together, we have a really good collaboration. I think there's lots of things if we collaborate really well on, for example, like a group. I know there's a new guideline, and we're actually doing a project on that announcing what the AVVVD collaboration has done in terms of managing moderate, mild, and severe groups. I think it's a really good space for us to work together, and I think the main important thing, we're all here for one reason, it's the patient. So by us working together like we are doing now, I think we can really deliver good patient care, by good communication. Yeah, I think that's absolutely okay. It's a really nice message to finish on. So thank you for that. I look forward to continuing to develop the relationship we have with VAD and grow and see how we can work to have some really fantastic outcomes. So thank you very much for joining me today, Harath. Thank you, Sam. Thank you. So David, I'd be keen to hear your thoughts more generally about the discussion with Harath in a moment, but I think it's worth addressing one of the more important questions first. When should we be looking to engage VVVD? I think whenever you're one drink, I think that's the, that's what I would say. And I often say this to registrars, if you have to ask yourself a question twice, then you need to address that and just pick up the phone and call someone. And that's, you know, if you're, if you're wondering, should I take this person to hospital or should I leave them at home? You've got someone to ask. So that's one situation. The other situation is obviously when we tell you to in a number of our guidelines do recommend for specific settings, calling VAD, but that's numerically a small group. The bigger group is the group of patients where the paramedic is thinking about non-transport and just needs a second opinion or non-transport rate as you heard when a paramedic does a VAD console is 85%. That's just incredible. And that actually probably means we're not referring enough patients. It probably means that we can get a little bit, I don't want to say riskier, but we can think about referring different cohorts of patients just to test the waters and see what's feasible. The doctors and nurses there aren't cowboys or cowgirls. They're coming from a risk of air space as well. They're fully aware of the limitations of virtual care. But I think this is a, this is a big, untapped resource for us. This isn't just for the super low risk patient who you, who you really know needs to not know, doesn't want to go to hospital anyway. You just, you just want an extra bit of reassurance. This is for the case we are genuinely not sure or you're, you've engaged in a conversation with the patient or their family and they're not sure or, you know, unfortunately, there is still a bit of a, rather they were just seen by a doctor and then you can say, okay, well, let's arrange that right now. So I think we can refer patients who actually are, you know, even some patients who may in previous times have been admitted to hospital, you heard about the virtual ward, the treatments that they can provide in the community are really things that we wouldn't have dreamed of a while back. Like someone, you know, an example, someone who's a bit dehydrated with gastroenteritis previously, if I'd heard that a paramedic had given someone a liter of fluid and an anti-amatic and left them at home, that would have been T and Bikki's territory, I think in terms of a very poor decision. But now you've consulted with the doctor, you've got, you know, a few sets of viral signs. The doctor has their own experience, their own internal risk calculation and it's not just someone dancer tron a liter of fluid and leave them at home. It's someone dancer tron a liter of fluid and then an hour later the, the VD nurse calls back to see how they're going and then the prescription arrives in the Uber and etc, etc, they're followed up the next day. It's about putting them into a system where they can receive follow-up. So I would argue, you know, there are the patients who clearly don't need to go to hospital and you can make that decision yourself. There's the patients who clearly need to go to hospital because they're really sick. There is an enormous group in the middle and enormous untapped group of patients that are entirely appropriate for a virtually deconcel. Yeah, as you said before, the sky is the limit. I mean, the kinds of patients, did you draw back the curtain a little bit to some of the guideline discussions we're having at the moment? We're talking about patients staying in the community with VVD consults that I never imagined. I mean, something is fundamental to ambulance practices. Chest pain. A low risk chest pain is going to happen this year. There'll be a low risk seizure pathway probably this year. Even hard pho there is on the horizon. It's just, it's incredible what might happen in this space. I wanted to pick up one of the themes that Herith talked about which was parental concern because it's a common sticking point. We mentioned it in our clinical flags guideline. I think it's a common point of frustration and confusion. The most common thing that people say about that, well, they call it an ambulance in the first place. So aren't they all parents concerned? And fair enough that there was concern. The point there is that after you have tried to address all of their areas of concern, is there some lingering sense of uncertainty, of discomfort? And the idea is that they have caught through their knowledge of their children, they have cotton on to some source of risk, some unmet need, something that's really hard to define. They can't define it. They won't be able to necessarily tell you, but it generates discomfort. And I mean, I think we should be doing what you should be using that, valuing that sense of discomfort. I think that evidence bears out that not all the time, but enough of the time that discomfort is well-founded if you can't reassure people. I'll even give an example from my personal life. We have this role in my marriage with my wife with my children. My wife's not a clinician. And if one of our kids is sick, I say, "Well, I think it's this, and I'm comfortable. Here's what I think we should do. Do you feel comfortable?" And my wife will say, "You know what, I don't know." A couple of times she said, "I don't know why, but I'm not." All right, let's go to hospital. And we have. And she has been right. That's still powerful. I don't know what's wrong, but something's wrong. You just miss that at your peril. And indeed in many hospitals now, that that is a criteria for calling a medical on an admitted patient. The patient or the family member, particularly of a child seeing something's not right, because that's their usually spot on. Now, we've recently updated our guidelines to change the way that we do things in relation to small infants. So we say now that if you're considering non-transport in an infant aged 28 days or younger, VBD consult is a must. And in that first three months,
of life, 29 days to three months, particularly if they're premature or if there's any degree of complexity, we really, really strongly recommend getting a VVD console. Now, we've said a part of why this has happened is that it's the standard of care in hospitals. It's what others are doing, which is part of the picture. We've said that a decision around discharge for small infants here in Victoria is usually exclusively a decision for a consultant physician with experience in assessing young infants. Oh. Such is the risk and the potential impact of getting that decision wrong. But why? Well, what conditions are easily missed? What is the source of risk in these young infants, though? The thing that we're worried about the most is sepsis. In a new neat, who's less than 28 days old, someone I will get this wrong, but this is this is coming from my understanding. They're in a phase where they haven't fully developed their own immune system, and the antibodies that they brought with them from mum are disappearing. So they're in a uniquely vulnerable, immuno-compromised phase. And a crying agitated, not feeding right, not quite right baby, could just be a crying agitated, not feeding right baby, or could be a baby with sepsis? Who might die? It's as simple as that. The there are life-threatening conditions that can be easily missed or easily mistaken for non-life-threatening common problems. And the only way to pick those with any degree of accuracy is experience. And hence why, in hospital, this is a decision that's only made by an experienced clinician. And I think this is, you just can't hammer this point home enough, something that we're often guilty of, as I've already alluded to, in paramedicities, not having as good an understanding of how things work in the hospital. And you could perhaps quite rightly say, "Well, I've been a paramedic for 20 years, and 10% of the patients that I've seen are children, and probably five, you're probably half of those are infants. So 5% of the patients I've seen over my 20-year career are infants. So I know what I'm doing. And you might be right. But you're not at the level of a consultant pediatric emergency physician or pediatrician who has seen probably hundreds of times more patients than you have, and and importantly, had feedback on the times where it hasn't gone well. And so they've put that feedback into their pattern recognition process. And I remember when we had this conversation with our pediatric colleagues and our virtually D colleagues, it was a pretty quick decision that we made, that we didn't require a lot of convincing that this is a really vulnerable cohort of patients. And we have an opportunity to make things safer for them. And we're currently doing something differently to what the rest of the health system is doing. So it was a relatively easy decision for me to make. And look, now that this process is in place, I can quite happily say, if I am called to an infant, our neonate, and I get there first before the ambulance crew, and I decide that they don't need, or I think that they don't need transport. So I cancel the ambulance. So it's just poor old me making the decision. I will call virtually D and I will ask to speak to the pediatric emergency physician because I, I haven't done pediatrics for more 15 plus years at least. And I wasn't very good at it then. So I, I, I, I have an awareness of of my own limitations. But more importantly, there's a rule here that's put there to help me and to protect patients. And if I can just quickly, in the preparation for this, I've tried to find a published paper to back this up and I can't find it. So what I'm telling you might be completely untrue and I might have completely misremembered it. I suspect this is going to be unpublished data that someone's told me somewhere. But if any of you can find the paper, please let us know. Apparently an ambulance service, I think it was in Australia. And the surveyed paramedics of varying levels of experience, they gave them clinical scenarios, I think, and asked whether they would transport the child or not. It was all pediatric related. And what they found is that new graduates or paramedics in their first year or two of practice transported pretty much every child. Between two and seven or eight years, the transport rate dipped. As paramedics became more experienced, the transport rate starts to go up again. As you begin to realize, either through hearing stories from others or learning more or having had a bad experience yourself where you got it wrong, that this is a difficult to diagnose and vulnerable group of patients and the perception is it's safer just to take them to hospital. And this is kind of the equivalent of that. And if I remember correctly, there was another interesting finding in that study, which is that there was a small number of the paramedics who had pediatric emergency nursing experience and they always transported all of the children. So that the people in the group who knew the most about pediatrics, who had the most experience transported everyone. Now, we don't think that transporting everyone is the right thing to do because the emergency department is not the right place for a screaming upset child with miserable parents, but we have an equally good alternative, which is the virtually deconcelt with a specialist pediatric emergency physician. Yeah, I was about to jump in and say, I'm going to say something controversial, but I would say that both the middle group where there are far fewer transports and then a fear and experience driven process of transporting more people are both wrong. Yeah, both reflect an unnewanced process of judging risk on its merit, on its individual merits. So if someone was to say, I heard some stories or had a couple of bad experiences and now I take all children to hospital, that is bad care. Just the same as it is bad care to not take anybody to hospital. This though, this though does reflect a quite nuanced approach that sees a higher level of expertise in a higher risk group of patients and they then can get a disposition or a care pathway that's right for them. So I spoke with one of our VVAD doctors and I asked them what VVAD would want to know and why, how can we best work with them? And what I'm about, the list that I'm about to run through is a paraphrased list of considerations that I think can really help to inform the interaction between ambulance Victoria and VVAD. And if you're listening from outside Victoria, I think this can be used more generally. I think this as a model for how you can interact with telehealth services or consultation services is more useful than just VVAD. So they recommended starting off with a full history that is specific to the small infant. It's a given that it's important to your decision making, but it's also useful to VVAD. It's information they'll ask about and they'll ask again that's fine, but asking multiple times is not a sign that you don't need to do it so much as it is a good opportunity to give patients time to process the answers to the questions. So we're talking about firstly, their anti-natal care and complications that they experienced during pregnancy. The birth history was at a vaginal birth versus a cesarean. What was the gestation at birth complications during birth? E-time spent in a special care nursery or NICU. And if so, why? Then how much time did they spend in hospital? Weight is the next big area. Their birth weight. How has it trended over time since they were born? What's the current weight? And has it trended as expected? Has it done so in a healthy way? Feeding. What's the feeding method? Is it formula? Is it breast milk or is it mixed? It's the amount. What's the frequency? How effective is the feeding? Is the baby waking for feeds? Then we're looking at the other end. The nappies. Frequent nappy changes are the nappies where each time about movements, color, frequency. Then the postnatal care. Have they been seen by a maternal child health nurse or a GP? Did they get vitamin K at birth, etc., etc.? Have they had any medical problems since birth like infections? This is not a comprehensive list. I think this list underscores why we need to be getting experts involved. Because as I run through that list, I then ask myself, like what are the actual implications of a variation in the expected weight? What are the implications of mixed feeding versus exclusive breast feeding? What's a wet nappy? How much feeding is enough? How frequently should they be feeding? What's a normal amount? What's the difference in risk between a baby who received vitamin K and one who didn't? No, I know a little about all of these areas, but for each of them, as I collect that piece of information, I think this is going to ultimately be a question for someone who does this all day, every day, for a living. I think we can do better in supporting paramedics to perform these assessments in a structured fashion and to understand.
the information that's collected. So we've committed to also including this information in the CPG in the future. So how you frame the consultation matters a lot in terms of retaining the patient's trust and their confidence in the process. An important part of this is not predetermining the outcome. So the problem that sometimes arises is that the crew say all the baby can stay at home, but we have to call the doctor first and it'll be fine. Now first of all, that's, I mean, it's obviously not true. If we knew the outcome, then if it was going to be the same in each case, we wouldn't have the consultation process. So it's best to keep it over mind. And then how you frame that flows naturally from a truthful discussion of what you found. Now this is all laid out in the ambulance-futuria patient assessment standards. These are publicly available if you happen to want to have a look outside of ambulance-futuria. They're in the AV CPG app. It's page 40 if you happen to be wondering. And also a shout out to the non-transport checklist in the app as well. So if you're honest and transparent around the elements of this discussion, the results of your assessment and the implications of those results, are they normal or they abnormal? What does that mean? Then the limitations of your assessment, which are inherently going to be many, what the potential care pathways could be, and then what you recommend. The young babies present a lot of challenges and this is really important. We need to make sure we get this right. So what I'd like to do is bring in another opinion from a doctor who specialises in children. Next is good light and a warm room. So don't underestimate just how much light you'll need to get good quality video that can really sharp all of the things that their person on the other end needs to see. And a full exposure of the baby in a warm room will allow for a good examination so you can expect that'll happen and if you've got a warm room, baby will be much happier. Be clear about the reason for your consultation. Convert your concerns, your thoughts, your reasoning. We are calling because we think this baby is well because X, Y and Z and we feel balanced so forth. Or we're calling because we're uncertain about whether or not we should transport because we found X, Y and Z. Then for small infants, the concept of observing a feed was raised. Now, the effectiveness of feeding in the very young infant is tremendously important. And I wonder whether or not we underestimate the importance. Is the time scales are totally different? You know, for an adult that we're obviously more familiar with doesn't need for a day or two or doesn't need effectively for a day or two. I mean, that really doesn't actually matter that much for the most part. For a newborn, that's life threatening. Problems with feeding are really common and they're not always totally obvious to the untrained eye. So observing a feed is an important part of the assessment, but to be honest, from the perspective of my own practice, I have mixed feelings about the value of me observing a feed. So I mean, I think I don't think it's too much to say that I have a bit more expertise in this area than many paramedics, not as much as some, but many. And I've spent enough time with lactation consultants to know how little I know. I know, for example, that I might be looking for for deeper, slower sucking, for audible swallowing, you can hear the milk being swallowed. I've seen years of effective breastfeeding, and I've also seen problems in breastfeeding. And then of course, after the feed, you might expect the breast to feel less full or softer after an effective feed. But there are so many caveats. It's a complex area. Now this is not AV policy, but I feel personally that if it's possible from the point of view of when the child needs to feed, that I might save the feed for when the VVD are on the phone, or if that's not possible, then potentially a family member or the patient, perhaps mum may wish to film it on their own phone. Involve the family in discussion as much as possible. And importantly, if they have a non-inclis speaking background, quick plug for the interpreter service, it's easily available when you can find the number in the CPG app. The last thing that I was asked to remind you all is that if you're not happy with the assessment, you can ask for a second opinion. You can escalate to the emergency physician in charge. So finally, small infants are undoubtedly a very vulnerable population. And the thing is that, as we've already said, they're not always really sick. Of course, they have minor issues. They have a lot of minor issues of that to them. It's just that when they are really sick, as David, as you said, David, it's not always obvious. So there will be a low threshold for face-to-face medical review and for a period of observation. But that doesn't necessarily mean that it has to occur via transport to hospital in an emergency ambulance. So that is perhaps a conversation that you can have as well if the recommendation is that the child needs to be reviewed face-to-face. As I said, this is not an exhaustive list, but I hope you find this useful. These are the considerations that the VVD doctors themselves find are important. David, over to you to wrap things up. So we've really been trying to kill a few birds with the one stone in this episode. And I think it's worth just taking a moment before we end to try and bring it all together. The key take homes for me have really been three things. One is that consultation is not a sign of weakness. It really is a mark of professional maturity. Even the most experienced clinicians seek second opinions. And as paramedics, as generous clinicians, knowing when to reach out and when to consult is one of the most important skills that I think we can develop as an emerging and growing profession. The second thing, as we've I think the labor is that young infants are are a uniquely high risk group. They can prevent in very subtle ways. And the consequences of missing a significant illness can be catastrophic. And that's why we have aligned our practice in ambulance Victoria with the other health services, the other hospitals in Victoria, such that if you are paramedic with ambulance Victoria and you're considering leaving a baby under 28 days at home, a VVD consult isn't just helpful, it is essential. And finally, as we increasingly engage with services, virtual consult services like VVD, structure matters, how we engage with these services matters. And a structured thorough assessment in hand over a well set up environment and making sure you have honest, open collaborative communication can really make all the difference, not just in safety, but in maintaining the trust of the families who've called us and are trusting us with the wellbeing of themselves or their kids. So I think this has been a great opportunity to hear from a pediatric colleague. For all of us to learn a bit about virtual ED, those of you from a jurisdiction that don't have a virtual emergency department, you need to start pestering your decision makers to help you get one. I hope it's been useful for you. I've really enjoyed the conversation and I'll follow it saying it on next time. It's been a great conversation and next month we'll be sticking with the pediatric theme speaking to our pediatric medical advisor, Dr. Claire Wilkin. But until then, if you've got feedback, get in touch with us,
[email protected]. We're on all the socials as well. Please do get in touch with us. We love to hear from you. But until next month, bye for now. Bye.
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