Trust your gut

Dr Conor Kenny shares his experience of trusting his gut instinct during Accident and Emergency rotation as an F2.

One month after commencing work at a paediatric emergency department at a large teaching hospital, frequent attender ‘Child A’ presented one busy evening at 9pm with his mother reporting that he was ‘not feeling himself’.

A detailed history revealed nothing untoward. Specifically, a review of body systems revealed that he was eating and drinking up to the consultation, bowels were opening normal formed stool and he was passing urine.

On my first observation of Child A, he appeared to be engaging with his mother, although he did appear lethargic. Child A had a low grade temperature of 37.6°C which had since settled since admission and cardiorespiratory, abdominal and neurological examination were unremarkable.

Playing with the child following the examination it struck me that whilst he participated in the activity, he did not appear engaged. While at the time of examination he scored one amber on the NICE traffic light system (for lethargy), I felt in my gut instinct that there was something not right.

Whilst Child A’s lethargy could be explained by the fact it was late in the evening, I discussed the case with a senior colleague. My senior colleague agreed that in view of the history and examination, we should safety net Child A as per NICE Guidance by providing his mother with clear written and verbal advice on signs and symptoms of worsening disease, and what to do if Child A becomes unwell.

When I returned, a fresh look at Child A from the end of the bed increased my gut instinct that something was untoward, I therefore decided to arrange some blood tests. Sixty minutes later our suspicions were confirmed when the white cell count was found to be significantly raised (22 x 109/L).

Child A was immediately commenced on empiric antibacterial treatment for bacterial meningitis and admitted for a period of four days. Six hours later Child A became haemodynamically unstable requiring close observation on the ward.

A lumbar puncture performed the following morning revealed a white cell count of 12,000mm3. Child A was admitted for a period of six days but unfortunately developed neurological sequelae. For a short term following the incident, my threshold for instigating investigations in similar cases reduced.   

Key learning points

• Trust your gut instinct (and indeed that of a parent).
• When communicating with seniors, it is important to be clear when you are concerned enough to warrant a full review.
• The importance of junior trainees having multiple safety nets when assessing sick children in the emergency department.
• It is important to have insight into the effect such incidents can have on your practice as evidenced by the fact that after this episode, my threshold for conducting investigations was lowered.
• It is important to recognise the effect of external variables in your decision making process – and have a mechanism for dealing with them – e.g. four hour wait, lack of beds.

References

1. Thompson MJ et al, Clinical Recognition of Meningococcal Disease in Children and Adolescents, J Lancet, 367:397-403 (2006)
2. Okike, Ifeanichukwu O et al, Trends in bacterial, mycobacterial, and fungal meningitis in England and Wales 2004–11: an observational study, Lancet Infect Dis 14.4, 301-307 (2014)
3. Thompson M et al, Systematic review and validation of prediction rules for identifying children with serious infections in emergency departments and urgent-access primary care, Health Technol Assess, 16:1-100 (2012)
4. Vital signs limited use Fleming S et al, Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies, J Lancet, 377:1011-8 (2011)
5. Woolf, Steven H et al, Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines, Br Med J, 318.7182, 527 (1999)
6. Richardson, Martin, and Monica Lakhanpaul, NICE guidelines: Assessment and initial management of feverish illness in children younger than 5 years: summary of NICE guidance, Br Med J, 334.7604, 1163 (2007)
7. National Institute of Clinical Excellence, Fever illness in children: assessment and initial management in children than 5 years (Accessed 1 September 2015)