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Paediatrics in general ICUs - striking the right balance

Todd Fraser on 24-07-2011

I worked in a small regional ICU for nearly 5 years. In that time I dealt with a number of very sick children, and many who were "not that sick". There was always great pressure from a number of fronts to send these patients out to a major tertiary paediatric unit. Trouble was, that was over 1000km away. While we certainly did not regard ourselves as a PICU, we had developed a broader paediatric skillset than most adult units, largely by necessity. The difficulty I always saw was that we needed to look after enough kids to get good at their early care (retrieval could take 24 hours in many cases), but at the same time be mindful of our limitations. Our intent was to keep as much as we could to maintain our skills. This was not always supported. It raises a number of questions for me. Given that many of the "new" jobs in ICU over the next 10 years will be in regional areas, is our current training program sufficient to equip junior consultants with the required skills? What is the role of the regional ICU, and what should it keep? Is its role different to that of a metropolitan tertiary adult unit? In Australia at present, we only seem to have level 3 PICUs. Perhaps there is scope for a regional unit to be classified as a Level 2 adult unit and a level 1 PICU?


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Alex McKenzie wrote 07-27-2011 11:54:20 am
I find the idea of looking after sick kids fairly scary. I know that a few years from now I'm more than likely going to be a consultant in a mixed, probably regional ICU, looking after kids, at least for a short period. It would be nice to be comfortable with this.

Does anyone have some advice on where to do a PICU term?

I agree - it would be nice to have this built into a CICM program. Is there any chance the college will develop a rural stream?



Oliver Arkell wrote 07-27-2011 09:07:28 pm
I'd like to do some time in a PICU. I'm based in Sydney so there are a couple of choices, but has anyone done time as a general trainee in a PICU elsewhere?



Todd Fraser wrote 07-28-2011 05:55:25 pm
I must say I like the idea of a "generalist" training pathway. How this works within the college training program is a little hard to say, but somehow focussing on the skills that a regional intensivist might need would be beneficial.

Check out Penny Stewart's podcast interview in the Podcast section - she identified where she wanted to go and then went back to a city to get the skills she needed.

I know Queensland is progressing towards an outcome-focussed training pathway - tailoring the program to suit the trainee's future needs. This sort of co-ordinated approach is fantastic and the way of the future.



ben gelbart wrote 08-10-2011 12:50:20 am
Can I recommend that those who are seeking to spend time in a PICU also spend time in your local general paediatric units (ie consultant rounds) or a tertiary general paediatric ward as well to see what degrees of illness gets managed on wards (whether as intensivists you agree or disagree). Obviously tertiary paediatrics will hold onto sicker children as intensive care is easily accessible. Either way the spectrum of illness will be helpful to see, helpful in developing confidence in recognising sick children needing and not needing intensive care and probably more relevant than too much post op congenital heart disease.



Todd Fraser wrote 08-10-2011 11:07:19 am
Great points Ben.

It does raise the question of what we are trying to train people to do. I strongly believe that we should be training intensivists for the regional areas and smaller hospitals. Whether this is a specific stream or is folded into general training is a matter of debate.

Should APLS be a mandatory course? Should we be setting up a college specific course to teach these skills? Agreed, post op congenital heart disease isn't what we need to know necessarily, but how do we adequately get a feel for what we're likely to see?



stanley nikki wrote 08-15-2011 04:09:25 am
did 6 months in the paeds icu(they are great) in perth when I was an ed trainee.(They kindly rotate ed/anesth/gen icu tainees in one of their jobs). Having said that I was doing a lot of peripheral ED with sick kids before that ,so it was a great experience.

It was 5 yrs ago now and although I don't do ED anymore, and adult ICU only, I still do APLS(yes very dogmatic but meet so many wise people every time...(we learn every day from everyone) every few yrs to stay skilled and a lot of it stays with me).

I would love to go back, probably to a bigger centre for more trauma, for another term. (and you learn to carry Frank Shann and Alan Duncan's paeds drug book (incl formulas and inotrope chart..even adult doses!!..in your pocket..with the roast potato instructions in the middle pages)(i phone version doesn't have inotrope table)

I can't say enough about the learning from the kids(and their crazy plumbing), the consultants & fellow reg's , and the nurses and families.



Benjamin Moran wrote 08-17-2011 09:46:36 pm
After heading down the adult ICU pathway, I started a job in a regional, tertiary ICU in NSW (John Hunter Hospital) this year. It's a mixed unit, which caters for most paediatric specialties (with the notable exception being cardiac surgery). It's not an ECMO centre, so the sick kids usually get a helicopter ride to Sydney. I found it very scary to make this transition. I went from looking after 88 year-olds, post emergency CABGs, to managing an intubated 2 year-old child with RSV bronchiolitis with a history of congenital heart disease. The consultants are always around to answer the mind-numbing questions I have for them (Is it ok to give a child frusemide!?), and our journal clubs have their fair share of adult and paediatric papers. It's a great learning experience, particularly for the fellowship exam. What they say about thinking about a patient you've treated in a particular situation to help answer your question- it's great to be able to apply it to kids. There is also some good ethical fodder- end of life issues, family involvement, resource allocation (who do you admit- the 65yo respiratory cripple or the 12 yo asthmatic?). Given the way that intensive care is heading, and the 'ruralisation' of ICU, I think these skills are going to become more a requirement rather than an elective.



Todd Fraser wrote 08-17-2011 11:28:24 pm
Exactly Ben - well said.

In fact, there are only a handful of centres which can truly regard themselves as able to provide all the "mandatory" requirements of training (large throughput, neurosurg, cardiothoracics, paediatrics, obstetrics) - and strangely enough, they are not in the big metro centres. Think Townsville, Newcastle...

So is it time that the curriculum for ICU training be adapted to reflect the likely practice of tomorrows graduates? My answer is yes...



 

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