​

Hey Reader,

Welcome to another edition of Bursting The Bubbles, DTFB's newsletter with some top tips, evidence highlights, and the best dad jokes.

This week we look at intraosseous access, debriefs, and promoting good sexual health

Let's do it...

​

WEEKLY BUBBLE WRAP: HOW CAN WE PROMOTE GOOD SEXUAL HEALTH

​

What’s it about?

Positive youth development (PYD) programs promoting adolescent sexual health behaviours differ from sex education programs in that they focus more on strengthening wellbeing, skills and relationships, with sexual health incorporated within these. The key elements of Positive Youth Development programs include a positive, supportive environment, strengthening the school and family context, empowering youth, building skills and engaging youth in real activities and roles.

​

​

This qualitative study undertaken with thirteen participants attending the Australian Positive Adolescent Sexual Health (PASH) conference in 2019 explored how the conference was able to engage young people to strengthen their sexual health & wellbeing.

​

Why does it matter?

“Sex ed” sucks. A 2013 study found that half of young Australians are dissatisfied with school-based sex education. They believe that Sex Ed programs are irrelevant to real-life experience and contain inadequate discussion of important issues, including consent or positive sexual relationships.

By contrast, PYD programs are more holistic, with an emphasis on strengthening wellbeing, skills and relationships, with sexual health incorporated as part of the program. As clinicians, we have an opportunity to provide strengths-oriented sexual health care to adolescents & young adults.

A great post on what’s ‘normal’ sexual behaviour in young children can be found here Sexual Behaviour in Children – what is “normal”? – Don’t Forget the Bubbles (dontforgetthebubbles.com)​

​

Clinically Relevant Bottom Line

Young people identified that having professionals who were comfortable discussing sex and sexual health was a positive way of normalising discussions around sex-related topics. As health professionals, we have a responsibility to normalise developmentally appropriate, non-judgemental conversations around sexual health.

​

Reviewed by: Henry Goldstein. Read the full Bubble Wrap here.

​

Brush Up On Your Grid Interview Skills! If you're a UK Paediatric Trainee with a grid interview coming up...this is for you. ​ 3 x Live Sessions on 9-11 January with everything you need to secure your grid post. ​ Small group coaching and 1:1 also available. ​ I want to get ready for my Grid Interviewt!

TOPIC OF THE WEEK: INTRAOSSEOUS ACCESS

When to go intraosseous (IO)?

Intraosseous (IO) is a rapid and effective method for accessing non-collapsible marrow veins without sacrificing pharmacokinetics.

Any delay in establishing vascular access can be potentially life-threatening.

The Royal Children’s Hospital Melbourne states, “In decompensated shock IO access should be established if IV failed or is going to be longer than 90 seconds”.

The decision to gain IO access should be considered in the following scenarios.

• Unsuccessful IV access
• Shock
• Sepsis
• ​Refractory seizure activity​
• Peri arrest / low flow state
• Cardiac arrest

​

​

What are the anatomical landmarks for IO access?

I considered all potential options for IO insertion before choosing the site most familiar to me– the proximal tibia. Other possible sites included:

• Distal tibia
• Distal femur
• Humeral head

Anatomical landmarks for the insertion site depend on whether you can palpate the tibial tuberosity. The tibial tuberosity does not develop until around two years of age. If you cannot feel the tibial tuberosity in the smaller child, palpate two fingerbreadths down from the inferior border of the patella, then one finger breath medial to this point. Where the tuberosity is palpable, go one fingerbreadth medial to it.

​

Target flat bone and pinch the tibia (especially in the very young patient) to reduce bone mobility and to prevent the skin from rotating with the driver before starting needle insertion.

​

​

How do you know if the IO is in the right place?

Attempt to aspirate marrow from your line (though it might not always be present). Flushing saline through with little to no resistance is very reassuring. No Flush = No Flow!

The line needs to be secured, and the extension tubing is attached properly with no identifiable leak points. What we give through the line should generate a physiological response – if it does not, always consider if the line has become displaced.

The proximal tibial site may not always be an option, so where else can we go?

Distal Tibia

Place one finger directly over the medial malleolus; move approximately 3 cm or two fingerbreadths proximal and palpate the anterior and posterior borders of the tibia to ensure that your insertion site is on the flat centre aspect of the bone.

​

Distal Femur

Midline, 2-3 cm above the external condyle or two fingerbreadths above the superior border of the patella. This is often an accessible site due to children having less muscle bulk. To ensure you avoid the growth plate, the leg should be outstretched when performing your landmarking above and aim about 15 degrees cephalad too.

Humeral Head:

The humeral head represents an excellent access point for large proximal vasculature (which lies closer to the heart). Flow rates may be higher here, too, due to lower intramedullary pressures. The greater tuberosity secondary ossification centre doesn’t appear until about five years of age, making the palpation of this landmark more of a challenge in the younger child. For this reason, it is more often used in older children, typically over seven years of age or only in those in whom the anatomy can be readily identified.

You may need to consider using a longer needle here due to the larger amount of soft tissue over this axillary area.

The insertion site is located directly on the most prominent aspect of the greater tubercle, 1 cm above the surgical neck. The surgical neck is where the bone juts out slightly – you will find this by running a thumb up the anterior aspect of the humerus until you feel a prominence. This is the greater tuberosity. The insertion site is approximately 1cm above this.

​

It is important to position the arm correctly.

Humeral IO placement techniques:

• Thumb to Bum – Move the patient’s hand (on the targeted arm) so that the patient’s thumb and dorsal aspect of the hand rest against the hip (“thumb-to-bum”).
• Palm to umbilicus – Move the patient’s hand (on the targeted arm) so that the palm rests over the umbilicus while maintaining the elbow close to the body.

​

​
Read more about intraosseous access in Gavin Hoey, Owen Keane, and Gyula Tovishazi's post here.

Not up to speed on managing paediatric minor injuries? ​ Check out our brand new Minor Injuries eBook which is the first in the series. ​ Get your copy now! YES! I WANT TO MASTER MINOR INJURIES

HIGHLIGHT: THE NEED FOR DEBRIEFS

In the realm of healthcare, the significance of clinical debriefing cannot be overstated. It emerges as a vital learning conversation, particularly in the aftermath of critical events, fostering a collective understanding within the entire medical team.

​

Sonia Twigg, a Paediatric Emergency Physician, shares insights into the significance of debriefing, particularly focusing on “hot debriefs" in the video below.

​

​

​

These discussions occur promptly after an event or, at the latest, by the end of a shift, aligning seamlessly with the workflow of emergency department physicians.

​

While the enthusiasm for debriefing is unanimous among clinicians, the implementation falls short of the ideal frequency. Despite its acknowledged value, barriers such as workload constraints, lack of institutional guidelines, and insufficient training impede the regularity of these crucial conversations. Addressing these barriers becomes paramount as clinical debriefing transcends mere individual learning; it evolves into a catalyst for team enhancement and system-wide improvement.

​

Benefits of Debriefing

Clinical debriefing offers a multifaceted approach to professional and personal development within healthcare settings.

​

Firstly, it serves as an invaluable educational tool, providing individuals with the opportunity to learn and grow through constructive feedback. This aspect is crucial for ongoing improvement, ensuring healthcare professionals can adapt and enhance their skills based on real-world experiences.

​

Additionally, debriefing plays a pivotal role in emotional processing, offering a structured environment for individuals to navigate and process the complex emotions that may arise after challenging cases. By acknowledging and addressing these emotions, healthcare professionals can foster resilience and maintain their well-being.

​

Moreover, the team support aspect of debriefing is integral to building a culture of solidarity and mutual learning. Through open discussions, team members can share their unique perspectives and insights, creating a collaborative environment where collective experiences contribute to the growth and cohesion of the entire healthcare team. In essence, the benefits of debriefing extend beyond individual skill enhancement, encompassing emotional well-being and fostering a sense of camaraderie and shared learning among healthcare professionals.

​

Practical Steps for Debriefing

There are many valuable tools to enhance the process. One such tool is the “Critical Incident Debriefing Toolkit” authored by Liz Crowe. This resource serves as a comprehensive guide, offering detailed steps to structure and optimise debriefing sessions.

​

The debriefing process encompasses several specific stages. These include pre-briefing, wherein objectives are set, facilitator roles are assigned, and the groundwork for the session is established. The reactions phase follows, providing a platform for participants to express their thoughts and emotions. Subsequently, a structured summary of the discussion ensues, facilitating a cohesive understanding of key takeaways. To further enhance the reflective process, Dr. Twigg introduces a plus-delta analysis, emphasising both positive aspects and areas for improvement.

​

In addition to these structured approaches, you can incorporate online tools to augment the debriefing experience. Platforms such as the “Talk Foundation” offer supplementary resources, contributing to the richness and effectiveness of the overall debriefing strategy.

​

To read more about this see Andy Tagg's full post here.

EVENT OF THE WEEK

January is Folic Acid awareness month.

​

Check out Lydia Garside's post on spina bifid to help understand the importance of folic acid in pregnancy here.

​

TIP OF THE WEEK

Salbutamol does not help babies with bronchiolitis.

​

Resist the urge to trial it in the under 1s!

​

Read more here.

​

JOKE OF THE WEEK

Why don't skeletons fight each other?

​

They don't have the guts!

​

That's it for this week, Reader.

​

Remember, your work makes a difference in the lives of paediatric patients every day.

​

Stay tuned for next week's edition of Bursting The Bubble.

​

From Tessa (on behalf of Team DFTB)

​

P.S. If you want to forward this email to someone who would enjoy the newsletter too, they can sign up here.

​

No longer interested in these emails? Click here to unsubscribe​