Commentary

The story of Jack is typical for many children, although for two serious problems to happen for the same child is rather unlucky. Medically his issues are that he has a viral croup, which needs treatment with intravenous (or oral, although the option is not given) steriods. He then has an inhaled foreign body, which needs to be removed at bronchoscopy. The challenge here is preparing the patient appropriately, as the bronchoscopy is not indicated based on the history initially given. 

Not recognizing the severity of illness in either of these admissions leads to a spell on PICU, and depending on the choices taken, substantial risk of death.

The case not only looks at common causes of respiratory distress in children, but also examines common types of medical error.

Decision steps 1: Fixation, ignorance, poor teamworking, bravado/timidity

The first part of the case sees the patient in Accident and Emergency with difficulty in breathing. There are of course many causes for this in childhood, and a good history and examination is key to identifying the cause, and identifying the severity of the condition. Key information is the stridor, work of breathing and saturations.

Treated optimally, Jack is given steroids immediately. The longer the interval between presentation and the steroids, the more unwell he becomes. Some sets of choices see Jack discharged home immediately, but others see him intubated, and one set even a crash call to accident and emergency. The route that leads to this is particularly slow in administering the steroids, demonstrating timidity. Some pathways will be chosen if players become fixated on a particular cause.

Ignorance of the mode of action and behavior of adrenaline leads to inappropriate reassurance when Jack improves after an adrenaline nebulizer. While this can give time for a more definitive action (steroids, intubation), alone it merely delays effective treatment and exposes the patient to danger.

The team and communication is important. Players of the case should identify if or when they are out of their depth and call the consultant. Bravado in continuing to attempt to manage the child as he deteriorates is very dangerous, and not identifying his deterioration (saturations, change in stridor) demonstrates a lack of skill.

Decision steps 2: Fixation, Triage, Ignorance, Insufficient skill, Playing the odds

In this section of the case, the child represents with another breathing problem. The key to its identification is the unequal breath sounds – suggesting that he has either a pneumothorax, pneumonia or an inhaled foreign body blocking a bronchus. The definitive test and treatment is a bronchoscopy, but this is not a realistic procedure until he has had a chest radiograph, showing none of these conditions (see below) and a full history has been taken. The history is important as the rapid onset of symptoms is common in inhaled foreign body. Without the radiograph and the detailed history, a bronchoscopy is not the best option for the child.

Before discussing where players may become mislead, it is worth noting that the chest radiograph is not normal – the right side is hyperinflated compared to the left, typical for a child with a partial obstruction in the right main bronchus.

By this stage in the case, Jack has had a number of respiratory problems – bronchiolitis, croup, a provisional diagnosis of asthma and now this presentation. Initial players may become fixated on asthma as a cause, but as the child does not improve with salbutamol, this is not likely. Further fixation may lead to inappropriate use of adrenaline or steroids at this stage too. Inhaled foreign body is much less common than asthma, and players may favour asthma as a diagnosis if they are playing the odds.

A child with a respiratory condition that is not obvious may legitimately have a chest radiograph taken to better identify the cause. Insufficient skill in reading the radiograph may prevent players seeing the subtle suggestions that the child has a foreign body inhalation rather then another cause.

Ignorance of inhaled foreign body may hinder students working out the best options, but should not be the reason that Jack is sent home. Triage ability is required to identify that there is a serious problem with Jack and this should be picked up from his low saturations in air.

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