Care of children with medical complexity and technology dependence — branching viva

Opening stem

A 6-year-old boy arrives by car at 02:10. He has a tracheostomy and home ventilator. His mother says he is less interactive than usual and the ventilator has been alarming for an hour. SpO2 on the monitor is 84%. There is no emergency care plan in the electronic record. [1]

Branch A — First actions

Examiner: What do you do in the first minute? [13]

Strong answer: Call for help. ABCDE with technology. Open oxygen, assess tracheostomy and circuit, suction, prepare for tube change if obstructed or dislodged, bag if needed. Compare to baseline. Do not park him as “baseline complex.” [1]

Fail cues: Sending for bloods first; dismissing parental concern; waiting for specialty teams before airway action. [1]

Branch B — Definitions

Examiner: Is this child “CMC”? Define your terms. [1]

Strong answer: Yes if domains align: chronic multi-system disease, functional limitation, high service use, family-identified needs (Cohen). Technology dependence is the device-critical overlay. Kuo AAP report frames recognition and management across the life course. [1]

Branch C — Tools vs bedside

Examiner: The data team says his PMCA stratum is complex chronic. How does that change tonight? [3]

Strong answer: It confirms population complexity for services. It does not give a severity number for the next ten minutes. Bedside assessment and device check still rule. CCC similarly classifies chronic multi-system disease/technology for data systems. [1]

Branch D — After stabilisation

Examiner: Tube suction clears thick plugs; SpO2 returns to his usual 94%. What next? [1]

Strong answer: Full reassessment; search for infection/aspiration triggers; review emergency plan gap; medication and feed plan; admission capability; structured handoff; caregiver support; create/update emergency care plan before discharge. [1]

Branch E — Systems and equity

Examiner: A junior says “he’s always like this.” Respond. [18]

Strong answer: Challenge diagnostic overshadowing and discrimination against CMC. Ask what is different from this child’s baseline. Caregiver burden is high in complex care households; listening is a safety behaviour. [1]

Branch F — Evidence close

Examiner: Quote one evidence point on handoffs and one on caregiver burden. [1]

Strong answer: Starmer structured handoff programme reduced medical errors. Kuo caregiver profile shows high coordination and life burden among caregivers of more medically complex children. [1]

Scoring anchors

• Separates device failure from disease progression. [13]
• Uses Cohen/Kuo language without inventing PEWS-like PMCA scores. [1]
• Builds emergency plan and medical-home steps. [1]
• Names caregiver concern as data and avoids overshadowing. [1]