Dale P. Woolridge

Point-of-care ultrasonography by pediatric emergency medicine physicians

Emergency physicians have used point-of-care ultrasonography since the 1990s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews.

Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Point-of-Care Ultrasonography by Pediatric Emergency Physicians

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

The "Good" Dean's Letter

Purpose To determine whether a correlation exists between the term “good” on the summative, comparative assessment of a students Medical Student Performance Evaluation (MSPE) and his or her actual performance in medical school. Method The authors reviewed the MSPEs submitted to three residency programs to determine the presence of the term “good” in either the summary paragraph or the appendices. Next, they noted, for institutions using “good,” the percentile rankings of those students who received “good” as a descriptor. To examine the consistency among institutions regarding the percentile ranking denoted by “good,” they dichotomized the data into students below and above the bottom 25th percentile. They analyzed the data using a nonparametric test because of their nonnormal distribution. Results The authors collected MSPEs from 122 of the 125 Liaison Committee on Medical Education–accredited medical schools that were graduating students in 2008. Of these 122 institutions, 34 (28%) used the term “good.” All 34 institutions used the term to characterize students in the bottom 50% of the graduating class. The authors found a significant difference in the percentile ranking of students described as “good” between institutions using it to describe the bottom 25% and institutions using the term to describe those in the 25th to 50th percentiles (median ranking of 12.5% versus 30%, P < .0001). Conclusions Overall, the term “good” in the MSPE describes students in the bottom 50% of the class; therefore, the term “good,” as used to describe performance in medical school, consistently indicates below-average performance.

THE EFFECTS OF RESIDENT LEVEL OF TRAINING ON THE RATE OF PEDIATRIC PRESCRIPTION ERRORS IN AN ACADEMIC EMERGENCY DEPARTMENT

BACKGROUND Medication errors are a leading cause of increased cost and iatrogenic injury in the pediatric population. In the academic setting, studies have suggested that these increased error rates are related primarily to resident inexperience, thus advocating a higher level of supervision. STUDY OBJECTIVE We sought to identify the number of prescription errors in our institutions academic Emergency Department, how this varied between the beginning and end of the academic year and between practitioners at varying levels of training. METHODS A retrospective review of computer-based outpatient prescriptions for children aged 0-12 years old was performed. Outpatient prescriptions were reviewed during a 2-week time block at the end of the academic year and beginning of the academic year (109 [June] and 111 [July] data sets, respectively). Prescriptions were retrieved electronically and reviewed for appropriate dosing. Errors were defined as those that varied>10% above or below recommended weight-based dosing. RESULTS Twenty-nine (16.1%) of 180 written prescription orders were determined to be incorrectly written. Error rates were not significantly different between the beginning and end of the academic year. In both sampling periods, a higher percentage were found to be derived from senior level practitioners in both data sets (9/14 and 10/15; respectively), but few of these were considered high-grade prescription errors. CONCLUSIONS Overall prescription error rates at our institution are comparable to nationally reported error rates in children. Error rates were not associated with newly matriculated residents. These findings dispute previously held opinion that physician level of training is a factor of prescription errors.

Cyclic adenosine monophosphate accumulation and β-adrenergic binding in unweighted and denervated rat soleus muscle

Unweighting, but not denervation, of muscle reportedly “spares” insulin receptors, increasing insulin sensitivity. Unweighting also increases β-adrenergic responses of carbohydrate metabolism. These differential characteristics were studied further by comparing cyclic adenosine monophosphate (cAMP) accumulation and β-adrenergic binding in normal and 3-day unweighted or denervated soleus muscle. Submaximal amounts of isoproterenol, a β-agonist, increased cAMP accumulation in vitro and in vivo (by intramuscular [IM] injection) to a greater degree (P < .05) in unweighted muscles. Forskolin or maximal isoproterenol had similar in vitro effects in all muscles, suggesting increased β-adrenergic sensitivity following unweighting. Increased sensitivity was confirmed by a greater receptor density (Bmax) for [125I]iodo-(−)-pindolol in particulate preparations of unweighted (420 · 10−18 mol/mg muscle) than of control or denervated muscles (285 · 10−18 mol/mg muscle). The three dissociation constant (Kd) values were similar (20.3 to 25.8 pmol/L). Total binding capacity (11.4 fmol/muscle) did not change during 3 days of unweighting, but diminished by 30% with denervation. This result illustrates the “sparing” and loss of receptors, respectively, in these two atrophy models. In diabetic animals, IM injection of insulin diminished cAMP accumulation in the presence of theophylline in unweighted muscle (−66% ± 2%) more than in controls (−42% ± 6%, P < .001). These results show that insulin affects cAMP formation in muscle, and support a greater in vivo insulin response following unweighting atrophy. These various data support a role for lysosomal proteolysis in denervation, but not in unweighting, atrophy.

Emerging Concepts in Pediatric Emergency Radiology

Radiologic studies are a vital component in the workup and diagnosis of disease. An appropriate radiographic study will accurately rule in or rule out disease with the least possible harm. Special considerations are necessary for the imaging of children. Current trends in pediatric imaging support the increased use of ultrasound and magnetic resonance imaging to decrease radiation exposure. In this review, we highlight some of the emerging concepts in the radiographic workup of pediatric disease, with a focus on decreasing ionizing radiation, increasing ultrasound use, and using clinical decision rules to identify children who do not need imaging.

Handoffs: Transitions of care for children in the emergency department

Transitions of care (ToCs), also referred to as handoffs or sign-outs, occur when the responsibility for a patient’s care transfers from 1 health care provider to another. Transitions are common in the acute care setting and have been noted to be vulnerable events with opportunities for error. Health care is taking ideas from other high-risk industries, such as aerospace and nuclear power, to create models of structured transition processes. Although little literature currently exists to establish 1 model as superior, multiorganizational consensus groups agree that standardization is warranted and that additional work is needed to establish characteristics of ToCs that are associated with clinical or practice outcomes. The rationale for structuring ToCs, specifically those related to the care of children in the emergency setting, and a description of identified strategies are presented, along with resources for educating health care providers on ToCs. Recommendations for development, education, and implementation of transition models are included.

Death of a Child in the Emergency Department

The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have collaborated to identify practices and principles to guide the care of children, families, and staff in the challenging and uncommon event of the death of a child in the emergency department in this policy statement and in an accompanying technical report.

Evaluation of Child Maltreatment in the Emergency Department Setting: An Overview for Behavioral Health Providers.

Emergency providers are confronted with medical, social, and legal dilemmas with each case of possible child maltreatment. Keeping a high clinical suspicion is key to diagnosing latent abuse. Child abuse, especially sexual abuse, is best handled by a multidisciplinary team including emergency providers, nurses, social workers, and law enforcement trained in caring for victims and handling forensic evidence. The role of the emergency provider in such cases is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and provide an ethical testimony if called to court.