Daniel W. Ochsenschlager

Communicating bad news: a pediatric department's evaluation of a simulated intervention.

Objective. To determine if pediatric residents and emergency department (ED) fellows could improve their ability to counsel and inform standardized patients (SPs) about bad news. Methodology. A crossover, self-controlled design in which trainees were their own control individuals, and SPs provided feedback after the first interview. The setting was the consultation room in the ED of a large childrens hospital. The outcome measures included examining the counseling and informing skills of study participants. Results. Trainees improved their informing skills after being provided feedback in the broad areas of communication and follow-up and in the total number of content areas asked. Their counseling skills improved in two areas: 1) promoting more trust and 2) making parents feel less dependent. Those trainees who scored higher on counseling skills discussed more total and critical content issues with SPs in the study. Trainee feedback revealed a very high rating of the educational process, and the trainees also felt much more confident about their skills after the first and second sessions. Conclusions. Using SPs to teach residents and ED fellows to give bad news is an effective educational process that provides trainees with interactions that simulate real-life experience

Age and outcome in pediatric cervical spine injury: 11-year experience

Age-related outcome in children with cervical spine injury has not been previously reported. We performed a retrospective chart review of all children with cervical spine injury who presented to a childrens hospital during an 11-year period; 73 patients were identified. Their mean age was 8.6 years, with bimodal peaks at 2 to 4 and 12 to 15 years. Sixty-seven percent of the injuries were traffic-related, resulting from motor vehicle crashes affecting passengers, pedestrians, or bicyclists. Distraction and subluxation injuries were the most common injuries in children aged eight years or younger, whereas fractures were more common in older children. Younger children sustained more severe injuries than older children, as measured by the Revised Trauma Score, Injury Severity Score, and Trauma Score-Injury Severity Score estimated probability of survival, and were more likely to sustain injuries to higher levels of the cervical spine. Deaths occurred exclusively in children eight years old or younger, but the rate of occurrence of neurologic disability was similar in both groups: 26% in those eight years old and under, and 25% in those more than eight years old. The mortality in younger patients was not caused exclusively by the higher level of cervical injury, but it occurred more often in the presence of head injury and multiple trauma.

Conservative management of pediatric distal esophageal coins

Management of the child with an esophageal coin has typically included an invasive coin removal procedure, usually endoscopy. Coins in the distal esophagus, however, often pass spontaneously into the stomach in the first 24 h after coin ingestion, suggesting that conservative management alone may be effective. Four children with distal esophageal coins who were successfully managed without an invasive procedure are presented. Recommendations for conservative management are given. Further study of the effectiveness of conservative management of distal esophageal coins in healthy children is warranted.

Conscious sedation of the pediatric patient for suturing: a survey.

No single drug or combination of drugs was used routinely in pediatric emergency departments to sedate children for suturing. A meperidine-promethazine-chlorpromazine “cocktail” was chosen most frequently. Many physicians were dissatisfied with the method they selected, however, leading some to experiment with newer medications such as fentanyl. The American Academy of Pediatrics (AAP) guidelines for the elective use of conscious sedation, specifically, those regarding monitoring during sedation and discharge post sedation, were not adhered to uniformly. Further study of conscious sedation in children is needed.

Spontaneous passage of coins lodged in the upper esophagus.

Coin ingestion with subsequent esophageal coin impaction is common in children. Although spontaneous passage to the stomach of coins at the gastroesophageal sphincter is fairly common, spontaneous passage of coins from the upper or mid-esophagus has only rarely been reported. Thus, in an effort at cost savings, an endoscopist might forego obtaining a second set of radiographs prior to removal of an esophageal coin. We present two cases of spontaneous passage of coins from the upper esophagus, both of which occurred hours after coin ingestion. These cases suggest that spontaneous passage of proximal esophageal coins does, in fact, occur in some children. A second set of radiographs, therefore, may identify these children, and prevent unnecessary invasive removal procedures.

Bilateral Femur Fractures

Figure 1. Bilateral Femur Fractures. Bilateral femur fractures are visible in a nine-month-old boy who was restrained with only a standard lap belt in the rear seat of an automobile that struck a post at 40 miles (65 km) per hour. The child required hospitalization and a prolonged period in a spica cast. A proper car seat is the only appropriate restraint for a small child.