Elizabeth Weinstein

Effect of introducing the mucosal atomization device for fentanyl use in out-of-hospital pediatric trauma patients.

BACKGROUND Pain associated with pediatric trauma is often under-assessed and under-treated in the out-of-hospital setting. Administering an opioid such as fentanyl via the intranasal route is a safe and efficacious alternative to traditional routes of analgesic delivery and could potentially improve pain management in pediatric trauma patients. OBJECTIVE The study sought to examine the effect of introducing the mucosal atomization device (MAD) on analgesia administration as an alternative to intravenous fentanyl delivery in pediatric trauma patients. The hypothesis for the study is that the introduction of the MAD would increase the administration of fentanyl in pediatric trauma patients. METHODS The research utilized a 2-group design (pre-MAD and post-MAD) to study 946 pediatric trauma patients (age <16) transported by a large, urban EMS agency to one of eight hospitals in Marion County, which is located in Indianapolis Indiana. Two emergency medicine physicians independently determined whether the patient met criteria for pain medication receipt and a third reviewer resolved any disagreements. A comparison of the rates of fentanyl administration in both groups was then conducted. RESULTS There was no statistically significant difference in the rate of fentanyl administration between the pre-MAD (30.4%) and post-MAD groups (37.8%) (P = .238). A subgroup analysis showed that age and mechanism of injury were stronger predictors of fentanyl administration. CONCLUSION Contrary to the hypothesis, the addition of the MAD device did not increase fentanyl administration rates in pediatric trauma patients. Future research is needed to address the barriers to analgesia administration in pediatric trauma patients.

Twelve tips for using applied improvisation in medical education

Abstract Future physicians will practice medicine in a more complex environment than ever, where skills of interpersonal communication, collaboration and adaptability to change are critical. Applied improvisation (or AI) is an instructional strategy which adapts the concepts of improvisational theater to teach these types of complex skills in other contexts. Unique to AI is its very active teaching approach, adapting theater games to help learners meet curricular objectives. In medical education, AI is particularly helpful when attempting to build students’ comfort with and skills in complex, interpersonal behaviors such as effective listening, person-centeredness, teamwork and communication. This article draws on current evidence and the authors’ experiences to present best practices for incorporating AI into teaching medicine. These practical tips help faculty new to AI get started by establishing goals, choosing appropriate games, understanding effective debriefing, considering evaluation strategies and managing resistance within the context of medical education.

Adolescent With Rash and Cough

A 12-year-old girl from rural Indiana presented to the emergency department for temperature of 40°C (104°F), cough, and a painful rash on her legs. Her symptoms began 1 month previously with cough and fever, with subsequent development of rash. Evaluation revealed a nontoxic, well-developed 12-year-old. She had a pulse of 142 beats/min, respiratory rate of 18 breaths/min, blood pressure of 110/67 mm Hg, and room air oxygen saturation of 99%. Her physical examination result was notable for anterior cervical adenopathy and tender erythematous nodular lesions on her lower extremities (Figure 1). Chest radiograph and chest Figure 1. Nodular skin lesions. Figure 2. Pulmonary nodule, right lung, on chest radiograph.

Frequency of Pediatric Emergencies in Ambulatory Practices

Through verification of EMS data, we objectively characterize the frequency and etiology of pediatric emergencies in ambulatory practices in a metropolitan area. BrightcoveDefaultPlayer10.1542/6138649665001PEDS-VA_2017-3082 Video Abstract BACKGROUND: Management of pediatric emergencies is challenging for ambulatory providers because these rare events require preparation and planning tailored to the expected emergencies. The current recommendations for pediatric emergencies in ambulatory settings are based on 20-year-old survey data. We aimed to objectively identify the frequency and etiology of pediatric emergencies in ambulatory practices. METHODS: We examined pediatric emergency medical services (EMS) runs originating from ambulatory practices in the greater Indianapolis metropolitan area between January 1, 2012, and December 31, 2014. Probabilistic matching of pickup location addresses and practice location data from the Indiana Professional Licensing Agency were used to identify EMS runs from ambulatory settings. A manual review of EMS records was conducted to validate the matching, categorize illnesses types, and categorize interventions performed by EMS. Demographic data related to both patients who required treatment and practices where these events occurred were also described. RESULTS: Of the 38 841 pediatric EMS transports that occurred during the 3-year period, 332 (0.85%) originated from ambulatory practices at a rate of 42 per 100 000 children per year. The most common illness types were respiratory distress, psychiatric and/or behavioral emergencies, and seizures. Supplemental oxygen and albuterol were the most common intervention, with few critical care level interventions. Community measures of low socioeconomic status were associated with increased number of pediatric emergencies in ambulatory settings. CONCLUSIONS: Pediatric emergencies in ambulatory settings are most likely due to respiratory distress, psychiatric and/or behavioral emergencies, or seizures. They usually require only basic interventions. EMS data are a valuable tool for identifying emergencies in ambulatory settings when validated with external data.

Teaching advocacy communication to pediatric residents: the efficacy of applied improvisational theater (AIT) as an instructional tool

ABSTRACT In today’s communication landscape, the public often turn to the Internet and social media instead of their physician for health information. To remain relevant and respected amidst the wealth of health information available online, physicians need to offer something the Internet cannot fully emulate: empathetic imagination and an ability to instantaneously tailor messages to reach and teach worried and often confused audiences effectively. We developed an instructional communication module for pediatric residents that used applied improvisational theater to help residents develop complex and dynamic communication skills. The module included opportunities to develop empathy, practice audience analysis, distill messages to key points, and apply these skills in media and community contexts. Attendees completed surveys regarding their perceptions of curricular structure, efficacy, and utility. Preliminary results indicate gains in communication confidence and skills. This type of instructional communication and training module encourages healthcare practitioners to position themselves as trusted experts and partners in helping clients make meaning of health information, thus empowering a new generation of pediatricians to bridge communication gaps created by new technologies and increased access to multiple information sources.

Mobile integrated health to reduce post-discharge acute care visits: A pilot study

Background: Mobile Integrated Health (MIH) leverages specially trained paramedics outside of emergency response to bridge gaps in local health care delivery. Study objective: To evaluate the efficacy of a MIH led transitional care strategy to reduce acute care utilization. Methods: This was a retrospective cohort analysis of a quality improvement pilot of patients from an urban, single county EMS, MIH transitional care initiative. We utilized a paramedic/social worker (or social care coordinator) dyad to provide in home assessments, medication review, care coordination, and improve access to care. The primary outcome compared acute care utilization (ED visits, observation stays, inpatient visits) 90 days before MIH intervention to 90 days after. Results: Of the 203 patients seen by MIH teams, inpatient utilization decreased significantly from 140 hospitalizations pre‐MIH to 26 post‐MIH (83% reduction, p = 0.00). ED and observation stays, however, increased numerically, but neither was significant. (ED 18 to 19 stays, p = 0.98; observation stays 95 to 106, p = 0.30) Primary care visits increased 15% (p = 0.11). Conclusion: In this pilot before/after study, MIH significantly reduces acute care hospitalizations.

Descriptive correlates of urban pediatric violent injury using emergency medical service patient-level data

Objective This study aimed to describe spatiotemporal correlates of pediatric violent injury in an urban community. Methods We performed a retrospective cohort study using patient-level data (2009–2011) from a novel emergency medical service computerized entry system for violent injury resulting in an ambulance dispatch among children aged 0 to 16 years. Assault location and patient residence location were cleaned and geocoded at a success rate of 98%. Distances from the assault location to both home and nearest school were calculated. Time and day of injury were used to evaluate temporal trends. Data from the event points were analyzed to locate injury “hotspots.” Results Seventy-six percent of events occurred within 2 blocks of the patients home. Clusters of violent injury correlated with areas with high adult crime and areas with multiple schools. More than half of the events occurred between 3:00 PM and 11:00 PM. During these peak hours, Sundays had significantly fewer events. Conclusions Pediatric violent injuries occurred in identifiable geographic and temporal patterns. This has implications for injury prevention programming to prioritize highest-risk areas.

Ambulance Transport of Noncritical Children Emergency Medical Service Providers’ Knowledge, Opinions, and Practice

Purpose. Safe ambulance transport of children presents unique challenges. Our study describes child passenger restraint practices during ambulance transport, Emergency Medical Service (EMS) providers’ knowledge, training, and use of child passenger restraint devices (CRD). Methods. A child passenger safety technician (CPST) recorded restraint used for pediatric ambulance transport. The CPST assessed and documented type of CRD used, securement, and whether the child was properly restrained. EMS providers’ knowledge, training, and CRD use for ambulance transport were assessed. Results. The study period spanned July 2009 to July 2010; 63 EMS personnel were interviewed and 40 children were observed. Approximately 75% of emergency medical technicians surveyed felt their knowledge of pediatric transport was adequate. Fourteen percent allowed a stable patient to be transported via parent’s lap. Twelve percent were transported unrestrained. None of the 11 patients, birth to 3 years, were found to be transported correctly. Conclusion. Study findings supports education and training of EMS personnel to improve the safe ambulance transport of children.

What Is the Role of Antiemetics in the Treatment of Children With Acute Gastroenteritis

DATA SOURCES The authors searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to July 2005), and EMBASE (1980 to July 2005). They also hand searched published abstracts from relevant conference proceedings and contacted content experts for unpublished data. This search was rerun in July 2006 and June 2008, yielding 2 additional trials. There were no language restrictions.