Jennifer Walthall

Best Educational Practices in Pediatric Emergency Medicine During Emergency Medicine Residency Training: Guiding Principles and Expert Recommendations

The state of pediatric emergency medicine (PEM) education within emergency medicine (EM) residency programs is reviewed and discussed in the context of shifting practice environments and new demands for a greater focus on the availability and quality of PEM services. The rapid growth of PEM within pediatrics has altered the EM practice landscape with regard to PEM. The authors evaluate the composition, quantity, and quality of PEM training in EM residency programs, with close attention paid to the challenges facing programs. A set of best practices is presented as a framework for discussion of future PEM training that would increase the yield and relevance of knowledge and experiences within the constraints of 3- and 4-year residencies. Innovative educational modalities are discussed, as well as the role of simulation and pediatric-specific patient safety education. Finally, barriers to PEM fellowship training among EM residency graduates are discussed in light of the shortage of practitioners from this training pathway and in recognition of the ongoing importance of the EM voice in PEM.

Nuances in pediatric trauma.

Pediatric trauma evaluation mimics adult stabilization in that it is best accomplished with a focused and systematic approach. Attention to developmental differences, anatomic and physiologic nuances, and patterns of injury equip emergency physicians to stabilize and manage pediatric injury.

Emergency department transport rates of children from the scene of motor vehicle collisions: do booster seats make a difference?

Background Motor vehicle collisions (MVCs) are the leading cause of death and disability among children older than 1 year. Many states currently mandate all children between the ages of 4 and 8 years be restrained in booster seats. The implementation of a booster-seat law is generally thought to decrease the occurrence of injury to children. We hypothesized that appropriate restraint with booster seats would also cause a decrease in emergency department (ED) visits compared with children who were unrestrained. This is an important measure as ED visits are a surrogate marker for injury. Objective The main purpose of this study was to look at the rate of ED visits between children in booster seats compared with those in other or no restraint systems involved in MVCs. Injury severity was compared across restraint types as a secondary outcome of booster-seat use after the implementation of a state law. Methods A prospective observational study was performed including all children 4 to 8 years old involved in MVCs to which emergency medical services was dispatched. Ambulance services used a novel on-scene computer charting system for all MVC-related encounters to collect age, sex, child-restraint system, Glasgow Coma Scale score, injuries, and final disposition. Results One hundred fifty-nine children were studied with 58 children (35.6%) in booster seats, 73 children in seatbelts alone (45.2%), and 28 children (19.1%) in no restraint system. 76 children (47.7%), 74 by emergency medical services and 2 by private vehicle, were transported to the ED with no significant difference between restraint use (P = 0.534). Utilization of a restraint system did not significantly impact MVC injury severity. However, of those children who either died (n = 2) or had an on-scene decreased Glasgow Coma Scale score (n = 6), 75% (6/8) were not restrained in a booster seat. Conclusions The use of booster-seat restraints does not appear to be associated with whether a child will be transported to the ED for trauma evaluation.

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.

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.

Before the Flood: Impact of Coordination of Care and Direct Admissions on Emergency Department Volumes

Background Transfers of pediatric patients occur to access specialty and subspecialty care, but incur risk, and consume resources. Direct admissions to medical and surgical wards may improve patient experience and mitigate resource utilization. Objective We sought to identify common elements for direct admissions, as well as the pattern of disposition for patients referred to our emergency department (ED). Design A retrospective qualitative analysis of patients transferred to our pediatric hospital for 12 months was performed. Different physician groups were evaluated for use of direct admissions or evaluation in the ED. Patients referred to the ED were additionally tracked to evaluate their eventual disposition. Results A total of 3982 transfers occurred during the 12-month analysis period. Of those, 3463 resulted in admission, accounting for 32.55% of all admissions. Transfers accepted by nonsurgical services accounted for 82% of the transfers, whereas 18% were facilitated by one of the surgical services. Direct admissions accounted for 1707 (44.8%) of all referrals and were used more often by nonsurgical services. Of patients referred to the ED (2101 or 55.2% of all referrals), most patients were admitted and 343 (16% of those referred to the ED) were discharged home. Conclusions The direct admission process helped avoid ED assessments for some patients; however, some patients referred to the ED were able to be evaluated, treated, and discharged. Consistent triage of the patients being transferred as direct admissions may improve ED throughput and potentially improve the patients experience, reduce redundant services, and expedite care.

Give sorrow words

A s emergency physicians, we spend a disproportionate amount of time delivering bad news. We are charged with the task of becoming adept, perhaps even expert, messengers of tragedy. We discuss unexpected, life-altering information lacking any longstanding relationships with our patients, positioned in a loud chaotic environment, and with other patients literally needing our care right now. Despite these situational barriers, residency training with faculty and ancillary service (chaplaincy, social work) feedback molds the emergency physician into a compassionate and masterful harbinger of doom. When we deliver bad news, we engage all our senses. We emote and respond, change tone in response to tears, agitation, pleading, or confusion. We ask for ancillary assistance if there is the smell of alcohol. We look for other family with injuries or illness. My approach to death telling began before the era of formal training and certainly suffered through many uncomfortable revisions. Now as a faculty member, I have the benefit of hindsight and evidence-based training modules like Dr. Cherri Hobgood’s cited GRIEV_ING mnemonic. I sign our residents’ competency forms for delivering bad news only after I have directly observed their experience and am more demanding in this particular milestone than in any other ‘‘procedure’’ except for airway management. So, what to do with delivering this news stripped of four of the five senses? Remote death telling seems to me to be like intubating a patient with a dim light on the blade and missing your left contact lens—I have seen it done, but it was not pretty. The process is missing; there is no family presence at the bedside during resuscitation, no quiet room, no chaplain, no box of tissue, no favorite nurse to hold a mother’s hand. We work in an environment where control is a meager resource, but talking about death on the phone can take the last measure of control out of the picture. Given this, death telling over the phone should be avoided if at all possible. There are a few facts from nonmedical specialties that bear this out: 1) the military does not deliver bad news by phone; 2) best practices in business management discourage firing by phone or e-mail; 3) lawyers are encouraged to deliver unfavorable case outcomes in person if at all possible; and 4) the British consul in Thailand has a phone protocol to inform next of kin of their loved ones as the victims of bombing, crash, or kidnapping. It suggests half an hour of uninterrupted time with multiple follow-up calls and an office debrief. But, this is the reality of real-time decision-making in the emergency department. This resident did not have the option to wait 5 hours. He had no specific emergency medicine literature to guide him and no obvious support surrounding him. How will he respond in the next event without knowing for certain if he was right? Several recommendations emerge from this portfolio. The first is a clarion call to academic faculty. Attend to your residents in death telling. This unique experience by phone would have been uncomfortable in any situation, but much of the reflection and answers to the questions that remain in his mind could have been efficiently addressed before the phone call was made, in a collaborative and supportive way. Even putting the call on speakerphone would have allowed for a postconversation debrief and feedback. Anticipating problems before they occur is the job of the teaching faculty, and this experience falls squarely in that category. Second, as in all of emergency medicine, we are built to modify. The GRIEV_ING education module points out the limitations in effective delivery of bad news remotely, but also demonstrates that it is possible to utilize specific elements when hard-pressed. If we cannot Gather, perhaps we do more Give. Ask the family to call the original provider or have them paged when they arrive for specific information. Or, move Space up to the beginning of the conversation, saying, ‘‘I am taking care of your loved one in the emergency department. Can you call me back in a moment if you are not in a good place to talk?’’ If that initial conversation seems high risk, deliver preliminary information only and help arrange safe transport, even a police escort if necessary. Although neither the American Red Cross nor individual state police agencies help with transportation other than for military families, state police are willing to help coordinate with other states for bad news delivery, especially if they are involved in investigating an accident or incident (personal communications: American Red Cross of Indianapolis and Indiana State Police). Use their car ride as Space, allowing for processing, assuring that someone else is with them for the drive. Do not deliver bad news while someone is driving. Families will not be able to directly access departmental Resources, so inquire of chaplaincy or