John M. Howell

Early Pediatric Emergency Department Return Visits: A Prospective Patient-Centric Assessment

Background A substantial percentage of emergency department (ED) patients return within 72 hours of their initial evaluation. Quality reviews typically demonstrate that most revisits do not seem to be directly related to problematic care provided on the first evaluation. We examined the possibility that return visits are related to nonmedical issues on the first visit, most notably patient discharge education. Objective We prospectively surveyed a convenience sample of caregivers in a pediatric ED to determine why they returned with their children within 72 hours of their initial ED visit. Design/Methods All patients who returned within 72 hours of a previous visit were identified and prospectively interviewed using a survey instrument with nominal (multiple choice) and brief descriptive responses. Results Caregivers of 124 children were prospectively surveyed; 93 children (75%) returned because their symptoms had not improved or worsened. Only 50 (53%) had contacted their primary medical doctor (PMD) prior to the second visit; of these, 14 (28%) could not get an appointment, and 32 (64%) were told to return to the ED. Discharge instructions were felt to be informative by 94% (n = 86) of caregivers with the same number (94%) reported being satisfied with the first ED physician. Twenty-nine children (30%) were admitted on the second visit. Conclusions Among children who are discharged from the emergency department and return within 72 hours, most caregivers are satisfied with the care and instructions provided on their first visits. Though most patients have a PMD, many do not call them prior to their return ED visit, and those who do either cannot schedule an appointment or are told to return to the ED. The majority of patients return for clinical progression of illness.

Factors That Influence Medical Student Selection of an Emergency Medicine Residency Program: Implications for Training Programs

OBJECTIVES An understanding of student decision-making when selecting an emergency medicine (EM) training program is essential for program directors as they enter interview season. To build upon preexisting knowledge, a survey was created to identify and prioritize the factors influencing candidate decision-making of U.S. medical graduates. METHODS This was a cross-sectional, multi-institutional study that anonymously surveyed U.S. allopathic applicants to EM training programs. It took place in the 3-week period between the 2011 National Residency Matching Program (NRMP) rank list submission deadline and the announcement of match results. RESULTS Of 1,525 invitations to participate, 870 candidates (57%) completed the survey. Overall, 96% of respondents stated that both geographic location and individual program characteristics were important to decision-making, with approximately equal numbers favoring location when compared to those who favored program characteristics. The most important factors in this regard were preference for a particular geographic location (74.9%, 95% confidence interval [CI] = 72% to 78%) and to be close to spouse, significant other, or family (59.7%, 95% CI = 56% to 63%). Factors pertaining to geographic location tend to be out of the control of the program leadership. The most important program factors include the interview experience (48.9%, 95% CI = 46% to 52%), personal experience with the residents (48.5%, 95% CI = 45% to 52%), and academic reputation (44.9%, 95% CI = 42% to 48%). Unlike location, individual program factors are often either directly or somewhat under the control of the program leadership. Several other factors were ranked as the most important factor a disproportionate number of times, including a rotation in that emergency department (ED), orientation (academic vs. community), and duration of training (3-year vs. 4-year programs). For a subset of applicants, these factors had particular importance in overall decision-making. CONCLUSIONS The vast majority of applicants to EM residency programs employed a balance of geographic location factors with individual program factors in selecting a residency program. Specific program characteristics represent the greatest opportunity to maximize the success of the immediate interview experience/season, while others provide potential for strategic planning over time. A working knowledge of these results empowers program directors to make informed decisions while providing an appreciation for the limitations in attracting applicants.

Are one or two dangerous? Clonidine and topical imidazolines exposure in toddlers

Clonidine and the imidazolines, commonly found in topical ophthalmic and nasal decongestants, are chemically related drugs that have been responsible for many pediatric poisonings. These medications can cause significant morbidity in small doses. A review of the available literature reveals that young children have exhibited severe signs and symptoms after ingesting as little as one to two clonidine tablets or 2.5 ml of a topical imidazoline product. Central nervous system depression, respiratory depression, and cardiovascular instability are the most common features of poisoning. Signs and symptoms develop rapidly, within 4-6 h. Care is supportive. Death is rare, but many poisoned patients require monitoring in an intensive care setting.

Inhalational Anthrax Due to Bioterrorism: Would Current Centers for Disease Control and Prevention Guidelines Have Identified the 11 Patients with Inhalational Anthrax from October through November 2001?

A panel of 10 physicians used the nominal group technique to assess the ability of the Centers for Disease Control and Prevention (CDC) interim guidelines for clinical evaluation of persons with possible inhalational anthrax (IA) to retrospectively identify the 11 patients with IA seen during the October 2001 bioterrorism outbreak. The guidelines would not have identified 10 of 11 of these patients, primarily because the guidelines were designed to address only those patients with a known history of exposure or clearly identified environmental or occupational risk. The panel suggested revisions to the guidelines, primarily consisting of broadening the criteria for evaluation to include either known exposure or environmental occupational risk, or to include clinical symptoms consistent with IA. These extensions of the guidelines retrospectively identified 8 of 11 of the patients with IA from October 2001.

Serious Infectious Complications Related to Extremity Cast/Splint Placement in Children

BACKGROUND Extremity injuries necessitating splinting or casting are commonly seen in the emergency department (ED) setting. Subsequently, it is not uncommon for patients to present to the ED with complaints related to an extremity cast or splint. OBJECTIVE To present a literature-based approach to the identification and initial management of patients with possible infectious cast/splint complications in the ED setting. CASE REPORTS We present two cases of serious infectious complications arising from extremity cast/splint placement seen in a single pediatric ED: a case of toxic shock syndrome in an 8-year-old child, and a case of necrotizing fasciitis resulting in upper extremity amputation in a 3-year-old child. CONCLUSIONS/SUMMARY A wide spectrum of potential extremity cast/splint infectious complications may be seen, which include limb- or life-threatening infections such as toxic shock syndrome and necrotizing fasciitis. Simply considering these diagnoses, and removing the cast or splint to carefully inspect the affected extremity, are potential keys to early identification and optimal outcome of cast/splint complications. It is also prudent to maintain particular vigilance when treating a patient with a water-exposed cast, which may lead to moist padding, skin breakdown, and potential infection. In patients with suspected serious infections, aggressive fluid management and antibiotic therapy should be initiated and appropriate surgical consultation obtained without delay.

Pediatric Genitourinary Emergencies

Pediatric medical complaints and differential diagnoses often vary from adults, requiring a specialized knowledge base and behavioral skill set. This article addresses a variety of congenital and acquired pediatric genitourinary disorders. Genitourinary emergencies include paraphismosis, priapism, serious infection, significant traumatic injury and gonadal torsion.

ACUTE MYOCARDIAL INFARCTION AND CONGESTIVE HEART FAILURE

The effective treatment of patients with acute myocardial infarction (AMI) and acute congestive heart failure (CHF) requires quick triage, accurate identification, and appropriate pharmacologic management. This article describes the initial assessment and management of adult patients with AMI and CHF, beginning with the first interaction of such patients with the emergency department staff.