Joshua Ross

EYE ON CHILDREN: ACUTE WORK-UP FOR PEDIATRIC HORNER'S SYNDROME. CASE PRESENTATION AND REVIEW OF THE LITERATURE

BACKGROUND Ptosis and anisocoria in a child may be subtle indications of occult pathology, and making the observation acutely in the emergency department (ED) is important in guiding patient management and treatment. Emergency physicians must evaluate patients to exclude serious or life-threatening emergencies and ensure correct disposition of patients. Horner syndrome in children may be considered congenital or acquired and may be from benign or malignant causes. When an isolated, acquired Horner syndrome is suspected in a pediatric patient, physical examination of the neck and abdomen for masses, as well as spot urine catecholamines, vanillylmandelic acid and homovanillic acid, and varying degrees of imaging are recommended as part of the initial evaluation. These evaluations may be performed in the ED or may require hospitalization, depending on the suspected anatomical localization and diagnostic considerations. CASE REPORT A 21-month-old, normally developed girl presented to the University Hospital ED with a 2-h history of right-sided eyelid drooping in the setting of a febrile illness. An eventual diagnosis of Horner syndrome from cervical lymph node compression was made on the basis of history, examination, and imaging findings. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ED evaluations of pediatric patients differ from adults. Evaluation and work-up of Horner syndrome in children can be challenging and can require varying degrees of assessment and evaluation, depending on the diagnostic considerations. This article will address the common pathologies responsible for isolated pediatric Horner syndrome and the recommended ED evaluation.

A 9-year-old boy with exertional syncope.

BACKGROUND Syncope in the pediatric population is a common and mostly benign event. There is a subset of patients, however, in whom exertional syncope is the manifestation of a life-threatening cardiac abnormality. OBJECTIVE We present a rare but serious cause of syncope in children that often presents as sudden cardiac death. CASE REPORT A 9-year-old boy presented to the Emergency Department (ED) after an episode of exertional syncope while in physical education class. This was the patients second episode of exercise-induced syncope within a 2-year period. There was no family history of sudden death or cardiac disease. The child had not undergone any prior diagnostic work-up for the syncope. He was admitted to the hospital for further evaluation, and was found to have an anomalous left coronary artery on transthoracic echocardiogram. CONCLUSION As a potential precursor of sudden death, exertional syncope in pediatric patients should prompt a thorough evaluation for a cardiac etiology.

Complexity of the pediatric trauma care process: implications for multi-level awareness

Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering methods, we combine interview, archival document, and trauma registry data to describe how intra-hospital care transitions affect process and team complexity. Specifically, we identify the 53 roles directly involved in patient care in each hospital unit and describe the 3324 total transitions between hospital units and the 69 unique pathways, from arrival to discharge, experienced by pediatric trauma patients. We continue the argument to shift from eliminating complexity to coping with it and propose supporting three levels of awareness to enhance the resilience and adaptation necessary for patient safety in health care, i.e., safety in complex systems. We discuss three levels of awareness (individual, team, and organizational), and describe challenges and potential sociotechnical solutions for each. For example, one challenge to individual awareness is high time pressure. A potential solution is clinical decision support of information perception, integration, and decision-making. A challenge to team awareness is inadequate “non-technical” skills, e.g., leadership, communication, role clarity; simulation or another form of training could improve these. The complex, distributed nature of this process is a challenge to organizational awareness; a potential solution is to develop awareness of the process and the roles and interdependencies within it, using process modeling or simulation.

Identifying Nontechnical Skill Deficits in Trainees Through Interdisciplinary Trauma Simulation

OBJECTIVE The goal of this study was to investigate nontechnical skills in a simulated trauma setting both before and after a debriefing session in order to better understand areas to target for the development of educational interventions. DESIGN Wilcoxon signed rank tests were used to compare scores on the 5 domains of the T-NOTECHS pre- and postdebriefings. A qualitative analysis using the PEARLS debriefing framework was performed to provide a rich description of the strategies used by the debriefing facilitators. SETTING The Joint Trauma Simulation Program is an interdisciplinary project designed to improve the quality of trauma care through simulation exercises emphasizing nontechnical skills development. PARTICIPANTS Thirteen teams of 5 trauma trainees participated in trauma resuscitation simulations: a surgical chief resident, a surgical junior resident, an emergency medicine resident, and 2 emergency medicine nurses. RESULTS Teams significantly improved on communication and interaction skills in the simulation scenarios from pre- to postdebriefing. The debrief facilitators spent most of their time engaged in Directive Performance Feedback (56.13%). CONCLUSIONS Interprofessional team simulation in trauma resuscitation scenarios followed by debriefing differently affected individual nontechnical skills domains. Additional facilitation strategies, such as focused facilitation and encouraging learner self-assessment, may target other nontechnical skills in different ways.

A cognitive apprenticeship-based faculty development intervention for emergency medicine educators

In just a few years of preparation, emergency medicine (EM) trainees must achieve expertise across the broad spectrum of skills critical to the practice of the specialty. Though education occurs in many contexts, much learning occurs on the job, caring for patients under the guidance of clinical educators. The cognitive apprenticeship framework, originally described in primary and secondary education, has been applied to workplace-based medical training. The framework includes a variety of teaching methods: scaffolding, modeling, articulation, reflection, and exploration, applied in a safe learning environment. Without understanding these methods within a theoretical framework, faculty may not apply the methods optimally. Here we describe a faculty development intervention during which participants articulate, share, and practice their own applications of cognitive-apprenticeship methods to learners in EM. We summarize themes identified by workshop participants, and provide suggestions for tailoring the application of these methods to varying levels of EM learners. The cognitive-apprenticeship framework allows for a common understanding of the methods used in clinical teaching toward independence. Clinical educators should be encouraged to reflect critically on their methods, while being offered the opportunity to share and learn from others.

Things Falling Through the Cracks: Information Loss During Pediatric Trauma Care Transitions

Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Several clinical teams converge to support trauma care in the Emergency Department (ED); the most severe trauma cases often need surgery in the operating room (OR) and/or are admitted to the pediatric intensive care unit (PICU). These care transitions can result in loss of information or transfer of incorrect information, We interviewed 18 clinicians about communication and coordination during care transitions between the ED, OR and PICU. Clinicians completed a short questionnaire about patient safety during transitions. Results show that, although many services and units involved in pediatric trauma work well together, important patient care information may be lost in the transitions. To safely manage transitions of this fragile, unstable, complex population, we need to better manage the information flow during these transitions.

Challenges of Disposition Decision Making for Pediatric Trauma Patients in the Emergency Department

About 9.2 million children visit the emergency department (ED) in the US annually because of trauma and 20% experience a missed injury. Upon arriving to the hospital, physicians evaluate the child and make the ED disposition decision of whether to admit, operate or discharge. The objective of this study is to report the challenges mentioned by healthcare professionals about ED disposition decision making. We conducted 11 interviews with 12 healthcare professionals and identified 2 challenges of ED disposition decision making. The first challenge was timing of the decision; e.g., an ED nurse explained that a quick decision by physicians is important for providing timely patient care to critically ill children. The second challenge was leadership and team organization; e.g., the OR nurse and surgery resident both mentioned the need to know who to listen to so that they can understand what to do. Analyzing these challenges to ED disposition decision making can help to identify sociotechnical solutions for enhancing team situation awareness.