Ronald I. Paul

Bedside ultrasound diagnosis of nonangulated distal forearm fractures in the pediatric emergency department.

Objectives: Ultrasound (US) may be a useful tool for rapidly diagnosing fractures. Our objective was to determine the accuracy of US as compared with radiographs in the detection of nonangulated distal forearm fractures. Methods: Distal forearm US was performed and interpreted at the bedside by a pediatric emergency medicine physician before radiography in a prospective sample of children with possible nonangulated distal forearm fractures. A second pediatric emergency medicine physician with extensive US experience gave a final interpretation of the images. This second reviewer was blinded to both clinical and radiographic findings. The primary outcome was accuracy in the detection of fracture via the blinded reviewers US interpretation when compared with the radiologists clinical radiography results. Patient-reported FACES pain scores (range, 0-5) associated with both US and radiography were compared. Results: Of 101 enrolled patients, 46 had a fracture detected by the radiologist. When compared with radiographs, the blinded US interpretation had an overall accuracy of 94% (95% confidence interval [CI], 88%-99%). Sensitivity and specificity were 96% (95% CI, 85%-99%) and 93% (95% CI, 82%-98%), respectively. Positive predictive value was 92%, and negative predictive value was 96%. Mean FACES pain scores were higher following radiography than US (1.7 vs 1.2, respectively; P = 0.004). Conclusions: For the diagnosis of nonangulated distal forearm fractures in children, bedside US holds promise as a diagnostic modality, particularly with appropriate training. Ultrasound is at least no more painful that traditional radiographs. Pediatric emergency medicine physicians should consider becoming proficient in this application.

Utility of toxicology screening in a pediatric emergency department.

Objective: To determine the types of patients who undergo toxicology screen testing (TS) and the clinical utility of the test in a pediatric emergency department. Design: Retrospective chart review. Setting: Urban pediatric emergency department. Patients or participants: All patients, n=338, less than 18 years of age who had a TS sent from the Kosair Childrens Hospital Emergency Department between 1/1/91 and 12/31/91. Results: Three hundred and thirty-eight charts were available for review from 344 patients who had TS testing. Seventyeight patients (23%) were less than 12 years old; 164 patients (49%) were female. Forty-four patients were tested by serum TS only; 195 patients by serum plus urine TS; 94 patients by urine TS; four patients by serum, urine, and gastric aspirate TS, and one patient by urine and gastric aspirate TS. Chief complaints of patients who had TS sent were as follows: ingestion (211), abnormal behavior (56), seizures (30), trauma (18), syncope/tingling (7), depression/suicide (6), chest pain/palpitations (3), headaches (3), and other (4). While 195 patients (57%) had positive TS for at least one item, only 22 patients (7%) had a positive TS for an unexpected item, including seven patients with ingestions, eight with abnormal behavior, four with seizures, two with syncope, and one with trauma. Only three patients with unexpected positive TS had a change in medical management as a result of the TS findings. All three of these patients had abnormal physical examinations. Conclusion: A minority of patients have unexpected TS results. TS results rarely necessitate a change in medical management. Emergency physicians should reevaluate indications for TS testing in pediatric patients.

A survey of policies at children's hospitals regarding immunity of healthcare workers: are physicians protected?

OBJECTIVE To determine policies at childrens hospitals regarding immunizations, annual tuberculosis (TB) screening, and blood or body fluid exposure follow-up, particularly as they apply to physicians. DESIGN AND PARTICIPANTS A three-page survey was sent to infection control practitioners (ICPs) in April 1994 at hospitals affiliated with the National Association of Childrens Hospitals and Related Institutions. One follow-up mailing was sent to nonresponding ICPs. RESULTS Responses were received from 62 (67%) of 93 ICPs. Thirty-five (66%) of 53 childrens hospitals had an immunity policy that applied to medical students, 42 (79%) of 53 to resident physicians, 32 (52%) of 62 to hospital-based physicians, and 18 (29%) of 62 to private or community physicians (who admit patients to one hospital). Physicians were required to show evidence of an annual TB screen at 36 hospitals (58%). Immunity policies or TB screening were provided for the following physician groups: medical students, 13 (21%); resident physicians, 43 (69%); hospital-based physicians, 50 (81%); and private or community physicians, 23 (37%). Infection control practitioners reported that the following diseases had been identified within the past 5 years at their hospitals: measles, 82%; mumps, 40%; rubella, 31%; TB, 94%; hepatitis B, 94%; pertussis, 90%; varicella, 98%; and influenza, 94%. Physicians in these institutions were reported to have contracted the following diseases from patient exposure: measles, hepatitis B, TB, pertussis, varicella, and influenza. CONCLUSION Childrens hospitals vary widely in their policies regarding healthcare-worker immunity, and, in many cases, physicians may not be protected from nosocomial transmission of community infections.

Sharp object ingestions in children: illustrative cases and literature review

Sharp object ingestions may require different management from other foreign body ingestions because of possible gastrointestinal tract perforation. Three cases of sharp object ingestion are presented to describe the possible outcomes. A review of the relevant literature follows.

Technical skills experiences in pediatric emergency medicine fellowship programs

Guidelines for Pediatric Emergency Medicine (PEM) fellowship programs were published by the Curriculum Subcommittee, Section of Emergency Medicine, American Academy of Pediatrics in February 1993. The guideline listed 120 technical skills that the subcommittee felt all fellows should be able to perform at the completion of their training. The purpose of this study was to measure the experience of PEM fellows in performing skills recommended by the subcommittee and to determine if documentation lists were being maintained. A written survey was mailed to 63 graduating fellows in May 1993, requesting information on the number of times procedure skills were performed. Limited experience was denned as having performed a procedure five or less times. Thirty-two surveys (51%) were returned. Eleven fellows (34%) stated they maintained a procedure documentation list. Of 117 skills analyzed, the majority of fellows had limited experience in 49 procedures and zero experience in 22 procedures. The majority of fellows had limited experience in 12 of 20 life- or limb-saving procedures and zero experience in five. Large emergency department volumes did not influence number of procedure completions. Our data indicate that graduating PEM fellows have limited experience in performing many common as well as several life- and limb-saving skills. Documentation lists of technical skills are not being maintained by most fellows.

Compliance with national recommendations for tuberculosis screening and immunization of healthcare workers in a children's hospital.

Physicians and clinical employees at a childrens hospital were surveyed to compare their tuberculosis (TB) screening and immunization statuses. Failure to offer screening and immunization services to non-employee physicians was associated with lower rates of reported immunity to several vaccine-preventable diseases and with markedly lower rates of TB screening.

Hospital admissions of children from the emergency department: Are decisions regarding children on public assistance different?

Objective: To better understand the variables that influence the physicians decision to admit children from the emergency department (ED) for nonmedical problems. Methods: A multicenter prospective questionnaire survey over a three-month study period. For all admitted children, the emergency physician completed a survey which recorded demographic data, insurance status, primary care provider (PCP), admitting diagnoses, and reason for admission. The reason for admission was noted as strictly medical or nonmedical (either an illness that could have been managed on an ambulatory care basis or a “psychosocial” admission). Group differences were analyzed by t test, X², or logistic regression analysis where appropriate. Results: There were 4318 ED admissions at five institutions of which 185 (4%) were judged to be nonmedical. No age or gender differences were found between the medical and nonmedical admission populations. Using logistic regression, adjusted odds ratios for nonmedical admissions were as follows: Medicaid insurance (2.34, 95% CI = 1.61-3.41), clinicbased primary care provider (1.54, 95% CI = 1.06-2.23), no or unknown primary care provider (2.40,95% CI = 1.52-3.78), and after hours [eg, 5 PM to 8 AM] admissions (1.86, 95% CI = 1.31-2.63). Conclusions: These data suggest that children with lower socioeconomic status and limited primary care resources are more likely to be admitted from the ED for nonmedical reasons than children with commercial insurance resources or a private physician.

Pediatric emergency physicians and communicable diseases: can we be trusted to take care of ourselves?

Objective: To determine if pediatric emergency physicians (PEP) are following Centers for Disease Control and Prevention (CDC) recommendations that all health care workers receive routine vaccines and annual tuberculosis screens. Design: A two-page mail survey with one follow-up mailing. Participants: All active members of the American Academy of Pediatrics (AAP), Section on Emergency Medicine. Additional inclusion criteria were completion of training and employment in an emergency setting. Results: Of 407 surveys, 286 (60%) were returned; 209 met inclusion criteria. Proof of immunization was not required of 43% of PEP; 42% were not required to have an annual tuberculosis (TB) screen. PEP reported immunity to the following: polio (95%), measles (94%), hepatitis B (91%), rubella (90%), mumps (90%), varicella (90%), and diphtheria-tetanus (86%). However, only 72% received a TB screen, and 60% received an influenza vaccine within the past year. Proof of vaccination for employment was required by 57/85 hospitals, 47/79 universities, and 6/32 self-employed/group practices (x2, P<0.001). Proof of an annual TB screen was required by 64/87 hospitals, 44/82 universities, and 8/32 self-employed/group practices (x2, P<0.001). PEP were more likely to have had a recent annual TB screen if required by their employer (104/117) than if left to their own initiative (42/87) (x2, P<0.001). Conclusions: Although PEP are well protected against most vaccine-preventable diseases, many are not receiving annual TB screens nor influenza vaccines. The CDC guidelines are not being routinely followed by PEP.

Roller coasters: let the rider beware.

Purpose: To describe a pediatric patient with a severe abdominal injury following a roller coaster crash, and to review the relevant literature of lap belt injuries and roller coaster safety regulations. Methods: Case report. Results: A seven-year-old girl sitting in the front seat of a two-person roller coaster car was injured when it crashed into the stopped car in front. The patients injuries, including a partial hepatic amputation, were due to the combined forces of both passengers applied against her lap belt. Conclusions: Roller coaster restraint systems do not have the same federal or state oversights as motor vehicles and can result in life-threatening injuries.

The case of the slandered hamburgers

Carbon monoxide poisoning is a common occurrence, especially during cold months. It can be overlooked, because its history and symptoms are often vague. We report a case of two children with carbon monoxide poisoning who typify the need for obtaining a careful history. A review of the literature, including clinical manifestations, diagnosis, and treatment, follows.