Left ventricular perforation with catheter decompression.

Thoracostomy tube placement is one of the more common procedures performed in the Emergency Department, most commonly for treatment of pneumothorax or hemothorax but occasionally for drainage of empyema or pleural effusion. Thoracostomy may be a life-saving procedure with a wide range of complication rates reported, ranging from 19.4-37%, most commonly extrathoracic placement. Most recent meta-analyses showed a relatively stable complication rate of 19% over the past three decades with the vast majority being benign in nature. We present a case with the rare complication of thoracostomy in which of a small-caliber thoracostomy tube was placed in the left ventricle. Although thoracotomy was performed to remove the catheter, the patient remained virtually asymptomatic and had an uneventful course.

Complexities of Consent: Ethics in the Pediatric Emergency Department.

Informed consent is a communicative process of sharing information with patients, which helps assure their understanding of the information provided and asks for their permission to proceed. Informed consent allows a patient or a patient's family to use his or her own value system to determine the need for a particular procedure or test. Asking a patient for permission to treat requires the provider to respect the patient's autonomy through allowing him or her to be an active part of the decision-making process. Consent in the pediatric emergency department can be a complex process. Parental consent is generally required for medical evaluation and treatment of pediatric patients, but in the pediatric emergency department, there are exceptions to this rule. If the provider determines that a parent's refusal of consent places the child at risk of harm, then consent is not necessary. By using the concepts of Emergency Medical Treatment and Active Labor Act, in emergent situations, consent may not be necessary. Finally, adolescents are often deeply concerned about privacy-their acceptance of appropriate care is often based on this promise of confidentiality. In the emergency department, adolescents can therefore be treated for issues relating to reproductive care without parental consent. It is important for the emergency department physician to understand the rules surrounding the care of pediatric patients to avoid compromising their privacy and ultimately their well-being and medical care.

Ethics in the Pediatric Emergency Department: When Mistakes Happen: An Approach to the Process, Evaluation, and Response to Medical Errors.

The emergency department (ED) is an environment that is conducive to medical errors. The ED is a time-pressured environment where physicians aim to rapidly evaluate and treat patients. Quick thinking and problem-based solutions are often used to assist in evaluation and diagnosis. Error analysis leads to an understanding of the cause of a medical error and is important to prevent future errors. Research suggests mechanisms to prevent medical errors in the pediatric ED, but prevention is not always possible. Transparency about errors is necessary to assure a trusting doctor-patient relationship. Patients want to be informed about all errors, and apologies are hard. Apologizing for a significant medical error that may have caused a complication is even harder. Having a systematic way to go about apologizing makes the process easier, and helps assure that the right information is relayed to the patient and his or her family. This creates an environment of autonomy and shared decision making that is ultimately beneficial to all aspects of patient care.

Point-of-Care Ultrasound Diagnosis of Multiple Mandibular Fractures in an Adolescent Presenting to the Pediatric Emergency Department.

We present a case of an adolescent patient with multiple mandibular fractures diagnosed by point-of-care ultrasound in the pediatric emergency department. Sonographic findings consistent with fracture were identified in our patient, and early consultation expedited interdepartmental coordination and disposition. The role of ultrasound in identifying various traumatic orthopedic and maxillofacial injuries is discussed.