Evaluation of Ventricle Size Measurements in Infants by Pediatric Emergency Medicine Physicians.

OBJECTIVES: The identification of hydrocephalus in infants by pediatric emergency medicine (PEM) physicians using cranial point-of-care ultrasound (POCUS) has not been evaluated. We aimed to conduct a pilot/proof-of-concept study to evaluate whether PEM physicians can identify hydrocephalus (anterior horn width >5 mm) in 15 infants (mean 69 ± 42 days old) from the neonatal intensive care unit using POCUS. Our exploratory aims were to determine the test characteristics of cranial POCUS performed by PEM physicians for diagnosing hydrocephalus and the interrater reliability between measurements made by the PEM physicians and the radiologist. METHODS: Depending on the availability, 1 or 2 PEM physicians performed a cranial POCUS through the open anterior fontanel for each infant after a 30-minute didactic lecture to determine the size of the left and right ventricles by measuring the anterior horn width at the foramen of Monroe in coronal view. Within 1 week, an ultrasound (US) technologist performed a cranial US and a radiologist determined the ventricle sizes from the US images; these measurements were the criterion standard. RESULTS: A radiologist determined 12 of the 30 ventricles as hydrocephalic. The sensitivity and specificity of the PEM physicians performed cranial POCUS was 66.7% (95% confidence interval [CI], 34.9%-90.1%) and 94.4% (95% CI, 72.7%-99.9%), whereas the positive and negative predictive values were 88.9% (95% CI, 53.3%-98.2%) and 81.0% (95% CI, 65.5%-90.5%), respectively. The interrater reliability between the PEM physician's and radiologist's measurements was r = 0.91. The entire POCUS examinations performed by the PEM physicians took an average of 1.5 minutes. The time between the cranial POCUS and the radiology US was, on average, 4 days. CONCLUSIONS: While the PEM physicians in our study were able to determine the absence of hydrocephalus in infants with high specificity using cranial POCUS, there was insufficient evidence to support the use of this modality for identifying hydrocephalus. Future studies with more participants are warranted to accurately determine test characteristics.

Parents' Perspective on Trainees Performing Invasive Procedures: A Qualitative Evaluation.

OBJECTIVES: When obtaining informed permission from parents for invasive procedures, trainees and supervisors often do not disclose information about the trainee's level of experience. The objectives of this study were 3-fold: (1) to assess parents' understanding of both academic medical training and the role of the trainee and the supervisor, (2) to explore parents' preferences about transparency related to a trainee's experience, and (3) to examine parents' willingness to allow trainees to perform invasive procedures. METHODS: This qualitative study involved 23 one-on-one interviews with parents of infants younger than 30 days who had undergone a lumbar puncture. In line with grounded theory, researchers independently coded transcripts and then collectively refined codes and created themes. Data collection and analysis continued until thematic saturation was achieved. In addition, to triangulate the findings, a focus group was conducted with Yale School of Medicine's Community Bioethics Forum. RESULTS: Our analysis revealed 4 primary themes: (1) the invasive nature of a lumbar puncture and the vulnerability of the newborn creates fear in parents, which may be mitigated by improved communication; (2) parents have varying degrees of awareness of the medical training system; (3) most parents expect transparency about provider experience level and trust that a qualified provider will be performing the procedure; and (4) parents prefer an experienced provider to perform a procedure, but supervisor presence may be a qualifying factor for inexperienced providers. CONCLUSIONS: Physicians must find a way to improve transparency when caring for pediatric patients while still developing critical procedural skills.

Diagnosis of a Posterior Fracture Dislocation of the Medial Clavicle in an Adolescent With Point-of-Care Ultrasound.

We report a case of an adolescent patient with medial clavicular tenderness after a fall on the lateral left shoulder. Initial radiographs did not reveal a fracture or dislocation. Point-of-care ultrasound was used to diagnose a posterior clavicular fracture dislocation.