Understanding Graduating Pediatric Emergency Medicine Fellow Priorities for Career Pathways and Faculty Recruitment for Academic or Community Emergency Departments.

OBJECTIVES: Factors influencing the employment of pediatric emergency medicine (PEM) fellows in a career in academic medicine versus community emergency department (ED) settings have not previously been explored. The purpose of this study was to explore PEM fellows' priorities in selecting jobs and to identify factors that influence their decisions regarding career choices through a multicenter, qualitative approach. We also explored program directors' beliefs about graduates' job selection priorities. METHODS: This was a cross-sectional study among a convenience sample of PEM fellows and PEM fellowship program directors and/or associate program directors in the United States. The data were collected in 2017, using a qualitative methodology known as free listing. The fellows and program directors were solicited through the American Academy of Pediatrics Section on Emergency Medicine. Using content analysis, all free-listing responses from participant samples were categorized into 14 distinct groupings. Thematic saturation was achieved, and member checking was performed to ensure trustworthiness. RESULTS: A sample of 63 fellows from six geographically diverse programs and 41 program and/or associate program directors were surveyed. Location, schedule/work-life balance and compensation were the most frequently cited factors taken into consideration for employment; these are not specific to PEM as a career choice. Other factors included patient population and ED resources. When deciding between academic and community employment, similar areas for the PEM physician emerged on both sides of the dichotomy: work-life balance, clinical hours, burnout, and acuity/patient complexity. CONCLUSIONS: There are universal factors that PEM physicians consider when choosing employment. The information elicited from this exploratory technique can inform content for national survey or other qualitative work to achieve richer descriptions of reported items and dichotomies to guide fellow recruitment and retention strategies.

Increasing Comfort with Sensory Processing Difficulties in the Prehospital Setting: Pre-Post Study of Education and Sensory Tools in EMS Providers.

OBJECTIVES: Interfacing with patients with sensory processing difficulties is challenging to healthcare providers and even more problematic for emergency medical services (EMS) personnel in the acute care setting. Sensory training may be an effective nonpharmacologic method to deal with these patient populations. The purpose of this study was to evaluate whether an educational session and placement sensory tools would improve the comfort of EMS providers in the prehospital setting. METHODS: EMS providers from two agencies in the Alabama Gulf EMS System were selected for this study. Preeducation questionnaires were administered to EMS providers to assess their frequency and comfort level in taking care of patients with sensory processing difficulties. The educational session included a video presentation of various topics related to sensory processing difficulties and education on sensory tools. Posteducation questionnaires were administered to EMS providers 3 months posteducational session to assess the use of sensory tools and their comfort in patient care. Comfort level was assessed on a Likert scale of 1 to 10, with 1 being not comfortable at all and 10 being extremely comfortable. We performed descriptive statistics and the nonparametric Wilcoxon signed rank test to compare medians. RESULTS: A total of 177 of 225 (78.6%) EMS providers completed the preeducation questionnaire. In the preeducation period, 159 (89.8%) EMS providers transported patients with sensory processing difficulties. The preeducation median comfort level was 7.5 (range 1-10). At postsurvey, 135 of 177 (76.3%) EMS providers received educational training; 37 (27.4%) used the sensory tools within the previous 3 months. The posteducation median comfort level was 8 (range 3-10). Pre- and post median comfort levels were significantly different using the Wilcoxon signed rank test (P = 0.006). CONCLUSIONS: Sensory training can be an effective method for EMS providers to increase comfort levels in taking care of patients with sensory difficulties. Further research with larger sample sizes is needed to confirm/refute these findings.

Funding Sources and Perceived Financial Insecurity in Pediatric Subspecialty Fellowship Programs.

OBJECTIVE: Shortages of pediatric subspecialists exist in many fields with insufficient recruitment of new fellows. The current system of funding graduate medical education is inadequate. We examined funding sources for trainee salary and educational expenses in pediatric fellowship programs, effects of funding constraints, and program characteristics associated with financial insecurity as reported by fellowship program directors (FPD). METHODS: We conducted a national survey of FPD between November 1, 2016 and February 9, 2017. We used multivariable logistic regression to examine the association between perceived financial insecurity, program characteristics, and funding sources for fellow salary. RESULTS: We obtained data from 519 FPD, representing 14 different pediatric subspecialties. FPD reported that funding limitations restricted program size and educational resources in 22% and 36% of programs, respectively. Nineteen percent of FPD perceived funding of their program to be insecure. Programs with 7 or more fellows (OR .50 [95% CI .27-.90], P = .03) or hospital or graduate medical education/Children's Hospital graduate medical education funding (OR .58 [95% CI .35-.96], P = .04) were less likely to be perceived as insecure. Conversely, programs with extramural (OR 1.74 [95% CI 1.07-2.81], P = .03) or division funding (OR 1.70 [95% CI 1.02-2.82], P = .04) or in subspecialties with more than 25% unfilled positions or programs (OR 1.86 [95% CI 1.11-3.09], P = .02) were more likely to be perceived as insecure. CONCLUSIONS: Perceived financial insecurity of fellowship programs was strongly associated with program size, funding source, and unfilled positions, limiting recruitment and resources. Stable funding of fellowship programs is critical to maintain an adequate pediatric subspecialty workforce.

Essentials of PEM Fellowship Part 2: The Profession in Entrustable Professional Activities.

This article is the second in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article describes the development of PEM entrustable professional activities (EPAs) and the relationship of these EPAs with existing taxonomies of assessment and learning within PEM fellowship. It summarizes the field in concepts that can be taught and assessed, packaging the PEM subspecialty into EPAs.

Attrition rates of pediatric emergency medicine fellowship graduates.

OBJECTIVES: To identify the percentage of alumni of one Pediatric Emergency Medicine (PEM) fellowship program who consider themselves to still practice in the field. METHODS: A brief survey (5 questions) was sent to all physicians who began the PEM fellowship program at the University of Alabama at Birmingham between the years 1986 and 2006. Survey included demographics, length of time out of fellowship, present work location, and whether the respondent considered themselves to be in the field of pediatric emergency medicine. RESULTS: Forty-three physicians were identified as beginning fellowship between 1986 and 2006. One physician was excluded as she was deceased. Forty (95%) of the 42 individuals graduated from a PEM fellowship program. Analyzing the 39 responding PEM graduates, 29 (74%) consider themselves practicing pediatric emergency medicine. Six (60%) of those not considered practicing in PEM (n = 10) are women. Four of these 10 individuals are still in academic medicine. Overall attrition rate for this cohort of PEM fellowship-trained physicians is 25.6% (95% confidence interval, 13.0-42.1). CONCLUSION: Overall attrition rates of fellowship-trained PEM physicians seems to mirror that of adult trained counterparts.

Cutaneous community-associated methicillin-resistant staphylococcus aureus among all skin and soft-tissue infections in two geographically distant pediatric emergency departments.

OBJECTIVES: To describe the culture results of cutaneous infections affecting otherwise healthy children presenting to two pediatric emergency departments (EDs) in the southeastern United States and southern California. METHODS: Medical records of 920 children who presented to the pediatric EDs with skin infections and abscesses (International Classification of Diseases, Ninth Revision codes 680.0-686.9) during 2003 were reviewed. Chronically ill children with previously described risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) were excluded. Data abstracted included the type of infection; the site of infection; and, if a culture was obtained, the organism grown, along with their corresponding sensitivities. RESULTS: Of the 270 children who had bacterial cultures obtained, 60 (22%) were CA-MRSA-positive cultures, most cultured from abscesses (80%). Of all abscesses cultured, CA-MRSA grew in more than half (53%). All CA-MRSA isolates tested were sensitive to vancomycin, trimethoprim-sulfamethoxazole, rifampin, and gentamicin. One isolate at each center was resistant to clindamycin. The sensitivities at both institutions were similar. CONCLUSIONS: The authors conclude that CA-MRSA is responsible for most abscesses and that the pattern of CA-MRSA infections in these geographically distant pediatric EDs is similar. These data suggest that optimal diagnostic and management strategies for CA-MRSA will likely be widely applicable if results from a larger, more collaborative study yield similar findings.

Drug-induced rhabdomyolysis.

PURPOSE OF REVIEW: Drug-induced rhabdomyolysis is a common syndrome that is complex and potentially life threatening. This article reviews the pathophysiology, clinical presentations, and common compounds that cause drug-induced rhabdomyolysis. RECENT FINDINGS: The list of drugs and inciting agents that cause rhabdomyolysis is quite extensive. Rhabdomyolysis is defined as skeletal muscle injury that leads to the lysis of muscle cells and the leakage of myocyte contents into the extracellular compartments. The presenting clinical features are myalgias, myoglobinuria, and an elevated serum creatine kinase. There have been several case reports in the literature involving some common pediatric drugs that are associated with rhabdomyolysis. Diphenhydramine, Ecstasy, and baclofen have recently been implicated as the etiology of drug-induced rhabdomyolysis in several pediatric patients. Alkalinization of the urine is a controversial treatment of drug-induced rhabdomyolysis and has proven to be beneficial in some patients. SUMMARY: A high index of suspicion, early recognition, and adequate treatment will result in an excellent prognosis of drug-induced rhabdomyolysis.

A randomized controlled trial of inhaled flunisolide in the management of acute asthma in children.

BACKGROUND: Inhaled corticosteroids (ICS) may provide benefit in the therapy of acute asthma. The purpose of this study was to test the hypothesis that ICS are as effective as oral corticosteroids (OCS) in the management of acute childhood asthma. METHODS: A randomized, masked, placebo-controlled study was conducted in children aged 6 to 16 years seeking emergent care for an acute exacerbation of asthma. Patients were randomized into one of two groups: group 1 (OCS), oral prednisone, 2 mg/kg (maximum of 60 mg/d) for 7 days, and placebo pressurized metered-dose inhaler with valved holding chamber, four inhalations bid; and group 2 (ICS), flunisolide, four inhalations (1 mg) bid for 7 days, and daily placebo tablets. Spirometry (FEV(1)) was performed at baseline, day 3, and day 7 of the study. A symptom diary and twice-daily peak expiratory flow were recorded. RESULTS: A total of 58 subjects receiving ICS (n = 27) or OCS (n = 28) were enrolled. Baseline asthma severity, race, gender, and age were balanced between the two groups. chi(2) showed no significant difference in symptom severity between the two groups at any time during the study. FEV(1) percentage of predicted was lower in the ICS group on day 3 (65% vs 78%, p = 0.03) and on day 7 (77% vs 95%, p = 0.002). CONCLUSION: ICS were found to be useful in the management of acute asthma in children; however, spirometry data suggested a more rapid resolution of asthma with OCS.

Impact of the rapid diagnosis of influenza on physician decision-making and patient management in the pediatric emergency department: results of a randomized, prospective, controlled trial.

OBJECTIVE: To determine the impact of the rapid diagnosis of influenza on physician decision-making and patient management, including laboratory tests and radiographs ordered, patient charges associated with these tests, antibiotics/antivirals prescribed, and length of time to patient discharge from the emergency department. METHODS: Patients aged 2 months to 21 years presenting to an urban children's teaching hospital emergency department were screened for fever and cough, coryza, myalgias, headache, and/or malaise. After obtaining informed consent, patients were randomized to 1 of 2 groups: 1) physician receives (physician aware of) the rapid influenza test result; or 2) physician does not receive (physician unaware of) the result. For patients in the physician aware group, nasopharyngeal swabs were obtained, immediately tested with the FluOIA test for influenza A and B, and the result was placed on the chart before patient evaluation by the attending physician. For the physician unaware group, nasopharyngeal swabs were obtained, stored according to manufacturer's directions, and tested within 24 hours. Results for the physician unaware group were not disclosed to the treating physicians at any time. The 2 resultant influenza-positive groups (aware and unaware) were compared for laboratory and radiograph studies and their associated patient charges, antibiotic/antiviral prescriptions, and length of stay in the emergency department. RESULTS: A total of 418 patients were enrolled, and 391 completed the study. Of these, 202 tested positive for influenza. Comparison of the 96 influenza-positive patients whose physician was aware of the result with the 106 influenza-positive patients whose physician was unaware of the result revealed significant reductions among the former group in: 1) numbers of complete blood counts, blood cultures, urinalyses, urine cultures, and chest radiographs performed; 2) charges associated with these tests; 3) antibiotics prescribed; and 4) length of stay in the emergency department. The number of influenza-positive patients who received prescriptions for antiviral drugs was significantly higher among those whose physician was aware of the result. CONCLUSIONS: Physician awareness of a rapid diagnosis of influenza in the pediatric emergency department significantly reduced the number of laboratory tests and radiographs ordered and their associated charges, decreased antibiotic use, increased antiviral use, and decreased length of time to discharge.

Pediatric orogastric and nasogastric tubes: a new formula evaluated.

STUDY OBJECTIVE: We sought to compare the traditional method of determining depth of gastric tube insertion, by measuring from the external landmarks of the nose or mouth, to the earlobe, to the xiphoid process (NEX method), with a graph for determining depth of gastric tube insertion that is based on patient height (graphic method). METHODS: A prospective, randomized, double-blinded study comparing NEX and graphic methods for gastric tube depth of insertion was undertaken. This study included a convenience sample of pediatric emergency department patients in need of gastric intubation. Patients were block randomized, and their gastric tubes were placed to the depth derived from the particular method employed. Alternate depth of insertion was measured on all patients. Abdominal radiographs were used to determine the distance that the end of the tube was from the center of the stomach. RESULTS: Forty-four patients each were in the NEX and graphic groups. The mean distance from the center of the stomach was -1.12 cm (SD 1.36) for the graphic group, compared with 1.31 cm (SD 3.39) for the NEX method. The difference between the 2 methods was 2.43 cm (95% confidence interval [CI] 1.33 to 3.54). Using absolute values, the mean distance from the center of the stomach was 1.26 cm (SD 1.23) for the graphic group compared with 2.60 cm (SD 2.51) for the NEX method. Using these values, the difference between the groups is 1.34 cm (95% CI 0.50 to 2.18). CONCLUSION: When compared with the NEX method, the graphic method demonstrates a significant ability to more consistently and accurately determine the depth of pediatric gastric tube insertion.

Marked hypocalcemia and ventricular fibrillation in two pediatric patients exposed to a fluoride-containing wheel cleaner.

In two separate cases, pediatric patients exposed to Armor-All Quicksilver Wheel Cleaner exhibited systemic toxicity including mental status changes, marked hypocalcemia, and ventricular fibrillation. One child also demonstrated profound hypomagnesemia. These are the first pediatric reports of near-fatal outcomes after ingestion or inhalation of a hydrofluoric acid-like product, namely, ammonium bifluoride.