A national survey of pediatric emergency medicine physicians on improving education in child maltreatment recognition and reporting child abuse & neglect.

BACKGROUND: Child maltreatment is an important public health problem with serious consequences. Even in the face of increased research and enhanced public awareness over the last decade, the rate of child fatalities due to reported child maltreatment has increased. OBJECTIVE: This study describes pediatric emergency medicine (PEM) physicians' knowledge, training, confidence, and barriers in recognition and reporting suspected child maltreatment. PARTICIPANTS AND SETTING: A nationally representative sample of PEM physician members of Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC) participated. METHODS: A cross-sectional 36-item survey study of PEM physicians with content domains including provider knowledge, preparedness, confidence, and barriers to identifying and reporting child maltreatment was conducted and distributed. RESULTS: 113 of 486 members completed the survey. Confidence with recognizing and reporting child abuse (95%) was greater than in child neglect (88%). Knowledge in child maltreatment recognition and reporting was significantly correlated with confidence in reporting and recognition (p < 0.001). There was a significant relationship between knowledge and confidence for respondents from states with training in child maltreatment recognition and reporting requirement as a condition of licensure and re-licensure compared to states without the requirement (p < 0.01). Qualitative responses revealed insightful themes to improve child maltreatment training, recognition and reporting. CONCLUSION: Our national survey study demonstrates that PEM-trained physicians have high confidence and knowledge with the management of child maltreatment, and that inclusion of mandated child maltreatment training in residency/fellowship and mandated training for medical licensure in all states could improve child maltreatment recognition and reporting.

End-tidal carbon dioxide and occult injury in trauma patients: ETCO2 does not rule out severe injury.

OBJECTIVE: To determine if early measurement of end-tidal carbon dioxide (ETCO2) in nonintubated patients triaged to a level 1 trauma center has utility in ruling out severe injury. METHODS: We performed a prospective cohort study of adult patients triaged to our urban, academic, level 1 trauma center. Included patients had ETCO2 measured within 30 minutes of arrival. Chart review was performed on enrolled patients to identify severe injury defined by: admission to an intensive care unit, need for an invasive procedure, blood product transfusion, acute blood loss anemia, and acute clinically significant finding on computed tomographic scan. RESULTS: Of 170 patients enrolled, 115 met the outcome of no severe injury. Mean ETCO2 for patients without and with severe injury was 33.1 mm Hg (SD, 5.8) and 30.3 mm Hg (SD, 6.7), respectively. This difference reached statistical significance (P=.05), but did not demonstrate added clinical utility when combined with Glasgow Coma Scale, systolic blood pressure, and age in predicting the primary outcome (area under curve, 0.70 with ETCO2 vs area under curve, 0.68 without ETCO2, P=.5). Patients with ETCO2 ≤30 mm Hg were found to be older, more likely to require intensive care unit admission or emergency operative intervention, develop acute blood loss anemia, and have an acute finding on computed tomography than patients with a higher ETCO2. CONCLUSION: End-tidal carbon dioxide cannot be used to rule out severe injury in patients meeting criteria for trauma center care. The ETCO2 ≤30 mm Hg may be associated with increased risk of traumatic severe injury.

Medical Student Performance on the National Board of Medical Examiners Emergency Medicine Advanced Clinical Examination and the National Emergency Medicine M4 Exams.

INTRODUCTION: In April 2013, the National Board of Medical Examiners (NBME) released an Advanced Clinical Examination (ACE) in emergency medicine (EM). In addition to this new resource, CDEM (Clerkship Directors in EM) provides two online, high-quality, internally validated examinations. National usage statistics are available for all three examinations, however, it is currently unknown how students entering an EM residency perform as compared to the entire national cohort. This information may help educators interpret examination scores of both EM-bound and non-EM-bound students. OBJECTIVES: The objective of this study was to compare EM clerkship examination performance between students who matched into an EM residency in 2014 to students who did not. We made comparisons were made using the EM-ACE and both versions of the National fourth year medical student (M4) EM examinations. METHOD: In this retrospective multi-institutional cohort study, the EM-ACE and either Version 1 (V1) or 2 (V2) of the National EM M4 examination was given to students taking a fourth-year EM rotation at five institutions between April 2013 to February 2014. We collected examination performance, including the scaled EM-ACE score, and percent correct on the EM M4 exams, and 2014 NRMP Match status. Student t-tests were performed on the examination averages of students who matched in EM as compared with those who did not. RESULTS: A total of 606 students from five different institutions took both the EM-ACE and one of the EM M4 exams; 94 (15.5%) students matched in EM in the 2014 Match. The mean score for EM-bound students on the EM-ACE, V1 and V2 of the EM M4 exams were 70.9 (n=47, SD=9.0), 84.4 (n=36, SD=5.2), and 83.3 (n=11, SD=6.9), respectively. Mean scores for non-EM-bound students were 68.0 (n=256, SD=9.7), 82.9 (n=243, SD=6.5), and 74.5 (n=13, SD=5.9). There was a significant difference in mean scores in EM-bound and non-EM-bound student for the EM-ACE (p=0.05) and V2 (p<0.01) but not V1 (p=0.18) of the National EM M4 examination. CONCLUSION: Students who successfully matched in EM performed better on all three exams at the end of their EM clerkship.