Adolescent alcohol use predicts cannabis use over a three year follow-up period.

Background: Alcohol and cannabis use frequently co-occur, which can result in problems from social and academic impairment to dependence (i.e., alcohol use disorder [AUD] and/or cannabis use disorder [CUD]). The Emergency Department (ED) is an excellent site to identify adolescents with alcohol misuse, conduct a brief intervention, and refer to treatment; however, given time constraints, alcohol use may be the only substance assessed due to its common role in unintentional injury. The current study, a secondary data analysis, assessed the relationship between adolescent alcohol and cannabis use by examining the National Institute of Alcohol Abuse and Alcoholism (NIAAA) two question screen's (2QS) ability to predict future CUD at one, two, and three years post-ED visit. Methods: At baseline, data was collected via tablet self-report surveys from medically and behaviorally stable adolescents 12-17 years old (n = 1,689) treated in 16 pediatric EDs for non-life-threatening injury, illness, or mental health condition. Follow-up surveys were completed via telephone or web-based survey. Logistic regression compared CUD diagnosis odds at one, two, or three-year follow-up between levels constituting a single-level change in baseline risk categorization on the NIAAA 2QS (nondrinker versus low-risk, low- versus moderate-risk, moderate- versus high-risk). Receiver operating characteristic curve methods examined the predictive ability of the baseline NIAAA 2QS cut points for CUD at one, two, or three-year follow-up. Results: Adolescents with low alcohol risk had significantly higher rates of CUD versus nondrinkers (OR range: 1.94-2.76, p < .0001). For low and moderate alcohol risk, there was no difference in CUD rates (OR range: 1.00-1.08). CUD rates were higher in adolescents with high alcohol risk versus moderate risk (OR range: 2.39-4.81, p < .05). Conclusions: Even low levels of baseline alcohol use are associated with risk for a later CUD. The NIAAA 2QS is an appropriate assessment measure to gauge risk for future cannabis use.

A Call to Restore Your Calling: Self-care of the Emergency Physician in the Face of Life-Changing Stress: Part 6 of 6: Trainee Burnout.

Whereas our last article focused on burnout in practicing pediatric emergency medicine (PEM) physicians, this article centers on burnout in PEM fellows. Our discussion is based solely on trainee burnout literature. As graduates of pediatrics or emergency medicine residencies, PEM fellows are charged with achieving attending-level clinical expertise while continuing to cope with trainee challenges, such as limited practice autonomy, low pay, financial debt, and uncertain future employment. In this article, we discuss PEM fellow burnout and review risk and protective factors, presentation, and evidence-based interventions to mitigate it. In the absence of PEM fellow-specific literature, we share pediatrics and emergency medicine residency data.This article is dedicated to the trainees we have lost to suicide. We miss you.

A Call to Restore Your Calling: Self-Care of the Emergency Physician in the Face of Life-Changing Stress: Part 5 of 6: Physician Burnout.

This fifth article in our series focuses on burnout in practicing pediatric emergency medicine physicians. As opposed to a general review of burnout, we address understudied and undervalued risk factors, drivers, and individual- and organizational-level solutions applicable to the emergency medicine workplace.Conflicting studies impact our understanding of the prevalence of burnout in our field and the role of depression. This article's story is anonymously submitted and leads us to our discussion of the heightened risk of burnout in underrepresented physicians, those who identify themselves as women, as belonging to a racial, ethnic, gender and/or sexual minority group, and/or as having a physical and/or sensory disability.Thus far, our articles have described coping tools for individuals and health care organizations to prevent and/or mitigate the untoward effects of life-changing stressors on a pediatric emergency physician's life. They include staying healthy and active, cultivating outside interests, and nurturing relationships with peers, friends, and family. We have shared the techniques and benefits of constructive engagement when one is faced with challenging events or individuals. We have underscored the value of peer support, support groups, emotional debriefing, and engaging with outside organizations able to address specific stressors. We have introduced the practice of political engagement as a way of addressing systems-level pressures. Throughout this series, we have emphasized the need to ask for help from family, friends, peers, primary care providers, and mental health professionals. This article describes the benefits of Employee Assistance Programs, Physician Wellness Programs, positive psychology, and grounding behaviors as self-care strategies.

Screening for Adolescent Alcohol Use in the Emergency Department: What Does It Tell Us About Cannabis, Tobacco, and Other Drug Use?

BACKGROUND: The pediatric emergency department (PED) represents an opportune time for alcohol and drug screening. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends a two-question alcohol screen for adolescents as a predictor of alcohol and drug misuse. OBJECTIVE: A multi-site PED study was conducted to determine the association between the NIAAA two-question alcohol screen and adolescent cannabis use disorders (CUD), cigarette smoking, and lifetime use of other drugs. METHODS: Participants included 12-17-year olds (n = 4834) treated in one of 16 participating PEDs. An assessment battery, including the NIAAA two-question screen and other measures of alcohol, tobacco and drug use, was self-administered on a tablet computer. RESULTS: A diagnosis of CUD, lifetime tobacco use or lifetime drug use was predicted by any self-reported alcohol use in the past year, which indicates a classification of moderate risk for middle school ages and low risk for high school ages on the NIAAA two-question screen. Drinking was most strongly predictive of a CUD, somewhat weaker for lifetime tobacco use, and weakest for lifetime drug use. This same pattern held for high school and middle school students and was stronger for high school students over middle school students for all three categories. This association was also found across gender, ethnicity and race. The association was strongest for CUD for high school students, sensitivity 81.7% (95% CI, 77.0, 86.5) and specificity 70.4% (95% CI, 68.6, 72.1). Conclusions/Importance: A single question about past year alcohol use can provide valuable information about other substance use, particularly marijuana.

A Call to Restore Your Calling: Self-Care of the Emergency Physician in the Face of Life-Changing Stress-Part 4 of 6: Physician Helplessness and Moral Injury.

Many aspects of our health care system in the United States can lead to physicians feeling helpless-an inability to save a dying child, an inability to protect an immunocompromised child from a vaccine-preventable illness because of waning herd immunity, and a burdensome new electronic medical record system that your employer insists you must use. The cumulative effect of these experiences can lead to moral distress and ultimately moral injury. We discuss helplessness, moral distress, and moral injury in the setting of today's practice of emergency medicine and provide concrete recommendations to help providers cope with their own reactions to distressing clinical situations.

A Call to Restore Your Calling: Self-Care of the Emergency Physician in the Face of Life-Changing Stress-Part 3 of 6: Physician Illness and Impairment.

Physicians suffer from most medical conditions at the same rate as their lay peers. However, physicians' self-care is often sacrificed for patient care. This third article in our series examines physician and trainee illness and impairment. Presenteeism, physician impairment, and substance use disorder (SUD) are defined. We call attention to the potential for harm of dated cultural norms, which often fuel physicians' neglect of their own health and development of ill-advised coping skills.Although any medical condition may become a functional impairment, the primary cause of physician impairment is SUD. Alcohol and prescription opioids top the list of substances used in excess by physicians. Although SUD is less prevalent in residency, we focus on the rise of marijuana and alcohol use in emergency medicine trainees. A nonpunitive model for the prevention and treatment of SUD in residency is described.Physicians are ethically and legally mandated to report any concern for impairment to either a state physician health program or a state medical board. However, recognizing physician SUD is challenging. We describe its clinical presentation, voluntary and mandated treatment tracks, provisions for protecting reporters from civil liability, prognosis for return to practice, and prevention efforts. We underscore the need to model healthy coping strategies and assist trainees in adopting them.In closing, we offer our colleagues and trainees today's to-do list for beginning the journey of reclaiming your health. We also provide resources focused on the practical support of ill and/or impaired physicians.

A Call to Restore Your Calling: Self-care of the Emergency Physician in the Face of Life-Changing Stress-Part 1 of 6.

Few practicing emergency physicians will avoid life-changing stressors such as a medical error, personal illness, malpractice litigation, or death of a patient. Many will be unprepared for the toll they will take on their lives. Some may ultimately experience burnout, post-traumatic stress disorder, and suicidal ideation. Medical education, continuing education, and maintenance of certification programs do not teach physicians to recognize helplessness, moral distress, or maladaptive coping mechanisms in themselves. Academic physicians receive little instruction on how to teach trainees and medical students the art of thriving through life-changing stressors in their career paths. Most importantly, handling a life-changing stressor is that much more overwhelming today, as physicians struggle to meet the daily challenge of providing the best patient care in a business-modeled health care environment where profit-driven performance measures (eg, productivity tracking, patient reviews) can conflict with the quality of medical care they wish to provide.Using personal vignettes and with a focus on the emergency department setting, this 6-article series examines the impact life-changing stressors have on physicians, trainees, and medical students. The authors identify internal constraints that inhibit healthy coping and tools for individuals, training programs, and health care organizations to consider adopting, as they seek to increase physician satisfaction and retention. The reader will learn to recognize physician distress and acquire strategies for self-care and peer support. The series will highlight the concept that professional fulfillment requires ongoing attention and is a work in progress.

Methodology and Demographics of a Brief Adolescent Alcohol Screen Validation Study.

OBJECTIVE: The aim of this study was to determine the psychometric properties of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question alcohol screen within 16 Pediatric Emergency Care Applied Research Network pediatric emergency departments. This article describes the study methodology, sample characteristics, and baseline outcomes of the NIAAA 2-question screen. METHODS: Participants included 12- to 17-year-olds treated in one of the participating pediatric emergency departments across the United States. After enrollment, a criterion assessment battery including the NIAAA 2-question screen and other measures of alcohol, drug use, and risk behavior was self-administered by participants on a tablet computer. Two subsamples were derived from the sample. The first subsample was readministered the NIAAA 2-question screen 1 week after their initial visit to assess test-retest reliability. The second subsample is being reassessed at 12 and 24 months to examine predictive validity of the NIAAA 2-question screen. RESULTS: There were 4834 participants enrolled into the study who completed baseline assessments. Participants were equally distributed across sex and age. Forty-six percent of the participants identified as white, and 26% identified as black. Approximately one quarter identified as Hispanic. Using the NIAAA 2-question screen algorithm, approximately 8% were classified as low risk, 12% were classified as moderate risk, and 4% were classified as highest risk. Alcohol use was less likely to be reported by black participants, non-Hispanic participants, and those younger than 16 years. DISCUSSION: This study successfully recruited a large, demographically diverse sample to establish rates of the NIAAA screen risk categories across age, sex, ethnicity, and race within pediatric emergency departments.

Intraosseous access.

BACKGROUND: Vascular access is of paramount importance in the care of the critically ill patient. When central or peripheral intravenous access cannot be accomplished in a timely manner, intraosseous access and infusion is a rapid and safe alternative for the delivery of fluids, medications, and blood products. The resurgence of the use of intraosseous access in the 1980s led to the development of new methods and devices that facilitate insertion. OBJECTIVES: This article discusses general indications, contraindications, and complications of intraosseous access and infusion, focusing on new devices and their insertion. DISCUSSION: Current research is focused on product innovation and improving drug delivery using intraosseous autoinjectors, finding new anatomic sites for placement, and expanding the use of different intraosseous devices to the adult population. CONCLUSIONS/SUMMARY: New, improved intraosseous systems provide health care providers with choices beyond traditional manual intraosseous access for administering fluids.

Ketamine/midazolam versus etomidate/fentanyl: procedural sedation for pediatric orthopedic reductions.

BACKGROUND: Orthopedic reductions are commonly performed procedures requiring sedation in the pediatric emergency department (PED). Ketamine is a widely used agent for pediatric procedural sedation, but its use may present difficulties in select populations, such as those with psychiatric diagnoses. In such a case, alternative agents that are safe and effective are needed. Etomidate is a commonly used induction agent for rapid-sequence intubation in the PED. Several retrospective and few prospective studies support etomidate's safety and efficacy in pediatric procedural sedation. OBJECTIVE: The objective was to compare etomidate/fentanyl (E/F) with ketamine/midazolam (K/M) for procedural sedation during orthopedic reductions in the PED. METHODS: Prospective, partially blinded, randomized controlled study comparing intravenously administered K/M with intravenously administered E/F. A convenience sample of patients, aged 5 to 18 years, presenting to an urban PED with fracture requiring reduction was enrolled. Outcome measures included guardian and staff completion of visual analog scale and Likert scales for observed pain and satisfaction, blinded OSBD-r (Observational Scale of Behavioral Distress-Revised) scoring of digital recordings of reductions, and sedation and recovery times. Descriptive tracking of adverse effects, adverse events, and interventions were recorded at the sedation. RESULTS: Twenty-three patients were enrolled, 11 in the K/M group and 12 in the E/F group. The K/M group had significantly lower mean OSBD-r scores compared with the E/F group (0.08 vs 0.89, P = 0.001). Parents rated lower visual analog scale scores with K/M than with E/F (13.7 vs 50.5, P = 0.003) and favored K/M on a 5-point satisfaction scale (P = 0.004). The E/F group had significantly shorter total sedation times (49.6 vs 77.6 minutes, P = 0.003) and recovery times (24.7 vs 61.4 minutes, P = 0.000). There were no significant differences with respect to procedural amnesia and orthopedic practitioner satisfaction. Adverse effects noted in the K/M group included dysphoric emergence reaction and vomiting. Vomiting, injection-site pain, myoclonus, airway readjustment, and supplemental oxygen use were observed in the E/F group. CONCLUSIONS: This is a small study that strongly suggests that, for pediatric orthopedic reductions, K/M is more effective at reducing observed distress than E/F, although both provide equal procedural amnesia. With its significantly shorter sedation and recovery times, E/F may be more applicable for procedural sedation for shorter, simpler procedures in the PED.

Predictive Validity of a 2-Question Alcohol Screen at 1-, 2-, and 3-Year Follow-up.

BACKGROUND: The National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question screen is a valid adolescent alcohol screening tool. No studies have examined if this tool predicts future alcohol problems. We conducted a study at 16 pediatric emergency departments to determine the tool's predictive validity for alcohol misuse and alcohol use disorders (AUDs). METHODS: Participants (N = 4834) completed a baseline assessment battery. A subsample of participants completed the battery at 1, 2, and 3 years follow up. RESULTS: Of the 2209 participants assigned to follow-up, 1611 (73%) completed a 1-year follow-up, 1591 (72%) completed a 2-year follow-up, and 1377 (62%) completed a 3-year follow-up. The differences in AUDs between baseline NIAAA screen nondrinkers and lower-risk drinkers were statistically significant at 1 year (P = .0002), 2 years (P <.0001), and 3 years (P = .0005), as were the differences between moderate- and highest-risk drinkers at 1 and 2 years (P < .0001 and P = .0088, respectively) but not at 3 years (P = .0758). The best combined score for sensitivity (86.2% at 1 year, 75.6% at 2 years, and 60.0% at 3 years) and specificity (78.1% at 1 year, 79.2% at 2 years, and 80.0% at 3 years) was achieved by using "lower risk" and higher as a cutoff for the prediction of a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis. CONCLUSIONS: The NIAAA 2-question screen can accurately characterize adolescent risk for future AUDs. Future studies are needed to determine optimaluse of the screen.

A randomized trial of nebulized epinephrine vs albuterol in the emergency department treatment of bronchiolitis.

OBJECTIVE: To determine if nebulized epinephrine is more efficacious than nebulized albuterol in the emergency department (ED) treatment of moderately ill infants with bronchiolitis. METHODS: Sixty-six patients between 0 and 12 months of age with new-onset wheezing, an antecedent upper respiratory tract infection, and a clinical score (Respiratory Distress Assessment Instrument) of 8 to 15 were randomized in a double-blind fashion to receive either 0.9 mg/kg of nebulized 2.25% racemic epinephrine (n = 34) or 0.15 mg/kg of nebulized 0.5% albuterol sulfate (n = 32) at 0, 30, and 60 minutes. MAIN OUTCOME MEASURES: Primary outcome measures were clinical score and respiratory rate. Secondary outcome measures were room air oxygen saturation, elapsed time to meeting clinical criteria for ED discharge, hospitalization rate, and proportion of patients relapsed within 72 hours of ED discharge (relapse rate). RESULTS: Both treatment groups experienced a similar pattern of change in mean clinical score, respiratory rate, and room air saturation over time. There were no significant differences between the groups by these same measures at any time. The median time at which infants were well enough for ED discharge was 90 minutes in the epinephrine-treated group vs 120 minutes in the albuterol-treated group (P =.01). Sixteen infants (47.1%) in the epinephrine-treated group were hospitalized compared with 12 infants (37.5%) in the albuterol-treated group (relative risk, 1.25; 95% confidence interval, 0.71-2.22). Relapse rate was 18.8% (3/16) in the epinephrine-treated group and 42.1% (8/19) in the albuterol-treated group (relative risk, 0.45; 95% confidence interval, 0.14-1.41). Adverse effects occurred infrequently. CONCLUSIONS: Although the patients treated with epinephrine were judged well enough for ED discharge significantly earlier than the patients treated with albuterol, epinephrine was not found to be more efficacious than albuterol in treating moderately ill infants with bronchiolitis.

Prolonged QT syndrome in children: an uncommon but potentially fatal entity.

Prolonged QT syndrome may be either congenital, as in Jervell and Lange-Nielsen or Romano-Ward syndromes, or acquired in nature. Affected children are at risk for syncope, seizures, dysrhythmias and sudden death. Physicians should consider long QT syndrome (LQTS) in all patients who present with syncope. A thorough personal and family history should be documented, with particular attention to prior syncopal episodes, congenital deafness, and unexplained sudden death. Syncope that is either recurrent or induced by exercise or stress is concerning and also should be noted. An electrocardiogram with manual calculation of the QT interval should be performed on all patients with a suggestive history. Furthermore, the diagnosis of LQTS warrants evaluation of all other family members. With recognition and appropriate treatment of affected patients, the potentially fatal consequences of LQTS may be prevented.

Best educational practices in pediatric emergency medicine during emergency medicine residency training: guiding principles and expert recommendations.

The state of pediatric emergency medicine (PEM) education within emergency medicine (EM) residency programs is reviewed and discussed in the context of shifting practice environments and new demands for a greater focus on the availability and quality of PEM services. The rapid growth of PEM within pediatrics has altered the EM practice landscape with regard to PEM. The authors evaluate the composition, quantity, and quality of PEM training in EM residency programs, with close attention paid to the challenges facing programs. A set of best practices is presented as a framework for discussion of future PEM training that would increase the yield and relevance of knowledge and experiences within the constraints of 3- and 4-year residencies. Innovative educational modalities are discussed, as well as the role of simulation and pediatric-specific patient safety education. Finally, barriers to PEM fellowship training among EM residency graduates are discussed in light of the shortage of practitioners from this training pathway and in recognition of the ongoing importance of the EM voice in PEM.