Facilitating the transition to residency: A resident-as-coach pilot program.

BACKGROUND: The transition from medical school to residency is a critical developmental phase; coaching may help students prepare for this role transition. AIMS: We explored whether near-peer coaching could improve a specific workplace skill prior to residency. METHODS: A resident-as-coach program was piloted for the medicine sub-internship, an advanced acting internship rotation. Between March and June 2021, 26 students were assigned a resident coach (n = 16). Resident coaches completed one training session, and student-coach dyads met for one coaching session on 'pre-rounding'- gathering patient data before rounds. The program was evaluated through surveys and focus groups. RESULTS: 20/26 students and 14/16 residents completed the survey. 19/20 students identified a pre-rounding challenge and reported increased pre-rounding efficiency; all committed to one actionable step for improvement. All 16 residents felt their coaching skills improved. In focus groups, students valued the program's focus on honing a relevant skill in a safe, near-peer setting. Residents expressed their intent to incorporate coaching into their future work. CONCLUSIONS: A resident-as-coach model can be effective in preparing students for residency, while concurrently building residents' coaching skills.

A pilot clinical skills coaching program to reimagine remediation: a cohort study.

Background New approaches are needed to improve and destigmatize remediation in undergraduate medical education (UME).  The COVID-19 pandemic magnified the need to support struggling learners to ensure competency and readiness for graduate medical education (GME).  Clinical skills (CS) coaching is an underutilized approach that may mitigate the stigma of remedial learning. Methods A six-month CS coaching pilot was conducted at Harvard Medical School (HMS) as a destigmatized remedial learning environment for clerkship and post-clerkship students identified as 'at risk' based on objective structured clinical examinations (OSCE).  The pilot entailed individual and group coaching with five faculty, direct bedside observation of CS, and standardized patient encounters with video review. Strengths-based coaching principles and appreciative inquiry were emphasized.  Results Twenty-three students participated in the pilot: 14 clerkship students (cohort 1) and 9 post-clerkship students (cohort 2).  All clerkship students (cohort 1) demonstrated sustained improvement in CS across three OSCEs compared to baseline: at pilot close, at 6-months post pilot, and at 21-24 months post-pilot all currently graduating students (10/10, 100%) passed the summative OSCE, an HMS graduation requirement. All post-clerkship students (cohort 2) passed the HMS graduation OSCE (9/9,100%). Feedback survey results included clerkship students (9/14; 64%) and post-clerkship students (7/9; 78%); all respondents unanimously agreed that individual coaching was "impactful to my clinical learning and practice". Faculty and leadership fully supported the pilot as a destigmatized and effective approach to remediation.  Conclusion Remediation has an essential and growing role in medical schools.  CS coaching for remedial learning can reduce stigma, foster a growth mindset, and support sustained progress for 'at risk' early clerkship through final year students. An "implementation template" with suggested tools and timelines can be locally adapted to guide CS coaching for UME remediation. The CS coaching pilot model is feasible and can be generalized to many UME programs.

Twelve tips for practical clinical skills coaching.

Coaching is rapidly evolving in clinical medicine, including for clinical skills (CS) learning. Yet a schema is needed for how to coach students in the many CS that are pivotal to the practice of medicine. These twelve tips aim to provide practical strategies for teachers and educators to coach students for CS learning. The tips cover many important aspects of CS coaching, including establishing a safe space, ways to prepare to coach, setting goals, guiding a coaching relationship, fostering coaching conversations, and in-person or virtual approaches. Together, the tips align as seven key steps of an overall coaching process. The twelve tips apply equally to coaching struggling students and all students seeking to improve CS and offer a guide for coaching at an individual or program level.

Firearm-related injuries in children and adolescents: an emergency and critical care perspective.

PURPOSE OF REVIEW: Firearms are a leading cause of death and injury in children, especially in the United States. Many of these injuries present to emergency departments and pediatric ICUs, prompting a need for updated prevention, interventions, and trauma-informed care. This review explores the evidence for prevention and screening for access to firearms, types of injuries, and considerations for mass casualty events. RECENT FINDINGS: Firearm-related injuries lead to over 20 000 emergency department visits annually in children and carry a higher risk of severe injury or death. Screening high-risk patients for access to firearms is suboptimal, despite evidence showing reduction in suicide deaths and increased safe storage. While mass casualty shootings represent a low proportion of all firearm-related morbidity, they have brought heightened attention to focus on quality research. SUMMARY: Firearm-related injury is a public health crisis and presents a unique risk to children and adolescents. A firearm in the home, especially one with children, significantly increases the risk of death by homicide or suicide. Research on gun violence is leading to important national conversations on gun control and the role of physicians in the prevention of injury and advocacy for effective interventions and legislation.

Cannabis-related emergencies in children and teens.

PURPOSE OF REVIEW: To examine the spectrum of emergency department presentations associated with cannabis use or misuse that are currently seen in the pediatric population. RECENT FINDINGS: There is a growing concern that pediatric emergency department visits related to cannabis are on the rise, especially given rapidly changing legislation on cannabis and its broad availability in certain areas. These concerns are substantiated in the current literature, as the evidence mounts for an array of emergency department presentations of intentional or accidental cannabis use. The range of presentations documented in the recent literature spans gastrointestinal, psychiatric and cardiorespiratory effects, in addition to traumatic injuries and accidental ingestions by younger children. Complications of chronic cannabis use, such as 'cannabis hyperemesis syndrome', depression, psychosis or cognitive impairment, are now recognized outcomes and even more are likely to emerge. SUMMARY: An array of cannabis-related symptoms is possible from acute use or exposure. Common presentations include acute intoxication, hyperemesis, depression and acute physical injuries from impaired psychomotor function. Uncommon presentations include cardiorespiratory effects, and a range of symptoms in young children that include hyperkinesis and coma. Clinical vigilance is needed to suspect and clinically diagnose cannabis exposure in the emergency department.

A 17-Year-Old Boy With High-Functioning Autism, Gastrointestinal Illness, and Seizures.

A healthy 17-year-old boy with a high-functioning pervasive developmental disorder presented to the emergency department after having a 4-minute episode of seizure-like activity in the setting of presumed viral gastroenteritis. Within an hour of emergency department arrival, he developed a forehead-sparing facial droop, right-sided ptosis, and expressive aphasia, prompting stroke team assessment and urgent neuroimaging. Laboratory results later revealed a serum sodium of 119 mmol/L. Neurologic deficits self-resolved, and a full physical examination revealed diffuse abdominal tenderness in the lower abdomen with rebound tenderness in the right-lower quadrant. The patient was admitted to the PICU for electrolyte management and monitoring. A computed tomography (CT) scan of the abdomen obtained the following morning revealed the patient's final diagnosis.

2018 Academic Emergency Medicine Consensus Conference: Advancing Pediatric Emergency Medicine Education Through Research and Scholarship.

To achieve high-quality emergency care for pediatric patients nationwide, it is necessary to define the key elements for pediatric emergency medicine (PEM) education and scholarship that would: 1) close the gaps in fundamental PEM education and 2) promote systems and standards that assure an ongoing communication of best practices between tertiary pediatric institutions, general (nonchildren's) hospital emergency departments, and urgent care centers. A working group of medical educators was formed to review the literature, develop a framework for consensus discussion at the breakout session, and then translate their findings into recommendations for future research and scholarship. The breakout session consensus discussion yielded many recommendations. The group concluded that future progress depends on multicenter collaborations as a PEM education research network and a unified vision for PEM education that bridges organizations, providers, and institutions to assure the best possible outcomes for acutely ill or injured children.

New directions in point-of-care ultrasound at the crossroads of paediatric emergency and critical care.

PURPOSE OF REVIEW: The diagnostic capability, efficiency and versatility of point-of-care ultrasound (POCUS) have enabled its use in paediatric emergency medicine (PEM) and paediatric critical care (PICU). This review highlights the current applications of POCUS for the critically ill child across PEM and PICU to identify areas of progress and standardized practice and to elucidate areas for future research. RECENT FINDINGS: POCUS technology continues to evolve and advance bedside clinical care for critically ill children, with ongoing research extending its use for an array of clinical scenarios, including respiratory distress, trauma and dehydration. Rapidly evolving and upcoming applications include diagnosis of pneumonia and acute chest syndrome, identification of intra-abdominal injury via contrast-enhancement, guidance of resuscitation, monitoring of increased intracranial pressure and procedural guidance. SUMMARY: POCUS is an effective and burgeoning method for both rapid diagnostics and guidance for interventions and procedures. It has clinical application for a variety of conditions that span PEM and PICU settings. Formal POCUS training is needed to standardize and expand use of this valuable technology by PICU and PEM providers alike.

Comparing Statewide and Single-center Data to Predict High-frequency Emergency Department Utilization Among Patients With Asthma Exacerbation.

BACKGROUND: Previous studies examining high-frequency emergency department (ED) utilization have primarily used single-center data, potentially leading to ascertainment bias if patients visit multiple centers. The goals of this study were 1) to create a predictive model to prospectively identify patients at risk of high-frequency ED utilization for asthma and 2) to examine how that model differed using statewide versus single-center data. METHODS: To track ED visits within a state, we analyzed 2011 to 2013 data from the New York State Healthcare Cost and Utilization Project State Emergency Department Databases. The first year of data (2011) was used to determine prior utilization, 2012 was used to identify index ED visits for asthma and for demographics, and 2013 was used for outcome ascertainment. High-frequency utilization was defined as 4+ ED visits for asthma within 1 year after the index visit. We performed analyses separately for children (age < 21 years) and adults and constructed two models: one included all statewide (multicenter) visits and the other was restricted to index hospital (single-center) visits. Multivariable logistic regression models were developed from potential predictors selected a priori. The final model was chosen by evaluating model performance using Akaike's Information Criterion scores, 10-fold cross-validation, and receiver operating characteristic curves. RESULTS: Among children, high-frequency ED utilization for asthma was observed in 2,417 of 94,258 (2.56%) using all statewide visits, compared to 1,853 of 94,258 (1.97%) for index hospital visits only. Among adults, the corresponding results were 7,779 of 159,874 (4.87%) and 5,053 of 159,874 (3.16%), respectively. In the multicenter visit model, the area under the curve (AUC) from 10-fold cross-validation for children was 0.70 (95% confidence interval [CI] = 0.69-0.72), compared to 0.71 (95% CI = 0.69-0.72) in the single-center visit model. The corresponding AUC results for adults were 0.76 (95% CI = 0.76-0.77) and 0.76 (95% CI = 0.75-0.77), respectively. CONCLUSION: Data available at the index ED visit can predict subsequent high-frequency utilization for asthma with AUC ranging from 0.70 to 0.76. Model accuracy was similar regardless of whether outcome ascertainment included all statewide visits (multicenter) or was limited to the index hospital (single-center).

Feasibility of "rapid" magnetic resonance imaging in pediatric acute head injury.

OBJECTIVE: The objective was to determine the feasibility of "rapid" magnetic resonance imaging (rMRI) versus noncontrast computed tomography (NCCT) for pediatric patients with possible traumatic brain injury and to compare the populations receiving imaging in an urban tertiary care emergency department ED. METHODS: We retrospectively reviewed the electronic medical records of ED patients younger than 19 years with possible traumatic brain injury over 4 years who received an rMRI and then age-matched with NCCT patients. Data collection and analysis included demographic and clinical variables, ED length of stay (LOS), and follow-up outcomes. RESULTS: The final cohort had 45 rMRIs and 45 NCCTs. The mean age was 2.7 years, 63% were male, and 65% sustained a fall. Age, sex, and injury mechanism were similar. Time parameters were longer for rMRI patients: ED arrival to completion of imaging (172 vs 93 minutes, P < .001) and ED LOS (266 vs 225 minutes, P = .008). The NCCT group had higher-acuity patients with higher pediatric intensive care unit admission rates (33% vs 7%, P = .002). No patients returned to the ED within 72 hours. Follow-up was available on 78% patients. No clinically significant intracranial injuries were missed. CONCLUSIONS: Rapid MRI may be a viable imaging modality for moderate-risk pediatric head injury. Although rMRI took longer to obtain during this pilot study, scan time was only 3 to 4 minutes; and LOS was only 41 minutes longer. Further integration of rMRI in patient care should decrease time variation. Future study of rMRI reliability and satisfaction is needed.

Advances in simulation for pediatric critical care and emergency medicine.

PURPOSE OF REVIEW: Routine integration of simulation into healthcare education and practice has gained momentum. Simulation is particularly important to acute and critical care pediatrics, as it offers alternative methods of training for high-risk and/or lower-frequency events in children. This review will discuss the recent advances in simulation education for pediatric critical care and emergency medicine and assess its potential for future growth through these subspecialties. RECENT FINDINGS: Research indicates that simulation with a high-fidelity manikin is more realistic than with a simple manikin. Multievent simulation centers, on-site suites and mobile units for in-situ training offer a variety of venues for training. High-fidelity simulation is now used to identify performance gaps, enhance educational curricula and assess core competencies. A landmark study demonstrated improvement in outcomes from in-hospital pediatric cardiopulmonary arrest following the introduction of a pediatric simulation-based mock code program. SUMMARY: High-fidelity simulation is emerging as a powerful tool for pediatric emergency medicine and critical care education through both individual and team-based training exercises. Programs can be tailored to meet specific institutional needs and budget limitations. As pediatric simulation-based programs evolve, further progress is anticipated in acute and critical care outcomes.

Minor head injury in children.

PURPOSE OF REVIEW: This review will examine mild closed head injury (CHI) and the current evidence on head computed tomography (CT) imaging risks in children, prediction rules to guide decisions on CT scan use, and issues of concussion after initial evaluation. RECENT FINDINGS: The current literature offers preliminary evidence on the risks of radiation exposure from CT scans in children. A recent study introduces a validated prediction rule for use in mild CHI, to limit the number of CT scans performed. Concurrent with this progress, fast (or short sequence) MRI represents an emerging technology that may prove to be a viable alternative to CT scan use in certain cases of mild CHI where imaging is desired. The initial emergency department evaluation for mild CHI is the start point for a sequence of follow-up to assure that postconcussive symptoms fully resolve. The literature on sports-related concussion offers some information that may be used for patients with non-sports-related concussion. SUMMARY: It is clear that CT scan use should be as safe and limited in scope as possible for children. Common decisions on the use of CT imaging for mild head injury can now be guided by a prediction rule for clinically important traumatic brain injury. Parameters for the follow-up care of patients with mild CHI after emergency department discharge are needed in the future to assure that postconcussive symptoms are adequately screened for full resolution.

Ophthalmologic complications of systemic disease.

The human eye, as an organ, can offer critical clues to the presence of systemic disease. This article discusses the various ophthalmologic manifestations of systemic disease that can be evident on examination by an emergency department provider, as well as some findings that can be discerned with specialty consultation. The following topics are reviewed with respect to potential ocular signs and complications: syphilis, herpes zoster, Lyme disease, acquired immunodeficiency syndrome, Reiter's syndrome, Kawasaki's disease, temporal arteritis, endocarditis, hypertension, and diabetes mellitus. Indications for emergent ophthalmologic consultation are also emphasized.

Pediatric office emergencies.

PURPOSE OF REVIEW: An emergency in the office setting can be problematic without adequate staff, support, tools, and protocols. Though many emergencies are not immediately life-threatening, one risks the 'worst case scenario' occurring if not adequately prepared. Pediatric patients are prone to respiratory distress and compromise in many emergencies, and can rapidly decompensate without adequate support. A review of the history of emergency medical services for children and the framework for office emergency preparedness offers insight into current challenges for primary care providers. RECENT FINDINGS: Research has demonstrated that many primary care offices and clinics are ill prepared to handle common pediatric emergencies. Reliance on the Emergency Medical Services system is insufficient to assure optimal outcomes, especially given variations in the equipment, training, and experience of Emergency Medical Services providers in the care of children, and in remote areas where access may be delayed. Preparation and practice for office emergencies through 'mock code' exercises can increase practitioner confidence and reduce anxiety to perform life-saving care. SUMMARY: Better outcomes for office emergencies can result from staff training, availability of appropriate equipment and medications, maintenance of skills via formal and informal practice, and pathways for expeditious transfer to a definitive care facility.