Perspectives on preparedness for pediatric emergencies after residency: A needs assessment.

Background: General emergency physicians provide most pediatric emergency care in the United States yet report more challenges managing emergencies in children than adults. Recommendations for standardized pediatric emergency medicine (PEM) curricula to address educational gaps due to variations in pediatric exposure during emergency medicine (EM) training lack learner input. This study surveyed senior EM residents and recent graduates about their perceived preparedness to manage pediatric emergencies to better inform PEM curricula design. Methods: In 2021, senior EM residents and graduates from the classes of 2020 and 2019 across eight EM programs with PEM rotations at the same children's hospital were recruited and surveyed electronically to assess perceived preparedness for 42 pediatric emergencies and procedures by age: infants under 1 year, toddlers, and children over 4 years. Preparedness was reported on a 5-point Likert scale with 1 or 2 defined as "unprepared." A chi-square test of independence compared the proportion of respondents unprepared to manage each condition across age groups, and a p-value < 0.05 demonstrated significance. Results: The response rate was 53% (129/242), with a higher response rate from senior residents (65%). Respondents reported feeling unprepared to manage more emergency conditions in infants compared to other age groups. Respondents felt least prepared to manage inborn errors of metabolism and congenital heart disease, with 45%-68% unprepared for these conditions across ages. A heat map compared senior residents to recent graduates. More graduates reported feeling unprepared for major trauma, impending respiratory failure, and pediatric advanced life support algorithms. Conclusions: This study, describing the perspective of EM senior residents and recent graduates, offers unique insights into PEM curricular needs during EM training. Future PEM curricula should target infant complaints and conditions with lower preparedness scores across ages. Other centers training EM residents could use our findings and methods to bolster PEM curricula.

Severe Epistaxis in the Pediatric Patient: A Simulation for Emergency Department Management.

Severe, uncontrolled epistaxis in a pediatric patient can lead to a compromised bloody airway and the potential need for significant volume resuscitation secondary to hemorrhagic shock if not managed emergently. In this report, a simulated 11-month-old patient with underlying liver disease presents to the emergency department setting. The goal was to familiarize advanced pediatric emergency medicine trainees and experienced providers with immediate bedside interventions and clinical management steps for a patient with severe, difficult-to-control epistaxis to increase preparedness for future clinical scenarios. Additionally, this case highlights resuscitation considerations for patients with liver disease, including sources of bleeding, consulting services, medications, and approach to massive transfusion in liver disease.

Augmented Reality in Pediatric Septic Shock Simulation: Randomized Controlled Feasibility Trial.

BACKGROUND: Septic shock is a low-frequency but high-stakes condition in children requiring prompt resuscitation, which makes it an important target for simulation-based education. OBJECTIVE: In this study, we aimed to design and implement an augmented reality app (PediSepsisAR) for septic shock simulation, test the feasibility of measuring the timing and volume of fluid administration during septic shock simulation with and without PediSepsisAR, and describe PediSepsisAR as an educational tool. We hypothesized that we could feasibly measure our desired data during the simulation in 90% of the participants in each group. With regard to using PediSepsisAR as an educational tool, we hypothesized that the PediSepsisAR group would report that it enhanced their awareness of simulated patient blood flow and would more rapidly verbalize recognition of abnormal patient status and desired management steps. METHODS: We performed a randomized controlled feasibility trial with a convenience sample of pediatric care providers at a large tertiary care pediatric center. Participants completed a prestudy questionnaire and were randomized to either the PediSepsisAR or control (traditional simulation) arms. We measured the participants' time to administer 20, 40, and 60 cc/kg of intravenous fluids during a septic shock simulation using each modality. In addition, facilitators timed how long participants took to verbalize they had recognized tachycardia, hypotension, or septic shock and desired to initiate the sepsis pathway and administer antibiotics. Participants in the PediSepsisAR arm completed a poststudy questionnaire. We analyzed data using descriptive statistics and a Wilcoxon rank-sum test to compare the median time with event variables between groups. RESULTS: We enrolled 50 participants (n=25 in each arm). The timing and volume of fluid administration were captured in all the participants in each group. There was no statistically significant difference regarding time to administration of intravenous fluids between the two groups. Similarly, there was no statistically significant difference between the groups regarding time to verbalized recognition of patient status or desired management steps. Most participants in the PediSepsisAR group reported that PediSepsisAR enhanced their awareness of the patient's perfusion. CONCLUSIONS: We developed an augmented reality app for use in pediatric septic shock simulations and demonstrated the feasibility of measuring the volume and timing of fluid administration during simulation using this modality. In addition, our findings suggest that PediSepsisAR may enhance participants' awareness of abnormal perfusion.

Arterial Fat Embolism in a Pediatric Patient with Femur Fracture: A Case Report.

CASE: Here, we present the case of a pediatric polytrauma patient found to have lower extremity intra-arterial fat embolism causing ischemic necrosis and ultimately necessitating below-the-knee amputation. CONCLUSION: Fat embolism, a common complication of long bone fractures in adults, can be associated with significant morbidity. Although rare, it should be considered among the possible etiologies for a pulseless limb after trauma. Early fracture stabilization may prevent fat embolism and fat embolism syndrome; however, there is no known definitive treatment, and management is supportive.

A Modern Epidemic: Increasing Pediatric Emergency Department Visits and Admissions for Headache.

OBJECTIVE: Headaches represent 0.9% to 2.6% of visits to a pediatric emergency department (PED). We noted a trend of increasing visits for headache in our tertiary care PED and sought to further characterize this trend. METHODS: We identified PED visits with International Classification of Disease, Ninth Revision, Clinical Modification diagnoses for headache at 25 hospitals in Pediatric Health Information System between 2003 and 2013. To further characterize demographics and treatment trends over time we used the electronic health record in our emergency department to identify children ages four to 18 between January 2007 and December 2014 with International Classification of Disease, Ninth Revision codes for headache: a random sample of 50 visits per year were chosen for chart review. RESULTS: Pediatric Health Information System visits for headache increased by 166% (18,041 in 2003 and 48,020 in 2013); by comparison, total PED visits increased by 57.6%. The percent admission increased by 300% (2020 admissions in 2003 and 8087 admissions in 2013). At our hospital, headache visits increased 111% from 896 visits in 2007 to 1887 visits in 2014; total PED visits increased 30.2%. The admission percentage for headache increased 187% with 156 admissions in 2007 and 448 in 2014. Management over time differed in the frequency of head computed tomography which decreased 3.7% per year (r = -0.93, 95% CI -0.99, -0.64) from 34% in 2007 to 18% in 2014. CONCLUSION: Pediatric emergency department visits for headache are increasing and a growing proportion of these patients are admitted. This finding identifies a potential patient population to target for interventions to improve outpatient management and reduce pediatric emergency department utilization.

Experiential Communications Curriculum to Improve Resident Preparedness When Responding to Discriminatory Comments in the Workplace.

BACKGROUND: Patients and families can make discriminatory comments leading to physician distress. Residents receive little training in appropriate responses to such comments and may be ill equipped to respond to intolerance without alienating the individual(s) making the comments. OBJECTIVE: We assessed whether a simulated curriculum would enhance pediatrics residents' ability to effectively respond to discriminatory comments. METHODS: In the 2016-2017 academic year, we modified an existing communication skills curriculum for senior pediatrics residents. Residents engaged a simulated parent who used discriminatory speech in 4 scenarios, followed by a group debriefing. We conducted anonymous surveys to assess residents' preparedness to respond to these comments before and immediately following participation and examined their experience with discriminatory comments in the workplace. RESULTS: The majority of residents reported prior experience with discriminatory comments (32 of 45 [71%] witnessed such comments, and 27 of 48 [56%] were targeted by such comments), most often regarding age, race, and ethnicity. Mean precourse scores ranged from 2.1 to 3.1 (on a 5-point scale) regarding ability to engage in a firm yet respectful dialogue, to reference the hospital code of conduct, to coach a learner to respond, and to facilitate a team debrief. Mean postcourse scores improved significantly for these questions (range 3.8-4.1). The greatest improvement was in referencing the code of conduct (2.1 versus 4.0, P < .001). CONCLUSIONS: Immediately after participating in simulation, pediatrics residents reported a significant improvement in self-reported readiness to respond to discriminatory comments made by a parent and reported the simulation experience was beneficial.

Neck Pain in a 12-Year-Old Female: An Unusual Diagnosis.

BACKGROUND: Neck pain in the pediatric population has a broad differential diagnosis, ranging from benign to imminently life-threatening causes. Trauma and infection represent the most common etiologies of pediatric neck pain in the pediatric emergency department (PED) setting. Malignancy, though a rare cause of pediatric neck pain, is important to consider in patients with acquired torticollis or focal neurologic signs. CASE REPORT: We describe the case of a previously healthy 12-year-old female who presented to the PED with neck pain radiating down her upper extremities. The physical examination revealed diminished strength in her upper extremities compared to her lower extremities. Further evaluation revealed lymphadenopathy in the cervical and mediastinal areas and an epidural tumor in the cervical spinal column. The ultimate diagnosis was Hodgkin lymphoma presenting in an unusual manner with cervical spinal cord compression. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Neck pain is a common chief complaint among pediatric patients in the emergency setting. This case of spinal cord compression caused by malignancy illustrates the necessity of detailed spinal imaging in patients with neck pain and "red flag" signs, including but not limited to an abnormal neurologic examination.

Empathy, Sense of Power, and Personality: Do They Change During Pediatric Residency?

OBJECTIVES: Empathy is a critical competency in medicine. Prior studies demonstrate a longitudinal decrease in empathy during residency; however, they have not included pediatric residents. The relations among the expression of empathy, sense of power (ability to influence other's behavior), and personality traits in residents also have not been addressed. Lastly, there are no data on how residents compare with the general nonmedical population in their expression of empathy. The purposes of our study were to assess whether empathy, sense of power, and personality type were statistically correlated; if resident empathy declines over time; and how resident empathy compares with that of nonmedical peers. METHODS: In 2010, a cohort of individuals entering pediatric residency were given three validated survey instruments at the beginning of their first and third years of training to explore longitudinal changes in empathy, sense of power, and major personality traits. RESULTS: We found no decrease in resident empathy in 2 years of pediatric training, no changes in their sense of power, and no statistically significant correlation between empathetic tendencies and sense of power. When compared with the general nonmedical population, pediatric residents rated themselves higher in empathy. As expected, the two components of empathy (empathic concern and perspective taking) were moderately correlated. Of the major personality traits, only agreeableness showed significant correlation with empathy. CONCLUSIONS: Pediatric resident empathy did not decrease longitudinally, unlike studies in other residents. There was no inverse relation between self-perceptions of sense of power and empathy as is present in the business literature. Finally, pediatric resident empathy was significantly higher when compared with a general nonmedical population.

Do empathy, perspective-taking, sense of power and personality differ across undergraduate education and are they inter-related?

Empathy is desirable in all health care professionals in their interactions with patients and each other. Empathy in its cognitive (perspective-taking) and affective forms has been well-studied in the literature and in fact, is shown in most studies to decline during undergraduate and graduate medical education. Empathy has also been shown to be inversely proportional to one's sense of power (SOP) in the business literature. In addition, the relationship of empathy to personality traits has not been examined. This cross-sectional study of four cohorts of undergraduate medical students at a private mid-Atlantic medical school compares the empathy of first, second, third and fourth year medical students to see if there is a decline across the medical school experience. It also examines the relationship among empathy, SOP and personality type across the 4 years of medical school. Unlike in many previous studies, we found no decline in student empathy. We found no significant relationship between SOP and empathy. Finally, there were no significant differences in power perception and personality measures across all educational years surveyed.