Analysis of Emergent Nonhospital-Based Retina Consultation Requests in an Academic Nonhospital-Associated Retina Practice.

PURPOSE: To evaluate the outcomes of after-hour encounters concerning patients referred by eye physicians to on-call retina services for emergent evaluation not seen in or referred by an emergency department. DESIGN: Retrospective study. PARTICIPANTS: Patients seeking treatment at 3 private practice institutions over a 2-year period between 2017 and 2018. METHODS: A retrospective chart review was conducted comprising all patients who sought treatment emergently and after clinic hours from 3 academic nonhospital-associated retina-only private practice institutions over a 2-year period. MAIN OUTCOME MEASURES: Patient presenting symptoms, diagnosis given at time of after-hours appointment, duration of symptoms, source of after-hours consultation (patient or provider), procedure performed at appointment, and appointments that led to surgery. RESULTS: Nine hundred eighty-seven charts were reviewed. Provider referrals accounted for 49.13% (n = 485) and patient-derived referrals accounted for 50% (n = 493) of appointments. New patients accounted for 27.6% (n = 146) of patient-derived and 85.2% (n = 413) of provider-derived referrals. The most common presenting symptoms were flashes and floaters (42.5%; n = 420), decrease in visual acuity (32.1%; n = 317), generalized eye pain (7.4%; n = 73), visual field disturbance (4.3%; n = 42), and postoperative ocular pain (3.4%; n = 34). An in-office procedure was performed at the time of examination in 18% of encounters (n = 178), with most of these being laser retinopexy. Surgery was performed within 24 hours in 18% (n = 180), within 48 hours in 20.6% (n = 203), within 72 hours in 21.7% (n = 214), and within 96 hours in 22.6% (n = 223) of the appointment. When combined with procedures, 36.2% (n = 358) of encounters led to urgent intervention within 24 hours. If a provider called about an existing patient, 37.5% of these appointments (n = 27) led to surgery versus 12.8% (n = 49) if an existing patient self-referred. If a provider called about a new patient, 31.7% of these appointments (n = 131) led to surgery versus 10% (n = 14) if a new patient self-referred. CONCLUSIONS: At these 3 private practice retinal specialty clinics, 41% of after-hours appointment requests resulted in an intervention within 96 hours, and 36% of these patients underwent an intervention within 24 hours.

A Novel Peer-Directed Curriculum to Enhance Medical Ethics Training for Medical Students: A Single-Institution Experience.

BACKGROUND: The best pedagogical approach to teaching medical ethics is unknown and widely variable across medical school curricula in the United States. Active learning, reflective practice, informal discourse, and peer-led teaching methods have been widely supported as recent advances in medical education. Using a bottom-up teaching approach builds on medical trainees' own moral thinking and emotion to promote awareness and shared decision-making in navigating everyday ethical considerations confronted in the clinical setting. OBJECTIVE: Our study objective was to outline our methodology of grassroots efforts in developing an innovative, student-derived longitudinal program to enhance teaching in medical ethics for interested medical students. METHODS: Through the development of a 4-year interactive medical ethics curriculum, interested medical students were provided the opportunity to enhance their own moral and ethical identities in the clinical setting through a peer-derived longitudinal curriculum including the following components: lunch-and-learn didactic sessions, peer-facilitated ethics presentations, faculty-student mentorship sessions, student ethics committee discussions, hospital ethics committee and pastoral care shadowing, and an ethics capstone scholarly project. The curriculum places emphasis on small group narrative discussion and collaboration with peers and faculty mentors about ethical considerations in everyday clinical decision-making and provides an intellectual space to self-reflect, explore moral and professional values, and mature one's own professional communication skills. RESULTS: The Leadership through Ethics (LTE) program is now in its fourth year with 14 faculty-clinician ethics facilitators and 65 active student participants on track for a distinction in medical ethics upon graduation. Early student narrative feedback showed recurrent themes on positive curricular components including (1) clinician mentorship is key, (2) peer discussion and reflection relatable to the wards is effective, and (3) hands-on and interactive clinical training adds value. As a result of the peer-driven initiative, the program has been awarded recognition as a graduate-level certification for sustainable expansion of the grassroots curriculum for trainees in the clinical setting. CONCLUSIONS: Grassroots medical ethics education emphasizes experiential learning and peer-to-peer informal discourse of everyday ethical considerations in the health care setting. Student engagement in curricular development, reflective practice in clinical settings, and peer-assisted learning are strategies to enhance clinical ethics education. The Leadership through Ethics program augments and has the potential to transform traditional teaching methodology in bioethics education for motivated students by offering protected small group discussion time, a safe environment, and guidance from ethics facilitators to reflect on shared experiences in clinical ethics and to gain more robust, hands-on ethics training in the clinical setting.

Venovenous Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure.

Conventional treatment of respiratory failure involves positive pressure ventilation that can worsen lung damage. Extracorporeal membrane oxygenation (ECMO) is typically used when conventional therapy fails. In this study, we evaluated the use of venovenous (VV)-ECMO for the treatment of severe pediatric respiratory failure at our institution. A retrospective analysis of pediatric patients (age 1-18) placed on ECMO in the last 15 years (1999-2014) by the pediatric surgery team for respiratory failure was performed. Five pediatric patients underwent ECMO (mean age 10 years; range, 2-16). All underwent VV-ECMO. Diagnoses were status asthmaticus (2), acute respiratory distress syndrome due to septic shock (1), aspergillus pneumonia (1), and respiratory failure due to parainfluenza (1). Two patients had severe barotrauma prior to ECMO initiation. Average oxygenation index (OI) prior to cannulation was 74 (range 23-122). No patients required conversion to VA-ECMO. The average ECMO run time was 4.4 days (range 2-6). The average number of days on the ventilator was 15 (range 4-27). There were no major complications due to the procedure. Survival to discharge was 100%. Average follow up is 4.4 years (range 1-15). A short run of VV-ECMO can be lifesaving for pediatric patients in respiratory failure. Survival is excellent despite severely elevated oxygen indices. VV-ECMO may be well tolerated and can be considered for severe pediatric respiratory failure.

Identification and Referral of Patients at Risk for Post-traumatic Stress Disorder: A Literature Review and Retrospective Analysis.

Post-traumatic stress disorder (PTSD) is a well-established psychological disorder after severe traumatic injury but remains poorly recognized. Recent changes in the "Resources for Optimal Care of the Injured Trauma Patient 2014" stress the need for comprehensive screening and referral for PTSD and depression after injury. Our purpose was to review the current PTSD literature and perform a retrospective chart review to evaluate screening at our institution. We hypothesized a lack of documentation and thus referral of these patients to mental health professionals. We performed a literature review of 43 publications of risk factors for PTSD in the civilian adult population followed by a retrospective review. Records were analyzed for basic demographics, risk factors found in the literature, and referrals to mental health providers. Risk factors included amputation, dissociative symptoms, female gender, history of mental health disorder, and peri-traumatic emotionality. Traumatic amputation status and gender were recorded in all patients. History of mental health disorder was present in 11.5 per cent patients, absent in 80.75 per cent, and not recorded in 7.75 per cent with an overall documentation of 91.75 per cent. Dissociative symptoms and peri-traumatic emotionality were recorded in 0.5 per cent and 1.0 per cent of patients, respectively. Only 13 patients of 400 (3.25%) were referred to mental health professionals. Despite extensive evidence and literature supporting risk factors for the development of PTSD, identification and treatment at our level 1 trauma center is lacking. There is a need for consistent screening among trauma centers to identify PTSD risk factors and protocols for risk reduction and referrals for patients at risk.