The Current State of Advanced Pediatric Emergency Medicine Point-of-Care Ultrasound (POCUS) Training: Exploring Recent POCUS Fellowship Application Trends and Alternate Training Models.

OBJECTIVES: This study aims to assess the current state of advanced pediatric emergency medicine (PEM) point-of-care ultrasound (POCUS) training in North America, including trends in dedicated PEM POCUS fellowships and alternative advanced POCUS training pathways, to better guide future educational efforts within the field. METHODS: We identified and surveyed 22 PEM POCUS fellowship directors across the United States and Canada regarding PEM POCUS fellowship application trends, potential barriers to pursuing additional POCUS training, and novel training models that meet the needs of the PEM POCUS workforce. RESULTS: The past 5 years have seen a growth in both PEM POCUS fellowship program number and trainee positions available, with a general impression by fellowship directors of a high demand for faculty who have these training credentials. However, there was a discordant drop in fellowship applicants and corresponding match rate in 2022, the cause of which is not clear. A number of programs are offering alternative advanced training options including combined PEM/POCUS fellowships and POCUS tracks within PEM fellowship. CONCLUSION: As POCUS use within PEM evolves, a growing number of advanced training options are being developed. Understanding the motivations and barriers for pursuing advanced POCUS training can help to shape these options going forward, to ensure the experience incorporated within each model meets the needs of trainees, the needs of PEM divisions, and the future needs of our field.

Management of pediatric urinary tract infections in the emergency department.

Urinary tract infection (UTI) is a common diagnosis in pediatric patients presenting to the emergency department. Although there are several evidence-based guidelines for UTI, they have small variations that can make the workup and management for UTI challenging. This issue reviews the current state of the literature and best practices for the diagnosis and management of UTI in children presenting to the emergency department, including criteria to help the clinician decide whether to test a patient's urine, the best method for urine testing based on the clinical scenario, and how to manage the patient based on the results of urine testing. Also discussed is the best antibiotic choice for specific patients, including the route of administration and duration.

Emergency department management of dangerous back pain in children.

Back pain in the pediatric population remains an unusual and concerning complaint that may be an indicator of serious underlying pathology. This issue reviews rare but dangerous etiologies of pediatric back pain and highlights signs and symptoms that may raise a red flag for potentially dangerous etiologies of back pain among children and teens. The evaluation of these patients, including judicious and effective imaging recommendations, is also discussed. A data-driven algorithm for evaluating patients can save the majority of patients from the expense and anxiety of unnecessary testing while effectively identifying the most appropriate means (and locations) for working up pathologic pediatric back pain.

Targeted organized teaching scripts (TOTS) in the pediatric emergency department.

In the pediatric emergency department (PED), considerable challenges inhibit educational opportunities for residents outside of being precepted. The use of teaching scripts specifically addresses these challenges by allowing faculty to have prepared, hyperfocused content that can be delivered in a short time. We developed a series of teaching scripts for 10 high-yield topics in the PED and assessed their effectiveness at improving educational experiences. Teaching scripts were inconsistently used but well received. Their use also correlated with increased resident satisfaction with clinical teaching. The majority of residents and faculty showed considerable interest in expanding the TOTS program to include additional pediatric emergency medicine topics.

"Code Green Active" Curriculum: Implementation of an Educational Initiative to Increase Awareness of Active Shooter Protocols Among Emergency Department Staff.

BACKGROUND: There has been an increase in violent acts against hospital employees, including active shooter events. Emergency department (ED) staff must be able to respond to these events efficiently to ensure the safest possible outcome. However, few in our ED were aware of our hospital's active shooter protocol. We aimed to increase staff knowledge of and confidence in these guidelines. METHODS: We developed and implemented a 7-week spiral curriculum using the Kern model of curriculum development. Each week, a segment of the hospital active shooter protocol was featured. Multimodal instructional methods including posters, instruction at daily team huddles, descriptions in the weekly division newsletter, and email summaries were used.A 10-question assessment was administered to ED staff both before and after the implementation of our curriculum. During both assessments, staff were asked to rate their confidence in both knowledge of and ability to follow hospital active shooter guidelines. RESULTS: There were 95 and 102 participants in the preintervention and postintervention periods, respectively.The median proportion of correct answers on the knowledge assessment increased when comparing preintervention with postintervention performances (P < 0.05).Staff confidence in both knowledge of and ability to follow active shooter protocols increased after the implementation of our curriculum (P < 0.05). CONCLUSIONS: Our 7-week curriculum resulted in improved knowledge of and confidence in hospital active shooter protocols among ED staff. Given that our sample was an unpaired convenience sample, inferences from our analysis were limited. Tabletop simulations are currently underway to further reinforce and clarify concepts.

Current risk landscape of point-of-care ultrasound in pediatric emergency medicine in medical malpractice litigation.

BACKGROUND: Point-of-care ultrasound (PoCUS) is expanding as a diagnostic tool in pediatric emergency medicine. Pediatricians are apprehensive to take on the risk of malpractice from incorrect interpretation of PoCUS imaging, therefore limiting its use. Although current studies provide reassurance to this concern, none look directly at the risk for pediatric emergency medicine physicians. Our study aims to evaluate the current medicolegal risk landscape posed by PoCUS in pediatric emergency medicine. METHODS: A search of case law was performed utilizing the LexisNexis caselaw database for the period of January 2011 through December 2021. Initial search results were reviewed by the attorney co-authors for relevance to medical malpractice surrounding PoCUS. The remaining cases were reviewed by physician co-authors to ensure their relevance to both ultrasound and the acute care setting. Identified cases were then classified into categories as per the reason for the claim. RESULTS: No cases of malpractice litigation were identified that directly related to PoCUS. Ten cases of ultrasound in the acute care setting were identified, 7 of which were in pediatric patients. The majority of these cases related to appendicitis or testicular torsion. Of these 10 cases, 2 cases claimed failure to consider the ultimate diagnosis, but ultrasound would have been an appropriate study had the diagnosis been considered. Of the 8 remaining cases, 6 were based on failure to perform or delay performing ultrasound, 1 claimed that improper ultrasound study was initially performed, and 1 case was based on an improper diagnosis made by ultrasound. DISCUSSION: PoCUS does not appear to pose a significant risk of malpractice litigation in pediatric emergency medicine.

Retrospective study comparing success rates of lumbar puncture positions in infants.

BACKGROUND: A lumbar puncture (LP) is performed in the emergency room for diagnostic purposes; unsuccessful or traumatic LPs can complicate decision making. The sitting position has a larger interspinous process compared to lateral recumbent and is safer in sick neonates at risk for cardiac and respiratory instability. PURPOSE: Our study aims to determine which position (lateral recumbent or sitting) is associated with a greater likelihood of successful lumbar puncture in infants <3 months when performed in the emergency room. BASIC PROCEDURES: This is a retrospective chart review in infants aged <3 months who had a LP performed in a pediatric emergency room. The primary outcome was the rate of successful LPs, defined as obtaining adequate CSF to send for all studies. The secondary outcome was the proportion of atraumatic LPs by position, defined as <500 RBCs or < 10,000 RBCs. MAIN FINDINGS: A total of 557 charts were reviewed with 116 in the sitting position and 441 in the lateral recumbent position. The primary outcome of adequate CSF fluid collection was not significantly different between groups (63% sitting position versus 58% lateral recumbent position; p = 0.22). In addition, the proportion of atraumatic LPs showed no significant difference regardless of RBC cutoff (<500 RBCs p = 0.83, <10,000 RBCs p = 0.60). PRINCIPLE CONCLUSIONS: This study found no evidence that there is a difference in rate of LP success nor the proportion of traumatic LP in infants less than 3 months of age when positioned in the sitting position compared to the lateral recumbent position.

Bedside Ultrasound for the Evaluation of Epidural Hematoma After Infant Lumbar Puncture.

BACKGROUND: Unsuccessful lumbar puncture (LP) attempts may lead to epidural hematoma (EH) formation within the spinal canal at the site of needle insertion, which can affect subsequent attempts. We aimed to determine the rate of EH formation after infant LP using bedside ultrasound (US). Furthermore, we aimed to correlate both perceived trauma during LP and cerebral spinal fluid (CSF) red blood cell (RBC) counts with EH formation. METHODS: We enrolled infants younger than 6 months who underwent LP in the emergency department. The primary investigator performed a bedside US of the lumbar spine, which was reviewed and interpreted by a pediatric radiologist. Treating clinicians performed the procedure and were asked to classify each attempt as "traumatic" or "atraumatic." Cerebral spinal fluid RBC counts were recorded. RESULTS: Thirty-one percent of patients had evidence of post-LP EH, 17% of which completely effaced the thecal sac. Forty percent of patients with at least 1 traumatic attempt had evidence of EH, whereas 25% without reported trauma showed EH (P = 0.17). Patients with EH had a median CSF RBC cell count of 186 cells/mm (range, 0-239,525) compared with 5 cells/mm (range, 0-3429) in patients without evidence of EH (P = 0.008). CONCLUSIONS: Epidural hematomas are frequent after LP. Perceived trauma during LP and CSF RBC counts are not adequate predictors of EH formation. Point-of-care US may be a valuable adjunct to help guide subsequent needle insertions sites for repeat attempts after an unsuccessful LP.

Primary Care Providers as Mental Health Counselors: Views from Urban, Minority Adolescents.

OBJECTIVE: To examine urban, minority adolescents' preferences for receiving guidance for mental health (MH) issues from primary care providers (PCPs) or from mental health providers (MHPs). METHODS: Adolescents (13-21 years) from three community clinics and one school-based health center (SBHC) in the Bronx, N.Y. completed anonymous surveys. Characteristics of adolescents who preferred the PCP vs. MHP and adolescents' attitudes about the PCP vs. the MHP were compared. RESULTS: Adolescents (N=135), mean age 16 years, majority Hispanic participated. Although 85% strongly agreed or agreed that their PCP was knowledgeable about MH, 57% preferred to talk to a MHP. Those who preferred the MHP were younger, attend a SBHC, and trust information on MH from a MHP. Those who preferred the PCP were more likely to report feeling comfortable talking to their PCP about MH. CONCLUSIONS: Although the majority preferred a MHP, PCPs appeared to be an acceptable alternative for MH care.