Search

Residents need to learn how to assess and accommodate to a variety of behaviors and affective styles presented by patients and their families. This requires those skills which enable them to facilitate interactions with people in a positive, effective, and efficient manner. The teaching of these interpersonal and communication skills should incorporate a multi-disciplinary model. The development and implementation of a successful resident training program requires careful attention to the establishment of goals and objectives, learning activities and evaluation strategies that will meet the needs of the resident. The utilization of a multi-teaching, multi-media, and collaborative team approach intensifies the effectiveness of the overall training program. This article describes a training program that focuses on communication skills while being mindful of the various settings in which residency training occurs. These include the use of video-tape of physician/patient interaction in continuing care clinic, communication with children in non-medical settings and audio-tape reviews of physicians telephone management in a pediatric emergency care setting. The evaluation instruments developed to assess interpersonal and communications skills are reviewed and discussed as an integral component of this educational and training model. [ABSTRACT FROM AUTHOR]

Study Objective: We designed this study to determine the experiences, attitudes, and beliefs of teenagers regarding violence in their lives and to gain an understanding of the perceived role of the emergency health care professional., Methods: A qualitative study involving 10-person focus groups was conducted in 4 cities representing urban/low socioeconomic and suburban/high socioeconomic areas. Participants were 14 or 15 years of age and were recruited from local community centers. Moderators were matched by sex to the teenagers, and groups were segmented by race and sex. A semistructured guide was developed to help facilitate the discussion. All groups were audiotaped and videotaped, and the tapes were reviewed by the investigators for reoccurring themes., Results: A total of 140 adolescents (14 groups of 10) participated; one half were male. Urban teenagers expressed concerns about gangs, rape, and homicide; suburban teenagers were concerned about parental pressure and suicide. The teenagers expressed distrust of teachers, police officers, and doctors and felt safest with their parents. The emergency department was viewed as a confusing and frightening place, and participants believed that the role of the ED staff was to treat the patient's medical problem and not inquire or counsel about violence., Conclusion: All of the teenagers, regardless of socioeconomic status, were concerned about violence in their lives. All of the teenagers believed that the emergency department is not the place for patients to be counseled about safety and violence prevention. A better understanding of the problem of violence from the point of view of the teenager is important in refining an effective role for the emergency health care provider in adolescent violent injury prevention.

Background: The educational goal of emergency medicine (EM) programs has been to prepare its graduates to provide care for a diverse range of patients and presentations, including pediatric patients., Objective: To evaluate the methods used to teach pediatric emergency medicine (PEM) to EM residents., Methods: A written questionnaire was distributed to 118 EM programs. Demographic data were requested concerning the type of residency program, number of residents, required pediatric rotations, elective pediatric rotations, type of hospital and settings in which pediatric patients are seen, and procedures performed. Information was also requested on the educational methods used, proctoring EM received, and any formal curriculum used., Results: Ninety-four percent (111/118) of the programs responded, with 80% of surveys completed by the residency director. Proctoring was primarily performed by PEM attendings and general EM attendings. Formal means of PEM education most often included the EM core curriculum (94%), journal club (95%), EM grand rounds (94%), and EM morbidity and mortality (M&M) conference (91%). Rotations and electives most often included the pediatric intensive care unit (PICU) and the emergency department (ED) (general and pediatric)., Conclusions: Emergency medicine residents are exposed to PEM primarily by rotating through a general ED, the PED, and the PICU, being proctored by PEM and EM attendings and attending EM lectures and EM M&M conferences. Areas that may merit further attention for pediatric emergency training include experience in areas of neonatal resuscitation, pediatric M&M, and specific pediatric electives. This survey highlights the need to describe current educational strategies as a first step to assess perceived effectiveness.

Context: Endotracheal intubation (ETI) is widely used for airway management of children in the out-of-hospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome., Objective: To compare the survival and neurological outcomes of pediatric patients treated with bag-valve-mask ventilation (BVM) with those of patients treated with BVM followed by ETI., Design: Controlled clinical trial, in which patients were assigned to interventions by calendar day from March 15, 1994, through January 1, 1997., Setting: Two large, urban, rapid-transport emergency medical services (EMS) systems., Participants: A total of 830 consecutive patients aged 12 years or younger or estimated to weigh less than 40 kg who required airway management; 820 were available for follow-up., Interventions: Patients were assigned to receive either BVM (odd days; n = 410) or BVM followed by ETI (even days; n = 420)., Main Outcome Measures: Survival to hospital discharge and neurological status at discharge from an acute care hospital compared by treatment group., Results: There was no significant difference in survival between the BVM group (123/404 [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.11) or in the rate of achieving a good neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22)., Conclusion: These results indicate that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system.

The out-of-hospital care of children has seen significant changes in the past 10 years. Much work has yet to be done to research interventions and prevention strategies that have a positive effect on the outcome of children. Physicians, nurses, and out-of-hospital providers must serve as advocates for children in their communities.

Little information is available about the effects of CPR in children, although it is known that the outcomes are dismal. Examples of unanswered questions include which advanced life support (ALS) procedures should be performed out-of-hospital, whether high-dose epinephrine improves survival, and the true prevalence of ventricular fibrillation as a presenting rhythm. Children differ from adults as to the cause and pathophysiology of cardiopulmonary arrest, but prehospital EMS and hospital resuscitation teams were initially designed for the care of adults. Because pediatric cardiopulmonary arrest is rare, prospective data are difficult to gather, and there are few large published studies. The purpose of this collective review was to review the current body of knowledge regarding survival rates and outcomes in pediatric CPR and, based on this review, to outline a course for future research.

Study Objective: To arrive at a consensus on the priorities for future research in emergency medical services for children., Methods: A consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Round 1 involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics on the basis of the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research, and whether the topic would (1) improve general knowledge, (2) change behavior, (3) improve health, (4) decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. Participants were also asked if the research would require a multicenter study and if the research were feasible. Round 2 of the study involved a meeting of the panel, where the results of Round 1 were discussed and the topics were reprioritized. The topics were given a rank order and a final ranking was done in Round 3., Results: The panel considered a list of 32 topics; these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care, systems organization, configuration, and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order., Conclusion: The panel was able to develop a list of important topics for future research in emergency medical services for children that can be used by foundations, governmental agencies, and others in setting a research agenda for such services.

Study Objective: The study objective was to arrive at a consensus on the priorities for future research in Emergency Medical Services for Children (EMSC)., Methods: A consensus group was convened using the Rand'-UCLA Consensus Process. The group took part in a 3-phase process. Phase I involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics based on the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research and whether the topic would (1) improve general knowledge, (2) change behavior, (3) improve health, (4) decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. They were also asked in the research would require a multicenter study and if the research were feasible. Round II of the study involved a meeting of the panel, where the results of Round I were discussed and the topics reprioritized. The topics were given a rank order and a final ranking was done in Round III., Results: The panel considered a list of 32 topics and these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care systems organization, configuration and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order., Conclusion: The panel was able to develop a list of important topics for future research in EMSC that can be used by foundations, governmental agencies, and others in setting a research agenda for EMSC.

An 11-year-old boy presented to the pediatric ED with signs and symptoms of Bell's palsy, which was believed to be a result of otitis media. He subsequently began to list to the left and could not walk erect. Because of a history of prochlorperazine use for vomiting, a diagnosis of a dystonic reaction to a phenothiazine was made, and the patient was treated with intravenous diphenhydramine. All symptoms resolved, including seventh nerve palsy, within 5 minutes of treatment. Medications are often prescribed by physicians for vomiting without caretakers being aware of the side-effects. Dystonic reactions can be severe and present with myriad neurologic signs and symptoms.

Study Objective: The National Highway Traffic Safety Administration developed the EMS (emergency medical services) Technical Assessment Program to assist states in developing and improving their EMS systems. The main goals of this evaluation were to document the level of improvement in EMS system development following completion of the Technical Assessment Program and to identify necessary program improvements at the National Highway Traffic Safety Administration., Design: Independent investigators retrospectively reviewed the information in Technical Assessment Program reports from 35 states that participated in the program during a 5-year period., Results: Training and certification programs for prehospital personnel were the most well-developed elements of EMS systems. Conversely, comprehensive quality management and EMS system evaluation programs were almost uniformly absent (89% of states). Areas of need targeted for improvement included enabling legislation for EMS (60%) or trauma system development (69%), an improved mechanism to assess system resources (71%), an established or updated state EMS plan (80%), aging and unreliable communications equipment (89%), fully operational prehospital data collection systems (89%), and consistent medical oversight for all prehospital providers (92%)., Conclusion: Program evaluation revealed that significant recommendation-based changes occurred in all components of EMS systems. The Technical Assessment Program is one tool that states can use to promote EMS system improvements.

Cardiopulmonary arrest in childhood is usually due to respiratory failure leading to hypoxemia, acidosis, cardiac dysfunction, and terminal asystole. Respiratory failure is the end result of either impaired oxygenation, impaired ventilation, or both. We report a case of severe fecal impaction in an eight year old that resulted in a significant depression of ventilation by severely restricting respiratory mechanics and that ultimately progressed to respiratory failure and circulatory compromise. Physicians should be aware of this rare but possible etiology for life-threatening events in children.

The cases are presented of three patients who sustained scald burns after placing their braided hair in boiling water to set the braids. Caretakers and cosmetologists should be warned of the potential danger from scald burns when setting hair braids. Emergency physicians should be aware of this mechanism of injury for scald burns to the scalp, face, back, and neck regions.

Curricula in pediatric resuscitation must be based on adult learning principles. The Pediatric Basic and Advanced Life Support Courses (PBLS, PALS) should use educational strategies fostering positive interactions between the instructor and learners and should take into consideration the learner's motivation for taking the course. Materials should be developed for a specific target audience; course design should be flexible to meet individual needs. The PBLS and PALS courses have different audiences. PBLS is targeted toward caretakers of children. This course will continue to emphasize primary injury prevention as the major strategy but also will give learners the knowledge and skills to perform CPR. To optimize retention of knowledge and skills, the course content must be simplified, and the sequencing of steps in basic life support must be modified. Health care providers caring for pediatric patients in acute care settings are the primary audience for the PALS course. This course already incorporates adult learning principles; only minor revisions are anticipated. Discussion of the trauma patient is limited in the PALS course; additional trauma education could be facilitated by the addition of a trauma module or by other educational courses. All aspects of the PBLS and PALS educational programs must be evaluated continually to determine whether learning objectives have been met and whether the teaching format is appropriate. The answers to evaluation questions will help determine the degree to which the American Heart Association is meeting its educational objectives and how to allocate resources for development and training.

Infection with the roundworm Ascaris lumbricoides is common in children and may mimic an acute abdomen. The cases of two pediatric patients who presented to the emergency department with signs and symptoms of a surgical abdomen are presented to highlight the presentation of this infection. Both cases were diagnosed by physical examination and radiographs and were treated successfully without surgical intervention. These cases illustrate the need for heightened awareness by the emergency physician of ascariasis in the differential diagnosis of acute abdomen.

There are limited data concerning pediatric prehospital care, although pediatric prehospital calls constitute 10% of emergency medical services activity. Data from 10,493 prehospital care reports in 11 counties of California (four emergency medical services systems in rural and urban areas) were collected and analyzed. Comparison of urban and rural data found few significant differences in parameters analyzed. Use of the emergency medical services system by pediatric patients increased with age, but 12.5% of all calls were for children younger than 2 years. Calls for medical problems were most common for patients younger than 5 years of age; trauma was a more common complaint in rural areas (64%, P = .0001). Frequency of vital sign assessment differed by region, as did hospital contact (P less than .0001). Complete assessment of young pediatric patients, with a full set of vital signs and neurologic assessment, was rarely performed. Advanced life support providers were often on the scene, but advanced life support treatments and procedures were infrequently used. This study suggests the need for additional data on which to base emergency medical services system design and some directions for education of prehospital care providers.

Ambulatory care centers have emerged as a new health care resource in many communities. Little information is available about the services that these centers offer to pediatric patients. A national survey of 254 ambulatory care centers was undertaken to determine their characteristics, including the number of pediatric patients seen, staffing patterns, and pediatric equipment and supplies available. Most clinics were located in urban areas and were within 5 miles of a hospital. They were staffed primarily by physicians who were board certified in emergency medicine, internal medicine, or family medicine. Not all centers had registered nurses on duty and few used extended-role nurses or physicians's assistants. The centers saw an average of 18 patients younger than 18 years of age per day. Some ambulatory care centers received emergency medical service and private ambulance calls and encountered serious illness such as chest pain, seizures, and anaphylaxis; the majority, however, handled mainly minor injuries and illnesses. Although most had pediatric equipment and supplies, some did not have a complete set of pediatric resuscitation equipment even though they were part of the emergency system offering care to the pediatric population.

Twenty-four percent of all medical care contacts are made on the telephone. Practicing pediatricians and emergency physicians often manage children's illnesses by telephone. Studies have shown that there is a need for improved communication between physicians and patients, and it is believed that quality of, and satisfaction with, health care services will improve with increased emphasis on interpersonal communication skills in medical training. The Department of Pediatrics at Harbor-UCLA Medical Center includes interpersonal telephone communication as part of residency training. This article describes the telephone program, which differs from other programs in medical settings in that it focuses on communication process skills only. A conceptual framework around the acronym T.A.L.K. is outlined. Topic sessions in the pediatric emergency department and individual resident review sessions are discussed. The guidelines designed to follow the conceptual framework are presented.

A study of 10,493 prehospital care report forms from 11 counties in California demonstrated that the adolescent age group (ages 12 to 18 years) accessed prehospital care through the emergency medical service (EMS) system more frequently than other pediatric patients (5978 reports). They did so most commonly for trauma (87.6%), but also for behavioral emergencies such as suicide and psychiatric problems. The most common cause of injury was automobiles, and care rendered was most commonly wound care and splinting. The most common substances given to adolescents in the prehospital setting were naloxone and 50% dextrose. EMS systems need to address the need for triage and care of adolescent patients.

Vital signs are an integral part of the field assessment of patients. A two-part study was undertaken to determine which vital signs are taken in the field assessment of pediatric patients and to determine whether the frequency of vital signs taken is influenced by base station contact, patient's severity of illness or injury, or paramedic demographic factors such as parenting and field experience. An initial pilot study of prehospital care records (run sheets) from two base hospitals in Los Angeles County revealed that there were significant differences between field vital sign assessment in pediatric and adult patients (P less than .0001). A retrospective review of 6,756 pediatric run sheets from Los Angeles County showed that the frequency of vital sign assessment varied with the age of the pediatric patient (P less than .05) (ie, the frequency of vital sign assessment increased correspondingly with the age of the patient). Base hospital contact occurred in 26% of the runs; when contact was made, vital signs were more likely to be taken in all age groups studied. Vital signs often were not assessed in children less than 2 years old, even if the patient's chief complaint suggested the possibility of a major illness or trauma. The second part of the study was a field assessment survey that was distributed to 1,253 active paramedics in Los Angeles County; the results showed that paramedics were less confident in their ability to assess vital signs in children less than 2 years old. Confidence increased with age of the patient.(ABSTRACT TRUNCATED AT 250 WORDS)

A convenience sample of 153 boys and girls, aged 3-16 years, inhabiting Wuvulu Island were examined for the prevalence of dental caries and periodontal disease and for oral hygiene status. Average df teeth and surface scores for the group were 2.08 and 3.35, respectively, while average DMF teeth and surface scores were 0.90 and 1.20, respectively. Of the sample, 30.7% were caries free. Oral hygiene was poor and males had significantly more periodontal disease than females. While primary teeth were about three times more susceptible to caries than permanent teeth, tooth loss due to caries was not a problem in primary teeth. The authors discuss findings of other researchers and reasons for the greater prevalence of caries in primary teeth.

Emergency medical systems are being developed throughout the United States primarily to deal with myocardial infarction and trauma. These programs often fail to recognize the special needs of the critically ill child. Data collected in Los Angeles County from the LA County Trauma Surveys, Mobile Intensive Care Unit Rescue Reports, and Base Station Hospitals demonstrate that children represent approximately 10% of the paramedic calls. The calls are for medical problems as well as trauma. These data suggest that children have a higher death rate in the field than adults, and deaths occur more commonly in areas where there are no pediatric centers. Children are often secondarily transferred from emergency departments to other centers for definitive care. This study suggests that the needs of children in the prehospital setting are not being met.

This article provides an extensive table of drugs and dosages for treatment of parasitic infections, listing the treatment regimen most commonly used. This is followed by a list of the recommended drugs, their preparations, toxicity, contraindications, and precautions.

The cestode Hymenolepis microstoma was grown axenically from oncosphere to infective cysticercoid. Reducing agents were not essential for development and produced structural abnormalities in the organisms. Cysticercoids grown in vitro were excysted, placed in culture, and developed into adults containing gravid segments, thus completing the life cycle in vitro.

Malaria continues to present staggering morbidity and mortality statistics. In this well-detailed article, the authors examine the increased incidence of malaria in many areas, describe the malarial parasites, discuss the clinical course, pathogenesis, diagnosis, and treatment, and address the issues of transfusion malaria, congenital malaria, immunity, chemoprophylaxis, and vaccine.

Cysticercoids of the tapeworm Hymenolepis nana were grown axenically in vitro, from oncospheres hatched in vitro to fully developed organisms infective to mice. A gas phase of 95 N2--5 CO2 was essential for normal development.

Three patients with meningitis due to the Lancefield group D enterococci are described and the pertinent literature is reviewed. Anatomic central nervous system (CNS) defects, prior neurologic or neurosurgical interventions, group D enterococcal endocarditis, and urinary tract infection appear to be important predisposing factors. Of note is the frequent lack of cellular response in the spinal fluid to enterococci. The mortality of this infection is high (33%) and is probably dictated as much by the underlying disorder as the infection itself. The therapeutic importance of careful separation of group D streptococcal isolates into enterococci and nonenterococci, especially in instances of CNS infections, is emphasized. We discuss the appropriate antimicrobial therapy for enterococcal meningitis.

Emergency medical services have been organized to meet the needs of adult patients. A study was undertaken to determine the training in pediatrics offered to paramedics and emergency medical technicians throughout the United States and the equipment carried by prehospital care provider agencies. Most training (50%) takes place at colleges and universities and the remainder at hospitals and emergency medical services agencies. Many programs (40%) have less than ten hours of didactic training in pediatrics and 41% offer ten hours or less of clinical experience. Some programs offer no training in pediatric emergency medicine. The most common deficiencies in pediatric equipment included backboards, pediatric drugs, resuscitation masks, and small intravenous catheters. More attention to training and equipping prehospital personnel for pediatric emergencies may help to improve outcomes of out-of-hospital resuscitations of infants and children.