Termination of Pediatric Resuscitation – the Elephant in the Room, Part 1

The picture of the grieving emergency physician who "couldn't save" a patient went viral in common media. However emergency physicians know that their emotions run even higher after we "couldn't save" someone because we are the "final call", the decision maker, the one that says "stop...right now." That responsibility in itself can make what might have been already a futile case feel gut-wrenching - especially when it involves a child. As pediatric emergency medicine physicians, we will all be faced with the decision to terminate a resuscitation following cardiac arrest. Clinically, this Read more [...]

What’s the plan, man? Assessing how trainees develop the plan of care

The Pediatric Milestones are now being used to guide the ongoing evaluation of trainees in all rotations. Certainly the most important Milestones vary from rotation to rotation. In the Pediatric Emergency Department (as in many others) making sure that you develop an effective plan for diagnosis and treatment is critical. This post is all about what we do multiple times a day: Developing a plan of care and carrying it out. Early/novice residents rely on theoretical knowledge that they gained in medical school. Having not seen the condition, especially in the context of the ED they lack the previous Read more [...]

Healthcare- heal thyself!

The other day, I as I scarfed a meal in 3 minutes flat – I thought to myself, why do I feel so guilty about eating? Doctors are never supposed to eat, pee or sleep. It is a sign of weakness. Some sauce dripped onto my shirt and stained like a scarlet letter. An object of scorn, an opportunity for a colleague to jab “hey what’d you get for me?”. I few years back, I wore the red cape of an ER physician, sacrificing self before everything else. Now I need to keep steady glucose levels during a shift or I won't function.  I also don’t bounce back from a night-shift like I used to. Read more [...]

Are We Doing It Right?

A 4-year-old patient was brought in for abdominal pain for the past day. He was brought to the ED a week prior with similar symptoms and was diagnosed with constipation. He has been taking Miralax regularly without improvement in bowel habits. We asked the parents how they use the medication. Their answer: feeding him the powder with a table spoon! Consider another patient I saw, whose father was concerned that she was vomiting blood. When we took a closer look we noticed that she was vomiting the red Gatorade she was trying to drink. In our profession we see many patients within a short Read more [...]

Do you have a guideline for that?

Clinical practice guidelines are an effective way of disseminating knowledge.  The best CPGs represent the culmination of research in a field translating into clinical practice and improved patient outcomes. Guidelines are generally produced by specialty societies and our young specialty has lagged other more established domains of medicine (GI, oncology, cardiology). The PECARN decision tool is a great example of knowledge translation (while not a CPG) that has been integrated into sites like med-calc and is used by ED providers across the country.  With the upcoming release of the Read more [...]

Just the Facts: Assessing How Trainees Gather Info

The Pediatric Milestones are now being used to guide the ongoing evaluation of trainees in all rotations. The most important Milestones vary from rotation to rotation. In the Pediatric Emergency Department (as in many others) making sure that you obtain the right history is key to assuring that you can develop an appropriate differential diagnosis and plan. Levels of Experience and Learning In general, early learners—for example interns—rely on basic pathophysiology and use analytic reasoning to generate mental maps to try to link their history and the exam. This history can be too extensive Read more [...]
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Answer: ‘Not So FAST!’

This post is in response to the post “Not so FAST!” To summarize, this was a 10-year-old boy complaining of abdominal pain after flipping over his handle bars while riding a bike.  An eFAST is performed and the following image of the right upper quadrant is obtained: Thank you to everyone who took the quiz! For question #1, 57% of you guessed correctly that there is free fluid in Morison’s pouch.  While this image is technically limited in that you can not fully visualize both the subphrenic recess (14%) or the inferior pole (24%), there is free fluid visualized in Morison’s Read more [...]
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Not so FAST!

A 16-year-old boy was trying to do a sweet jump off his friend's brand new Sledgehammer bike... https://www.youtube.com/watch?v=oYdps2cQkic But unfortunately, he was not as successful as his friend Pedro and is brought into your ED by EMS after flipping over his handle bars. He is alert and oriented, and hemodynamically stable. He denies any loss of consciousness but complains of abdominal pain. You perform an eFAST and obtain the following image of the right upper quadrant. http://lng801.polldaddy.com/s/what-is-your-interpretation-of-this-image-of-right-upper-quadrant Thank Read more [...]