Using an iPad to Remotely Assess Seriously Ill Kids

TOPTENAndrea Cruz (Texas Children’s) and Michelle Macy (Michigan) presented the best PEM-related articles of 2016 at AAP this past October. If you weren’t one of the tens of thousands of people in the room that day, we’re going to be counting them down in no particular order over the next few weeks. 

#10: Reliability of Telemedicine in the Assessment of Seriously Ill Children

Siew L, Hsiao A, McCarthy P, Agrawal A, Lee E, Chen L. Pediatrics. 2016.

Unmet needs addressed

Telemedicine has the potential to bridge the distance between the provider and the patient, expand access to specialized care, and would make it feasible to evaluate ill children remotely. But PEM is different than dermatology and hospital medicine, which both have shown promise in using telemedicine. For PEM to integrate telemedicine into widespread practice, it’s important to know if telemedicine is reliable enough to make clinical recommendations and decisions.


The study was prospective and done in an urban tertiary care pediatric ED with 35,000 annual visits. The study compared telemedicine observations to bedside observations in assessing two specific PEM populations: febrile children 2-36 months old and children 2 months to 18 years in respiratory distress. Patients were excluded if they were thought to be “clinically too unstable.” Authors used inter-rater reliability to determine if telemedicine observations were significantly different than bedside assessments.

Bedside and telemedicine observers completed their Yale Observation Scales (for febrile patients) or Respiratory Observation Checklists (for respiratory patients) at the same time and were blinded to each other’s assessments.

The telemedicine was done using FaceTime on an Apple iPad with an assistant holding the iPad and controlling the distance and camera angles. The observer could ask for different angles and views.

Main Results

The study found excellent agreement on both febrile children and children in respiratory distress between telemedicine and bedside observations (kappa > 0.8). This suggests that both bedside observation and telemedicine came to similar conclusions when it came to these two populations of sick children.

How did this make our Top Ten?

  • This means that fever and respiratory distress—both common conditions seen in children—may be assessed remotely by clinicians with pediatric expertise.
  • The use of iPads means that the technology is both accessible and (relatively) affordable.
  • There is lower agreement between bedside and telemedicine observation for intercostal retractions. Perhaps this was due to camera and Wi-Fi limitations.
  • Integration of telemedicine into routine PEM practice would require use of platforms that would seamlessly link into the electronic health record in a way that preserves patient confidentiality.

Have You Searched For Yourself Online? You’re Not The Only One

Professionalism is one of your most important and irreplaceable assets, built up over years of training, work, and compassion. Professionalism is one of the few aspects of your career entirely under your control. However Facebook, Twitter, and the rest of the digital age has the potential to take that control from you if you are not also proactive and careful.

In the short video below, Brad Sobolewkski, MD, MEd, describes the many threats to your professionalism in the digital age and gives concrete advice on how to maintain control of it. It’s part of a presentation he gave at a national conference for PEM fellows this week. It’s short, watch it with a friend.

Your Uber Is On Its Way

by Cindy Soon MD and edited by Lorraine Ng MD and Sonny Tat MD MPH

UBER_ultrasoundMany new start-ups are promoting themselves as the Uber Something these days. There is the Uber of Dog Walking, The Uber of Snow Plows, and even The Uber of Dental Hygiene. Being the Uber of Something means disrupting existing approaches and instant gratification. In this way, The Uber of Pediatric Emergency Medicine may be Point of Care Ultrasound. It took one case to convince me.

She was a 12-year old girl with abdominal pain and no other symptoms. She was afebrile, tachycardic, had normal blood pressure, and an oxygen saturation of 91%. Her abdomen was diffusely tender but did not have rebound or guarding. Aside from the tachycardia, the rest of her exam was reassuring. We initially thought her abdominal pain may have been constipation, so we ordered an abdominal x-ray. While the abdominal part of the x-ray was unremarkable, the x-ray caught the bottom of the heart and it looked borderline enlarged.

At that point, it seemed like there were more questions than answers. We needed more information but what were our options in a busy ED?

Fortunately, Dr. Russ Horowitz was the attending that night and also the department’s director of ultrasound. He performed a bedside echo that showed severely depressed cardiac function and a fractional shortening of 11%.

Image 1

Fractional shortening measured using M-mode (parasternal long view) with “A” representing LVESD and “B” representing LVEDD.

Her BNP was elevated at 600 and EKG showed sinus tachycardia. Cardiology confirmed the echo findings and the patient was admitted to the cardiac intensive care unit. She did well on milrinone and was eventually discharged home a week later having recovered from a significant case of viral myocarditis.

The point-of-care (POC) ultrasound led to a timely diagnosis by zeroing in on poor cardiac function as the cause of abdominal pain. Without ultrasound, her evaluation would have been delayed and we could even imagine that if she had improved with pain medications, she may have even been discharged home.

Apical four views of the heart showing a severely depressed cardiac function.

Now widely accepting in emergency medicine, POC ultrasound has started gaining traction in pediatric emergency medicine. In 2011, 88% of pediatric emergency medicine programs provided training in POC ultrasound and 95% endorsed using POC ultrasound in their emergency department. In 2015, The American Academy of Pediatrics recommended that PEM physicians should receive POC ultrasound training, an acknowledgement of ultrasound’s potential.

Medicine is evolving, and physicians have to keep up with both the latest guidelines and the latest technological advances that help us become better, more effective clinicians. For example, instead of waiting for an x-ray to diagnose cases of questionable pneumonia, we can now place an ultrasound probe on the patient’s chest and make the diagnosis immediately. In addition to expediting clinical decision-making, POC ultrasound improves procedural success and can decrease patient lengths of stay.

One day in the near future, every clinician may have their own affordable and portable ultrasound device. POC ultrasound will move being from an optional skill to a basic clinical tool. Your Uber of pediatric emergency medicine will be arriving shortly.

We are hosting a 2-day hands-on pediatric ultrasound conference this May 19th and 20th in Denver, CO. Click to register or get more information.

How I work: Managing My Reference Manager

My first time using a reference management system was a high school research paper on the Meiji Restoration. References weren’t found using an Internet search, as Al Gore had only recently invented it. I managed my references with a pile of index cards, handwritten in pencil, and organized alphabetically in a small box.

Research has come a long way since then. We spend less time in the library and more time on computers. Articles are often electronic rather than print. Reference managers are the modern day box of note cards except faster, more flexible, and less embarrassing to carry around. The following is a step-by-step tutorial on using a reference manager.

There are many reference managers out there including RefWorks, Papers, Mendalay, and a whole slew of others I have never heard of. I use EndNote (Version 7) so will be referring to it as we go. I also use Microsoft Word for Mac 2011. There will be subtle differences between EndNote and Word versions but the ideas are similar.

Get a copy of EndNote and read on.

Getting started

If you have access to an academic library with subscriptions to journals, you’ll be able to get more full text copies and bring them directly into EndNote. Log on to your VPN before opening EndNote. If you are on your university network, this is usually automatic. If you don’t have access to an academic library, you can still use EndNote. You’ll just be less likely to get full text.

Orienting to EndNote

The first time I open EndNote, I get the following screen.

Slide01This is called a library. I think of this as a catalog that indexes my articles. The library screen is organized into columns. The left column is where I navigate my library and as I move from left to right on the screen, the information gets more specific.

The left column contains my folder system for this library. This system is broken down into Group Sets (folders) and Groups (sub-folders). More on Groups and Group Sets later.

Integrated Search means "Let me search my computer and Internet."

Integrated Search means “Let me search my computer and Internet.”

The middle column contains references, search results, and search boxes. The right column provides details and attachments of the reference I am working with.

The first time I use EndNote, I start by selecting “Integrated Library and Online Search Mode” at the top. (The square with the globe in it, see figure). That gives me the option to search both the catalog on my computer and online databases like PubMed straight through EndNote. I do not know why this isn’t the default option.

Import your references

Now that I have my library set up, I’m ready to search for and import references.

Unless I know the exact reference I’m looking for, I do not use EndNote’s built-in PubMed search to look for articles. EndNote’s search interface is cumbersome and usually gives me either too many references to be useful or none at all.

Instead, I use either PubMed or Google Scholar to search. In PubMed, I perform my standard search. PubMed search strategies are beyond the scope of this post but a medical librarian will tell you there is a smart way to do it.


Identify your article somewhere else, bring it into EndNote here.

When I find an article I want on PubMed, I go back to EndNote and select “PubMed” in the left column. This brings search fields into the middle column. In the search fields, I enter an author’s last name, the publication year, and one unique word in the title that I found in PubMed. I use a unique word to limit the unrelated references that EndNote lists. The references come up in the middle column and are organized by author, year, and title. If my search is unique, the article I am looking for comes up.

I often also use Google Scholar to search for articles. Since Google Scholar lists search results by relevance instead of most recent (as PubMed does), I get different results. After I identify the article I want, I go back to EndNote as before and bring the reference in using the PubMed search feature as above.

A little known feature of Google Scholar plays nice with reference managers.

Cite: A little known feature of Google Scholar plays nice with reference managers.

With Google Scholar, I can also bypass this searching step within EndNote by importing the reference directly into EndNote from Google Scholar. I do this by clicking on “Cite” underneath the search result. This downloads the reference data, which I can then open with EndNote and file it as before. This Google Scholar workaround is a little bit more efficient than the PubMed workaround.

Importing full text

The Full Text button has a lot going on.

Has anyone actually used a magnifying glass to find anything?

Neither of these methods imports the actual pdf for me to read. To do that, I select the reference and click on the “Find Full Text” icon at the top. This poorly designed icon is supposed to be a document with a magnifying glass but for the longest time I thought it was letters “LO” and stood for “LOcate.”

Clicking on this icon tells EndNote to search for the PDF. If the PDF is publicly available or my institution has a subscription to this journal, it will find and automatically attach the PDF.

Follow the Paperclip to full text

Follow the Paperclip to full text

I can tell if EndNote finds the full text by the paperclip that shows up next to the reference. Now I can double click on the reference and open the full PDF to read it. I find full text for multiple articles at once by selecting multiple references and clicking on “Find Full Text.” EndNote will look for the full text for each reference selected.

Organize, search, and sort references

Slide09I organize my references by using Group Sets and Groups. I create a Group Set for each project I am working on. Within each Group Set I create a Group for each topic of my project or section of a planned paper.

To create new Group Sets and Groups, I right-click on the left column and select the appropriate Group or Group Set option that pops up. I can create and rename these at anytime.

I had initially not used Group Sets, creating only Groups for each project. I found that this lazy strategy made it hard to find the right article when I had more than 15-20 papers per project. Another strategy is creating different libraries for various projects but I think navigating between libraries is fussier than working within a single library.

I can also file any reference in more than once group. One article may apply to two or three papers, projects, or sections. I can drag the reference into as many groups as are applicable.

Immediately after finding the article I’m looking for, I drag the reference into the appropriate Group. Otherwise, my search results will go into the “All References” group, and may be hard to locate later.

Insert references and renumber automatically

This is the big money with a reference manager. Without a reference manager, inserting references is time consuming and tedious. With a reference manager like EndNote, I click in the document where I want to insert the reference, go back to EndNote and select the reference I want to insert, and click on the insert button. The icon for inserting a reference is inexplicably an arrow pointing to a right quotation mark and is located on the top right of the EndNote window.


For such a useful button, the Insert Reference icon could be much better.

This inserts the reference into the text and places the formatted reference at the end of your document. Moving references around and deleting references is just as easy. Delete the reference from the body of the text and the reference at the end of the paper will be deleted as well. I can re-insert the reference anywhere else in the paper and the formatted reference will be added to the end of the document in the proper order. References CANNOT be dragged from one place to another. This confuses the program. Instead, references must be deleted and re-inserted. This is non-intuitive although infinitely better than manually inserting and renumbering.

Formatting references


No more retyping references when submitting to a different journal.

The last beautiful part of a reference manager is that it can format my bibliography with just a few clicks. If I am submitting a paper to the New England Journal of Medicine, I can go to Tools > EndNote > Configure Bibliography. From there I can browse and select the Bibliography style I am looking for. But if I get rejected from NEJM and I want to re-submit to the Lancet, I can select Lancet from the list. The whole document is reformatted for the appropriate journal. Click!

That’s a basic overview of how I work with references. Next time, I will share my strategy for using EndNote in a shared paper and across multiple computers.

What EndNote Does Well For Me

  • Imports references automatically so I don’t have to type them out
  • Organizes references and makes them searchable and sortable
  • Inserts references and renumbers them automatically
  • Organizes my full text pdfs

What EndNote Fails At for Me

  • Browsing and searching for articles in a database like PubMed. The search function is terrible in EndNote.
  • Taking notes on articles and annotating. Read-only. I wish there was a way to annotate the articles as I am reading them.
  • Mobile access is non-existent, at least in the version I have.
  • Icon design: The opposite of sleek and efficient.