Emergency Medicine Fellowship Research Articles

Current Utilization of Continuous End-Tidal Carbon Dioxide Monitoring in Pediatric Emergency Departments

End-tidal carbon dioxide (ETCO2) monitoring has numerous clinical applications in the emergency setting. This study was designed to explore the current availability and utilization patterns for continuous ETCO2 monitoring in pediatric emergency departments. A Web-based survey was distributed to directors of all accredited pediatric emergency medicine fellowship programs in the United States and Canada. Eighty-one percent of directors completed this survey. Eighty-eight percent had access to ETCO2 monitoring for intubated patients and 53% for nonintubated patients. Seventy-nine percent of respondents used ETCO2 monitoring "always" or "often" for endotracheal tube confirmation. Only 20% of respondents used ETCO2 monitoring "always" or "often" for moderate sedation, 16% for trauma, and 6% for acid-base disturbances. One hundred percent of respondents who used ETCO2 monitoring felt that it was easy to use. The most common reason for not using ETCO2 monitoring was lack of equipment (65%). ETCO2 monitoring is widely available, yet underutilized, for spontaneously breathing patients in pediatric emergency departments.

Outcomes Evaluation of the 2005 National Pediatric Emergency Medicine Fellows' Conference

Evaluate the effectiveness of the 2005 National Pediatric Emergency Medicine Fellows' Conference in achieving predefined objectives in scholarship, leadership, and partnership. Preconference and postconference questionnaires measured knowledge, research-related confidence, beliefs about institutional support for emergency medical services for children (EMSC) research, and intentions to engage in 7 specific behaviors relating to scholarship, leadership, and partnership. Bivariate correlations among the variables were assessed. Repeated-measures analysis of variance measured change between preconference and postconference measures. Hierarchical multiple linear regression models identified predictors of postconference intentions to engage in each of the 7 specific behaviors controlling for preconference intentions. Ninety-two pediatric emergency medicine fellows attended; more than 90% completed preconference and postconference questionnaires, and 88% completed both. Knowledge (P < 0.001) and confidence (P < 0.001) improved after the conference. Increases were observed in fellows' intentions to establish national mentoring relationships (P < 0.001), continue in EMSC research (P = 0.003), and participate in national collaborations (P = 0.022). Confidence and subjective norms correlated significantly (P < 0.05) with each of the behavioral intentions in bivariate tests. In the multivariable regression models, confidence correlated with 4 behavioral intentions (P < 0.02), and subjective norms correlated with one (P < 0.001). Forty-eight percent established a mentoring relationship with a faculty member; 25% planned to collaborate on research with other attendees. The 2005 National Pediatric Emergency Medicine Fellows' Conference resulted in positive, measurable outcomes relating to the professional development of attendees, including increased conference-specific knowledge, confidence, and intentions to continue in EMSC research, join national collaborative research networks, and establish national mentoring relationships.

EMCON 2007: 9th Annual Conference of the Society for Emergency Medicine

EMCON 2007: 9th Annual Conference of the Society for Emergency Medicine

Pediatric Emergency Medicine Fellowships: Faculty and Resident Training Profiles

The objective of this study was to evaluate the faculty and graduate training profiles of Pediatric Emergency Medicine (PEM) fellowship training programs. An electronic 10-point questionnaire was sent to 57 PEM fellowship directors, with a 70% response rate. Analysis of the individual certification of faculty members in PEM training programs demonstrated that the largest represented training types were general pediatricians and pediatricians with PEM sub-certification (29% and 62% representation, respectively). The remaining faculty types consistently showed < 5% overall involvement. Reported estimates on faculty delivery of clinical training, didactic training, and procedural skills demonstrated that pediatricians sub-board certified in PEM consistently administered the highest percentage of these skill sets (74%, 68%, and 68%, respectively). Emergency Medicine-trained physicians showed a relative increase of involvement in fellowship programs administered by Emergency Medicine departments and in those programs located within adult hospitals. Yet, this involvement still remained substantially lower than that of the pediatric-type faculty. Program directors of fellowships within pediatric hospitals and those administered by Pediatric programs demonstrated a preference for general pediatricians with sub-board certification in PEM to improve their faculty pools. Program directors of fellowship programs located in adult hospitals and those administered by departments of EM demonstrated no preference in training type. Lastly, program directors report that 95% of past graduates received their primary board certification through Pediatrics and only 5% received their primary board certification through Emergency Medicine. There are currently many more pediatric-trained physicians among PEM fellowship faculty and graduates. This survey has demonstrated that there has been a decline in EM-trained physicians involved in PEM fellowships since 2000.

The International Journal of Emergency Medicine: a new journal for a new era

The past decade has witnessed the emergence and substantial growth of the specialty of emergency medicine as a truly international medical discipline that refuses to be restrained by barriers of language, culture or geography. While the formal recognition of the specialty of emergency medicine is relatively young in most countries and nonexistent in some, the provision of emergency care is as ancient as the art of medicine itself. Descriptions of emergency care are documented in the Ebers Papyrus of ancient Egypt (2600 BC) [1], in the ancient teachings of traditional Chinese [2] and Ayurvedic [3] medicine and in the earliest writings of western medical care [4]. The growth of emergency medicine globally has been spurred by a number of factors, including population growth, urbanization, globalization and increasing expectations of patients around the world who are aware of what can be done to provide for emergency care [5]. The international growth of emergency medicine has resulted in an expanding presence of emergency medicine and related topics in scientific journals. In addition, the US has recently seen substantial growth in the number of international emergency medicine fellowship programs [6], and the international section and interest groups of emergency medicine societies are typically among the largest and most active in these organizations. A recent review of international emergency medicine from 2006 noted that one of the greatest obstacles to continue the growth of international emergency medicine remains the lack of high-quality, consolidated, and easily accessible evidence-based literature in this field [7]. This review of the literature from 2006 identified 25 international emergency medicine research articles. These articles include broad categories that cover the areas of evaluating EMS and trauma care services in both developed and developing countries, the global spread of emergency medicine and ways to improve emergency care for special populations within a developing country. A large proportion of international emergency medicine studies examines the methods for evaluating morbidity and mortality and improving the delivery of humanitarian aid during disasters and conflicts. The field of international emergency medicine has several major components that have been identified. These include (1) relief and disaster medicine, (2) prehospital care systems and infrastructure, (3) health-care policy at the national, regional and local levels, (4) clinical emergency medicine including the provision of emergency care in settings of limited resources, (5) emergency medicine research and (6) emergency medicine education. All of these domains have enjoyed development and continue to grow robustly.

Use of an Automated Electronic Case Log to Assess Fellowship Training

The Accreditation Council for Graduate Medical Education has mandated the assessment of medical training across 6 core competencies. The patient care competency is at the core of medical training. With the introduction of patient tracking systems used in emergency departments, patient-physician encounters can be systematically studied. The combination of tracking data with other clinical information systems can be used to create an electronic case log to quantify the experience of fellows, thereby offering a summative measure of the patient care competency. We used an automated case log to assess clinical exposure in our pediatric emergency medicine fellowship.

A profile of US asthma centers, 2006

Asthma is a significant public health problem that results in 1.8 million annual emergency department (ED) visits. Many ED visits may be prevented with specialized asthma care. To describe US asthma centers with a long-term goal of exploring their potential role in improving outcomes for ED patients with acute asthma. We conducted initial online surveys in 2004. One survey identified asthma centers and their directors through reports by emergency medicine researchers and fellowship directors (allergy/immunology, pulmonary, and critical care) at US hospitals. A second survey asked asthma center directors to describe their asthma center. Follow-up surveys were conducted 2 years later in 2006. Eighty-seven (49%) of the 177 hospitals surveyed have asthma clinics. Although spirometry was available on the day of the visit at all asthma centers surveyed in 2006, only 21% (95% confidence interval, 11 %-34%) of sites reported that at least 90% of visits per week included a spirometry test. Only one quarter (26%; 95% confidence interval, 15%-40%) of asthma centers reported that at least 90% of patients undergo a skin or blood test for environmental allergens during 1 of their visits. Half of center directors (53%) were unsure of the approximate number of annual ED visits for acute asthma at their hospital. No significant measured changes were noted in asthma centers between 2004 and 2006. Asthma centers are heterogenous, with different services available. Although challenges remain, collaboration between EDs and asthma centers may contribute to improved asthma outcomes and merits further study.

Current Trends in the Management of Common Painful Conditions of Preschool Children in United States Pediatric Emergency Departments

Trends in pain management practice by Pediatric Emergency Medicine fellows in the United States were described and analyzed. Self-administered surveys on pain management practices conducted among Pediatric Emergency Medicine fellows at the national Pediatric Emergency Medicine fellows' annual conference in 1996 and 2004 were compared. In comparison to the 1996 survey, the 2004 survey noted a significant increase in narcotics use for headache (6% versus 12%; P = .001), abdominal pain (4% versus 50%; P = .001), and burn patients (46% versus 68%; P = .001). There was also an increase in reported use of topical/ local anesthetics for venipuncture (6% versus 18%, P = .001) and lumbar puncture (49% versus 80%; P = .001), and ketamine for repairing lacerations (16% versus 56%; P = .001), incision and drainage (12% versus 58%; P = .001), and reduction of fractures (38% versus 79%; P = .001). The reported use of pain medication use by Pediatric Emergency Medicine fellows increased during the study period.

Emergency medicine in modern Europe

Emergency medicine in the highly advanced world is traditionally performed in two different ways. The first is the well-known Anglo-American system with skilled EDs, and a pre-hospital emergency medical service utilizing paramedics. The second is the so-called Franco-German system, with a highly developed pre-hospital emergency physician service, but only a basic organization of hospital-based emergency medicine. This gap is now closing fast because of the rapid advancement of hospital-based emergency medicine in Europe. Four criteria might be used to measure this: the recognition as a specialty, the specialist training programme, the professional organization of emergency physicians and the presence of academic centres in Europe. Eleven of the 27 European countries recognize hospital-based emergency medicine as a specialty already. These include Belgium, Czech Republic, Estonia, Hungary, Ireland, Italy, Malta, Poland, Romania, Slovenia and the United Kingdom. Other nations are striving to do so, for example Sweden, France, Germany and Greece. There is no doubt that emergency medicine is gaining momentum and other countries will follow. Training for the specialty of emergency medicine is advanced already. Several curricula presently exist in the respective European countries. A task force, governed by the European Society for Emergency Medicine has been working hard to create a model curriculum for all of Europe, which is expected to be published in 2007. This comprises a 5-year specialty training, with three of them spent in an ED. The curriculum follows a symptom-oriented approach to emergency medicine, and includes a skilled description of the key competencies of the future trained emergency physicians. Given the century-long history of the pre-hospital emergency physician service in some European countries, a number of professional bodies exist representing pre-hospital emergency doctors. Within the last few years, ED physicians followed suit forming organizations of their own. In some countries, the next step of amalgamation has occurred, with the merger of EMS and ED emergency physician organizations, although no country has abolished the pre-hospital emergency physician service. The last milestone, the development of academic emergency centres, has only just started. This process will take some time. The present paper describes the present and future of emergency medicine in some European countries using these criteria.

Les maladies rares aux urgences : état des lieux

There is a lack of information available to emergency physicians on the management of patients with a rare disease requiring emergency care. In this report, we present the results of a survey conducted by Orphanet and the French Society for Emergency Medicine (SFMU) aimed towards identifying the current methods and needs of emergency physicians requiring useful information in these situations. The survey was made up of three parts: a description of the activity of the participant, data concerning prior experience with rare diseases, and the physicians needs with regard to the information available. In total, 207 physicians participated in the survey. Nearly 53% of the emergency physicians had managed a patient with a rare disease, and during the past year 8% of these physicians managed more than 10 patients affected by one of 110 different pathologies or groups of pathologies spanning all medical specialities. Information about the disease was obtained in nearly 70% of cases, either by Internet (60% of these cases) or by contacting a specialist (38% of these cases). This information led to a change in patient management in 42% of the cases and prevented complications in 12% of the cases. The two principal sources of information requested were personalised healthcare cards carried by the patients (91%) and emergency guidelines available by Internet (75%). Such guidelines are currently being made available through a collaboration between Orphanet, emergency physicians and the centres of reference for rare diseases.

Job Market Survey of Recent Pediatric Emergency Medicine Fellowship Graduates

The American Academy of Pediatrics Section of Emergency Medicine's Subcommittee on Administration developed a survey tool targeting recent pediatric emergency medicine (PEM) fellowship graduates to assess the current PEM job market in a variety of areas including (1) the new positions accepted, (2) perspectives of fellowship training, and (3) the relationship between PEM and general emergency medicine practice. The 40-question internet-based survey was developed through www.surveymonkey.com. Solicitations to PEM fellowship graduates who completed training between the years 2000 and 2005 were sent via the Section of Emergency Medicine member e-mail list as well as the PEM LISTSERV. Data collection occurred from April to May 2005. Of 125 survey respondents, 89% completed a 3-year pediatrics residency plus a 3-year PEM fellowship. Offers to graduates of positions with research expectations outnumbered clinical positions, 3:2, with an average of 5 total positions offered per respondent. Thirty-four percent remained at the institution of fellowship graduation, and 71% accepted faculty appointments with medical school affiliation. Seventy percent of work time was spent on clinical duties and 10% on research. Most felt better prepared in the areas of clinical training and teaching than in the areas of research and administration. Additional general emergency medicine exposure was not desired. Half of the respondents felt that a 2-year fellowship program would have met their career goals. Recent PEM fellowship graduates felt that job availability was good and were satisfied with their new positions. Respondents perceived better fellowship training in clinical and teaching aspects than in research and administration. New positions were heavily clinical and matched career goals.

The Use of Local Anesthetic Techniques for Closed Forearm Fracture Reduction in Children

Although local anesthetic techniques (hematoma blocks, nerve blocks, intravenous regional anesthesia) for forearm fracture reduction are well described and commonly used in adults, it is unclear how often these techniques are used in children. To characterize the use of local anesthesia for pediatric closed forearm fracture reduction by pediatric and orthopedic physicians practicing in teaching hospitals in Canada and the United States. An on-line survey targeting physicians practicing in hospitals with pediatric emergency medicine (PEM) fellowships in Canada and the United States was sent to the PEM fellowship director and orthopedic department head at each hospital. Sixty-three orthopedic surgeons and 69 PEM physicians were invited to participate in the survey, and 63% responded of all invited participants. All respondents routinely use sedation for forearm fracture reduction. Local anesthesia is used by 78% of respondents (55% rarely, 28% sometimes, and 17% frequently). Hematoma blocks are used by 92% of respondents who use local anesthesia; 20% use Bier blocks, and 2% use cubital blocks. Among respondents who never use local anesthesia, all believe that sufficient analgesia is obtained from procedural sedation alone, and 35% believe that local anesthesia is ineffective. Local anesthetic techniques are used only occasionally by those surveyed. More studies examining the use of local anesthesia for forearm fractures in children are necessary to evaluate the need for more widespread use.

Pediatric Emergency Medicine Fellowship Programs

Pediatric Emergency Medicine Fellowship Programs

Procedural Pain Management Patterns in Academic Pediatric Emergency Departments

To describe the current state of the art for pain and sedation management for five common pediatric emergency department (ED) procedure scenarios. Fellowship directors of U.S. EDs with a pediatric emergency medicine fellowship training program were surveyed by mail and asked to choose the one most commonly used pain or sedation management option for five clinical scenarios: facial laceration repair, cranial computed tomography in a toddler, closed fracture reduction, neonatal lumbar puncture, and intravenous catheter insertion. Results were analyzed by using descriptive statistics, and the differences between high and low volume departments were compared by using a chi-square test. Thirty-eight of 51 fellowship programs responded (75%). The majority of respondents were fellowship directors (76%). Topical anesthetics were most commonly reported as used for a simple facial laceration (84%), whereas ketamine sedation was most popular for fracture reduction (86%). Pain management for the other scenarios was more variable. More than half of the respondents (53%) would not sedate at all for cranial computed tomography, and only 38% reported use of pharmacologic pain management for intravenous catheter insertion. The majority (74%) reported use of anesthetic (topical or injected local) for neonatal lumbar puncture. High volume departments were more likely to use pain management for intravenous catheter insertions. Pain and sedation management methods for pediatric procedures continue to evolve. Despite gains, there is still room for improvement, particularly regarding intravenous catheter insertions.

Need for Standardized Sign‐out in the Emergency Department: A Survey of Emergency Medicine Residency and Pediatric Emergency Medicine Fellowship Program Directors

To determine the existing patterns of sign-out processes prevalent in emergency departments (EDs) nationwide. In addition, to assess whether training programs provide specific guidance to their trainees regarding sign-outs and attitudes of emergency medicine (EM) residency and pediatric EM fellowship program directors toward the need for the development of standardized guidelines relating to sign-outs. A Web-based survey of training program directors of each Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency and pediatric EM fellowship program was conducted in March 2006. Overall, 185 (61.1%) program directors responded to the survey. One hundred thirty-six (73.5%) program directors reported that sign-outs at change of shift occurred in a common area within the ED, and 79 (42.7%) respondents indicated combined sign-outs in the presence of both attending and resident physicians. A majority of the programs, 119 (89.5%), stated that there was no uniform written policy regarding patient sign-out in their ED. Half (50.3%) of all those surveyed reported that physicians sign out patient details "verbally only," and 79 (42.9%) noted that transfer of attending responsibility was "rarely documented." Only 34 (25.6%) programs affirmed that they had formal didactic sessions focused on sign-outs. A majority (71.6%) of program directors surveyed agreed that specific practice parameters regarding transfer of care in the ED would improve patient care; 80 (72.3%) agreed that a standardized sign-out system in the ED would improve communication and reduce medical error. There is wide variation in the sign-out processes followed by different EDs. A majority of those surveyed expressed the need for standardized sign-out systems.

Need for Standardized Sign-out in the Emergency Department: A Survey of Emergency Medicine Residency and Pediatric Emergency Medicine Fellowship Program Directors

Need for Standardized Sign-out in the Emergency Department: A Survey of Emergency Medicine Residency and Pediatric Emergency Medicine Fellowship Program Directors

Transitional Medicine

Currently, approximately 85% of children with significant congenital heart problems survive to adolescence and adulthood. This survival rate represents a dramatic improvement in the medical and surgical care of congenital heart disease (CHD) during the last 35 years. Nevertheless, these patients remain at increased risk for significant cardiac problems long after primary interventions are completed. They are more likely than the general population to seek urgent medical care, often in an emergency department setting. They represent a new and growing population of emergency department patients with a specialized set of problems not traditionally part of the training for emergency medicine (EM) physicians. We investigated the current scope and status of training for EM physicians in the immediate management of CHD patients as they grow to adolescence and adulthood. We conducted 2 cross-sectional surveys to assess the current training environment for 2 specific groups: (1) US general EM (GEM) residency programs, and (2) US and Canadian pediatric EM (PEM) fellowship programs. Surveys were mailed to program directors during the summer of 2005. A total of 198 surveys were sent out: 134 to GEM residency directors and 64 to PEM fellowship directors. The response rate overall was 68%, with a 64% response rate from the GEM residency directors and 77% from the PEM fellowship directors. Across all programs, 43% (56/130 respondents) were "unsure" about the existence or location of an adult CHD (ACHD) clinic in their area. When asked to rate the importance of ACHD as a training topic, 40 (85%) of 47 PEM fellowship directors and 62 (74%) of 84 GEM residency directors ranked it as "low priority" or "unnecessary." However, 70 (55%) of 127 respondents were "unsure," "uncomfortable," or "worried" about the ACHD training their trainees receive (PEM, 59%; GEM, 53%). In addition, most program directors (75%) estimated that their trainees care for 5 or fewer ACHD patients annually. There seems to be a mismatch between the growing need for ACHD emergency care and the current state of this topic in both GEM residency and PEM fellowship training programs.

An Automated Electronic Case Log: Using Electronic Information Systems to Assess Training in Emergency Medicine

As part of the Outcome Project of the Accreditation Council for Graduate Medical Education, training programs are required to evaluate trainees across six general competencies. Assessment of the patient-care competency by direct observation can be supplemented with a quantification of overall experience through the use of case logs. However, manual entry of information into such registries frequently is incomplete. The authors report on the development of an automated electronic case log as a novel tool for evaluating the experience of individual trainees or an entire training program. Specific examples of use of the case log are provided. The authors use a pediatric emergency medicine fellowship as a paradigm to demonstrate the potential utility across all emergency medicine training programs. In addition, the authors discuss how additional information technologies might be incorporated to further these evaluative efforts in the future.

Procedural skills quality assurance among Australasian College for Emergency Medicine fellows and trainees

Presently, no objective quality control mechanism exists for monitoring procedural skills among Australasian College for Emergency Medicine trainees. The present study examined trainee and fellow procedural experience and perceived competency, participation in accredited training courses and support for a procedural logbook. A cross-sectional mail survey of Australasian College for Emergency Medicine advanced trainees and fellows was performed. Experience and perceived competency in 23 common and important ED procedures were examined. In total, 202 fellows and 264 trainees responded (overall response rate 39.0%). Overall, fellow procedural experience and perceived competency were reasonable. However, some fellows had never performed a number of procedures including some common procedures (e.g. nasal packing, fracture reduction) and there were reports of 'very poor' competency for 17 (73.9%) procedures. Trainee experience and perceived competency were less than the fellows but showed similar patterns. Perceived numbers of each procedure required to achieve competency varied considerably between the procedures and among the respondents. However, there were no significant differences in the perceived numbers reported by the trainees and the fellows (P > 0.05). Variable proportions of trainees and fellows had undertaken courses that incorporated procedural skills training. More fellows (75.7%, 95% confidence interval 69.1-81.4) than trainees (59.9%, 95% confidence interval 53.6-65.8) supported the use of a procedural logbook (P = 0.003). Lack of experience in some procedures among some fellows, especially commonly performed procedures, might represent a deficiency in existing quality assurance mechanisms for procedural skills training. Greater participation in skills courses, to improve experience in difficult and uncommonly encountered procedures, is recommended. Improved quality assurance mechanisms, including a procedural logbook, should be considered.

Pediatric Emergency Medicine Fellowship Programs

Pediatric Emergency Medicine Fellowship Programs