General Emergency Medicine Research Articles

A survey of Canadian emergency physicians' experiences and perspectives during the COVID-19 pandemic.

BackgroundThe objective of this study was to explore Canadian emergency physicians’ experiences, concerns, and perspectives during the first wave of the coronavirus disease (COVID-19) pandemic.MethodsThis cross-sectional survey of physician members of Pediatric Emergency Research Canada and the Canadian Association of Emergency Physicians explored: personal safety/responsibility to care; patient interactions; ethical issues in pandemic care; institutional dynamics and communication practices. Data analysis was descriptive: categorical data were summarised with frequency distributions, continuous data [100 mm visual analog scales (VAS)] were analysed using measures of central tendency. Short open-ended items were coded to identify frequencies of responses.ResultsFrom June 29 to July 29, 2020, 187 respondents (13% response rate) completed the survey: 39% were from Ontario and 20% from Quebec, trained in general (50%) or pediatric (37%) emergency medicine. Respondents reported a high moral obligation to care for patients (97/100, IQR: 85–100, on 100 mm VAS). Fear of contracting COVID-19 changed how 82% of respondents reported interacting with patients, while 97% reported PPE negatively impacted patient care. Despite reporting a high proportion of negative emotions (84%), respondents (59%) were not/slightly concerned about their mental health. Top concerns included a potential second wave, Canada’s financial situation, worldwide solidarity, and youth mental health. Facilitators to provide emergency care included: teamwork, leadership, clear communications strategies.ConclusionCanadian emergency physicians felt a strong sense of responsibility to care, while dealing with several ethical dilemmas. Clear communication strategies, measures to ensure safety, and appropriate emergency department setups facilitate pandemic care. Emergency physicians were not concerned about their own mental health, requiring further exploration.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43678-021-00129-4.

Prevalence of hearing impairment in patients with diabetes mellitus at tertiary care center of Nepal

Background: Diabetes mellitus is a chronic, systemic and metabolic disorder known to affect almost every organ due to its unequivocal complications. The auditory organ is often affected but usually ignored complications of diabetes mellitus. With the rise in the prevalence of diabetes mellitus and hearing impairment in developing countries, it becomes a crucial public health issue if both of them are found to be associated. Objective: To find the prevalence of hearing impairment in diabetic patients. Materials and Methods: This was a cross-sectional study conducted at the Department of Clinical Physiology in collaboration with the Department of General Practice and Emergency Medicine and the Department of Otorhinolaryngology- Head and Neck Surgery, Tribhuvan University Teaching Hospital. After applying exclusion criteria, 55 subjects were recruited for the study. Pure Tone Audiometry, a non-invasive test was used to assess hearing threshold in this study. Audiogram findings of diabetics were then analyzed. Results: Outcomes of the tests revealed that 17 (30%) of subjects with diabetes mellitus had hearing loss, out of which 13 had mild hearing loss. A significantly positive correlation was found between age and hearing threshold at every frequency. Higher frequencies were found to be more affected. The best cut-off age for onset of hearing loss in diabetics was found to be 51.50 years. Conclusion: Current study suggests a 30% prevalence of hearing loss in diabetes mellitus. We observed hearing loss more among the elderly at higher frequencies

Multidisciplinary simulation-based trauma team training with an emphasis on crisis resource management improves residents’ non-technical skills

BackgroundNon-technical skills impact trauma resuscitation time. Crisis resource management teaches non-technical skills required for effective teamwork in a crisis. We developed a simulation-based multidisciplinary trauma team training, with an emphasis on crisis resource management and a goal of improving residents’ non-technical skills. MethodsTwenty-five post-graduate year-1 general surgery and emergency medicine residents were divided into multidisciplinary teams with embedded nurse participants. Teams underwent 3 trauma resuscitation scenarios followed by a crisis resource management debrief. Additionally, a Just-In-Time crisis resource management didactic was delivered before 1 scenario. Teams’ non-technical skills in each scenario were assessed by expert raters using non-technical skills scale for trauma and scenario scores before and after the Just-In-Time didactic were compared. Multiple linear-regression calculating the impact of clinical scenario, case order, and timing relative to the Just-In-Time didactic on a teams’ non-technical skills scale for trauma score was performed. ResultsSeventy-four team T-NOTECHS ratings were completed. T-NOTECHS total score was significantly higher on the third training case regardless of clinical scenario or timing relative to the Just-In-Time didactic (pre = 15.58 vs post = 18.11, P = .117). Teams scored an average of 15.44 on the first scenario of the day, 16.63 on the second, and 19.04 on the last (P < .001). ConclusionCrisis resource management-focused multidisciplinary team training significantly improves residents’ non-technical skills in the simulated environment. Case repetition followed by crisis resource management focused debriefings outweighed the effect of a single Just-In-Time crisis resource management didactic.

633 Use of an ICU Rounding Tool Enhances Critical Care Learning for Trainees on a Burn Surgery Rotation

Abstract Introduction An institutional Burn Intensive Care Unit (ICU) Rounding Tool was implemented for both quality improvement data collection and trainee education. Forms are completed by trainee team members daily for all critically ill patients prior to teaching rounds. Gathered data are structured to facilitate evaluation of patient volume status, sepsis risk and ventilator management. The forms are then used to guide discussion among students, residents, mid-level providers, fellows, attending surgeons and other members of the multi-disciplinary rounding team. We conducted a series of interviews with trainees regarding their user experience to assess the tool’s educational utility. Methods A convenience sample of residents who had recently completed their Burn Surgery rotation were interviewed in a structured format. Questions focused on the form’s ease of use and comprehensibility. Emphasis was placed on the extent to which it stimulates learning while rounding. Additional feedback was sought for the purpose of improving the tool for continued use. Results Participants were post-graduate year one or two resident physicians training in General Surgery, Urology, Emergency Medicine or Anesthesia. Prior experience and comfort with ICU level care ranged from very little to moderate. All interviewees found the tool helpful in their patient assessments, though the current layout of the form was a frustration for many. Overall, they unanimously found the forms beneficial for preparation of patient presentations and felt that utilization during rounds facilitated learning. Conclusions Interviews with trainees on their burn surgery rotation demonstrate that implementation of an ICU Rounding Tool has provided educational benefit, particularly for those less experienced in intensive care. Feedback from this cohort will be used to improve the tool’s usability. Our next steps will include a more formal survey of all trainees involved since the inception of this project.

Quality Improvement Efforts to Reduce Opioid Prescribing From a Pediatric Emergency Department.

Since the early 1990s, the United States has been fighting the epidemic of opioid addiction. Increases in the prescription of over-the-counter opioid pain medications were correlated with a notable rise in overdose deaths as early as 1999.1 These trends may have been driven in part by national efforts to improve the assessment and management of pain among patients and the “pain as a fifth vital sign” culture.2 In this issue of Pediatrics, Bryl et al3 describe their quality improvement (QI) initiative to decrease prescription of opioid medications at discharge from their urban pediatric emergency department. Evaluation of data showing that nearly half of the opioid-related deaths among patients 0 to 21 years in the San Diego area involved patients seen at their institution prompted a call to action. As the largest pediatric provider in that region, achieving a decrease in the group’s prescription of opioid medications could have a significant impact on this population.The team used rigorous QI methods to guide their initiative. These included developing a specific aim; defining outcome, process, and balancing measures; and implementing interventions by using plan-do-study-act cycles. Statistical process control charts were used to track and analyze their data. Their results were dramatic: they achieved >90% reductions in their primary outcome measures of opioid doses prescribed per week and per visit in the emergency department. Importantly, they did not see any concerning trends in their balancing measures of return visits or poor pain control assessed on follow-up phone calls.First, among their interventions, the strongest appeared to be the use of clinical decision support as a “nudge” in the form of fixed discharge dosage limits within the electronic medical record (EMR).4 First described in 2008, clinical nudges represent low-cost, highly effective strategies for changing behaviors by limiting choice, leading to decreased variation. These types of interventions are often instrumental in sustaining change long-term.Second, any effort to reduce opioid prescriptions must use a balanced approach to achieve safe prescribing while adequately treating pain. Bryl et al3 used several balancing measures, including follow-up phone calls to discharged patients, and found no evidence of undertreatment. It is notable, however, that the group only reached 17% of patients, making it difficult to assess the impact of this project’s dosage choice on pain management at this time.Third, although the overall QI methods used were robust, their QI team did not include patients and families. When developing initiatives involving direct patient care, it is important to consider inclusion of patients and families, because these stakeholders can provide pivotal information related to patient adherence and preferences.The work of Bryl et al3 should be considered in the larger context of opioid reduction efforts. With their study, they support the current literature that leftover opioid medication can be a major source of misuse, abuse, and diversion.5 It is evident that reducing overall opioid doses prescribed may be an important avenue toward addressing the opioid crisis. However, opioid prescribing for children and adolescents accounts for only a fraction of the overall opioids prescribed.6,7 This highlights the critical need for partnering with general emergency medicine colleagues and adult health care providers to ensure improved stewardship of opioid prescribing. Groenewald et al8 suggest best practices include: “1) create guidelines to guide responsible opioid prescribing and reduce leftover medications, 2) educate adolescents about risks of opioids and how to safely dispose of opioids, and 3) reduce illicit prescriptions by using state Prescription Drug Monitoring Programs (PMPs).” The study by Bryl et al3 demonstrates how use of QI methodology can bring these strategies to front line providers in the pediatric emergency department.Initiatives involving guideline development, EMR modifications, and education have broad applicability and are easily implemented, making them ideal interventions for most emergency departments. The dramatic overall opioid reduction achieved by Bryl et al3 is not surprising. In a previous study, Guarisco et al9 used similar interventions in a general emergency department setting and demonstrated a 70% reduction in prescription rates for some physicians, without negatively impacting patient satisfaction scores. This suggests that such opioid reduction outcomes could be successfully replicated in other institutions and interventions are generalizable to all age groups. Another impressive achievement with this study is the sustainability of the initiative. Although strategies such as education have been shown to wane over time, fixed function changes, such as EMR dosing limits, are neither time-bound nor provider-dependent and are easily tracked for data collection.This initiative provides a wonderful example of a project which can be undertaken within other emergency departments to decrease opioid prescribing in the pediatric population. Thoughtful QI efforts and a commitment to change can have broad implications in the care we provide to our patients.

Wide Complex Tachycardia

Wide-complex tachycardias (WCTs) should always alert the emergency physician to a potentially immediate or rapidly developing, life-threatening scenario. The approach to these patients should follow general emergency medicine principles. The review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of WCT. Figures show a basic electrocardiogram (ECG) tracing, an ambulatory monitoring strip of a patient with recurrent presyncope showing repetitive monomorphic ventricular tachycardia, a 12-lead ECG of a rapid wide QRS tachycardia due to an antidromic atrioventricular reciprocating tachycardia in a patient with Wolff-Parkinson-White (WPW) syndrome, an example of pacemaker-mediated tachycardia, ventricular tachycardia occurring in the context of QT prolongation consistent with torsades de pointes, a 12-lead ECG in a patient with WPW syndrome showing a rapid, irregular ventricular rate and wide QRS complexes of atrial fibrillation with a short refractory period, an ECG representative of tricyclic antidepressant overdose, and an algorithm for identifying patients with systolic heart failure and left ventricular ejection fraction less than or equal to 35% who are candidates for an implantable cardioverter-defibrillator. Tables list causes of regular WCT, causes of prolonged QT interval, common medications with potential QT prolongation activity, pharmacologic treatment options for stable patients with WCT, Kindwall and colleagues’ criteria for ventricular tachycardia, Brugada and colleagues’ criteria for ventricular tachycardia, Vereckei and colleagues’ aVr algorithm for the diagnosis of ventricular tachycardia, and a comparison of self-reported sensitivities, specificities, and test accuracies of the algorithms presented by Kindwall, Brugada, and Vereckei and their colleagues. Key words: prolonged QT interval, supraventricular tachycardia, ventricular tachycardia, wide-complex tachycardias This review contains 8 highly rendered figures, 8 tables, and 59 references.

Initial Resuscitation of a Multisystem Trauma Patient Following a Fall From Height: A Complete Simulation Scenario for Medical Students.

Management of a complex trauma patient is a critical skill for medical students, particularly during a general surgery or emergency medicine clerkship. However, gaining proficiency with this skillset may be challenging without prior medical or simulation experience. The aim of this technical report is to present a comprehensive high-fidelity medical simulation of a polytraumatized patient with numerous injuries sustained from a 20-foot fall. As the scenario unfolds, students identify multisystem injuries including acute hemorrhage, femur fracture, tension pneumothorax, and traumatic brain injury. The case was designed as an assessment tool to evaluate the knowledge of preclinical medical students obtained through a one-day workshop on the primary survey. This technical report provides simulation designers with a premade script, flowchart, labs, images, and supplies needed to successfully recreate the case.

Pediatric emergency medicine literature 2020.

Most children are treated at general Emergency Departments (EDs) and not specialized pediatric EDs. Therefore, it is crucial for emergency medicine physicians to be aware of recent developments in pediatric emergency medicine. Often impactful articles on pediatric emergency medicine are not published in the journals regularly studied by general emergency medicine physicians. We selected ten studies that we found impactful, robust, and relevant for practicing general emergency physicians. This review includes studies of status epilepticus, cardiac arrest, asthma, infant fever, wound care, rapid sequence intubation, coronavirus, and trauma.

What is the Impact of Lumbosciatic Infiltration on the Evolution of Herniated Disc and Dorsolumbar Asthrosis?

Lumbosciatica is a frequent reason for consultation in general medicine and emergency medicine with an estimated incidence between 2% and 14%. There are several therapeutic modalities, including infiltrations, which are very controversial. Based on this observation, we conducted a prospective study in which 19 patients had undergone epidural and peri-radicular infiltration; the epidural was the most represented infiltration in 68.4% of the patients, the peri-radicular was in 21.1% of them and the combination of both was in 10.5% of the cases, with only 30.6% of the infiltrations carried out under radioscopy. The molecules used were Triamcinolone Acetonide-based Kenacort and Methylprednisolone Acetate-based Depo-Medrol. The evolution of post-infiltration pain decreased significantly in 94.7% of cases, with a statistically significant difference (p = 0.04). No complications were observed in our patients and none of them had resorted to surgery during the follow-up period except for a single case of recurrence of pain relieved by periodic spaced infiltrations. Despite the small size of our sample, we can conclude that infiltration techniques still have a place in the management of Lumbosciatica alongside the surgery.

Soran Akram Agha Chawishly

Soran Akram Agha Chawishly was born on 4 January 1951 in Erbil, Iraq, to Akram and Rasmieh Chawishly, their second son and one of six children. After completing his primary...

Influenza Vaccination Hesitancy among Healthcare Workers in South Al Batinah Governorate in Oman: A Cross-Sectional Study.

Background: Seasonal influenza infections are a major cause of morbidity and mortality worldwide. Healthcare workers (HCWs) are an important target group for vaccination against influenza due to their increased risk of infection and their potential to transmit the infection to their patients, families and communities. The aim of this study was to assess the potential hesitancy and its associated factors towards influenza vaccination amongst HCWs in the South Al Batinah governorate in Oman. Methods: A cross-sectional survey of 390 HCWs with direct or indirect patient contact was conducted in May and June 2019 using a self-administered questionnaire. Associations between HCW characteristics and vaccination status were examined using bivariate and multivariate analyses to identify the likelihood of vaccination against seasonal influenza among HCWs. Results: Overall, 60% of HCWs were vaccinated in the 2018/2019 season; vaccine uptake among nurses was 52% and uptake was higher among women. Self-protection and protection of the community were the most cited reasons for vaccine acceptance, with side effects being the main reason for hesitancy. Vaccinated respondents had a higher mean knowledge score (7.18; standard deviation SD: 2.14) than unvaccinated respondents (6.30; SD: 2.2). Odds of vaccination were highest among respondents who believed influenza vaccine should be mandatory for HCWs (Odds ratio (OR): 2.04 [1.30–3.18]), those working in the general medicine, emergency medicine, or intensive care units (OR: 1.92 [1.20–3.10]), nurses and doctors (OR: 1.75 [1.09–2.79]) and those who believe that HCWs should receive an influenza vaccine (OR: 1.35 [1.07–2.77]). Conclusions: The study provides valuable insights into the enablers and barriers of influenza vaccination practices among HCWs and may inform interventions to increase acceptance of vaccination.

Closing the Loop: Program Description and Qualitative Analysis of a Pediatric Posttransfer Follow-up and Feedback Program.

Follow-up and feedback foster improvement. General emergency medicine providers working in community hospitals desire follow-up and feedback on pediatric patients transferred to children's hospitals. We implemented a novel program to provide these data to our colleagues. The objective of this study was to explore stakeholder perspectives of our program. We provided secure, electronic reports on transfers from 7 general emergency departments (GEDs). Patient follow-up and feedback data were delivered to the GED's pediatric emergency care coordinator. Seven pediatric emergency care coordinators and 2 children's hospital liaisons participated in semistructured interviews. Five researchers coded and analyzed transcribed data using the constant comparative method of grounded theory. Codes were refined and clustered to develop themes. Perceived values of the program included GED appreciation of closing the loop on transferred patients, providing education, and informing quality improvement. Participants valued the concise and timely nature of the reports and their empathetic delivery. Facilitators of program implementation included established professional relationships between the GED and the children's hospital liaisons and a GED's culture of self-inquiry. Barriers to program implementation included potential medicolegal exposure and the time burden for report generation and processing. Suggested programmatic improvements included focusing on generalizable, evidence-based learning points and analyzing care trends. Stakeholders of our pediatric posttransfer follow-up and feedback program reported many benefits and provided key suggestions that may promote successful dissemination of similar programs nationwide. Examining data trends in transferred children may focus efforts to improve the care of children across all emergency care settings.

Development of an App to Facilitate Communication and Shared Decision-making With Parents of Febrile Infants≤60 Days Old.

We aimed to develop and test a tool to engage parents of febrile infants≤60days of age evaluated in the emergency department (ED). The tool was designed to improve communication for all parents and to support shared decision-making (SDM) about whether to perform a lumbar puncture (LP) for infants 29 to 60days of age. We conducted a multiphase development and testing process: 1) individual, semistructured interviews with parents and clinicians (pediatric and general emergency medicine [EM] physicians and pediatric EM nurses) to learn their preferences for a communication and SDM tool; 2) design of a "storyboard" of the tool with design impression testing; 3) development of a software application (i.e., app) prototype, called e-Care; and 4) usability testing of e-Care, using qualitative assessment and the system usability scale (SUS). We interviewed 27 parents and 23 clinicians. Interviews revealed several themes, including that a communication tool should augment but not replace verbal communication; a Web-based format was preferred; and information about infections and testing, including the rationales for specific tests, would be valuable. We then developed separate versions of e-Care for infants≤28days and 29 to 60days of age, in both English and Spanish. The e-Care app includes four sections: 1) homepage; 2) why testing is done; 3) what tests are done; and 4) what happens after testing, including a table for parents of infants 29 to 60days of age to compare the risks/benefits of LP in preparation for an SDM conversation. Parents and clinicians reported that e-Care was understandable and helpful. The mean SUS score was 90.3 (95% confidence interval= 84 to 96.6), representing "excellent" usability. The e-Care app is a useable and understandable tool to support communication and SDM with parents of febrile infants≤60days of age in the ED.

Procedural Training in Pediatric Emergency Medicine Fellowship: What Are We Teaching and What Do Fellows Need to Learn?

Life-saving procedures are rarely performed on children in the emergency department, making it difficult for trainees to acquire the skills necessary to provide proficient resuscitative care for children. Studies have demonstrated that residents in general pediatrics and emergency medicine lack exposure to procedures in the pediatric context, but no studies exist regarding procedural training in pediatric emergency medicine (PEM). Although the Accreditation Council for Graduate Medical Education (ACGME) provides a list of procedures in which PEM fellows must be competent, the relevance of this procedure list to actual PEM practice has not been studied. This study sought to determine whether PEM fellowships currently provide sufficient exposure to the skills most relevant for practicing PEM physicians. Data were collected via anonymous electronic survey from physicians who graduated from PEM fellowship between 2012 and 2016. Survey items measured respondents' comfort with performing critical procedures, and their perceptions of the necessity of knowing how to perform each procedure in their current practice environment. A total of 133 individuals responded to the survey. Respondents unanimously agreed that 18 of the 36 procedures required by the ACGME are necessary to know in their current practice environment. For the remaining 18 mandated procedures, there was significant disagreement among respondents both as to the necessity of the procedure in current practice and respondents' degree of comfort with performing each procedure. Among recent PEM fellowship graduates, there is significant variation in comfort with performing ACGME-mandated procedures. These data highlight important opportunities for curricular enhancement in the procedural training of PEM physicians.

The role of PAs in providing mental health care.

The prevalence of psychiatric and substance use disorders in the United States is rising and of growing concern. Because such behavioral conditions are widespread, one approach is to collaborate with various medical professionals to help offset this demand. To address this issue, the frequency and types of mental health conditions encountered by physician assistants (PAs) were assessed. The National Commission on the Certification of Physician Assistants Practice Analysis was examined for the types of mental health conditions encountered across the spectrum of medical and surgical practices. The findings reveal that, in 2015, at least 62% of PAs saw and evaluated mental health conditions and behavioral disorders at least weekly in their settings. These patient diagnoses were seen with variability based on the specialty of the PA. The highest percentage of cases reported by PAs were in psychiatry, followed by general internal medicine, emergency medicine, family medicine, and hospital medicine. With the profession projected to grow, recruiting, retaining, and integrating more PAs into mental health care is a suggested strategy for addressing national provider shortages.

Relationship between medical students' career priority and specialty choice: A nationwide multicenter survey.

BackgroundThe shortage of physicians in several specialties has been brought to public attention in several countries. However, little is known about factors affecting medical students’ specialty choice. The objectives of our study were to illustrate medical students’ career priority clusters and to assess their association with specialty preference.MethodsWe conducted a nationwide multicenter survey in 2015 at 17 medical schools. The study participants were asked their top three specialty preferences, demographic characteristics, and 14 career priority questions. Multilevel logistic regression models were used to determine the effect of each variable on student career choice.ResultsA total of 1264 responses were included in the analyses. The top five specialty choices were internal medicine: 833, general practice: 408, pediatrics: 372, surgery: 344, and emergency medicine: 244. An exploratory factor analysis mapped the 14 career priorities into 3‐factor solution: “primary care orientation,” “advanced and specific care,” and “personal life orientation.” Multilevel logistic regression models yielded satisfactory accuracy with the highest ROC curve (AUROC) noted in surgery (0.818), general practice (0.769), and emergency medicine (0.744). The career priorities under “primary care orientation” had positive association with choosing general practice, emergency medicine, internal medicine, and pediatrics. The “advanced and specific care” career priorities facilitated surgery and emergency medicine choice, while reducing the likelihood of choosing less procedure‐oriented specialties, such as internal medicine, general practice, and pediatrics.ConclusionsOur results demonstrated medical students’ career priorities and their association with specialty preference. Individualized career support may be beneficial for both medical students and each specialty fields.

Assessment of general emergency medicine physicians’ medical education regarding management of pediatric emergencies in western Normandy, France

ObjectivesGeneral emergency medicine physicians sometimes have to deal with acute management of pediatric emergencies. The objectives of this study were to assess the pediatric medical education background of emergency physicians, how often they encounter pediatric emergencies, as well as the knowledge and organizational gaps regarding the management of children in general emergency departments. MethodsA survey was conducted from March 25 to June 25, 2017, by emailing an anonymized questionnaire to all senior emergency physicians of the 22 general emergency departments of western Normandy public hospitals. ResultsA total of 81 responses were analyzed. In all, 83% percent of respondents had previously worked in a pediatric department. In total, 90% of the respondents reported caring for children within their emergency department and 93% out-of-hospital (100% of them during primary interventions and 39% during secondary interventions such as inter-hospital transfers). Fourteen percent of the respondents considered that the pediatric medical education they received was adapted to their current practice, while 73% reported experiencing difficulties during management of pediatric emergencies (technical difficulties, unsuitable material and therapeutics, relational problems, personal apprehension, disease- or age-specific difficulties, especially with children under the age of 2–3 years). ConclusionMost general emergency physicians report caring for children despite a lack of medical education in pediatrics. Pediatric medical education as well as collaborations between general practitioners and specialized pediatric teams should be enhanced to better match the needs of general emergency departments and improve the quality of primary and acute care for children.

Virtual Pediatric Emergency Department Telehealth Network Program: A Case Series.

Pediatric patients living in rural, underserved areas have reduced access to medical care. There is a lack of research describing the use of telemedicine (TM) for general pediatric emergency medicine (PEM). In 2013, we established the Child Ready Virtual Pediatric Emergency Department Telehealth Network (CR-VPED), a PEM TM consultation service serving rural hospitals across the state of New Mexico. The aim of this article is to describe our experience for 6 years (2013-2018). We describe the process of establishing the CR-VPED Telehealth Network. We reviewed all the TM consultations completed from June 22, 2013, to September 6, 2018. In our review, we focus on patient demographics, medical complaint, transfer status, type of referring provider, and problems encountered with each TM consultation. We had a total of 58 PEM TM consultations between June 22, 2013, and September 6, 2018. All consultations occurred at 6 of the 12 established sites. Most TM consultations (71%; 41/58) were with Indian Health Service sites. Among all TM consultations, patients ranged in age from 30 days to 17 years (mean, 54 months; median, 32 months). Only 26% (15/58) of the patients with TM consultations were transferred to the tertiary care hospital. There was a heterogeneous mix of chief complaints and diagnoses. Rash was the most common chief complaint (24%; 14/58). There was a mix of referring providers, with family medicine physicians being most common (31%; 18/58). Common technical issues were not properly recording the encounter into the electronic medical record (12%; 7/58) and difficulty logging into the CR-VPED Telehealth Network (9%; 5/58). Previous studies have investigated the use of TM in pediatric acute care, but most studies have focused on critical care or subspecialty care in the office setting. Our experience with CR-VPED has shown that it has been feasible to provide general pediatric emergency care to patients in underserved, rural emergency departments across New Mexico. Patients requiring TM consultation were heterogeneous in age and presentation.

Pyoderma gangrenosum underrepresentation in non-dermatological literature.

Pyoderma gangrenosum (PG) is a chronic, ulcerative neutrophilic dermatosis. PG presents a diagnostic challenge, largely due to the many mimicking diseases, the lack of confirmatory laboratory or biological markers, and the absence of widely accepted diagnostic criteria. In particular, PG is often mistaken for necrotizing soft tissue infections (NSTI). We reviewed four major textbooks each in general surgery, plastic surgery, trauma surgery, vascular surgery, emergency medicine, and dermatology. We also performed a search of review articles addressing NSTI and necrotizing fasciitis (NF). Ten out of the 20 non-dermatology textbooks did not list PG anywhere, and only two listed a differential diagnosis for PG. None of the non-dermatology textbooks indicated PG in the NSTI differential diagnosis, while three of the dermatology textbooks included PG in the NSTI differential diagnosis. PG was listed in all of the dermatology textbooks. Only one of the NSTI and NF articles mentioned PG in the differential diagnosis. There is an underrepresentation in major textbooks of surgery and emergency medicine and in NSTI and NF review articles when it comes to diagnosing PG. This might be leading to trainees and advanced providers in these fields being uninstructed on PG, and likely contributes to PG misdiagnosis and mismanagement. We recommend PG be included in the differential diagnosis of chronic ulcers and NSTI in non-dermatology textbooks. We also suggest adding identification and diagnosis of inflammatory mimickers of NSTI (e.g. PG) in teaching modules in surgical and emergency specialties to address this knowledge gap.

The Practice of Obtaining a Chest X-Ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department: A Survey of Attending Physicians.

Routine use of chest X-ray (CXR) in pediatric patients presenting with their first episode of wheezing was recommended by many authors. Although recent studies conclude that a CXR is not routinely indicated in these children, there continues to be reports of overuse. To examine the attitudes of practicing physicians in ordering CXRs in pediatric patients presenting with their first episode of wheezing to an emergency department (ED) and the factors that influence this practice by surveying ED physicians. A survey targeting pediatric emergency medicine (PEM) and general emergency medicine attending physicians was distributed electronically to the nearly 3000 members of the PEM Brown listserve and the Pediatric Section of American College of Emergency Physicians listserve. The 14-item survey included closed ended and free text questions to assess the respondent's demographic characteristics, their belief and current practice of obtaining a CXR in pediatric patients presenting with their first episode of wheezing. Data were analyzed using descriptive statistics and χ test. Of the 537 attending physicians who participated, their primary residency training was: 42% pediatrics, 54% emergency medicine, and 4% other. Seventy-two percent of participating physicians supervise residents, 54% were board-eligible or -certified in PEM. Thirty percent (95% confidence interval [CI], 26-34) of participants indicated that they would always obtain a CXR in pediatric patients presenting with their first episode of wheezing. Eighty-one percent (95% CI, 75-87) of those who always obtain a CXR believe that it is the standard of care. Of the 376 physicians who do not always obtain a CXR, 18% (95% CI, 15-23) always obtain a CXR under certain age (2 weeks to 12 years, median of 1 year). Physicians who report a primary residency in pediatrics, who supervise residents, who were board-eligible or -certified in PEM, and who were practicing for greater than 5 years were less likely to obtain a CXR (P < 0.001, P < 0.001, P < 0.001, P = 0.001). In our study, a significant number of practicing ED physicians routinely obtain a CXR in children with their first episode of wheezing presenting to the ED. The factors influencing this practice are primary residency training, fellowship training, resident supervision, and years of independent practice. This identifies a target audience that would benefit from education to decrease the overuse of CXRs in children with wheezing.