Acute care issues in internationally adopted children

Over the past decade there has been a dramatic increase in international adoptions in the United States. While most adopted children will have common illnesses, others may have unique medical issues as a result of the conditions in their birth country requiring a broadened differential diagnosis. Knowledge of these issues is essential in the management of these patients. This review will predominately focus on infectious disease issues commonly seen in international adoptees but will also discuss other medical conditions and some of the psychosocial issues which may be encountered by caregivers in the emergency department.     

Complaints and compliments in the pediatric emergency department

We conducted an analysis of all communications received from patients or their families by the director of a pediatric emergency department over a three-year period, during which approximately 150,000 visits occurred. Communications were characterized as complaint or compliment and subclassified by type: waiting time, staff attitude, quality of medical care, and billing. Chi 2 analysis was used to identify factors that predisposed to complaint or compliment and to identify the subtype. After quality-of-care issues, complaints stemmed most often from billing issues or waiting time for care for nonurgent disorders (especially medical problems), while complimentary letters most frequently addressed staff attitude and quality of care. The problems that we identified might be addressed by providing families improved access to non-emergency department care sources, education regarding the role of an emergency department, and better explanation of billing procedures during the registration process. Additionally, our findings serve as a reminder that many parents appreciate the care given to their children, particularly for life-threatening emergencies.     

Emergency Department Evaluation of the Pediatric Heart Transplant Recipient

With an increasing number of pediatric heart transplant patients, it is inevitable that they will seek medical care at an emergency department for cardiac or noncardiac complaints. Given the special issues associated with transplant (some of which are similar to other organ transplants and some of which are unique to cardiac transplantation), the emergency care provider should have an understanding of what care can be independently provided, concerns which may require additional testing or expertise, and when to call the cardiac consultant. The goal of this review is to address these issues.     

Bioterrorism and pediatric emergency medicine

Bioterrorism as a national threat poses enormous challenges to emergency department staff and emergency medical services personnel, and requires thoughtful planning and preparations. Several issues are special or unique in contemplating this threat as it applies to pediatric victims and the pediatric emergency medicine community. This report reviews some of the general principles of medical preparedness for bioterrorism, focuses on management issues for several of the most feared threats, such as bioweapon threats, and attempts to highlight pediatric issues as applicable.     

Vaccination-related adverse events

Vaccine-related adverse events are uncommon and typically mild. Children may experience conditions such as rashes, fevers, syncope, protracted crying, or seizures shortly after receiving their routine immunizations. When children are brought to the emergency department or clinic to be evaluated for one of these conditions, the health care provider may be called upon to determine the likelihood that it was caused by a recently administered set of vaccines. This determination has substantial implications for medical care, including the safety of administering future vaccines. This article reviews the current understanding of vaccine-related adverse events. Using this information, clinicians should be able to identify those events likely to be related to vaccine administration and those that are not. The appropriate management of vaccine-related adverse events is also discussed.     

Point‐of‐care lung ultrasound in paediatric critical and emergency care

Ultrasound techniques have been developed since the past century and are becoming more useful in different areas of medical knowledge. More recently, lung ultrasound gained importance throughout artefacts analysis to help clinical evaluation at bedside and became subject of interest in the paediatric intensive care and emergency department settings for both procedural and diagnostic purposes. The normal pattern of lung ultrasound is defined by the presence of lung sliding associated with A‐lines whereas B‐lines may be representative of pathologic findings. This review focuses on some of the most common pulmonary conditions, their respective sonographic features and clinical implications in the emergency department and paediatric intensive care unit.     

When Child Neglect Is an Emergency

Neglect is the most prevalent form of child maltreatment. Neglect can lead to serious medical issues requiring emergency department care including injuries, ingestions, decompensation of chronic illnesses, and urgent behavioral health concerns. Knowledge of different types of neglect, and of how each type could result in an emergency department (ED) visit could help clinicians to recognize and respond to neglect. This review will outline supervisory, medical, dental, emotional, and physical neglect. Children could also present to the ED for evaluation after a substantiated report for neglect. Therefore, this review also covers important elements of medical evaluations for children who have experienced neglect. Neglect is the most common reason for foster care placement, and considerations for emergency medicine providers caring for children in foster care are outlined. Avenues for prevention of neglect in the ED setting are also discussed.     

Managed care and the pediatric emergency department

The growth of managed care has provided health benefits to millions of children while attempting to control the increase in health care costs. In adhering to these goals, MCOs are often at odds with emergency departments, and the emergency department physicians providing emergency care. The appropriateness or inappropriateness of emergency department visits can be disputed, but no criteria have been established. Even the definition of emergency is debated, although many states are adopting a prudent layperson standard. Emergency medicine physicians, primary care providers, and MCOs must cooperate to fully educate parents about the appropriate use of pediatric emergency services. Patients and MCOs should use facilities that can deliver pediatric emergency and critical care or provide appropriate transport systems to facilities that can. COBRA and EMTALA set the legal requirements to which emergency departments must comply when patients present for care. The basic caveats under COBRA require a medical screening examination for every patient and the stabilization of all patients with emergency medical conditions before inquiring about insurance or patients' ability to pay. A part of gatekeeping, MCOs often require authorization for treatment. MCOs authorize payment only. Evaluation and emergency treatment should not be withheld pending authorization. After the medical screening examination, recommended treatment should be in patients' best interests. All patients with potentially life-threatening conditions should be stabilized before transport, and all transfers must comply with the EMTALA. The transfer of unstable patients purely for economic reasons is a violation of the EMTALA. When stable, patients may be transferred to other facilities, but patients requiring specialty care should be taken to facilities best able to provide that care. Financial considerations should be superseded by medical necessity. Finally, improvements can be made in the way emergency medical service is provided to children within the current managed care system. The primary care provider is in a key position to inform parents about the types of pediatric emergencies, what to do in case one occurs, and to provide follow-up care. MCOs should incorporate clear information on pediatric emergencies. A mutual understanding of services needed, and how best to provide those services, are needed to forge a system that is responsive to children's emergency care needs.     

Pediatric observation units

Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a well-defined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization.     

Do not get burned: preventing iatrogenic fires and burns in the emergency department

Burns are a common emergency in children but are rarely sustained in the emergency department. While iatrogenic burns in the operating room have been detailed in the medical literature, there is little or no information on iatrogenic burns in the emergency department. We present 2 cases of patients who sustained burns in the emergency department and review the most common mechanisms for this to happen. It is not always evident that certain procedures can cause unexpected burns to our patients. A survey of pediatric emergency medicine fellowship programs indicates that most programs have no training about these dangers. Recommendations are made to help prevent and control iatrogenic fires in the emergency department.     

Correlates of violent behavior among adolescents presenting to an urban emergency department

OBJECTIVE: To examine rates and correlates of self-reported perpetrated violence among teens presenting to an urban emergency department. STUDY DESIGN: Cross-sectional study of a consecutive sample of youth (12-17 years) presenting to an urban emergency department. The youth were surveyed about demographics, community violence exposure, parental monitoring, substance use, weapon carriage, group fighting, and aggression (past 12 months). Bivariate and multivariate analyses were performed to identify correlates of the severity of the violence (none, moderate, or severe) perpetrated in the past year. RESULTS: A total of 115 youth were surveyed (males, 47%; response rate, 85%). The sample group was 51% African American. A total of 77% of the youth reported that they perpetrated violence in the past year, with 37% reporting severe violence (use of a weapon, group fighting, causing an injury requiring medical care). All patients who self-reported perpetrating severe violence in the past year were discharged home from the emergency department. The diagnosis made in the emergency department (illness versus injury) was not associated with the violence perpetrated in the past year. Sex was not a significant predictor of severe perpetrated violence. CONCLUSIONS: Youth presenting to urban emergency departments report high rates of perpetrating violence in the past year that, on the basis of other studies, is likely to continue. These results suggest that future emergency department-based violence prevention efforts should consider universal screening of adolescents.     

Dispensing medications at the hospital upon discharge from an emergency department

Although most health care services can and should be provided by their medical home, children will be referred or require visits to the emergency department (ED) for emergent clinical conditions or injuries. Continuation of medical care after discharge from an ED is dependent on parents or caregivers' understanding of and compliance with follow-up instructions and on adherence to medication recommendations. ED visits often occur at times when the majority of pharmacies are not open and caregivers are concerned with getting their ill or injured child directly home. Approximately one-third of patients fail to obtain priority medications from a pharmacy after discharge from an ED. The option of judiciously dispensing ED discharge medications from the ED's outpatient pharmacy within the facility is a major convenience that overcomes this obstacle, improving the likelihood of medication adherence. Emergency care encounters should be routinely followed up with primary care provider medical homes to ensure complete and comprehensive care.     

Child bicyclist injuries: are we obtaining enough information in the emergency department chart?

OBJECTIVE: The purpose of this study was to assess the range of information relevant to bicyclist injury research that is available on routinely completed emergency department medical records. METHODS: A retrospective chart review of emergency department medical records was conducted on children who were injured as bicyclists and treated at an urban level I pediatric trauma center. A range of variables relevant to bicyclist injury research and prevention was developed and organized according to the Haddon matrix. Routinely completed free text emergency department medical records were assessed for the presence of each of the targeted elements. In addition, medical records of seriously injured patients (for whom a more structured medical record is routinely used) were compared to free form records of less seriously injured patients to identify differences in documentation that may be related to the structure of the medical record. RESULTS: Information related to previous medical history (96% of records), diagnosis (89%), documentation of pre-hospital care (82%), and child traumatic contact points (81%) were documented in the majority of medical records. Information relevant to prevention efforts was less commonly documented: identification of motor vehicle/object involved in crash (58%), the precipitating event (24%), the location of the crash (23%), and documentation of helmet use (23%). Records of seriously injured patients demonstrated significantly higher documentation rates for pre-hospital care and child traumatic contact points, and significantly lower documentation rates for previous medical history, child kinematics, main body parts impacted, and location of injury event. CONCLUSIONS: Routinely completed free text emergency department medical records contain limited information that could be used by injury researchers in effective surveillance. In particular information relating to the circumstances of the crash event that might be used to design or target prevention efforts is typically lacking. Routine use of more structured medical records has the potential to improve documentation of key information.     

Consent for emergency medical services for children and adolescents

Pediatric patients frequently seek medical treatment in the emergency department (ED) unaccompanied by a legal guardian. Current state and federal laws and medical ethics recommendations support the ED treatment of minors with an identified emergency medical condition, regardless of consent issues. Financial reimbursement should not limit the minor patient's access to emergency medical care or result in a breach of patient confidentiality. Every clinic, office practice, and ED should develop policies and guidelines regarding consent for the treatment of minors. The physician should document all discussions of consent and attempt to seek consent for treatment from the family or legal guardian and assent from the pediatric patient. Appropriate medical care for the pediatric patient with an urgent or emergent condition should never be withheld or delayed because of problems with obtaining consent. This statement has been endorsed by the American College of Surgeons, the Society of Pediatric Nurses, the Society of Critical Care Medicine, the American College of Emergency Physicians, the Emergency Nurses Association, and the National Association of EMS Physicians.     

Overcoming legal obstacles involving the voluntary care of children who are separated from their legal guardians during a disaster

A large-scale disaster may separate children from their parents or guardians and may strand many children in the care of temporary caregivers, including physicians and nurses. In general, unless a physician or nurse is a member of a public sector emergency response program (a "VHP"), parental consent is required for the treatment of minors outside of an emergency department unless the minor is suffering from an imminently life-threatening condition. Physicians or nurses who are not VHP's may be held liable (civilly, criminally and administratively) if they provide care without parental consent outside of an emergency room to a child who is not suffering from an imminently life-threatening condition. The existing rules regarding parental consent would, in many cases, limit (or at least discourage) the provision of optimal health care to children in a large-scale disaster by restricting care aimed to alleviate pain, the treatment of chronic conditions as well as the treatment of conditions, or potential conditions, that could worsen or develop in the absence of treatment.Additionally, "Good Samaritan" laws that generally limit the liability of health care providers who voluntarily provide care in an emergency may not apply when care is provided in a crude or makeshift clinic or when care is not provided at the scene of the emergency. Thus, benevolent physicians and nurses who voluntarily provide care during a large-scale disaster unjustly risk liability. The prospect of such liability may substantially deter the provision of optimal medical care to children in a disaster. This article discusses the shortcomings of current laws and proposes revisions to existing state laws. These revisions would create reasonable and appropriate liability rules for physicians and nurses providing gratuitous care in emergencies and thus would create reasonable incentives for health care providers to deliver such care. ("Gratuitous care" is the legal term for care provided voluntarily and without expectation of payment.).     

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.     

Screening for suicide risk in the pediatric emergency and acute care setting

PURPOSE OF REVIEW: This paper reviews epidemiology, psychiatric comorbidities, risk factors, warning signs, screening measures, and issues related to screening for suicide risk in the pediatric emergency department and acute care settings. RECENT FINDINGS: For the first time in over a decade, rates of adolescent suicide are increasing. A recent review found physician gatekeeper training to be one of only two effective prevention strategies. Limited methods exist to assess for suicide risk in pediatric acute care settings that are able to meet the demands and challenges presented in time-limited medical settings. SUMMARY: Suicide is the third leading cause of death in adolescents. Although a prior suicide attempt is the single most important risk factor, affective, cognitive, family and peer factors also affect risk of completed suicide. Practitioners in the acute care and emergency department setting are well positioned to identify, assess, and appropriately refer these adolescents and their families. Screening instruments in this setting need to be accurate, brief, and relevant to patients, families, and providers. We propose a two-question algorithm that targets imminent risk for a suicide attempt. This type of screening also needs to be accompanied by hospital or community-based support systems for further assessment, intervention and follow-up.     

Ethical and legal aspects at the emergency department

OBJECTIVE: To discuss ethical and legal aspects of physician? attitudes in emergency departments under the light of Brazi?s codes and laws.METHODS: The authors raise questions based upon case reports and comment using the medical ethical code, laws that protect children and adolescents, hospitalized children and adolescents rights statement and medical federal council decisions.RESULTS: The authors discuss child patients' rights and the parents disclosure right; the problem of domestic violence and abuse and the physician duty to denunciate this kind of practice for the child security and protection; the medical responsability even under workplace adverse conditions, as well as the concerns related to transportation of patients to another hospital; the dilemma between withholding and withdrawing life support measures at the emergency department and the prohibition to certificate death in violent death situations; the autonomy and decision-making capa-city of adolescent patients and their limitations, including violation of confidentiality.CONCLUSIONS: The commentaries presented in the article try to explain to the pediatrician how to identify ethical and legal conflicts in the emergency department and to prepare him (her) to assume attitudes based on codes and legal statements, as well as to respect the patient's rights.     

Paediatric spinal conditions

Children with spinal problems present to a wide range of healthcare providers. These providers include the emergency department, their GPs, physiotherapy and the paediatric medical and surgical clinics (including orthopaedics). They may present with a variety of symptoms, but the common complaints are: back pain, leg pain or a change in back shape (spinal deformity). Some children may experience a combination of these problems. A systematic approach to the history and examination with knowledge of the common spinal conditions in children will allow you to select the best investigations. This will maximize the chance of making the correct diagnosis and providing appropriate care. This article aims to give an overview, appropriate for surgeons in the early years of their training.