Posts (154)

Fri, Feb 28 1:04pm · Early recognition of Child Abuse

Public domain image from Pixabay.

Author: Mark Mannenbach, MD @MMannenbach

My
memory of the small boy with dark eyes and curly hair comes back
quickly as the medical students I am working with share what they are
thinking and what they would do next. I saw him first
on a busy evening shift along with a new resident rotating in the ED for
the first time. I was fairly new in the ED in my first job out of
training.

The
boy was brought in by his mother with his older sister along for the
ride. His mother was concerned about his vomiting which began earlier
that day. No other symptoms. No fever. No diarrhea.
No cold. No cough. No bile or blood in his vomitus. He was “just
vomiting” and he wouldn’t stop.

After
what I thought was a good exam including a thorough abdominal exam, I
fed the infant small amounts of Pedialyte myself. He took it well and
had no episodes of vomiting after watching
him for about 30 minutes. I discharged him home with a supply of
Pedialyte and instructions to return if not better by the next day.

He
did return the next day with more vomiting along with posturing and a
fixed gaze to one side. He received several doses of medications for
seizures, but he continued to seize. He was intubated
easily on the first attempt. His head CT revealed diffuse brain
swelling, inter-hemispheric bleeding, and no evidence of fracture.

I
learned of his return visit later that day when I came back for my
evening shift. My colleague who cared for him that day graciously took
me aside and shared the update with me. She reassured
me with the words, “It could happen to any of us.”

I
learned later about the state-of-the-art care he received from my
mentors in the PICU. He stayed in the hospital for several months. He
was discharged to his mother’s care after she learned
how to use his feeding tube, care for his tracheostomy, and administer
his anti-epileptic medications.

These
events occurred more than 25 years ago and it truly seems like it
happened yesterday. I recall a visit with one of the hospital Vice
Presidents who also ended our conversation with
“It could happen to any of us.” I still review what I did and didn’t do
during that visit in the ED. I am not certain of much more today than I
was when I discharged the boy home with his mother so many years ago.

As
I have processed the care I gave that day, I have made a deliberate
point to learn more about the presentation, diagnosis, and management of
child physical abuse. I have found myself reaching
out to others like these medical students to share what I have learned. I
share about epidemiology, risk factors, and injury patterns. I am not a
child abuse pediatrician and I still have a lot to learn. But, I think
the one of the most important things I need
to share is the fact that I still choke up and fight to get the words
out when I retell the story of the boy with dark eyes and curly hair. I
hope this blog spot helps others in their journey caring for children.

What do I want to share?

  1. Learn about the early signs and symptoms of child physical abuse to allow for prompt recognition.  (See Maguire, S. Which Injuries may indicate child abuse? Arch Dis Child Educ Pract Ed 2010;95:170–177.) 
  2. Be in the moment when these signs and symptoms appear.
    1. Take time to be with your patients.
    2. Do a complete head-to-toe exam especially in infants. Undress them for a complete view. Put your hands on them to see where they hurt and where they don’t.
    3. Consider establishing a team approach to broaden the net for recognition. Listen to the concerns raised by others.
  3. Maintain an objective view and explore other possible diagnoses. There are some medical conditions that may appear to be due to abuse. Learn what these might be and do the appropriate testing to make sure the child is getting the right care. (See Christian C. Medical mimics of child abuse. AJR. 2017;208:982-990.)
  4. Be an advocate for your patient. Report your concern/suspicion for abuse. If done in good faith, you cannot be held liable for reporting. We do lumbar punctures to look for meningitis. More often than not the fluid is clear, but we still do the LP. You do the LP because of your suspicion and not of your certainty. Understand your process to reduce the stress in the moment. Learn how to make reports the right way in your new electronic health record. Orient your new hires and supplemental staff to the process involved.
  5. Be prepared for the time you will not promptly make the diagnosis of physical abuse. If you do practice acute care Pediatrics long enough, you will see child physical abuse. You are also likely to miss it. You miss appendicitis, osteomyelitis, and buckle fractures in children. Why wouldn’t you miss abuse? In addition to the general challenges faced when caring for kids, the caretaker with the child may be unaware, aware but not willing to share it/face it, or may be the perpetrator. (See Tiyyaguar, G.  Barriers and facilitators to detecting child abuse and neglect in general emergency departments. (Ann Emerg Med. 2015;66:447-454.)
  6. Take time to process what you have experienced.  None of us wants to overlook things. We all want to do what is best for our patients. We can be devastated by missing the diagnosis and wonder what we would have done differently.

At the end of the day, I encourage you to consider the opportunities for earlier recognition including:

  1. develop processes and a team approach to recognition, evaluation, and reporting.
  2. learn more and reach out to others to process the experience.
  3. share
    this blog post to help others experience a smoother journey through the
    challenges of recognizing and evaluating abused children.

May 10, 2019 · Mayo Clinic EM at SAEM19

Wednesday May 15, 2019

TOP 100 abstract: 17 Pediatric Opioid Use in the Emergency Department: A 10-Year National Trend Study
Larissa Shiue, Sheagleigh Funni, Jonathan Inselman, Molly Jeffery, M. Fernanda Bellolio, Jana Anderson
Time: 1:00 PM-2:30 PM
Location: St. Thomas B- ORAL presentation

117 Subgroup Effects of a Shared Decision Making Intervention in Children With Minor Head Trauma
Rachel Michelle Skains, James L. Homme, Anupam B. Kharbanda, Leah Tzimenatos, Jeffery P. Louie, Daniel M. Cohen, Lise E. Nigrovic, Jessica J. Westphal, Nilay Shah, Jonathan Inselman, Michael J. Ferrara, Jeph Herrin, Victor M. Montori, Nathan Kuppermann, and Erik P. Hess
Time: 1:00 PM-2:30 PM
Location: Antigua B-Lightning Oral

158 Electronic Medical Record Phenotyping Accurately Identifies Opioid Use Disorder in the Emergency Department
Daniel P. Nogee, David Chartash, Hyung Paek, James D. Dziura, William K. Ross, Eric Boccio, Molly M. Jeffery, Cynthia A. Brandt, Katherine C. Couterier, and Edward R. Melnick
Time: 4:30 PM-5:30 PM
Location: Antigua B-Lightning Oral

Thursday May 16, 2019

587 Impact of Scribes on Throughput Metrics and Billing During an Electronic Medical Record Transition
Emily Schwartz, Laura Walker, Kristine Thompson, Christine Lohse, Ryan Monroe, Karen Koch, Thomas Hellmich, Heather Heaton
Time: 8:00-9:30 AM
Location: Montego A ePoster

208 External Validation of Emergency Department Derived Delirium Prediction Models Using a Hospital-Wide Cohort
Sangil Lee, Karisa Harland, Nickolas M Mohr, Grace Matthews, Erik Hess, M. Fernanda Bellolio, Jin H Han, Michelle Weckmann, Ryan Carnahan
Time: 9:00 AM-10:00 AM
Location: Jamaica A- Lighting Oral

649 Formative Evaluation for Emergency Department-Initiated Buprenorphine User-Centered Decision Support
Jessica M. Ray, Osama M. Ahmed, Yauheni Solad, Matthew J. Maleska, Shara Martel, Molly M. Jeffery, Tim Platts-Mills, Erik P. Hess, Gail D’Onofrio, and Edward R. Melnick
Time: 1:00– 2:30 PM
Location: Montego A ePoster

687 Women in the Pipeline: Chief Residents in Emergency Medicine
Laura E. Walker, Heather Heaton, Nicole Battaglioli, Annie Sadosty
Date: Thursday May 16, 2019
Time: 3:00-4:00 PM
Location: Montego A ePoster

Friday May 17, 2019

343 Rates of Emergency Department return among patients with dementia
Jessica A. Stanich, Molly M. Jeffery, Susan M. Bower, Laura E. Walker, Ronna L. Campbell, Paul Takahashi, M. Fernanda Bellolio
Time: 9:00 AM-10:00 AM
Location: Antigua A-Lightning Oral

784 Efficacy of Retreats on Resident Wellness as Measured by Maslach Burnout Index Analysis
Shelby Hopp, Kristyn McLeod, Emily Schwartz, Jim Colletti, Christine Lohse, M. Fernanda Bellolio
Time: 11:00 AM – 12:30 PM
Location: Montego A-ePoster

Sep 23, 2018 · Mayo Clinic at ACEP Scientific Assembly 2018

 

Sunday Sep 30

All day

ACEP Council Meeting

Venk Bellamkonda, Heather Heaton and David Nestler

 

 

Monday Oct 1

 

10:00-12:00

QI, operations and administrative job opportunities (EMRA). Ranch Santa Fe, N Tower. 3rd Floor.

Venk Bellamkonda.

4:00pm – 5:00pm

 

Clinical features associated with nonhistaminergic and histaminergic angioedema in emergency department patients

Lucas Oliveira J. e Silva, Xiao-wei Liu, Ronna L. Campbell, David W. Barbara, Kiran Goyal, Ana Castaneda-Guarderas, Benjamin J. Sandefur.

 

Tuesday Oct 2

9:00am – 10:15am

 

Predictors of 30-day return visits among octogenarians presenting to the Emergency Department

Fernanda Bellolio, Jessica Stanich, Laura Walker, Ronna Campbell, Nataly Espinoza, Molly Jeffery.

EMF. Paths of ED Care: Facilitating shared decision-making in goals of care discussions in the acute setting

Laura Walker, M. Fernanda Bellolio, Mike Wilson, Bjorg Thorsteinsdotti, Kevin Shaw, Ian Hargraves, Erik Hess

 

Everyone loves a popsicle— a simple and affordable intervention to improve patient satisfaction

Jacob Voelkel, Ryan Finn, M. Fernanda Bellolio, Jeff Wiswell.

 

The satisfaction of empathy. QIPS Lecture.

Ashley Sievers. Convention Center, Upper Level, Room 10.

 

 

10:45am – 12:00pm

 

Validation of the Elderly Risk Assessment Index in the Emergency Department

Nataly Espinoza, Laura Walker, Jessica Stanich, Molly Jeffery, Ronna Campbell, Paul Takahashi, M. Fernanda Bellolio.

 

Prevalence of Pediatric Pain-Related Visits and Opioid use in the Emergency Department

Jana Anderson, Shealeigh Funni, Molly M. Jeffery, M. Fernanda Bellolio.

 

 

4:00 pm- 5:00 pm

 

Effectiveness and safety of droperidol in an emergency department in United States

Charlene M. Gaw, Daniel Cabrera, M. Fernanda Bellolio, Alicia E. Mattson, Molly M. Jeffery.

 

 

5:00pm – 6:00pm.

 

The Impact on ED Visits with a Telemedicine Program Interfacing with a Nurse Triage Call Line

Christopher Russi, Kerie Olson,  Debra Cox, Elizabeth Fogelson, Alex Beuning, Skip Powell, Peter Smars

 

Sep 23, 2018 · Effect of the Head CT Choice Decision Aid in Parents of Children With Minor Head Trauma

Authors: Erik Hess, MD (UAB)

Comment on: Hess, Homme et al. Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head TraumaA Cluster Randomized Trial. JAMA Open.

Each year, 450,000 children present to U.S emergency departments for evaluation of head trauma.  Physicians obtain head computed tomography (CT) scans in 37%-50% of these patients, with less than 10% showing evidence of traumatic brain injury and only 0.2% that require neurosurgical treatment.  In order to avoid unnecessary CT scans and to limit radiation exposure, the Pediatric Emergency Care Applied Research Network (PECARN) developed 2 clinical prediction rules, one for children less than 2 years of age and one for children 2-18 years of age. Each of these clinical prediction rules consist of 6 readily available factors that can be assessed from the history and physical examination.  If none of these risk factors are present, a CT scan is not indicated.  If either of 2 high risk factors such as altered mental status or signs of a skull fracture are present, CT scanning is indicated.  If 1 or 2 non-high risk factors such as vomiting or a history of loss of consciousness are present, then either CT scanning or observation are recommended, depending on considerations such as parental preference, clinician experience and/or symptom progression.  This study designed a decision aid, “Head CT Choice” to educate parents about the difference between a concussion – which does not show up on a CT scan – and a more serious brain injury causing bleeding in or around the brain.  The decision aid also shows parents their child’s risk for a serious brain injury – less than 1% risk in the majority of patients in the trial – and what to observe their child at home for should they opt not to obtain a CT scan, along with the advantages and disadvantages of CT scanning versus home observation.  This trial did not observe a difference in the rate of head CT scans obtained in the ED but did find that parents who were engaged in shared decision-making using Head CT Choice were more knowledgeable about their child’s risk for serious brain injury, has less difficulty making the decision because they were clearer about the advantages and disadvantages of the diagnostic options, had greater trust in their clinician and were more involved by their clinician in decision-making.  Parents also less frequently sought additional testing within 1 week of the emergency department visit.

Aug 2, 2018 · The opioid epidemic

Author: Molly Jeffery PhD @mollyjeffery

Commentary about: Jeffery at al. Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study. BMJ 2018.

With all the attention that is being paid to opioid prescribing over the past few years, we wanted to know whether we’re moving the needle: are fewer people taking opioids now than a few years ago?

Surprisingly, we found that the percentage of people who take opioids hasn’t changed much since the rates started to level off in about 2012. Specifically, among commercially insured people—people who generally get their health insurance from their or a family members’ employer—and people aged 65 and older who have Medicare Advantage insurance, we have seen very little change in the proportion of people taking prescribed opioids.

In the third population we looked at—people with long-term disabilities who have Medicare Advantage—we saw minor changes, but use has been nearly flat since 2012. And in all three groups, use was higher in 2016 than at the beginning of the study in 2007.

What does this mean?  The United States uses opioids in a way no other country does. We use nearly twice as much opioids per person as the next closest countries (Canada and Germany), and about 7 times as much as the UK. We don’t know the ideal level of opioid use that balances risks and benefits to patients and societies, but it seems pretty clear that we in the US are above that ideal level.

To change that, we need to address two different problems. First, we need to do a better job with opioids for acute pain, and there may be a role for emergency medicine in that effort. In earlier work (https://doi.org/10.1016/j.annemergmed.2017.08.042

), we found that first-time opioid prescriptions (that is, prescriptions for people who haven’t taken opioids in at least 6 months) written in the emergency department were for shorter durations and lower doses than first-time prescriptions written in other settings. Still, researchers at UPenn have found substantial national variation (https://doi.org/10.1016/j.annemergmed.2018.06.003) in the proportion of people being treated for ankle sprains in the ED, with state rates as high as 40% and as low as 3%.

Some health systems have had success reducing opioid prescriptions by instituting voluntary prescribing guidelines. Here at Mayo Clinic, the department of orthopedic surgery looked at their data on opioid prescribing after surgery and developed a voluntary guideline that resulted in a nearly 50% reduction in the volume of opioids prescribed after hip and knee replacement surgeries  (doi: 10.1007/s11999.0000000000000292). And this was accomplished without an increase in the proportion of patients requesting refills. In other words, the new lower prescribing does not seem to have negatively impacted patient pain control.

The second problem we need to address is opioid prescribing for chronic pain. Our study found that in the commercially insured population, the 3% of opioid use episodes that represented long-term use were associated with 62% of all opioids dispensed to that group. The scientific evidence suggests that on average, long-term opioid use is not an effective treatment for chronic pain (https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm). Some patients are able to achieve improved functioning and pain reduction when using opioids long term, but most are not. We desperately need more effective treatments for chronic pain and better access to non-opioid treatments we already have. For example, multidisciplinary pain programs have been found to help patients with chronic pain improve function and pain management, but they can be expensive and difficult to access, with some insurers reluctant to cover them. (http://americanpainsociety.org/uploads/about/position-statements/interdisciplinary-white-paper.pdf)

Some have suggested that we need laws or policies to cut off access to high dose or long-term opioid therapy. The trouble with that is that there is no such thing as a one-size-fits-all treatment plan for pain. Different types of pain respond to different treatments, and so do different patients. Policies that require the insurance company to sign off on an opioid dose above some level can have an unfair impact on patients with fewer resources. If you have the cash to pay, you can fill that high dose prescription written by your physician. But if you need your insurance company to pay, you may have to leave the pharmacy without your medication. You may have to spend substantial time on the phone to get the treatment approved. You may have to wait until the physician and insurance company contact each other. It’s not the right way to treat people.


Reducing prescribed opioid use is going to take time to do humanely and effectively. It will take partnership between providers and patients, but it can be done.

Jun 14, 2018 · Blockchain: A new technology for health professions education

Author: Eric Funk, MD @efunkem

 

This is commentary of Funk et al. Blockchain Technology: A Data Framework to Improve Validity, Trust, and Accountability of Information Exchange in Health Professions Education. Academic Medicine. In press.

Since the inception of Bitcoin in 2009, the use of blockchains has steadily gained attention. What began as mild interest from computer scientists has now grown to a fervor pitch. The initial impacts have been seen in the world of finance and are now spreading to many other sectors. More recently, thought leaders and entrepreneurs have begun to explore how the idea of blockchain could be used to improve healthcare. The obvious progression of this idea is to explore how blockchain will influence the education and training of healthcare workers. In our recent paper in Academic Medicine, we have laid out a basic framework for how blockchain could impact healthcare education.

Healthcare education has a long history of adopting new technological innovations in order to improve student’s learning. This has included MOOCs, digital platforms, and the #FOAMed movement. Using blockchains to improve education is the logical next step.

What is blockchain?

It’s a new way of storing data. Most people don’t think about how their data is stored, but it has a large impact on how the data can be used. In a blockchain, a recording of every transaction between users during a time period is group together in a “block”. These blocks are then “chained” together in chronological order. The recording of transactions and linking of blocks are done with advanced mathematics. Fortunately, it is not necessary for end-users to understand all of the technical concepts in order to benefit from using a blockchain (just as it is not necessary to know how to build an engine in order to drive a car). The chain of blocks is completely open and can be inspected by anyone to see the entire history of interactions. Since every single person involved can inspect the blockchain, it is nearly impossible to change the record of events.

How can blockchain allow educators to better track their impact?

It has traditionally been very difficult for clinical educators to get credit for their work, especially compared to their peers who focus primarily on research output. Recording this information in the blockchain will easily allow educators to track their impact as their students ultimately become educators themselves, and pass along their knowledge to each subsequent class of students. It will also allow for easy tracking of the most utilized and most effective learning modules.

How can blockchain make CBME (competency based medical education) and EPAs (Entrustable Professional Activities) better?

The blockchain can serve as a digital ledger of the behaviors that are critical for assessment. This will allow learners to easily see how they compare to their peers at various other universities or institutions. One significant improvement is that this system allows for asynchronous evaluation of milestones, that are completed independent of location. It better allows learners to progress through the required knowledge at their own pace.

How can blockchain improve credentialing?

Using a blockchain allows for one decentralized database of information. Anyone who has recently applied for medical licenses in multiple states or gone through the process of applying for hospital privileges will be able to appreciate this benefit. Rather than combing through information that is scattered across multiple different sources, a decentralized blockchain will be able to efficiently store this information. There will be easily accessible proof of completing a degree, diplomas, certifications in other states, procedure logs, etc… rather than trusting unverified information coming from various sources.

These ideas represent the potential benefit that blockchain could bring to medical education. They do not represent a prediction of the future or a magical solution for all the problems facing educators and students. Many blockchain platforms already exist that could be used to implement these ideas (Ardor and Ethereum being a few of the more technologically advanced and accessible blockchain platforms), or new ones could be created. The next step in exploring these ideas will be for developers and forward-thinking educators to join forces and begin producing real-life products that allow for implementation of these ideas. The future is bright.

 

 

 

Contact Us · Privacy Policy