Category Archives: Ped EM Section Columns

Is it time to rethink fasting times in the emergency department?

Chumpitazi, CE, Camp, EA, Bhamidipati, DR, et al. “Shortened Preprocedural Fasting in the Pediatric Emergency Department.” The American Journal of Emergency Medicine, vol. 36, no. 9, 2018, pp. 1577–1580.

Carmen D. Sulton, MD

The relationship between pre-procedural fasting times and aspiration and/or pulmonary complications are often a topic in anesthesia and sedation literature. In particular, fasting or nil per os (NPO) guidelines for urgent procedures outside of the operating room continue to be vague.  Prolonged fasting times can often be difficult for both emergency providers and families to manage. The American Society of Anesthesiologists (ASA) guidelines focus on 2 hours of fasting for clear liquids and up to 8 hours for full fatty meals. The American College of Emergency Physicians (ACEP) states that procedures in the emergency department (ED) setting should not be delayed based on fasting times alone. Many studies looking specifically at fasting times and adverse events often are under-powered, or may not focus specifically on patients in the ED setting.  read more

Would This Happen in your Emergency Department Waiting Room?

Michael H. Greenwald, MD

Jakelin Caal Maquin.  That is the name of the 7 year old girl who died in the custody of US officials soon after arriving at our border. More details about her death may follow, but, as of now, we know that she reportedly died from dehydration after a long journey from Guatemala. Apparently she was in US custody for 90 minutes before receiving any medical attention. Finger pointing will now ensue and the death of this little girl may serve as a political football for advocates on different sides of the issues. read more

How to Give a Lecture

Intro by Chair-Elect Taryn Taylor, MD, FAAP, FACEP

ACEP in San Diego was an enriching experience. We had an opportunity to learn new techniques, see old friends and reinforce critical concepts that are essential to our practice. We opened the ACEP PEM section meeting with a dynamic presentation from Dr. Christopher Amato, who provided guidance on being an effective speaker. November’s microsite highlights education, and the editor’s thought it  a timely opportunity to showcase  a portion of Dr. Amato’s presentation. Enjoy! read more

Time to rethink fluids in DKA?

A comment on “Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis” by Kuppermann et al. (2018)

Jessica Wall, MD, MPH

In medical school and residency we are taught to be vigilant for mental status changes and cerebral edema in our pediatric patients with diabetic ketoacidosis (DKA).  It is medical dogma that we must rehydrate them gently and slowly to prevent such a devastating complication, but the little evidence that we have for this teaching is observational and/or decades old.  Recently, “Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis” was published in The New England Journal of Medicine, with which Nate Kuppermann and the PECARN DKA FLUID Study Group have taken a major first step in changing how we think about fluid administration in DKA.

The structure of their study is elegant in that they completed a large, randomized study in which there was a 2-by-2 factorial design, allowing for the assessment of both fluid type (0.9% sodium chloride or 0.45% sodium chloride) and rate of administration (10% of body weight replaced in a 36 hour regimen or 5% body weight replaced in a 48 hour regimen).  This design allowed for an assessment of both sodium chloride concentration and fast replacement with a higher volume versus slow replacement with a lower volume.

And drum roll please…  there was no significant difference in proportion of patients with a drop in Glasgow Coma Score or neurocognitive assessment after recovery between all four treatment groups.  Interestingly, there was a trend to a higher incidence of clinically apparent brain injury in the slow hydration groups, but this was not statistically significant.   Now there were a few differences between non-neurologic adverse events, mainly higher rates of hyperchloremic acidosis in the 0.9% sodium chloride group and/or rapid administration group, and higher rates of hypocalcemia and hypophosphatemia in the 0.9% sodium chloride groups.  However, the take home point from this study is that isotonic versus hypotonic intravenous hydration and slow versus fast hydration does not affect the incidence of neurologic compromise in diabetic ketoacidosis.  We can hydrate these patients when they are in extremis without having that nagging thought in the back of our minds that we are increasing the risk of cerebral edema.

It is time to rethink our protocols and open discussion with our endocrinology and critical care colleagues about fluids in DKA.

 

Reference:

Kuppermann N, Ghetti S, Schunk JE, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018;378(24):2275-2287. doi:10.1056/NEJMoa1716816.

What is Your Blindspot: Managing Cognitive Bias

Taryn R Taylor MD, MEd

I can vividly remember my first day as a REAL doctor. I started on the pediatric pulmonology service, and recall spending what felt like an hour, deliberating whether I could order Tylenol for my patient. Would it interact with the Pulmozyme treatment? Fortunately, I had very patient senior resident who calmed my nerves and was empathetic to my intern anxiety.  July is an exciting, terrifying, rewarding and sometimes frustrating month, as we celebrate a new “medical year.” Whether or not you subscribe to the controversial premise of the July effect, there is no doubt that during this time you can leave a pivotal educational footprint in the life and career of a young doctor.

As we lead these learners on this educational journey, one of the most poignant lessons we can teach them is how to think critically. This includes recognizing and managing cognitive biases. Pattern recognition, which primarily occurs unconsciously, and analytical thinking which is deliberate and conscious, are the principle means by which we make medical decisions.  Cognitive biases are errors in reasoning that affect primarily the pattern recognition pathway. Debiasing strategies focus on transitioning from pattern recognition to a more analytic approach.1  By utilizing these debiasing strategies, we can reduce clinical errors committed by our learners and ourselves.

The first step in this process is to define and recognize the different type of cognitive errors that most commonly occur in medicine.

Anchoring: The patient’s chief complaint is sore throat, and they report an exposure to a family member with “strep.” This preliminary information seems quite convincing for a Group A beta-hemolytic streptococcal infection. However, upon further history gathering, the patient reveals symptoms of periodic heartburn, frequent belching and the sensation of food “getting stuck.”  Your learner, however, despite this additional information, is convinced that the patient should be treated immediately with antibiotics for the infectious process. This is an example of anchoring, during which one prematurely locks on to a diagnosis based on important preliminary information and fails to adjust this impression when additional information becomes available.

Information Bias: Innovative medical technology has afforded us the use of advanced radiologic imaging techniques and near instantaneous laboratory testing results. The utilization of such is not always efficient, affordable or practical. The tendency to believe that the more data one can collect to support a diagnosis the better, is called information bias.

Blind Spot Bias: As a seasoned, skilled physician, you have developed well defined illness scripts. You can recognize when a learner is going astray and are able to gently guide him or her back on track. Perhaps you do not recognize your own tendency towards gender bias or stereotyping. This is an example of blind spot bias: the ability to recognize the weakness or cognitive errors in others, and a tendency to overlook our own.

Over 100 different types of cognitive biases have been described in the literature. We are all vulnerable to these types of errors and being aware of them is a meaningful start to mitigating their effects. Wilson and Brekke 2 suggest an algorithmic approach to managing bias:

  • Become aware of the bias
  • Ensure that you and your learner are motivated to correct the bias
  • Recognize the magnitude of the bias
  • Apply an appropriate debiasing strategy

The authors suggest that successful completion of these steps lead to optimal decision making, however failure to complete these tasks leads to distortion of clinical reasoning. Dr. Croskerry 3,4 describes the following debiasing strategies.

  • Consider the alternatives: Routinely ask, “What else might this be?” Systematically generate and work through a differential diagnosis.
  • Metacognition: Metacognition is defined as the awareness and understanding of one’s own thought processes. Encourage learners to reflect on their approach to problem solving and self-critique, asking themselves what cognitive biases are at risk.
  • Decrease reliance on memory: One can improve the accuracy of judgments by using cognitive aids. These include mnemonics, clinical practice guidelines and algorithms, and the use of FOAM (Free Open Access to Meducation)
  • Feedback: Provide specific and timely feedback to decision makers so that errors are immediately appreciated, understood, and corrected.
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