About Dina Wallin, MD

ALiEM Series Editor, The Leader's Library
Co-Medical Director of Pediatric Emergency Medicine,
Zuckerberg San Francisco General Hospital;
Director of Didactics, SFGH-UCSF Emergency Medicine Residency;
Assistant Clinical Professor of Emergency Medicine and Pediatrics,
University of California San Francisco

PEM Pearls: An Approach to Infant Apnea

infant

A 2-day-old female born at 41 weeks presents to the Emergency Department (ED) for an episode of apnea. Her parents noticed she stopped breathing, went limp, and turned blue. They are not sure for how long. The infant has had decreased urine output but is otherwise well without any other symptoms. Mom has an unspecified autoimmune condition and is taking hydroxychloroquine. The pregnancy and birth were largely uneventful. Mom was positive for Group B. Strep, had prolonged rupture of membranes, and was appropriately treated with antibiotics.

Vitals: The infant’s vital signs in the ED are within normal limits except for mild tachypnea.

Initial Exam: Her exam is nonfocal.

Background

Apnea among infants occurs when an infant stops breathing for 20 seconds or longer or stops breathing, for any amount of time, with bradycardia, cyanosis, pallor, and/or hypotonia. The overall incidence of apnea is 1 in 1,000 full-term infants. Infants who are premature (<37 weeks) are at increased risk for apnea; the incidence is almost 100% in infants born less than 28 weeks. Apnea is more common in premature infants due to their immature respiratory systems and physiologic stressors often manifest as respiratory depression in infants [1].

For infants that are actively apneic, the approach is similar to any pediatric resuscitation: ABCs (see ED approach below for management).

For infants who had an apneic episode that has since resolved, one has more time to think about the differential.

Differential Diagnosis

Apnea can be benign and physiologic, typically lasting between 5-10 seconds and more often occurring between 2 weeks to 6 months of life. Because physiologic stressors can manifest as respiratory depression in infants, the differential for pathologic apnea is broad. The following are broad categories to consider (similar to “the misfits” mnemonic for the crashing neonate).

Sepsis: UTI, pneumonia, necrotizing enterocolitis, meningitis/encephalitis
Pulmonary disease: pneumonia, pneumothorax, viral illness
Congenital heart disease
Metabolic disease: glucose, inborn errors of metabolism, electrolytes
Intracranial abnormalities
Non-accidental trauma
Toxins: carbon monoxide, botulism, maternal opioid use

It’s important to note that apnea in infants may qualify as a BRUE (brief, resolved, unexplained event). However, in this case, the infant is less than 60 days old. This is NEVER a low-risk BRUE [2].

Approach for the ED Provider

For the emergency provider, considering all of this can be overwhelming. Our job is to collect pertinent data, stabilize the infant, and start empiric treatment in order for the inpatient teams to further investigate the exact cause of the apnea. The following is a simplified ED approach:

Key history questions:

How was the delivery: Was meconium present? Was there prolonged rupture of membranes?
How was the pregnancy: Did mom get prenatal care? Were there any abnormal results with prenatal testing? What are mom’s medical conditions? Did mom get any treatment during her pregnancy (e.g. PCN for syphilis)?
How is the infant feeding, stooling, and urinating? Are there any other symptoms?

Key workup to initiate (in bold are items we wouldn’t typically send for adult workups and may be forgotten by ED providers who do not primarily care for children):

VBG, CBC, CMP, ammonia (for metabolic conditions), blood culture, urinalysis, lumbar puncture (if concerned about sepsis)
Respiratory viral panel, pertussis (if endemic and/or area with low vaccination rates)
ECG, chest X-ray (if hypoxic or abnormal clinical exam)
Pre and post-ductal oxygen saturation and four-point blood pressure (for heart disease, primarily coarctation of the Aorta)

Key physical exam findings (undress the patient fully):

Are there bruises or other signs of abuse?
What is the fontanelle size? How do the pupils appear?
Is there wheezing, rhonchi, or rales on lung auscultation? Are breath sounds equal? Is there increased work of breathing?
Is there abdominal distension or guarding?
Are there rashes? Is there edema in the extremities?

Management for infants currently apneic: ABCs.

Establish access, connect to monitors, and get a full set of vitals (including rectal temperature).
Support the airway. Start with oxygenation and ventilation. Utilize noninvasive pressure ventilation with continuous positive airway pressure (CPAP) or High Flow Nasal Canula (HFNC). Consider intubation if there is no improvement, however, do not jump immediately to intubation as an infant’s respiratory status can quickly change with respiratory support.
Start CPR if there is no pulse or the pulse is less than 60 beats per minute.
Begin intravenous fluids at 10-20ml/kg (be careful if you have concerns about heart failure).
Obtain a point of care glucose (and if available, venous blood gas). Consider naloxone if opioid ingestion is possible.

Management for the infants who are not currently apneic:

Monitor vital signs and support respiration as needed (e.g. nasal cannula, CPAP).
Give empiric antibiotics if there is a concern for sepsis. Remember, avoid ceftriaxone in neonates less than 28 days due to concern for kernicterus. Instead, use ampicillin and gentamicin. Add vancomycin if concerned about MRSA.
Nutritional support – remember that infants have low glucose stores. Start maintenance fluids (D10W (if <28 days) or D5NS +/- KCl).
The NICU may want you to start caffeine and/or theophylline in the ED for treatment for apnea of prematurity.

Disposition is mainly to the Neonatal Intensive Care Unit (NICU).

Case Resolution

While in the ED, the infant desaturates to the 80s with improvement on HFNC. She has a full sepsis workup and is started on empiric antibiotics (ampicillin/gentamicin) and antivirals (acyclovir). The infant is found to have hypoglycemia and metabolic acidosis. Her neurologic, cardiac, and infectious workups are unremarkable and she doesn’t have any apneic/cyanotic episodes while hospitalized. She is discharged home with suspected hypoglycemia from poor feeding as the cause.

Conclusion

The workup for apnea in infants is broad and not limited to pulmonary pathology.
Remember your ABCs, ask key history questions (prenatal, intrapartum, postpartum), send key diagnostics (including ammonia and pertussis), and collect key physical exam findings (including pre and post-ductal saturation and four-point blood pressure).
Call your NICU team early.
You will likely not arrive at the cause of the apnea in the ED, but your early workup and empiric treatment (e.g. CPAP, antibiotics) are critical in caring for these infants.

References

Kondamudi NP, Khetarpal S. Apnea In Children. [Updated 2022 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK441894/ .Accessed September 21, 2022.
Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants [published correction appears in Pediatrics. 2016 Aug;138(2):]. Pediatrics. 2016;137(5):e20160590. PMID 27244835

Podcast Preview

Brief Summary

The New Rules of Work: The Muse Playbook for Navigating the Modern Workplace by Alexandra Cavoulacos and Kathryn Minshew was published in 2019, but couldn’t feel more timely. This book targets all professionals, whether those of you just starting out in your careers, midway through and hoping to shake things up, or in the latter years of emergency medicine practice and hunting for a new role. The authors write, “whatever your current obstacle is, you can face it. The only thing you shouldn’t be doing if you’re feeling stuck or disillusioned or stressed out is nothing. There are always next steps to take, new strategies to try, and new skills to build.”

Stuck? Yes.

Disillusioned? Maybe.

Stressed out? YES.

Cavoulacos and Minshew describe one’s career as “a lifelong process of honing skills, developing self-awareness, and understanding what really makes you tick– and how you can best apply all of that to your work,” and we couldn’t agree more. Rather than a cut-and-dry definition of what a career in emergency medicine looks like (ex. decades of working X number of 8-hour shifts a month, teaching some learners, and doing your administrative work), instead we face a perpetual journey of examination, semi-intentional detours, and self-challenge. In The New Rules, the authors guide the reader through several stages of a career pivot, starting with self-reflection on current values and mindset. They then provide concrete strategies for building one’s brand, networking, interviewing, and negotiating, and round things out with several suggestions for improving efficiency and effectiveness in the workplace. Some favorites:

Under the Old Rules, one made their career decision in young adulthood, stuck to it, and followed a preordained path to an inevitable conclusion. The New Rules reframe that to focus on the next 2-5 years: “…this isn’t about finding the perfect career forevermore– it’s about finding a job that’s the best fit for you right now.” The last 2 years have taught us that nothing is certain in the future, so why center decades from now in our decision-making, rather than the present?
Networking under the Old Rules felt like a disingenuous, awkward activity focused on shameless self-promotion, and I avoided it like someone coughing maskless on the bus. The New Rules, however, encourage us to “look at networking as building relationships that grow over time, rather than a business transaction where you need something” to allow its value to multiply. That I can do (and the authors even offer a list of “Seven Ways to Fit Networking into Your Really Busy Schedule”– a really busy thank you!).
Although the Old Rules sold interpersonal skills as personality traits inherent to the individual, something you either had or ya didn’t, the New Rules emphasize personal responsibility for professional development, urging readers to intentionally approach “refining your interpersonal skills, which includes both building strong relationships with your colleagues and learning how to manage up early in and throughout your career.” Cavoulacos and Minshew do a deep dive into effective strategies for this managing up, as well as running meetings, corresponding over email, public speaking, conflict resolution, and even delegation and mentorship.

Lots to cover in one lil’ volume, but The Leader’s Library is here to help! Whether you’re a C-suite executive hoping to close out your career with a new role in education, a student hoping to meld multiple passions into your future emergency medicine career, or a mid-career faculty member wondering where your post-Covid professional journey may take you, our next discussion is for you! Grab the book and join a diverse group of emergency medicine faculty whose widely varied career paths will converge on the discussion from April 18-20 on Slack. Everyone is welcome. Sign up now!

When: April 18-20, 2022*
Platform: Slack app
Size: 40 registrants

* The Leader’s Library runs asynchronously on the Slack app– jump in whenever you have time!

Signup Process

Deadline to sign up: March 30, 2022

Submit your interest form with your contact information.
We will inform you if you’re selected by April 1, 2022.

We would absolutely love to learn and grow with you! Sign up now to secure your spot!

SIGN UP

Team

Al’ai Alvarez, MD: Director of Well-Being at Stanford Emergency Medicine (@alvarezzzy)
Felix Ankel, MD: Emergency Physician, Regions Hospital. Medical Director, Education, HealthPartners Institute, Professor of Emergency Medicine, University of Minnesota Medical School (@felixankel)
Winnie Chan, MD: Associate Physician Eden Emergency Medical Group, Per Diem Physician at San Francisco General Hospital and Kaiser Permanente Redwood City (@chanEMdoc)
Nikita Joshi, MD: Medical director of Alameda Hospital Emergency Department, Chief of Staff Alameda Hospital (@njoshi8)
Sreeja Natesan, MD: Associate Program Director, Duke University (@sreeja_natesan)
Deepa Ravikumar, MD: Senior Medical Director, Ro, Healthcare Technology Company; Clinical Instructor, Mount Sinai Hospital Emergency Department
Dina Wallin, MD: Co-Medical Director of PEM, San Francisco General Hospital; Director of Didactics, UCSF-SFGH EM residency, San Francisco, California

Learn more about the other Leader’s Library book clubs.

Listen to all of The Leader’s Library podcasts

By Dina Wallin, MD|2022-03-14T19:32:27-07:00Mar 15, 2022|Book Club, Leaders Library, Podcasts|

Last month, 30 people from 4 different countries and 15 different states + Puerto Rico, ranging from their early twenties to mid sixties, bravely jumped into a two-and-a-half day conversation on Slack about creativity, resilience, and their careers– the fifth version of The Leader’s Library. We discussed the book Keep Going: Ten Ways to Stay Creative in Good Times and Bad by Austin Kleon, and reflected together on the evolution of our creativity from childhood through middle age, and how a career in emergency medicine requires creativity in every possible form. Please see our earlier post for a more detailed summary of the book; below, we share the highlights of the group’s discussion.

Day 1

The first day started out with a personalized welcome video from Austin Kleon himself and introductions of participants. People shared what drew them to The Leader’s Library (connection, reflection, building community) and where they would like to incorporate more creativity (heal personal and societal wounds, bring innovative approaches to “wicked problems”, appreciate the beauty and joy in connections between things.) We then discussed the influence of specific individuals on personal creativity and how some have created a personal creative network (PCN) similar to personal learning networks (PLN). This was followed by a discussion about the spaces where people felt most creative, with many describing the benefit of being outside and disconnected from the activities of daily electronic living, while others felt most creative when connected with others through electronic means. Participants then volunteered their preferred medium for expressing creativity with lots of sharing of paintings, photography, poetry, and welding projects.

Day 2

On the second day, we covered the first 8 tenets of the book.

1. Every day is groundhog day.

This is really about having a daily discipline: take one day at a time, establish a daily routine, and have reflective practice. Participants discussed morning and evening routines, journaling as an anchor, and the importance of routine in setting boundaries between “doing” and “being”. Some discussed an unease with routines, as our chosen lives as emergency physicians are by nature unpredictable. However, this discomfort belied participants’ flexibility and resiliency– even in pure chaos when nothing is going as planned, we’ll get through, the day/shift/week will inevitably end, and we’ll start again tomorrow.

2. Build a bliss station.

This is a “space” or “time” to disconnect from the outside world to connect with yourself. The concept of being on “airplane mode” even when not on an airplane resonated with many. Participants shared examples of their physical (outdoors, home office, kitchen island) and temporal bliss stations; for some, their bliss station was simply an extra in-tune state of mind. The conversation also revolved around the art of “saying no” and of intentionality when creating one’s career journey. Some highlights: recognize that one’s capacity is finite, and in order to say “yes” to one opportunity, one must say “no” to another; when invited to do something, ask, “What is this person really trying to achieve? Can I help them in a different way to achieve this goal?”; and journal in the days following activities and review how you felt afterward– did this project invigorate you, or were you entirely drained? Use this insight to inform future decisions.

3. Forget the noun, do the verb.

We often define our identity with who we are rather than what we do. Kleon suggests that “creative” is not a noun and that real work is play. We had a robust discussion on what “verb”-ing looks like for each of us. In looking at our careers, many of us recognized our professional “nouns” in one bucket (emails, meetings, academic rat race), and our liberating, expansive doctor “verbs” in another bucket (to help, think, read, teach). We discussed ways to contract bucket 1 (wait 24 hours to answer an email, skip meetings that aren’t action-oriented) and expand bucket 2 (step out of academia, work only on passion projects [that whole “saying no” thing again!]).

4. Make gifts.

This was about the importance and joy of gifts. This was also about the trappings of “suckcess” and the tyranny of metrics. Kleon suggests that we should leave money on the table, we should forget to take things to the next level, and let low hanging fruit fall off and rot. Instead of the quantitative, focus on the qualitative. Be kind, be generous, be unique.

5. The ordinary + extra attention = the extraordinary.

This tenet resonated with many. Participants discussed ways they’ve cultivated over the past year to slow down and pay attention to the world around them with mindfulness techniques. With slowing down, we can finally focus attention on what we’re paying attention to, then with intentionality nurture this by giving extra attention and create something extraordinary. An interesting angle discussed how Peleton pandemic buys helped people get into the mode to conserve cognitive load and emotional labor, to slow the mind through exercise.

6. Slay the art monsters.

Kleon’s “art monsters” are those ubiquitous beings who somehow create beautiful work while behaving badly and contributing net negativity to the world. We reflected that we don’t want to become “monsters” in the same way, prioritizing output and the final project over the craft of medicine. Kleon argues here that “art is for life, not the other way around,” and this was a good reminder that we chose our careers because we wanted to make our, and others’, lives better, not to drag ourselves or others down. Many discussed this juxtaposition of simultaneously loving their practice (caring for patients, educating others) with living periods of time where pursuing their craft made themselves and others miserable. We all can have monsters coming to visit; the key is keep them around for the shortest time possible.

7. You are allowed to change your mind.

This tenet challenges the obsession with being right (hello, medicine!). Our discussion revolved around history-as-educator (“history may not repeat, but it sure does rhyme”) and philosophy-as-educator [Daily Stoic]. Some participants regularly revisit their own history through re-reading old journals; others learn through reading others’ histories in books, applying lessons from our ancestors’ missteps to our own current leadership challenges. There was also discussion of the (inverse) relationship between confidence in a position and being right. See the Dunning-Kruger prayer. In Kleon’s words, “to change is to be alive.”

8. When in doubt, tidy up.

We closed the day with a discussion of tidying our workspaces, both mental and physical. Sleep tidies up your brain. Tidying up your workspace is an exploration and a great way to focus energy when stuck or overwhelmed. Participants discussed their approach to tidying up offices, kitchens and gardens and the positive creative effects it had on their creativity.

9. Demons hate fresh air.

On the third and final day of discussion, we covered Kleon’s final 2 tenets. This is one of the more intuitive tenets– that getting one’s bootie off one’s chair and going outside can stimulate creativity and launch us past writer’s block. However, Kleon takes this beyond endorphins and argues that, by going outside, we better integrate ourselves into our communities and reality: “If we do not get outside, if we do not take a walk out in the fresh air, we do not see our everyday world for what it really is, and we have no vision of our own with which to combat disinformation.” Participants had varied strategies for getting themselves OUT, though most agreed that getting outside had been critical to their physical and mental wellbeing over the past year. Several people cultivated a habit of photographing their surroundings while out walking, a practice which helped them stay present. One participant shared that for them, this tenet took on a metaphorical meaning– by letting their internalized shame out to “fresh air” through writing or speaking, its power over them lessened.

10. Plant your garden.

Kleon, and our participants, focused on seasonality here. We don’t expect plants to flower in the winter, nor do we furiously cling to an oak tree’s leaves when they tumble off in the autumn; why, then, in academic emergency medicine, in medical education, in medicine in general, do we completely disregard this natural rhythm and instead attempt to overpower it with a decades-long continuous stream of hard work? Why are we surprised that our creativity stalls periodically, when we know innately that everything in our world is cyclical? Participants brainstormed ways to integrate periods of recuperation and recharge (what Kleon calls “dormancy” in this essay) into their professional lives, not just for rest, but also to enhance creative output. One participant reflected, “I’ve personally struggled with having to ALWAYS be ‘on’ in terms of being creative, but now understand that creativity ebbs and flows and the key now is to capitalize when the time is right.”

Synchronous Conversation

We closed out The Leader’s Library with a live video conversation, during which participants ranging from medical student to late-career professor mused about the connections they formed during The Leader’s Library, new ideas they’d be taking back to their institutions, and shocking realizations they’d had while learning from and with their co-participants. Independent of differences in prior life experiences and current situations, all participants affirmed a renewed appreciation for the role of creativity in their professional lives.

Conclusion

Whether in the US or India, academic or community emergency medicine, medical student or faculty, leading or trying to lay low, our facilitators and participants all need to keep going– and the past year plus has made this an incredible challenge. We’ve known a solution to this challenge since our preverbal years– taking a handful of crayons to a blank page helped us cope with doctor’s visits and tortuously slow restaurant service, art allowing our brains to take a break from the world around us and observe with a new lens. Participants left the fifth iteration of The Leader’s Library with plans to better support creativity in themselves and their colleagues, with a goal of improving not only the quality of their work, but also the quality of their existences.

The facilitation leadership team were wholly inspired by the participants and their vulnerability and candid insight. Stay tuned for our next turn in the fall and until then, ta-ta for now!

By Dina Wallin, MD|2021-06-17T10:47:44-07:00Jun 29, 2021|Book Club, Leaders Library, Medical Education|

The Leader’s Library: Keep Going | Sign up to join the book club discussion

As we submit our responses to the daily health screen for the thousandth time; realize, after having removed a mountain of PPE and sanitized our hands, that we left our phone in the patient’s room and would need to re-don everything; repeatedly observe the inevitable struggle with mute/unmute on Zoom; with all of these regular tasks and activities enveloping our lives these days, it’s hard to feel creative. Is the practice of emergency medicine a creative endeavor? How can we increase not just our creative or scholarly output, but also our internal sense of artistry and creation?

Podcast Preview of the Book

Brief Summary of Book

In Keep Going: 10 Ways to Stay Creative in Good Times and Bad, Austin Kleon attempts to answer this question (somewhat prophetically, given the book’s 2019 publication)– how can we, even in trying times, continue to nurture our creativity? Throughout the engaging, full-of-art book, Kleon outlines his argument for how, regardless of occupation, each of us can thrive in our creation of new, meaningful output:

Every day is groundhog day.
Build a bliss station.
Forget the noun, do the verb.
Make gifts.
The Ordinary + Extra Attention = Extraordinary
Slay the art monsters.
You are allowed to change your mind.
When in doubt, tidy up.
Demons hate fresh air.
Plant your garden.

Although Kleon himself writes and draws for a living, his suggestions are also applicable to the practice of emergency medicine, especially for those of us who are in academic, educational, and leadership positions and who need to constantly be creating to stay afloat. The book has an almost Zen quality to it, centering around mindfulness and reframing how we experience the life in front of us, rather than focusing ourselves on chasing an unachievable ideal or becoming absorbed by the mundane. For example, when we’re feeling a creative block, Kleon suggests that we set aside time to draw, like a child does, applying instrument to medium simply to enjoy the process and without an end product in mind– he writes:

“Drawing is simply another way of seeing, which we don’t really do as adults… we’re all going around in a cloud of remembrance and anxiety… and the act of drawing helps us live in the moment and concentrate on what’s really in front of us.”

A cloud of remembrance and anxiety! Yes! That is what the past year has felt like.

If you’re looking to rise out of your personal cloud of remembrance and anxiety, and explore how to infuse your career with creativity to just Keep Going, come join us for the next version of The Leader’s Library! All leaders (past, current, and future) in emergency medicine, of all professions and all locations, are welcome to participate. The book is short and full of drawings, so don’t worry that you won’t have time to read. This will be the most playful and fun iteration of TLL yet! Can’t wait to create with you!

Update

Summary of Book Club Discussion

Book Discussion Group

When: May 25-27, 2021*
Platform: Slack app
Size: 40 registrants

* The Leader’s Library runs asynchronously on the Slack app– jump in whenever you have time!

Signup Process

Deadline to sign up: May 9, 2021

Submit your interest form with your contact information.
We will inform you if you’re selected by May 10, 2021.

We would absolutely love to learn and grow with you. Sign up now to secure your spot!

Team

Felix Ankel, MD: Emergency Physician, Regions Hospital. Medical Director, Education, HealthPartners Institute, Professor of Emergency Medicine, University of Minnesota Medical School (@felixankel)
Nikita Joshi, MD: Emergency Department medical director, Alameda County Medical Center, Oakland, California (@njoshi8)
Peter Tomaselli, MD: Assistant Residency Program Director, Emergency Medicine, Thomas Jefferson University Hospital/Sidney Kimmel Medical College, Philadelphia, Pennsylvania (@pjtomaselli)
Victoria Brazil, MD, MBA: Medical Director of Goal Coast Simulation Service; Co-Producer of Simulcast and Harvard Macy Institute podcasts, Emergency Physician, Bond University (@SocraticEM)
Dina Wallin, MD: Assistant Medical Director of PEM, San Francisco General Hospital; Director of Didactics, UCSF-SFGH EM residency, San Francisco, California

Learn more about the other Leader’s Library book clubs.

Listen to all of The Leader’s Library podcasts

By Dina Wallin, MD|2021-07-01T18:55:21-07:00Apr 30, 2021|Book Club, Leaders Library, Wellness|

PEM Pearls: To Scan or Not to Scan? CT Abdomen in Children with Blunt Torso Trauma

An 18-month-old female with no past medical history is brought in by ambulance after a motor vehicle collision (MVC) at highway speed, restrained in an appropriate car seat. Mom was also brought in after delayed extrication with an obvious femur deformity. EMS reports that the patient had emesis on the scene, was fearful but calm, and has been moving all extremities.

Vitals per EMS: HR 120, BP 100/60, RR 30, SpO2 99%, Temp 36.5 C

Initial Exam:

General: crying
Neuro: Glasgow Coma Scale (GCS) of 13 (eyes shut unless talked to, crying spontaneously, moving all extremities)
MSK: atraumatic chest, erythema on the left leg
Abdomen: without tenderness

Blunt Torso/Abdominal Trauma

An intra-abdominal injury (IAI) is considered to be any radiographically or surgically apparent injury to an intra-abdominal structure (urinary tract, gastrointestinal tract, spleen, liver, pancreas, gallbladder, adrenal gland, vasculature, and fascia). An intra-abdominal injury requiring intervention (IAI-I) is any IAI that causes death or requires an intervention such as laparotomy, angiographic embolization, blood transfusion, or even admission for intravenous fluids [1].

Despite our curiosity and desire to diagnose all injuries, emergency medicine teams must focus on recognizing IAI-I and tailor their workup accordingly given the negative consequences of excessive workup and treatment of stable IAIs (e.g., unnecessary splenectomies, hepatectomies, increased length of stay, radiation, and increased medical costs/resources).

Although the incidence of pediatric blunt torso trauma in the United States was 110,525 cases in 2016, the prevalence of IAI has been quoted to be as low as 6.3%; more importantly, the prevalence of IAI-I is less than 2% [1]. Non-pediatric level 1 trauma centers were more likely to use computed tomography (CT) in pediatric trauma patients compared to pediatric trauma centers, even after adjusting for injury severity [2].

Clinical Decision Rule

The Pediatric Emergency Care Applied Research Network (PECARN) conducted a prospective study of over 12,000 children ages 0-18 years presenting to pediatric and general EDs with blunt torso trauma. Significant predictors of IAI-I were low GCS, abdominal tenderness, abdominal wall trauma, thoracic wall trauma, decreased breath sounds, and vomiting. The authors developed a prediction rule with a sensitivity of 97% (93.7, 98.9) and a negative predictive value of 99.9% (99.7, 1.00) [1]. External validation had similar sensitivity (99% 96-100%) reinforcing the utility of this clinical decision rule (CDR) in identifying low-risk individuals and decrease the use of CT [4].

In comparison to other CDRs, this rule does not include a gestalt variable but outperforms clinical gestalt with a lower miss rate (6 compared to 23) [5]. Of note, this prediction rule is not a two-way tool and was created only to determine individuals at low risk of IAI-I, rather than to assist providers in deciding who needs a CT scan.

Adapted from Holmes JF et al 2013 [1]

Reviewing the cases missed by the prediction rule in the initial study, possible clinical findings that could be captured with adjuncts, such as labs and imaging, include:

Gross hematuria
Microscopic hematuria (Red Blood Cells on Urinalysis)
Elevated AST/ALT
Rib fracture

Adjuncts

No single test effectively screens for IAI-I or IAI, but additional testing can increase the index of concern in cases that already have a higher pre-test probability (individuals who have any of the variables factored into the prediction rule). The following adjuncts can be considered for children who are not deemed very low risk.

Labs

Hematocrit <30% [3,7-8]
AST>200 U/L, ALT>125U/L [3,7, 9-10]
Lipase >100 U/L [9,11-12]
UA Gross hematuria [12-17]

Focused Assessment with Sonography for Trauma (FAST)

The diagnostic role of a FAST in pediatric trauma is less established than in adult trauma [18].
Application of FAST increases as provider suspicion for IAI increases [19].
As an adjunct to the clinical exam, FAST can be incorporated into decision making for selected cases of increased IAI concern [20].

Chest X-ray (CXR)

Injuries noted on a CXR may contribute to increased concern for IAI depending on location, mechanism, and type of injury [21].

Review of Case

Returning to our case, findings of concern include her GCS of 13 and reported emesis. Although it was a high-speed MVC and may represent a more severe mechanism, this variable was not found to be a predictor of IAI-I and should not in isolation inform your evaluation of her abdominal injury.

Application of the PECARN CDR demonstrates that the patient is not at very low risk for IAI-I. Labs and a FAST are performed and medications are given for symptom control.

The patient’s results are:

Labs:

HCT 35%
Lipase 20 U/L
AST 23 U/L, ALT 30 U/L
UA: no gross hematuria

FAST: Negative

On re-evaluation after ondansetron and acetaminophen, the patient has a GCS of 15 and is excitedly playing with her new teddy bear from the fire department while sipping apple juice. The patient is safely discharged home with her dad after a very frightening experience without unnecessary costs or radiation.

Take-Home Points

While blunt pediatric abdominal trauma has a high incidence, the prevalence of IAI-I is rather low.
The PECARN prediction rule for blunt torso trauma can identify patients that are very-low-risk for an IAI-I.
Notably, the mechanism of injury is not a predictable factor in determining IAI-I.
Clinicians should consider the use of labs, FAST, and CXR for risk stratification of patients that are not found to be very-low-risk.

References

Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013;62(2):107-116.e2. doi:10.1016/j.annemergmed.2012.11.009. PMID: 23375510
Marin JR, Wang L, Winger DG, Mannix RC. Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits. J Pediatr. 2015 Oct;167(4):897-904.e3. doi: 10.1016/j.jpeds.2015.06.052. PMID: 26233603
Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002;39(5):500-509. doi:10.1067/mem.2002.122900. PMID: 11973557
Springer E, Frazier SB, Arnold DH, Vukovic AA. External validation of a clinical prediction rule for very low risk pediatric blunt abdominal trauma. Am J Emerg Med. 2019 Sep;37(9):1643-1648. doi: 10.1016/j.ajem.2018.11.031. PMID: 30502218.
Mahajan P, Kuppermann N, Tunik M, et al. Comparison of Clinician Suspicion Versus a Clinical Prediction Rule in Identifying Children at Risk for Intra-abdominal Injuries After Blunt Torso Trauma. Acad Emerg Med. 2015;22(9):1034-1041. doi:10.1111/acem.12739. PMID: 26302354
Nishijima DK, Yang Z, Clark JA, Kuppermann N, Holmes JF, Melnikow J. A cost-effectiveness analysis comparing a clinical decision rule versus usual care to risk stratify children for intraabdominal injury after blunt torso trauma. Acad Emerg Med. 2013;20(11):1131-1138. doi:10.1111/acem.12251. PMID: 24238315
Taylor GA, Eichelberger MR, O’Donnell R, Bowman L. Indications for computed tomography in children with blunt abdominal trauma [published correction appears in Ann Surg 1992 Jul;216(1):99]. Ann Surg. 1991;213(3):212-218. doi:10.1097/00000658-199103000-00005. PMID: 1998402
Taylor GA, O’Donnell R, Sivit CJ, Eichelberger MR. Abdominal injury score: a clinical score for the assignment of risk in children after blunt trauma. Radiology. 1994;190(3):689-694. doi:10.1148/radiology.190.3.8115612. PMID: 8115612
Streck CJ, Vogel AM, Zhang J, et al. Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely. J Am Coll Surg. 2017;224(4):449-458.e3. doi:10.1016/j.jamcollsurg.2016.12.041. PMID: 28130170
Streck CJ Jr, Jewett BM, Wahlquist AH, Gutierrez PS, Russell WS. Evaluation for intra-abdominal injury in children after blunt torso trauma: can we reduce unnecessary abdominal computed tomography by utilizing a clinical prediction model?. J Trauma Acute Care Surg. 2012;73(2):371-376. doi:10.1097/TA.0b013e31825840ab. PMID: 22846942
Adamson WT, Hebra A, Thomas PB, Wagstaff P, Tagge EP, Othersen HB. Serum amylase and lipase alone are not cost-effective screening methods for pediatric pancreatic trauma. J Pediatr Surg. 2003;38(3):354-357. doi:10.1053/jpsu.2003.50107. PMID: 12632348
Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care. 2006;22(7):480-484. doi:10.1097/01.pec.0000227381.61390.d7. PMID: 16871106
Mee SL, McAninch JW, Robinson AL, Auerbach PS, Carroll PR. Radiographic assessment of renal trauma: a 10-year prospective study of patient selection. J Urol. 1989;141(5):1095-1098. doi:10.1016/s0022-5347(17)41180-3. PMID: 2709493
Morey, Allen F., et al. “Efficacy of Radiographic Imaging in Pediatric Blunt Renal Trauma.” Journal of Urology, vol. 156, no. 6, 1996, pp. 2014–2018., doi:10.1016/s0022-5347(01)65422-3.
Brown SL, Haas C, Dinchman KH, Elder JS, Spirnak JP. Radiologic evaluation of pediatric blunt renal trauma in patients with microscopic hematuria. World J Surg. 2001;25(12):1557-1560. doi:10.1007/s00268-001-0149-6. PMID: 11775191
Santucci RA, Langenburg SE, Zachareas MJ. Traumatic hematuria in children can be evaluated as in adults. J Urol. 2004;171(2 Pt 1):822-825. doi:10.1097/01.ju.0000108843.84303.a6. PMID: 14713834
Levy JB, Baskin LS, Ewalt DH, et al. Nonoperative management of blunt pediatric major renal trauma. Urology. 1993;42(4):418-424. doi:10.1016/0090-4295(93)90373-i. PMID: 8212441
Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg. 2007 Sep;42(9):1588-94. doi: 10.1016/j.jpedsurg.2007.04.023. PMID: 17848254
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Day 1: Create

The first day of The Leader’s Library started with participants describing particularly memorable moments in their lives. Inevitably, the conversation shifted to the concepts of time and timing, and a nuanced discussion ensued around our relationship with the two (how is a minute different from a moment?). In the Greek language there are two words for time: chronos and kairos. Most of our professional energy is spent focusing on time (chronos), while most meaningful moments are more significantly influenced by timing (kairos); participants discussed how we can shift our worlds more toward kairos to maximize great moments. (For example, selecting a kairos time to deliver important feedback might create a defining moment for the recipient, while a feedback session centered around chronos is just another meeting.)

We then contemplated how mindset can affect moments, and whether people with a growth mindset inherently experience moments differently than ones with a fixed mindset (participants felt that they do– a growth mindset allows an individual to recognize a low point or “pit” as a valuable learning opportunity, a powerful moment, while a fixed mindset might only perceive an obstacle).

We then discussed transition. Acknowledging that many memorable moments happen during times of transition (birthdays, graduations, weddings, funerals), how can we as leaders and educators choreograph inevitable transitions (such as the start of a new rotation, or the beginning of a new postgraduate year of training) to maximize and enhance the experience for our learners? Participants shared a wealth of great ideas, such as a resident receiving the “golden laryngoscope” trophy once they’ve signed off on intubations, bringing a cake to a trainee’s last shift of residency and sending a picture of them cutting it to their family, and welcoming a resident who’s been lost in off-service land with a cup of coffee and a granola bar on their first shift back in the ED.

Lastly, we explored how we can maximize moments in non-transitions. The authors write that “breaking the script” can help elevate an everyday experience into a powerful moment, and ideas our readers had included holding small meetings outside, taking a walk with a mentee instead of sitting in an office, and giving kudos spontaneously when it’s earned, rather than storing it up for a semi-annual evaluation.

Day 2: Reflect

On day 2, we turned inward to reflect on defining moments, both positive and negative, that we’d experienced over the course of our lives and careers. One participant applied the chicken-egg paradox to moments, and wondered if moments are external stimuli that happen to us and shape the stories we tell ourselves to make sense of the universe around us, or if moments are only perceived and noticed after an internal reflection process– do moments shape our stories, or do our stories shape our moments? The consensus was a resounding YES (to both).

We explored the authors’ proposed formula for leaders seeking to stretch their team members into growth– many participants work with learners of all stages, and easily applied these managerial concepts to medical education. The Heaths argue that (high standards + assurance) + (direction + support) = enhanced self insight, or personal growth. How might this look in medicine? A faculty member working on a manuscript with a trainee might say, “I wrote several revision suggestions. I expect high-quality writing out of you, and know you can achieve it. I pulled some examples of outstanding scientific writing for you. We’ll meet again next week, and I’m available by e-mail in the interim.” This sure has a different impact than simply sending the trainee a document full of markup and critiques! By applying this formula and thinking in moments, we shifted this encounter from discouraging to motivating, from banal to defining, all with an extra 1-2 minutes of effort.

Early career participants reflected that this might be easier in theory than in practice; one participant stated, “The knife’s edge balance of being shamed vs having high expectations placed on us, then living up to them, is crazy!” A mid-career participant sagely counseled, “As I’ve continued to have fascinating professional opportunities, I find that less surprises me and fewer things wound me. Cultivating equanimity… and caring about life, but with a certain indifference to the details, helps transform a wider array of experiences into growth opportunities rather than moments of hurt.” Yet again we returned to the premise of thinking in moments facilitating continual professional development and evolution.

We closed day two with a discussion of purpose vs passion. Although “passion” seems like an exotic way to fuel one’s career, the authors maintain that “purpose trumps passion:”

Passion is individualistic. It can energize us, but also isolate us, because my passion isn’t yours. By contrast, purpose is something people can share. It can knit groups together.

Successful leaders can cultivate a shared purpose in their organization, so everyone (passionately) fulfills their roles to the best of their ability toward this common purpose– from respiratory therapists to attending physicians to child life specialists, each team member is united in this purpose. And how do we unearth such purpose? By asking a series of “whys.” The authors use a great example from healthcare, querying a hospital custodian:

Why do you clean hospital rooms? “Because that’s what my boss tells me to do.”
Why? “Because it keeps the rooms from getting dirty.”
Why does that matter? “Because it makes the rooms more sanitary and more pleasant.”
Why does that matter? “Because it keeps the patients healthy and happy.”

Narrowing the scope from organizational to individual, one participant mused that this exercise could have incredible value as one contemplates one’s own career, or scaffolds a mentee as they generate a 5 year plan, although “it almost seems invasive, like if I did it in a residency interview it would be too much… but not too much for me alone with a piece of paper, and maybe not too much for a conversation with a learner struggling to find their purpose, if it felt safe for them to look that deep.”

Day 3: Capitalize

Discussion on day 3 focused on actions we can take to make the most of the moments, both big and small, that we experience and create throughout our careers. We discussed several ways of highlighting little moments we experience every day. Some participants plan to ask themselves and their learners after a shift about what they learned and who they learned from to highlight and celebrate that learning and teaching, and to cultivate a gratitude practice. Monthly didactics can be reframed from a residency requirement to an opportunity to create positive moments for learners– a chance to celebrate milestones and forge connection. Participants reflected that sharing one’s own journey and personal defining moments can spark new powerful moments for others. One person shared a cool practice: “I am pretty old school and prefer to read paper books. I have a habit when I finish reading a book, I write my major learning points inside the cover, and then I think of someone to give the book to, or sometimes mail to. Eventually this process is repeated, and that inside cover is chock-full of amazing ways the book has inspired people.” Mind blown.

The Power of Moments: Take home quotes from our discussion

Several discussants plan to do something similar; we’ll close this post with some major messages they would write inside the cover of this book. Thanks to our outstanding facilitators, engaged participants, and you, the ALiEM community, for constantly pushing your leaders to grow. Hope to grow with you at The Leader’s Library, V5 in the spring!

“I’d write the table of contents… It really sums up so many of the key points of the book and in very few words.” – Table of contents: Defining Moments. Thinking in Moments. Build Peaks. Break the Script. Trip Over the Truth. Stretch for Insight. Recognize Others. Multiply Milestones. Practice Courage. Create Shared Meaning. Deepen Ties. Making Moments Matter.

“Small moments can have great impact as defining moments. Commemorate milestones, no matter how small.”

“We remember our lives as a series of moments, good or bad, large or small. While many moments happen organically, some can be created, engineered, or encouraged. Remember your moments and learn from them. Encourage positive moments for those around you.”

“Pause. Soak up the present. You could be missing out on a moment that could impact you or someone around you. Try to make it a better moment.”

And, a final quote from she who started it all, Dr. Michelle Lin: “Moments matter. Pass it on.”

By Dina Wallin, MD|2021-04-23T19:33:45-07:00Dec 23, 2020|Book Club, Leaders Library|

The Power of Moments in The Leader's Library

Thus far, 2020 has been a year of catastrophic events, some surprising and others disappointingly predictable, and many people are struggling to navigate the chaos, to grasp at some semblance of a routine in the face of an unpredictable near future. Time has become a blur, a coalescence of unremarkable (yet unprecedented) moments.

What if we have the possibility to intentionally create these moments, for ourselves and those around us? What if, by reframing the way we view memory, experience, and time, we could be the powerful author of our own moments?

(more…)

By Dina Wallin, MD|2021-09-15T11:41:13-07:00Aug 30, 2020|Academic, Book Club, Leaders Library|

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About Dina Wallin, MD

Background

Differential Diagnosis

Approach for the ED Provider

Case Resolution

Conclusion

Read more pediatric emergency medicine topics as part of the PEM Pearls Series on ALiEM.

References

Read more pediatric emergency medicine topics as part of the PEM Pearls Series on ALiEM.

Blunt Torso/Abdominal Trauma

Clinical Decision Rule

Adjuncts

Review of Case

Take-Home Points

Read more pediatric emergency medicine topics as part of the PEM Pearls Series on ALiEM.

References

Read more pediatric emergency medicine topics as part of the PEM Pearls Series on ALiEM.