Wednesday, March 27, 2013

Critical Deficiencies in Pediatric EM Training

This article is an overview of the critical procedures performed over a one-year period at Cincinnati Children's, a large, well-respected, level 1 trauma center with a pediatric emergency medicine fellowship program.  In theory, this facility ought to provide trainees with top-flight training, including adequate exposure to critical life-saving procedures.

Not exactly.

In that one year period, the PEM fellows performed 32 intubations, 7 intraosseus line placements, 3 tube thoracostomies, and zero central line placements.  This accounted for approximately 25% of all available procedures – attending physicians and residents poached the remainder of procedures during the year.  Therefore, based on this observational data, these authors conclude the training in PEM might not be sufficient to provide adequate procedural expertise.  Then, the authors note pediatric emergency departments have such routinely low acuity – 2.5 out of every 1,000 patients requiring critical resuscitation – that it is inevitable these skills will deteriorate.

Essentially, this means the general level of emergency physician preparedness for a critically ill child is very low.  PEM folks might have more pediatric-specific experience – but very limited procedural exposure – while general emergency physicians perform procedures far more frequently – but on adults.  The authors even specifically note 63% of PEM faculty did not perform a single successful intubation throughout the entire year.

Their solution – which I tend to agree with – is the development of high-quality simulation tools to be used for training and maintenance of skills.  Otherwise, we won't be providing optimal care to the few critically ill children who do arrive.

"The Spectrum and Frequency of Critical Procedures Performed in a Pediatric Emergency Department: Implications of a Provider-Level View"
www.ncbi.nlm.nih.gov/pubmed/22841174

1 comment:

  1. This one hits home. While children aren't little adults, critical care is still critical care. To get the exposure, I think PEM fellows should work some in critical care sides of adult EDs. While pedi airways are different from adult airways, they're closer than *No* airways. Same for IOs, chest tubes, central lines, etc. Sure, adults don't get UA catheters, but neither do most kids.
    With the infighting between who "owns" PEM, I doubt this will happen.

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