A 4-year-old girl was brought to our hospital by her parents because of abdominal pain. She hadsuffered minor trauma after rolling from her standard-height bed 2 days prior. Vital signs wereappropriate for age. Physical examination was remarkable for decreased breath sounds to the left sideof the chest. A chest radiograph (Figure) demonstrated a large gas-filled structure in the left side of thechest with mediastinal shift. [West J Emerg Med. 2012;13(1):117–118.]

Introduction: Violence against healthcare workers in the medical setting is common and associatedwith both physical and psychological adversity. The objective of this study was to identify featuresassociated with assailants to allow early identification of patients at risk for committing an assault inthe healthcare setting.

Methods: We used the hospital database for reporting assaults to identify cases from July 2011through June 2013. Medical records were reviewed for the assailant’s (patient’s) past medical andsocial history, primary medical complaints, ED diagnoses, medications prescribed, presence ofan involuntary psychiatric hold, prior assaultive behavior, history of reported illicit drug use, andfrequency of visits to same hospital requesting prescription for pain medications. We selectedmatched controls at random for comparison. The primary outcome measure(s) reported are featuresof patients committing an assault while undergoing medical or psychiatric treatment within themedical center.

Results: We identified 92 novel visits associated with an assault. History of an involuntarypsychiatric hold was noted in 52%, history of psychosis in 49%, a history of violence in the ED ona prior visit in 45%, aggression at index visit noted in the ED chart in 64%, an involuntary hold (orconsideration of) for danger to others in 61%, repeat visits for pain medication in 9%, and history ofillicit drug use in 33%. Compared with matched controls, all these factors were significantly different.

Conclusion: Patients with obvious risk factors for assault, such as history of assault, psychosis, andinvoluntary psychiatric holds, have a substantially greater chance of committing an assault in thehealthcare setting. These risk factors can easily be identified and greater security attention given tothe patient.

Introduction: To assess if families presenting to a pediatric emergency department (PED) with multiple children as patients require interventions at the same rate as families presenting with a single child.

Methods: This is a retrospective chart review looking at PED encounters for families presenting with single children versus multiple children as patients. Patients presenting with siblings were retrospectively selected from the electronic tracking board, and we randomly selected age/gender matched single-patient controls from a comparable time period. The primary outcome was a comparison of visit acuity between families presenting with single versus multiple children, with the hypothesis that families presenting with multiple children as patients would require less utilization of services (as a surrogate for acuity). Admission, intravenous fluid administration (IVF), planned observation, subspecialty consultation, performance of procedures, laboratories and radiographs, administration of prescription medications, and prescription medications for home were all recorded and compared via chi-squared comparison. We considered 5 interventions (admission, subspecialty consultation, performance of procedures, IVF administration, and observation > 6 hours) “critical interventions” and compared them separately.

Results: In our sample of 83 patients from 41 families registering multiple children and 248 singleton controls, we found a significant difference in the percentage of patients requiring critical interventions (4.8% versus 32.5%, P < 0.0001).

Conclusion: Families presenting with multiple children concurrently to an ED require critical interventions at a much lower rate than children presenting as single patients. Many of these families could be well-served at an urgent care or primary care provider. [West J Emerg Med. 2013;14(5):525–528.]

Introduction: Little is known about the use of involuntary psychiatric holds in preadolescentchildren. The primary objective was to characterize patients under the age of 10 years on involuntarypsychiatric holds.

Methods: This was a two-year retrospective study from April 2013 – April 2015 in one urbanpediatric emergency department (ED). Subjects were all children under the age of 10 years whowere on an involuntary psychiatric hold at any point during their ED visit. We collected demographicdata including age, gender, ethnicity and details about living situation, child protective servicesinvolvement and prior mental health treatment, as well as ED disposition.

Results: There were 308 visits by 265 patients in a two-year period. Ninety percent of involuntarypsychiatric holds were initiated in the prehospital setting. The following were common characteristics:male (75%), in custody of child protective services (23%), child protective services involvement(42%), and a prior psychiatric hospitalization (32%). Fifty-six percent of visits resulted in dischargefrom the ED, 42% in transfer to a psychiatric hospital and 1% in admission to the pediatric medicalward. Median length of stay was 4.7 hours for discharged patients and 11.7 hours for patientstransferred to psychiatric hospitals.

Conclusion: To our knowledge, this study presents the first characterization of preadolescentchildren on involuntary psychiatric holds. Ideally, mental health screening and services could beinitiated in children with similar high-risk characteristics before escalation results in placement ofan involuntary psychiatric hold. Furthermore, given that many patients were discharged from theED, the current pattern of utilization of involuntary psychiatric holds in young children should bereconsidered.

Introduction: The emergency medicine clerkship curriculum at Los Angeles County + University of Southern California Medical Center includes monthly lectures on pediatric fever and shortness of breath (SOB). This educational innovation evaluated if learning could be enhanced by “priming” the students with educational online videos prior to an in-class session. Factors that impacted completion rates were also evaluated (planned specialty and time given for video viewing).

Methods: Twenty minute videos were to be viewed prior to the didactic session. Students were assigned to either the fever or SOB group and received links to those respective videos. All participating students took a pre-test prior to viewing the online lectures. For analysis, test scores were placed into concordant groups (test results on fever questions in the group assigned the fever video and test results on SOB questions in the group assigned the SOB video) and discordant groups (crossover between video assigned and topic tested). Each subject contributed one set of concordant results and one set of discordant results. Descriptive statistics were performed with the Mann-Whitney U test. Lecture links were distributed to students two weeks prior to the in-class session for 7 months and three days prior to the in-class session for 8 months (in which both groups included both EM-bound and non-EM bound students).

Results: In the 15 months study period, 64% of students rotating through the EM elective prepared for the in class session by watching the videos. During 10 months where exclusively EM-bound students were rotating (n=144), 71.5% of students viewed the lectures. In 4 months where students were not EM-bound (n=54), 55.6% of students viewed the lectures (p=0.033). Participation was 60.2% when lecture links were given three days in advance and 68.7% when links were given two weeks in advance (p=0.197). In the analysis of concordant scores, the pre-test averaged 56.7% correct, the immediate post-test averaged 78.1% correct, and the delayed post-test was 67.2%. In the discordant groups, the pretest averaged 51.9%, the immediate posttest was 67.1% and the delayed by 68.8%. In the concordant groups, the immediate post-test scores improved by 21.4%, compared with 15.2% in the discordant groups (p = 0.655). In the delayed post-test the concordant scores improved by 10.5% and discordant scores by 16.9 percent (p=0.609). Sixty-two percent of students surveyed preferred the format of online videos with in-class case discussion to a traditional lecture format.

Conclusion: Immediate post-tests and delayed post-tests improved but priming was not demonstrated to be a statistically superior educational method in this study. Medical student completion of the preparatory materials for the emergency medicine rotation session increased when the students were emergency medicine-bound. Participation rates were not significantly different when given at 2 weeks versus 3 days.