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D S Diekema

Publications and source records attributed to D S Diekema.

18 recordsLinked to original sources
PubMed2000

Attitudes toward limitation of support in a pediatric intensive care unit.

OBJECTIVE: To prospectively determine opinions of members of a pediatric intensive care unit (PICU) team regarding the appropriateness of aggressive care. The types of support that caregivers sought to limit and their reasons for wanting these limits were collected over time. DESIGN: Prospective survey of caregiver opinions. SETTING: PICU in an academic tertiary care children's hospital. SUBJECTS: A total of 68 intensive care nurses, 11 physicians attending in the PICU, 10 critical care and anesthesia fellows, and 24 anesthesia and pediatric residents. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During a 6-month period, 503 patients were admitted to the PICU. Within this time period, 52.4% of all deaths were preceded by limitation of support, with 100% of noncardiac surgical deaths preceded by limitation of medical interventions. At least one caregiver wished to limit care for 63 of these patients (12.5%). When caregivers wished to limit support they most frequently wished to limit invasive modes of support such as cardiopulmonary resuscitation (94%) and hemodialysis (83%). The ethical rationales identified most often for wishing to limit support were burden vs. benefit (88%) and qualitative futility (83%). Preadmission quality of life was cited less frequently (50%). Caregivers were less likely to limit care on the basis of quality of life. Nurses and physicians in the PICU were very similar to each other in the types of support they thought should be limited and their ethical rationales. CONCLUSIONS: When making decisions about whether or not to limit care for a patient, caregivers were more likely to rely on the perceived benefit to the patient than preadmission quality of life.

Caregivers↗
PubMed1999

Discordant radiograph interpretation between emergency physicians and radiologists in a pediatric emergency department.

OBJECTIVES: To describe the types of discrepancies in radiograph interpretation between emergency physicians and radiologists in a pediatric emergency department, and to determine the impact of discrepant interpretations on patient care. METHODS: Prospective cohort study of discordant radiographs from the period beginning March 1, 1995 and ending March 31, 1996. During this period, 2083 radiographs were coded by the radiologist as concordant or discordant. Three hundred forty-nine were coded as discordant, and 324 were eligible for the study. Charts were reviewed for relevant physical examination findings and emergency department management. Discrepancies that affected patient care were deemed clinically significant. RESULTS: Twenty-three (1.1%) of 2083 radiographs were interpreted differently by the emergency physician and the radiologist in a way that might have changed patient management. This represents 7% (23/324) of the radiographs originally coded by a radiologist as discrepant. The most common discrepancy was a patient with a normal chest examination and a radiograph interpreted as having an infiltrate by the emergency physician, but subsequently read as having no infiltrate by a radiologist (12/324). These patients may have received antibiotics unnecessarily. Two discrepant interpretations had the potential to have serious consequences to the patient if not identified. One patient with cardiomegaly and another patient with free air on abdominal radiograph were not noted by the emergency physician. CONCLUSIONS: Emergency physicians would benefit from more rigorous interpretation of chest x-rays to avoid unnecessary treatment with antibiotics. Emergency physicians do a good job interpreting plain radiographs, but occasionally miss significant findings that could lead to adverse outcomes. The presence of radiologists to immediately read radiographs 24 hours a day could prevent missed findings, but, given the small number of significant misinterpretations, is unlikely to be cost effective.

Bone and Bones↗
PubMed1998

Pediatric wilderness recreational deaths in western Washington State.

STUDY OBJECTIVE: To determine the causes and characteristics of pediatric recreational wilderness deaths. METHODS: All deaths of children between 12 months and 20 years of age involving a wilderness recreational activity in 5 western Washington counties between 1987 and 1996 were identified by medical examiners' logs. Univariate analysis was used to examine variables such as age, gender, activity, mechanism of injury, adult presence, blood alcohol level, safety equipment, and mode of evacuation. RESULTS: Of 40 cases meeting inclusion criteria, 90% involved male subjects and 83% of victims were 13 to 19 years old. Hiking (33%), swimming (20%), and river rafting (10%) were the most common activities. Death was most often by drowning (55%) or closed head injury (26%). No victim was alone. All children younger than 10 years of age were accompanied by an adult, in contrast to only 26% of individuals 10 years or older. Only 4 victims had drugs or alcohol in their system. No victim wore a personal flotation device or helmet, and only 5% had foul weather gear. Although nearly one third of victims were transported by airlift, more than half of the victims were dead at the scene. CONCLUSION: Males and teenagers were the 2 major risk groups for recreational wilderness deaths. Traditional activities such as hiking and swimming were the most common causes of death. Children younger than 10 years died despite the presence of an adult, whereas teenagers were usually with groups of peers. The majority of victims were not prepared for adverse events with basic safety equipment.

Adolescent↗
PubMed1998

A wilderness medicine course for pediatric residents.

OBJECTIVE: To design a structured curriculum to teach pediatric residents about wilderness medicine. BACKGROUND: An increasing number of children are involved in more rigorous and potentially risky outdoor activities. Despite the breadth of exposure characteristic of most pediatric residences, we are aware of no formalized syllabus that prepares residents to both treat injuries sustained in outdoor pursuits, and help parents and children to prepare safely for such activities. METHODS: The first half of the course was designed to teach a broad range of topics in wilderness medicine through a series of readings, lectures, and field trips. The second half of the course involved a six-day course in wilderness skills. RESULTS: Over a three-week period, the major topics of wilderness medicine were thoroughly covered. The three residents involved in the planning and execution of the course felt that the course succeeded in filling an important gap in their pediatric residency training. CONCLUSIONS: The addition of a structured wilderness medicine elective to pediatric residencies, with or without a field component, may provide a valuable opportunity for pediatric residents to broaden their skills and knowledge base to include these increasingly important topics.

Child↗
PubMed1997

An ethics curriculum for the pediatric residency program. Confronting barriers to implementation.

BACKGROUND: The 1997 Residency Review Committee requirements in pediatrics mandate a structured curriculum in medical ethics for all accredited pediatric residency programs. To our knowledge, there are no published models for the development of an ethics curriculum for pediatric residents. Several obstacles may confront those attempting to begin an ethics teaching program. OBJECTIVE: To describe the successful implementation of a structured ethics curriculum for pediatric residents. METHODS: Our program was designed to overcome the following obstacles: (1) time constraints of faculty and residents, (2) scheduling difficulties and lack of continuity, (3) attitudes of residents toward the material, and (4) inadequate ethics training among faculty. In addition to traditional topics in medical ethics, the curriculum focuses on issues that confront residents primarily during their training, issues that may shape their professional values in important ways. RESULTS: This ethics curriculum has been successfully implemented in our own program and offers solutions to common barriers faced by those seeking to implement an ethics curriculum for pediatric residents. CONCLUSION: We present the ethics curriculum currently in use at our institution as a tool that may be adopted as it stands or as altered by others as they develop their own program's ethics curriculum. We believe the proposed curriculum directly confronts many of the barriers to successful ethics education of pediatric residents.

Curriculum↗
PubMed1997

Dystonic reaction associated with dextromethorphan ingestion in a toddler.

INTRODUCTION: Accidental ingestions of cough and cold preparations containing dextromethorphan (DM) are common in the toddler age group and rarely have serious consequences. Even large intentional overdoses by adults seldom lead to serious morbidity. There have been no previous reports of an extrapyramidal reaction due to a DM ingestion. CASE REPORT: We report a 30-month-old girl who ingested approximately 38 mg/kg dextromethorphan. She presented with opisthotonus, ataxia, and bidirectional nystagmus. There was no change in her status with the administration of naloxone. The child was given diphenhydramine with clearing of her opisthotonus but persistence of her ataxia and nystagmus. DISCUSSION: A moderate ingestion of dextromethorphan in a toddler resulted in extrapyramidal symptoms with opisthotonus that responded to diphenhydramine. Dextromethorphan is known to have complex CNS effects and, in sufficient doses, may have dopamine receptor blocking activity resulting in this dystonic reaction.

Antidotes↗
PubMed1996

Physicians' children are treated differently in the emergency department.

The objective was to determine whether children with a physician parent receive treatment different from that of children of nonphysician parents when they present to the emergency department (ED). The design was a retrospective cohort study. The setting was a university-affiliated children's hospital ED. All children with a physician parent seen in the ED during a 16-month period were identified. Children with a nonphysician parent were matched to children with a physician parent by date and time of visit. Length of stay in ED, performance of laboratory or radiological testing, evaluation by a consultant, and training level of the least experienced physician to evaluate the patient in the ED were measured. The authors identified 92 children with a physician parent and 181 children with nonphysician parents. Children of physician parents were similar to controls with regard to age, sex, nursing acuity level, length of stay, and whether a laboratory or radiographic procedure was performed. Children with a physician parent saw significantly fewer nonconsultant physicians while in the ED (P = .005). Compared with controls, the most junior member of the medical team seen by children of a physician parent was less likely to be a medical student (relative risk [RR] = 0.22) or a resident (RR = 0.71) and more likely to be an ED staff physician (RR = 1.52) or consultant (RR = 1.84). This trend was statistically significant (P = .002). The children of physician parents are more likely to see only an ED staff physician and/or consultant and less likely to see trainees than other children presenting to the pediatric ED.

Adolescent↗
PubMed1996

Physician parents and utilization of a pediatric emergency department.

OBJECTIVE: Health care costs might be reduced if patients could be taught to avoid using an emergency department (ED) for nonurgent illness. This study sought to determine whether children with a physician parent, a group whose parents possess special expertise in judging the severity of acute illness, utilize a pediatric ED differently from children with non-physician parents. DESIGN: Retrospective cohort study. SETTING: A children's hospital ED. PARTICIPANTS: The study population consisted of all children who visited the ED over an 11-month period who had a physician parent. These children were compared to 1000 controls randomly selected from children who visited the ED over the same time period. Two other groups were selected for comparison to controls: children with a nurse parent and children with an attorney parent. MAIN OUTCOME MEASURES: Urgent versus nonurgent final diagnosis. RESULTS: There were no clinically important or statistically significant differences with regard to age, sex, time of presentation, disposition from the ED, or nursing acuity level when the 72 children with a physician parent, the 136 children with a nurse parent, or the 135 children with an attorney parent were compared to the control children. Compared to the control group, children of physician parents were less likely to have a nonurgent final diagnosis: 33 versus 53%; relative risk (RR) 0.62 (95% confidence interval [CI] 0.44-0.87). Children with a nurse parent and children with an attorney parent were no more likely to present with a nonurgent diagnosis compared to control children: 49 versus 53%, RR 0.92 (95% CI 0.76-1.10) for children with a nurse parent and 45 versus 53%, RR 0.85 (95% CI 0.70-1.03) for children with an attorney parent. CONCLUSIONS: Children with a physician parent were less likely to use a pediatric ED for nonurgent problems compared to other children. However, children with a nurse parent, a group whose parents have more medical education than we can expect the general public to ever attain, had a pattern of pediatric ED utilization that was similar to the control children. These data suggest that improved parental education alone may not decrease ED use for conditions that could be managed in a less costly setting.

Adolescent↗
PubMed1996

Children first: the need to reform financing of health care services for children.

Many children in the United States live in poverty, lack health insurance, and receive inadequate health care. Current methods of financing health care fail to adequately provide for the needs of children. On the basis of the moral principles of beneficence and justice, adult members of society have a duty to assure that all children receive at least a basic level of health care. Any reorganized health care system should assure health care coverage for all children, health insurance plans must guarantee access and adequate coverage for important medical needs of children, and out-of-pocket expenditures must not discourage the use of effective health care for children.

Beneficence↗
PubMed1995

What is left of futility? The convergence of anencephaly and the Emergency Medical Treatment and Active Labor Act.

In 1986, Congress passed legislation intended to prevent hospitals from "dumping" patients who were unable to pay for their care. This legislation was appended to the Consolidated Omnibus Budget Reconciliation Act as the Emergency Medical Treatment and Active Labor Act (EMTALA). The EMTALA imposes two sets of duties on all hospitals that receive Medicare funds. Since 98% of hospitals in the United States participate in the Medicare program, EMTALA applies to nearly all hospitals in the United States. In short, hospitals with an emergency department must provide an appropriate screening examination to any patient who requests treatment. The purpose of the medical screening examination is to determine whether an "emergency medical condition" exists. If an emergency medical condition is discovered, the hospital must either provide treatment sufficient to stabilize the patient's condition or transfer the patient to another medical facility in an acceptable fashion.

Anencephaly↗
PubMed1993

Epilepsy as a risk factor for submersion injury in children.

The purpose of this study was to determine the risk of submersion injury and drowning among children with epilepsy and to define further specific risk factors. In a population-based retrospective cohort study the authors identified and reviewed records of all 0-through 19-year-old residents of King County, Washington, who suffered a submersion incident between 1974 and 1990. Children with epilepsy were compared with those without epilepsy with regard to age, sex, site of incident, supervision, outcome, and presence of preexisting handicap. Relative risks were determined using population-based estimates of epilepsy prevalence. Of 336 submersions, 21 (6%) occurred among children with epilepsy. Children with epilepsy were more likely to be greater than 5 years old (86% vs 47%) and more likely to submerge in a bathtub (38% vs 11%). The relative risk of submersion for children with epilepsy was 47 (95% confidence interval [CI] 22 to 100) in the bathtub and 18.7 (95% CI 9.8 to 35.6) in the pool. The relative risk of drowning for children with epilepsy was 96 (95% CI 33 to 275) in the bathtub and 23.4 (95% CI 7.1 to 77.1) in the pool. These data support an increased risk of submersion and drowning among children with epilepsy.

Adolescent↗
PubMed1986

Jacob.

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Adult↗