Faculty Bibliography

Simulation-based health professions educators can advance diversity, equity, and inclusion by cultivating structural competency, which is the trained ability to discern inequity not only at an individual level, but also at organizational, community, and societal levels. This commentary introduces Metzl and Hansen's Five-Step Model for structural competency and discusses its unique applicability to the metacognitive underpinnings of simulation-based health professions education. We offer a pragmatic guide for simulation-based health professions educators to collaboratively design learning objectives, simulation cases, character sketches, and debriefs in which structural competency is a simulation performance domain, alongside patient management, resource usage, leadership, situational awareness, teamwork, and/or communication. Our overall goal is to promote a paradigm shift in which educators are empowered to partner with patients, colleagues, and communities to recognize, learn about, and challenge the factors driving health inequities; a skill that may be applied to a broad range of health professions education within and outside of simulation.

INTRODUCTION/UNASSIGNED:Family presence during pediatric medical resuscitation has myriad benefits. However, there is significant heterogeneity in provider acceptance and implementation of the family support role. We designed this curriculum to teach all members of the health care team best practices in the Family Presence Facilitator (FPF) role during pediatric medical resuscitations. METHODS/UNASSIGNED:We applied Kern's six-step approach to develop an FPF curriculum comprising didactic and interactive elements, along with training for simulated participants. We implemented the curriculum through (a) live sessions (30-minute didactic or 90-minute workshop) for learners; (b) a 20-minute asynchronous version of the didactic curriculum for self-directed learning; and (c) a 1-hour, monthly, in situ simulation curriculum in a pediatric emergency department setting. Curriculum evaluation surveys queried self-reported engagement, satisfaction, relevance, confidence, commitment, knowledge, skills, and attitudes in a retrospective pre/post format. RESULTS/UNASSIGNED:We collected data from 153 learners, including attendings, fellows, residents, advanced practice providers, medical students, and child life specialists, between October 2022 and September 2023. Only 22% of participants had received similar prior training. One hundred percent of learners found the curriculum enjoyable and engaging; learners also agreed the curriculum improved their knowledge and skills in providing empathetic and respectful communication (99%); nonspeculative, clear information (100%); and nonverbal support (99%). Of respondents, 100% believed the curriculum would improve the patient care experience. DISCUSSION/UNASSIGNED:Facilitating family presence during pediatric medical resuscitations is a crucial skill. Our curriculum improves self-reported confidence, knowledge, and skills among interprofessional learners. Next steps include expanding this curriculum beyond the pediatric setting.

Ventricular septal defect (VSD) is the most common congenital heart lesion among children. In most cases, however, it is identified and corrected in childhood, before long-term sequelae such as pulmonary hypertension develop. In this case report, we present a young man with an undiagnosed VSD with consequent Eisenmenger syndrome who initially presented to medical attention with diplopia found to be caused by cerebral infarcts.

INTRODUCTION:The use of simulation to develop clinical reasoning and medical decision-making skills for common events is poorly established. Validated head trauma rules help identify children at low risk for clinically important traumatic brain injury and guide the need for neuroimaging. We predicted that interns trained using a high-fidelity, immersive simulation would understand and apply these rules better than those trained using a case-based discussion. Our primary outcomes were to determine the effectiveness of a single targeted intervention on an intern's ability to learn and apply the rules. METHODS:This was a prospective randomized controlled trial. Interns were randomized to participate in either a manikin-based simulation or a case discussion. Knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool were assessed both under testing conditions using standardized vignettes and in clinical encounters. In both settings, interns completed a validated assessment tool to test their knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool when assessing patients with head injury. RESULTS:Under testing conditions, both being in the simulation group and shorter time from training were independently associated with higher score under testing conditions using standardized vignettes (P = 0.038 and P < 0.001), but not with clinical encounters. CONCLUSIONS:Interns exposed to manikin-based simulation training demonstrated performance competencies that are better than those in the case discussion group under testing conditions using standardized vignettes, but not in real clinical encounters. This study suggests that information delivery and comprehension may be improved through a single targeted simulation-based education.

OBJECTIVES/OBJECTIVE:Minor head trauma is a common cause of pediatric emergency room visits. The Pediatric Emergency Care Applied Research Network head trauma clinical decision rules (PECARN-CDR) are designed to assist clinicians in determining which patients require imaging. However, only minimal data are available on the accuracy of residents' assessments using PECARN-CDR. Prior research suggests that trainees often come to erroneous conclusions about pediatric head trauma. The objective of the present study was to assess concordance between pediatric residents' and attending physicians' assessments of children with low-risk head trauma, with the ultimate goal of improving education in pediatric trauma assessment. METHODS:This is a retrospective cohort study analyzing concordance between pediatric residents and pediatric emergency attendings who provided PECARN-CDR-based evaluations of low-risk head injuries. It is a planned subanalysis based on a prospectively collected, multicenter data set tracking pediatric head trauma encounters from July 2014 to June 2019. RESULTS:Data were collected from 436 pediatric residents, who encountered 878 patients. In the case of patients younger than 2 years, low concordance between residents and attendings was observed for the following elements of the PECARN-CDR: severe mechanism (κ = 0.24), palpable skull fracture (κ = 0.23), Glasgow Coma Scale (GCS) score less than 15 (κ = 0.14), and altered mental status (AMS; κ = -0.03). There was moderate to high agreement between residents and attendings for loss of consciousness (κ = 0.71), nonfrontal hematoma (κ = 0.48), and not acting normally per parent (κ = 0.35). In the case of patients older than 2 years, there was low concordance for signs of basilar skull fracture (κ = 0.28) and GCS score less than 15 (κ = 0.10). Concordance was high to moderate for history of vomiting (κ = 0.88), loss of consciousness (κ = 0.67), severe headache (κ = 0.50), severe mechanism (κ = 0.44), and AMS (κ = 0.42). Residents were more conservative, that is, more likely to report a positive finding, in nearly all components of the PECARN-CDR. CONCLUSIONS:Resident assessment of children presenting to the ED with minor head trauma is often poorly concordant with attending assessment on the major predictors of clinically important traumatic brain injury (abnormal GCS, AMS, signs of skull fracture) based on the PECARN-CDR. Future work may explore the reasons for low concordance and seek ways to improve pediatric resident education in the diagnosis and management of trauma.

Multiple sclerosis (MS) is a progressive demyelinating disease of the central nervous system with a wide array of symptoms. We present a healthy young woman who came to the Emergency Department with two days of isolated vertical nystagmus and was subsequently diagnosed with MS on imaging. Although bilateral vertical nystagmus is not a common presentation of MS, its presence should prompt inclusion of this disease process in the differential diagnosis.

Humans and other animals routinely encounter visual stimuli that indicate whether future reward delivery depends upon the identity or location of a stimulus, or the performance of a particular action. These reinforcement contingencies can influence how much attention is directed toward a stimulus. Neurons in the primate amygdala encode information about the association between visual stimuli and reinforcement as well as about the location of reward-predictive stimuli. Amygdala neural activity also predicts variability in spatial attention. In principle, the spatial properties of amygdala neurons may be present independent of spatial attention allocation. Alternatively, the encoding of spatial information may require attention. We trained monkeys to perform tasks that engaged spatial attention to varying degrees to understand the genesis of spatial processing in the amygdala. During classical conditioning tasks, conditioned stimuli appeared at different locations; amygdala neurons responded selectively to the location of stimuli. These spatial signals diminished rapidly upon stimulus disappearance and were unrelated to selectivity for expected reward. In contrast, spatial selectivity was sustained in time when monkeys performed a delayed saccade task that required sustained spatial attention. This temporally extended spatial signal was correlated with signals encoding reward expectation. Furthermore, variability in firing rates was correlated with variability in spatial attention, as measured by reaction time. These results reveal two types of spatial signals in the amygdala: one that is tied to initial visual responses and a second that reflects coordination between spatial and reinforcement information and that relates to the engagement of spatial attention.