Medicine and Health Sciences Commons^™

Delays To Antibiotics In The Emergency Department And Risk Of Mortality In Children With Sepsis., Roni D. Lane, Troy Richardson, Halden F. Scott, Raina M. Paul, Fran Balamuth, Matthew A. Eisenberg, Ruth Riggs, W Charles Huskins, Christopher M. Horvat, Grant E. Keeney, Leslie Hueschen, Justin M. Lockwood, Vishal Gunnala, Bryan P. Mckee, Nikhil Patankar, Venessa Lynn Pinto, Amanda M. Sebring, Matthew P. Sharron, Jennifer Treseler, Jennifer J. Wilkes, Jennifer K. Workman

Manuscripts, Articles, Book Chapters and Other Papers

IMPORTANCE: Pediatric consensus guidelines recommend antibiotic administration within 1 hour for septic shock and within 3 hours for sepsis without shock. Limited studies exist identifying a specific time past which delays in antibiotic administration are associated with worse outcomes.

OBJECTIVE: To determine a time point for antibiotic administration that is associated with increased risk of mortality among pediatric patients with sepsis.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data from 51 US children's hospitals in the Improving Pediatric Sepsis Outcomes collaborative. Participants included patients aged 29 days to less than 18 years with sepsis recognized within 1 hour …

Contraceptive Counseling For Adolescents In The Emergency Department: A Novel Curriculum For Nurse Practitioners And Physician Assistants., Laurel S. Gabler, Michelle Shankar, Tara Ketterer, Jennifer Molnar, Amber Adams, Jungwon Min, Elizabeth Miller, Romina Barral, Aletha Akers, Melissa K. Miller, Cynthia Mollen

Manuscripts, Articles, Book Chapters and Other Papers

Many adolescents use the emergency department (ED) as their primary source of health care. As a result, the ED serves as a unique opportunity to reach adolescents. Although many adolescent visits to the ED are related to reproductive health, ED providers report barriers to providing this care, including lack of training. Nurse practitioners (NPs) and physician assistants (PAs) serve a vital role in the provision of consistent care to adolescents in the ED. The purpose of this study was to create a curriculum to train NPs and PAs at two pediatric institutions to provide patient-centered contraceptive counseling to adolescents in …

Simulation-Based System Analysis: Testing Preparedness For Extracorporeal Membrane Oxygenation Cannulation In Pediatric Covid-19 Patients., Alyssa Stoner, Robert Schremmer, Mikaela A. Miller, Kari L. Davidson, Rachael L. Pedigo, Jamie S. Parson, Christopher S. Kennedy, Eugenia K. Pallotto, Jenna Miller

Manuscripts, Articles, Book Chapters and Other Papers

Introduction: Coronavirus Disease-2019 presents risk to both patients and medical teams. Staff-intensive, complex procedures such as extracorporeal membrane oxygenation (ECMO) or extracorporeal cardiopulmonary resuscitation (eCPR) may increase chances of exposure and spread. This investigation aimed to rapidly deploy an in situ Simulation-based Clinical Systems Testing (SbCST) framework to identify Latent Safety Threats (LSTs) related to ECMO/eCPR initiation during a pandemic.

Methods: The adapted SbCST framework tested systems related to ECMO/eCPR initiation in the Neonatal and Pediatric Intensive Care Units. Systems were evaluated in six domains (Resources, Processes/Systems, Facilities, Clinical Performance, Infection Control, and Communication). We conducted three high-fidelity simulations with …

Initiative To Increase The Rate Of Emergency Department Physician Preprocedure Time-Out Documentation., Arjun Sarin, Nikita Sharma, Shobhit Jain

Manuscripts, Articles, Book Chapters and Other Papers

The preprocedure time-out is an important safety measure to verify patient identity and accuracy of a planned procedure. The time-out is an institutional and Joint Commission requirement. However, physicians in our emergency departments (EDs) document it inconsistently. We aimed to improve physician preprocedure time-out documentation for deep sedation (ketamine and/or propofol) from 75% to 90%, and separately for cutaneous abscess incision and drainage (I&D) from 94% to 98% by June 2020.

Methods: We analyzed 1 year of baseline data and weekly electronic medical record (EMR) reports from November 2019 through June 2020. Our outcome measures were the rate of physician …

A Novel Approach To Explore Safety-I And Safety-Ii Perspectives In In Situ Simulations-The Structured What If Functional Resonance Analysis Methodology., Ralph James Mackinnon, Karin Pukk-Härenstam, Christopher S. Kennedy, Erik Hollnagel, David Slater

Manuscripts, Articles, Book Chapters and Other Papers

OBJECTIVES: With ever increasingly complex healthcare settings, technology enhanced simulation (TES) is well positioned to explore all perspectives to enhance patient safety and patient outcomes. Analysis from a Safety-II stance requires identification of human adjustments in daily work that are key to maintaining safety. The aim of this paper is to describe an approach to explore the consequences of human variability from a Safety-II perspective and describe the added value of this to TES.

METHODS: The reader is guided through a novel application of functional resonance analysis methodology (FRAM), a method to analyse how a system or activity is affected …

A Multicenter Evaluation Of Viral Bloodstream Detections In Children Presenting To The Emergency Department With Suspected Systemic Infection., Christina A. Rostad, Neena Kanwar, Jumi Yi, Claudia R. Morris, Jennifer Dien Bard, Amy Leber, James Dunn, Kimberle C. Chapin, Anne J. Blaschke, Judy A. Daly, Leslie Hueschen, Matthew Jones, Elizabeth Ott, Jeffrey Bastar, Kevin M. Bourzac, Rangaraj Selvarangan

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: Fever is a common symptom in children presenting to the Emergency Department (ED). We aimed to describe the epidemiology of systemic viral infections and their predictive values for excluding serious bacterial infections (SBIs), including bacteremia, meningitis and urinary tract infections (UTIs) in children presenting to the ED with suspected systemic infections.

METHODS: We enrolled children who presented to the ED with suspected systemic infections who had blood cultures obtained at seven healthcare facilities. Whole blood specimens were analyzed by an experimental multiplexed PCR test for 7 viruses. Demographic and laboratory results were abstracted.

RESULTS: Of the 1114 subjects enrolled, …

Thyrotoxic Periodic Paralysis In An Adolescent Male: A Case Report And Literature Review., Luke He, Veronica Lawrence, Wayne V. Moore, Yun Yan

Manuscripts, Articles, Book Chapters and Other Papers

Thyrotoxic periodic paralysis (TPP) is rarely seen in children and adolescents. Clinical manifestations in children and adolescents may vary. It is important for clinicians to be aware of this rare and life-threatening condition.

Pediatric Outpatient Utilization By Differing Medicaid Payment Models In The United States., Therese L Canares, Ari Friedman, Jonathan Rodean, Rebecca R Burns, Deena Berkowitz, Matt Hall, Elizabeth Alpern, Amanda Montalbano

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: In the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients' healthcare utilization. Adults in capitated plans utilize primary care providers (PCP) more than emergency departments (ED), compared to fee-for-service (FFS). Pediatric data are lacking. We aim to determine the association between US capitated and FFS Medicaid payment models and children's outpatient utilization.

METHODS: This retrospective cohort compared outpatient utilization between two payment models of US Medicaid enrollees aged 1-18 years using Truven's 2014 Marketscan Medicaid database. Children enrolled > 11 months were included, and were excluded for eligibility due to disability/complex chronic condition, lack of …

Factors Associated With Urgent Care Reliance And Outpatient Health Care Use Among Children Enrolled In Medicaid., Rebecca R. Burns, Elizabeth R. Alpern, Jonathan Rodean, Therese Canares, Brian R. Lee, Matt Hall, Amanda Montalbano

Manuscripts, Articles, Book Chapters and Other Papers

Importance: Urgent care (UC) centers are a growing option to address children's acute care needs, which may cause unanticipated changes in health care use.

Objectives: To identify factors associated with high UC reliance among children enrolled in Medicaid and examine the association between UC reliance and outpatient health care use.

Design, Setting, and Participants: A retrospective cohort study used deidentified data on 4 133 238 children from the Marketscan Medicaid multistate claims database to calculate UC reliance and outpatient health care use. Children were younger than 19 years, with 11 months or more of continuous Medicaid enrollment and 1 or …

Defining And Measuring Quality In Acute Paediatric Trauma Stabilisation: A Phenomenographic Study., Ralph James Mackinnon, Karin Pukk-Härenstam, Ulrica Von Thiele Schwarz, Christopher S. Kennedy, Terese Stenfors

Manuscripts, Articles, Book Chapters and Other Papers

Objectives: Trauma is the leading cause of death in children. The lack of an accepted definition of what constitutes a high-quality stabilisation of a traumatically injured child has limited the evaluation of direct interventions in simulation-based education and service-delivery models to improve trauma care. The aim of this study was to create a framework that delineates quality by exploring the perceptions of the multi-disciplinary team providing and improving this initial care.

Methods: Interviews were conducted with 36 experienced UK trauma team members and governance administrators (clinical directors to executive board level), from three standard UK trauma units. This study used …

Shared Decision-Making Tools In Pediatric Acute Care: Enhancing Parent Knowledge And Trust., M Denise Dowd

Manuscripts, Articles, Book Chapters and Other Papers

Comment on

• Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head Trauma: A Cluster Randomized Trial. Hess EP, Homme JL, Kharbanda AB, Tzimenatos L, Louie JP, Cohen DM, Nigrovic LE, Westphal JJ, Shah ND, Inselman J, Ferrara MJ, Herrin J, Montori VM, Kuppermann N.JAMA Netw Open. 2018 Sep 7;1(5):e182430. doi: 10.1001/jamanetworkopen.2018.2430.PMID: 30646167 Free PMC article. Clinical Trial.

Increasing Ed Use Of Jet Injection Of Lidocaine For Iv-Related Pain Management., Shobhit Jain, Mary A. Hegenbarth, Sharon Humiston, Erin Gunter, Lynn Anson, Joan Giovanni

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND AND OBJECTIVE: Venipuncture is a leading cause of procedural pain for children. Jet injection of lidocaine (JIL; J-Tip) has been demonstrated to be effective in controlling intravenous (IV) placement-related pain and, due to its rapid onset, is particularly suited to emergency department (ED) use. Our objective was to increase JIL use with IV placements in our ED from 11% at baseline to 50% within 12 months.

METHODS: We initiated the project at our urban, tertiary pediatric ED in July 2014. We surveyed medical and nursing teams to identify barriers to JIL use. We initiated changes at monthly intervals: (1) …

Impact Of Smartphone Digital Photography, Email, And Media Communication On Emergency Room Visits Post-Hypospadias Repair., Michael E. Chua, Megan A. Saunders, Paul R. Bowlin, Jessica M. Ming, Roberto Iglesias Lopes, Walid A. Farhat, Joana Dos Santos

Manuscripts, Articles, Book Chapters and Other Papers

INTRODUCTION: Advances in communication technology are shaping our medical practice. To date, there is no clear evidence that this mode of communication will have any effect on unnecessary postoperative emergency room (ER) visits. We aim to evaluate the effect of email and media communication with application of smartphone digital photography on post-hypospadias repair ER visit rates.

METHODS: This prospective cohort study included all patients who underwent hypospadias repair performed by a single surgeon from October 2014 to November 2015. Patients were categorized into two groups: Group A consented for smartphone photography and email communication and Group B declined. Reason for …

Does Mental Status Impact Therapist And Patient Communication In Emergency Department Brief Interventions Addressing Alcohol Use?, Brian Borsari, Timothy R. Apodaca, Ali Yurasek, Peter M. Monti

Manuscripts, Articles, Book Chapters and Other Papers

Motivational interviewing (MI) is often incorporated into screening, brief intervention, and referral to treatment (SBIRT) interventions in critical care settings to address alcohol and other drug use. However, cognitive status has been linked to differential response to MI sessions in emergency department (ED) settings. The current study examined one possible explanation for this differential response: whether higher versus lower mental status impacts patient response to clinician statements during MI sessions conducted in an ED. Participants were 126 patients receiving an MI-based single-session alcohol brief intervention, and 13 therapists who provided treatment. Participants completed a mental status exam (MSE) as part …

Firearm Injury Prevention In Clinical Practice: Staying On Message., M Denise Dowd

Manuscripts, Articles, Book Chapters and Other Papers

No abstract provided.

Indoor Tobacco Legislation Is Associated With Fewer Emergency Department Visits For Asthma Exacerbation In Children., Christina E. Ciaccio, Tami Gurley-Calvez, Theresa I. Shireman

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: During the past 3 decades, numerous cities and states have adopted laws that ban smoking in public indoor spaces. The rationale for these policies has been to protect nonsmokers from the adverse health effects of secondhand smoke.

OBJECTIVE: To determine whether the implementation of indoor smoking legislation is associated with a decrease in emergency department visits for asthma in children.

METHODS: This retrospective analysis used a natural experiment to estimate the impact of clean indoor air legislation on the rate of emergency department admissions for asthma exacerbation in children. Data were obtained from the Pediatric Health Information System. A …

The Influence Of Age On The Diagnostic Performance Of White Blood Cell Count And Absolute Neutrophil Count In Suspected Pediatric Appendicitis., Richard G. Bachur, Peter S. Dayan, Nanette C. Dudley, Lalit Bajaj, Michelle D. Stevenson, Charles G. Macias, Manoj K. Mittal, Jonathan Bennett, Kelly A. Sinclair, Michael C. Monuteaux, Anupam B. Kharbanda

Manuscripts, Articles, Book Chapters and Other Papers

OBJECTIVE: White blood cell (WBC) count and absolute neutrophil count (ANC) are a standard part of the evaluation of suspected appendicitis. Specific threshold values are utilized in clinical pathways, but the discriminatory value of WBC count and ANC may vary by age. The objective of this study was to investigate whether the diagnostic value of WBC count and ANC varies across age groups and whether diagnostic thresholds should be age-adjusted.

METHODS: This is a multicenter prospective observational study of patients aged 3-18 years who were evaluated for appendicitis. Receiver operator characteristic curves were developed to assess overall discriminative power of …

Urgent Care And Emergency Department Visits In The Pediatric Medicaid Population., Amanda Montalbano, Jonathan Rodean, Juhi Kangas, Brian R. Lee, Matt Hall

Manuscripts, Articles, Book Chapters and Other Papers

Background: Urgent care (UC) is one of the fastest growing venues of health care delivery. We compared clinical and cost attributes of pediatric UC and emergency department (ED) visits that did not result in admission.

Methods: Our study examined 5 925 568 ED and UC visits of children under 19 years old in the 2010 through 2012 Marketscan Medicaid Multi-State Database. Basic demographics, diagnoses, severity, and payments were compared. Between ED and UC visits, χ(2) tests were used for proportions and Wilcoxon rank-sum tests were used for continuous variables.

Results: The UC and ED had the same most common diagnoses. …

Factors Associated With Interest In Same-Day Contraception Initiation Among Females In The Pediatric Emergency Department., Melissa K. Miller, Kimberly A. Randell, Romina Barral, Ashley K. Sherman, Elizabeth Miller

Manuscripts, Articles, Book Chapters and Other Papers

PURPOSE: The purposes were to describe interest in hormonal contraception initiation among female adolescent in the emergency department (ED) and to assess for associations with factors known to increase pregnancy risk such as violence victimization.

METHODS: We used a computerized survey to assess sexual and dating practices, pregnancy history/likelihood, contraception use (including long-acting reversible contraception [LARC]) and concerns, contraception initiation interest, violence victimization, medical utilization, and demographics among sexually experienced females aged 14-19 years in our ED. The primary outcome was interest in contraception initiation. We compared responses between subgroups using the chi-square test.

RESULTS: A total of 168 adolescents …

Current Workforce Characteristics And Burnout In Pediatric Emergency Medicine., Marc H. Gorelick, Robert Schremmer, Holly Ruch-Ross, Carrie Radabaugh, Steven Selbst

Manuscripts, Articles, Book Chapters and Other Papers

OBJECTIVES: Changes in health care delivery and graduate medical education have important consequences for the workforce in pediatric emergency medicine (PEM). This study compared career preparation and potential attrition of the PEM workforce with the prior assessment from 1998.

METHODS: An e-mail survey was sent to members of the American Academy of Pediatrics (AAP) Section on EM and to non-AAP members board certified in PEM. Information on demographics, practice characteristics and professional activities, career preparation, future plans, and burnout (using two validated screening questions) was analyzed using standard descriptive statistics.

RESULTS: Of 2,120 surveys mailed, 895 responses were received (40.8% …

Ketogenic Diet Decreases Emergency Room Visits And Hospitalizations Related To Epilepsy., Husam R. Kayyali, Anastasia Luniova, Ahmed Abdelmoity

Manuscripts, Articles, Book Chapters and Other Papers

Background. Approximately, one-third of patients with epilepsy are refractory to pharmacological treatment which mandates extensive medical care and imposes significant economic burden on patients and their societies. This study intends to assess the impact of the treatment with ketogenic diet (KD) on reducing seizure-related emergency room visits and hospitalizations in children with refractory epilepsy. Methods. This is a retrospective review of children treated with the KD in one tertiary center. We compared a 12 months' period prior to KD with 12 months after the diet was started in regard to the number of emergency department (ED) visits, hospitalizations, …

Prevalence Of And Risk Factors For Intracranial Abnormalities In Unprovoked Seizures., Peter S. Dayan, Kathleen Lillis, Jonathan Bennett, Gregory P. Conners, Pam Bailey, James Callahan, Cigdem Akman, Neil Feldstein, Joshua Kriger, W Allen Hauser, Nathan Kuppermann

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND AND OBJECTIVES: Prospective data are lacking to determine which children might benefit from prompt neuroimaging after unprovoked seizures. We aimed to determine the prevalence of, and risk factors for, relevant intracranial abnormalities in children with first, unprovoked seizures.

METHODS: We conducted a 6-center prospective study in children aged >28 days to 18 years with seemingly unprovoked seizures. Emergency department (ED) clinicians documented clinical findings on a standardized form. Our main outcome was the presence of a clinically relevant intracranial abnormality on computed tomography (CT) or MRI, defined as those that might change management, either emergently, urgently, or nonurgently.

RESULTS: …

Point-Of-Care Ultrasonography By Pediatric Emergency Medicine Physicians., Jennifer R. Marin, Resa E. Lewiss, American Academy Of Pediatrics, Committee On Pediatric Emergency Medicine, Society For Academic Emergency Medicine, Academy Of Emergency Ultrasound, American College Of Emergency Physicians, Pediatric Emergency Medicine Committee, World Interactive Network Focused On Critical Ultrasound, Gregory P. Conners

Manuscripts, Articles, Book Chapters and Other Papers

Emergency physicians have used point-of-care ultrasonography since the 1990 s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing …

Point-Of-Care Ultrasonography By Pediatric Emergency Medicine Physicians, American Academy Of Pediatrics, Committee On Pediatric Emergency Medicine, Society For Academic Emergency Medicine,Academy Of Emergency Ultrasound, American College Of Emergency Physicians, Pediatric Emergency Medicine Committee, World Interactive Network Focused On Critical Ultrasound, Gregory P. Conners

Manuscripts, Articles, Book Chapters and Other Papers

Point-of-care ultrasonography is increasingly being used to facilitate accurate abstract and timely diagnoses and to guide procedures. It is important for pediatric emergency medicine (PEM) physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. PEM fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital …

Best Practices For Improving Flow And Care Of Pediatric Patients In The Emergency Department., Isabel Barata, Kathleen M. Brown, Laura Fitzmaurice, Elizabeth Stone Griffin, Sally K. Snow, American College Of Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association Pediatric Committee, Gregory P. Conners, American Academy Of Pediatrics Committee On Pediatric Emergency Medicine

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This report provides a summary of best practices for improving flow, reducing waiting times, and improving the quality of care of pediatric patients in the emergency department.

Patient- And Family-Centered Care Of Children In The Emergency Department., Nanette Dudley, Alice Ackerman, Kathleen M. Brown, Sally K. Snow, American Academy Of Pediatrics Committee On Pediatric Emergency Medicine, American College Of Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association Pediatric Committee., Gregory P. Conners

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Patient- and family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in a mutually beneficial partnership among patients, families, and health care professionals. Providing patient- and family-centered care to children in the emergency department setting presents many opportunities and challenges. This revised technical report draws on previously published policy statements and reports, reviews the current literature, and describes the present state of practice and research regarding patient- and family-centered care for children in the emergency department setting as well as some of the complexities of providing such care.

Death Of A Child In The Emergency Department., American Academy Of Pediatrics Committee On Pediatric Emergency Medicine, American College Of Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association Pediatric Committee, Gregory P. Conners

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The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have collaborated to identify practices and principles to guide the care of children, families, and staff in the challenging and uncommon event of the death of a child in the emergency department in this policy statement and in an accompanying technical report.

Death Of A Child In The Emergency Department., Patricia O'Malley, Isabel Barata, Sally Snow, American Academy Of Pediatrics Committee On Pediatric Emergency Medicine, American College Of Emergency Physicians Pediatric Emergency Medicine Committee, Gregory P. Conners

Manuscripts, Articles, Book Chapters and Other Papers

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of …

Pediatric Care Recommendations For Freestanding Urgent Care Facilities., Committee On Pediatric Emergency Medicine, Gregory P. Conners

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Treatment of children at freestanding urgent care facilities has become common in pediatric health care. Well-managed freestanding urgent care facilities can improve the health of the children in their communities, integrate into the medical community, and provide a safe, effective adjunct to, but not a replacement for, the medical home or emergency department. Recommendations are provided for optimizing freestanding urgent care facilities' quality, communication, and collaboration in caring for children.

Withholding Or Termination Of Resuscitation In Pediatric Out-Of-Hospital Traumatic Cardiopulmonary Arrest., American College Of Surgeons Committee On Trauma, American College Of Emergency Physicians Pediatric Emergency Medicine Committee, National Association Of Ems Physicians, American Academy Of Pediatrics Committee On Pediatric Emergency Medicine,, Mary E. Fallat, Gregory P. Conners

Manuscripts, Articles, Book Chapters and Other Papers

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary …