How is an Eye Globe Rupture Treated?

Patient Presentation
A pediatrician was hiking in a backcountry mountainous location with her family and a guide. During a rest break, the guide reminded everyone to drink lots of fluid and to eat a snack to maintain energy and avoid dehydration. He also checked with everyone to make sure that equipment was fitting well and no hot spots or blisters were developing on people’s feet. The youngest boy took off his sunglasses during the break and the guide asked him to please put them back on. The boy said, “The sun’s not out and I can see fine.” The guide said, “I know that but there are small branches on the trees right at head height that could poke you, or a branch could snap back or you could even fall. Your glasses won’t prevent everything, but can still give you some eye protection.” He went on to say, “In over 20 years of guiding, I’ve only had one serious injury. Someone caught a branch in their eye. Once a globe is ruptured, the vision is not coming back. I’ve always felt bad about it.” The boy put the glasses back on immediately.

Discussion
Acute eye injuries usually need medical evaluation after the injury to assess the injury extent. Some can be appropriately treated by non-ophthalmologists such as corneal abrasions or minor chemical splashes. Serious or indeterminant injury needs ophthalmological evaluation. Acute globe rupture requires immediate ophthalmological care, often requiring emergency surgery.

Globe rupture is defined as any full-thickness injury to the sclera, cornea or both. It can be caused by penetrating or blunt trauma. Penetrating injuries including scissors, knifes, sticks, nails, projectiles (i.e. BBs, paintballs etc.). Blunt injuries can include sports, traffic accidents, child maltreatment, falls, and there has even been one report of an injury from a mobile videogame console (e.g. WiiTM game system). Blunt injuries are caused when sclera tears from increased intraocular pressure; thus these injuries occur usually where the sclera is thinnest such as the limbus, insertion of the extraocular muscles or previous surgical sites. These sites are often difficult to see because of location.

Globe injuries occur more commonly in males than females because of occupational and recreational activities. Men have more penetrating injuries and women have more blunt injuries. Globe injuries can be obvious or more difficult to diagnose. Globe rupture may be indicated by a visible foreign body or wound or extruded eye contents, self-sealing tract (e.g. discoloration from the sclera or iris closing the wound), decreased mobility of eye, shallow anterior chamber, pupillary irregularity, and chemosis or hemorrhage (particularly circumferential). Using protective eyewear for occupational and recreational activities is the prevention mainstay.

Learning Point
Emergency first aid treatment for a ruptured globe includes:

  • No eye manipulation including no irrigation or instillation of eye drops or other medicines, and no further physical examination of the eye.
  • Placing a rigid surface object such as an eye shield over the eye and securing it to the bony surfaces around the eye. No pressure should be put on the eye so that eye contents remain in the globe and are not extruded or further extruded.
    A foam cup for example can be used. An eye patch is contraindicated because it can put pressure on the globe.

  • Keeping the person calm, again so pressure (ie. valsalva maneuver) does not increase and extrude eye contents. If available in the proper setting, sedation may be used especially in young children.
  • If a foreign body is in the globe, leave it in place.
  • Transporting the patient to a center with ophthalmological care as soon as possible.
  • Keep the patient NPO.
  • Treatment of other injuries as appropriate.
  • Check the tetanus status and administration of tetanus vaccine as appropriate.

Surgical treatment depends on the location, extent, foreign body, etc. and other injuries. Initial surgical treatment includes primary closure along with possible lentectomy andvitrectomy. Other surgical treatments can include intraocular lens implantation, keratoplasty, endolaser, scleral buckle and silicone oil.
Antibiotics to try to prevent endophthalmitis is necessary.
Visual outcome depends much on the extent of the initial injury. Open globe injuries have worse visual outcomes in children. For open globe injuries in children, other poor prognostic factors include young age, poor initial visual acuity, relative afferent papillary defect, absent red reflex, cataract, and the number and types of surgeries.

Questions for Further Discussion
1. What are the common organisms causing endophthalmitis?
2. What are common causes of monocular vision loss in children?
3. What are the possible complications of an acute globe rupture?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Eye Injuries

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Burns GA. Primary Repair of the Posterior Segment: Penetrating, Performating and Blunt Rupture Injures. In Ophthalmic Care of the Combat Casualty. US Army Medical Department Borden Institute. Office of the Surgeon General of the Army. 2003:211-223.
Available from the Internet at http://www.bordeninstitute.army.mil/published_volumes/ophthalmic/OPHch13.pdf (rev. 2003, cited 3/19/2012).

Lee CH, Lee L, Kao LY, Lin KK, Yang ML. Prognostic indicators of open globe injuries in children. Am J Emerg Med. 2009 Jun;27(5):530-5.

Gupta A, Rahman I, Leatherbarrow B. Open globe injuries in children: factors predictive of a poor final visual acuity. Eye (Lond). 2009 Mar;23(3):621-5.

Golden DJ. Doren SC. Globe Rupture. Medscape. Available from the Internet at http://emedicine.medscape.com/article/798223-overview (rev. 2/18/2010, cited 3/19/2012).

Yalcin Tok O, Tok L, Eraslan E, Ozkaya D, Ornek F, Bardak Y, Prognostic factors influencing final visual acuity in open globe injuries. J Trauma. 2011 Dec;71(6):1794-800.

Skarbek-Borowska SE, Campbell KT. Globe rupture and nonaccidental trauma: two case reports. Pediatr Emerg Care. 2011 Jun;27(6):544-6.

Razavi H, Lam G. Wii eye injury: self-inflicted globe rupture and vision loss in a 7-year-old boy from a video game accident. J AAPOS. 2011 Oct;15(5):491-2.

ACGME Competencies Highlighted by Case

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How are Brain Tumors Classified?

    Patient Presentation
    A 10-year-old male came to the emergency room with double vision. Four weeks previously he was playing baseball and had a sudden attack of double vision. This stopped after a few minutes. The family saw an optometrist who changed his glasses’ prescription. The double vision then started to occur at other times, particularly with lateral gaze. He also had increased headaches, nausea and was tripping when walking. He was seen again by the optometrist and referred to the emergency room. The past medical history showed asthma and varicella. The family history was non-contributory. The review of systems revealed progressive headaches for 9 months.

    The pertinent physical exam showed a well appearing male who was alert and oriented x 4. His heart rate was 99 and a blood pressure was 117/61 with other vital signs normal. Growth parameters were 25-50%. Eye examination revealed PERRLA, EOMI and lateral gaze evoked an increase in double vision. Fundascopic examination showed bilateral papilledema. Neurological examination showed normal strength and tone, DTRs were +2/+2, there was no truncal ataxia but difficultly walking because of his vision. The radiologic evaluation showed a right cerebellar cystic mass. The surgical pathology after complete excision revealed a diagnosis of a low-grade pilocytic astrocytoma.

    Case Image

    Figure 97 – Axial images from a CT scan of the brain performed without intravenous contrast demonstrates a heterogenous mass in the right cerebellum causing displacement of the slit-like fourth ventricle to the left (left image) and obstructive hydrocephalus with transependymal flow of cerebrospinal fluid (right image). The mass was felt to most likely represent a cerebellar astrocytoma.

    Discussion
    Primary brain tumors are a diverse group of tumors that together form the most common solid tumors in children. It is estimated that there are 2500-3500 children diagnosed each year in the U.S. with a brain tumor. Brain tumor causes remain unknown and the best treatment has not been determined. Overall 5-year survival is ~70% but the rates are diverse depending on the stage and tumor type. Multimodal treatment is often essential including neurosurgery, oncology, radiation oncology, neuroradiology, endocrinology, rehabilitation and psychology. Unfortunately many children may have long-term or late sequelae because of the treatment, particularly for younger children. Tumor recurrence is also not uncommon.

    Some common ways that brain tumors present include: headache, nausea/emesis, ataxia including truncal, visual changes, clumsiness, back pain, subtle personality or performance changes, or found incidentally (e.g. found on imaging during head trauma evaluation).

    A differential diagnosis of papilledema can be found here.

    Learning Point
    Brain tumors are classified according to location and histology and include:

    • Supratentorial
      • Astrocytomas
      • Atypical teratoid/rhabdoid tumor
      • Ependymomas
      • Gliomas
      • Oligodendrogliomas
      • Meningiomas
      • Neuronal and mixed neuronal glial tumors
      • PNETs (primary neuroectodermal tumors)
      • Choroid plexus tumors
      • Pineal region tumors
      • Metastasis from distant sites
    • Infratentorial or Posterior Fossa
      • Astrocytomas
      • Atypical teratoid/rhabdoid tumors
      • Ependymomas
      • Gliomas
      • Glioneuromas rosette-forming tumor of the 4th ventricle
      • Medulloblastomas
      • Choroid plexus tumors
    • Parasellar
      • Astrocytomas
      • Craniopharyngiomas
      • Germ cell tumors
    • Spinal cord
      • Astrocytomas
      • Ependymomas
      • Gangiliomas

    Overall the most common pediatric brain tumor is medulloblastoma. It accounts for 40% of tumors in the posterior fossa and 10-20% overall.

    Questions for Further Discussion
    1. At what point does recurrent emesis or headache indicate the need for head imaging?
    2. How should adult survivors of childhood cancers be followed?
    3. What is the role of primary care providers in the treatment of childhood tumors?
    4. What is the differential diagnosis of blurred or double vision?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Childhood Brain Tumors

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Kupfer GM, Arceci RM. Childhood Cancer Epidemiology. Medscape. Available from the Internet at http://emedicine.medscape.com/article/989841-overview#a1 (rev. 4/7/2011, cited 3/8/2012).

    National Cancer Institute. General Information About Childhood Brain and Spinal Cord Tumors. Available from the Internet at http://www.cancer.gov/cancertopics/pdq/treatment/childbrain/healthprofessional (rev. 12/15/2011, cited 3/8/2012).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Type of Problems is Bullying Associated With?

    Patient Presentation
    An 8-year-old male came to clinic for health supervision. His mother said that he seemed to be on the losing end of verbal playground confrontations and was not being included in organized soccer and football games at school. These were games that he loved to play and there had been no problems until the new school year began. The patient was having no other social problems. The pertinent physical exam showed a healthy male with growth parameters in the 10-25% and his examination was normal.

    The diagnosis of a healthy male was made. More history showed that a new boy had started school in the fall who was almost a year older and physically larger. The patient stated that the new boy usually picked the teams and decided who would play each recess. The patient and another boy who was also physically smaller were not included very often but were told “you can play in a little while” which didn’t happen by the end of the recess. This occurred before school and during recesses. The patient related that the new boy also was loud in the classroom and lunchroom and would make fun of others, particularly younger children or those that were physically smaller. He would call hiimnames such as “baby” and “twerp.” The new boy would not physically hurt someone but would take advantage of mishaps such as mis-talking or dropping an object to make fun of a person, and when he did so it was quite loud. The patient didn’t feel he could do anything about this. The mother was surprised to hear these details.

    The physician and mother agreed that contacting the school counselor to help address the playground and lunchroom relational dynamics would be a good first step. Additionally, the mother thought the counselor could also help her to make the classroom teachers aware of the problem. At followup a few weeks later, the patient reported that he was getting to play with all the kids and do the things he liked to do. The mother reported that counselor and teachers were working with the new boy to give him positive outlets for his leadership abilities (i.e. lunchroom helper) and opportunities to work with smaller children (i.e. reading with first grade students). They also did specific student pairings in academic groups to help the new boy and the other victims learn more about each other as people. On the playground, the teachers reiterated and monitored the school rules that everyone gets a chance to play in activities. The patient said that the new boy was “nicer” now.

    Discussion
    Bullying is the use of power and aggression to cause distress or control another person. Bullying is an aggressive behavior conducted from a position of power (which may be obvious or not obvious to others such as size, strength, social status, etc.) and is repeated over time. Although repeated behavior is a key element (and necessarily excludes normal negative interactions such as verbal disagreements), one episode of use of power and aggression is many times seen by children as bullying. Direct bullying is an observable behavior including verbal aggression (e.g. insults, threats, sexual or racial harassment) and physical aggression (e.g. hitting, kicking, punching, etc.) Indirect bullying is sometime called relational aggression and may be unobservable or covert manipulation of social relationships (e.g. rumor spreading, gossiping, exclusion) that hurts or excludes a victim. Cyberbullying is one example of indirect bullying.

    Although bullying is seen in all age levels, most people talk about bullying in children and teens.
    There are basically 4 groups: children that bully, children that are victims, children that bully and are victims, children that are neither.
    A 2009 study in Massachusetts of 5800 middle and high school students (~2900 in each group) found that children who bullied or were bully-victims had higher odds-ratios of being a victim of physical violence and especially of being witness to domestic violence. This increased odds-ratio for domestic violence and bully-victims is especially important as the bully-victims would have the experience of seeing both bully and victim in the domestic violence situation.

    Percentage		Neither	Bully		Victim 	Bully-Victim
    Middle School		56%		7.5%		26.8%	9.6%
    High School		69.5%	8.4%		15.6%	6.5%
    
    Odds Ratios
    Middle School
    Being physically hurt				--		4.4		2.9		5.0
    Witnessing family violence 		--		2.9		2.6		3.9
    
    High School
    Being physically hurt				-- 		3.8		2.8		5.4
    Witnessing family violence		-- 		2.7		2.3		6.8
    

    After identifying a possible bullying situation, physicians can ask the “5W’s and H” questions to help determine what type of help may be appropriate for an individual situation.

    • Who do you bully/who bullys you?
    • What do you do to others/what do others do to you? (e.g. gossiping, insults, hitting, etc.)
    • When and how often do you bully/are you bullied?
    • Where do you bully/where are you bullied?
    • Why do you bully others/why do you think you are bullied?
    • How do you think the kids feel when you bully them or how do you feel when you are bullied?

    Bullying is a multifaceted, relational problem, so multimodal approaches helping individuals, families and the community appear to be the best. Study results appear mixed when looking at the specific types of interventions and their efficacy. School based programs have been evaluated and again their effectiveness is mixed. The CDC recommends: “1) establish a social school environment that promotes safety; 2) provide access to health and mental health services; 3) integrate school, family and community prevention efforts; and 4) provide training to enable [school] staff members to promote safety and prevent violence effectively…. [C]omprehensive strategies that encompass the school, family and community are most likely to be effective.”

    Learning Point
    Bullying has been associated with poor school/academic achievement, mental health problems, physical health symptoms, substance abuse and other forms of violence. Indicators of children who bully or are victims often are the same including: physical symptoms such as headache or stomachache, difficulty sleeping, enuresis, school problems including absenteeism, dropping out or low grades, drug and alcohol abuse, anxiety and depression and even suicidal thoughts, attempts or completions. Children who bully may also display manipulation and/or aggression towards family members or animals, show little concern for others feelings or posess items/money that are unexplained. Children who are victims may display injuries or have damaged items or clothing. They may need money, be hungry after school or lose items. They may also threaten or carry out injury to themself or others.

    Questions for Further Discussion
    1. What resources are available in your community for bullying and/or domestic violence?
    2. What attributes could be protective against bullying?
    3. When does bullying reach the level that the law enforcement needs to be involved?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Bullying

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Mishna F. Learning disabilities and bullying: double jeopardy. J Learn Disabil. 2003 Jul-Aug;36(4):336-47.

    MMWR. The Effectiveness of Universal School-Based Programs for the Prevention of Violent and Aggressive Behavior. August 10, 2007. Vol. 56. No. RR-7. Available from the Internet at http://www.cdc.gov/mmwr/pdf/rr/rr5607.pdf (rev. 8/7/2007, cited 3/8/2012).

    Vreeman RC, Carroll AE. A systematic review of school-based interventions to prevent bullying. Arch Pediatr Adolesc Med. 2007 Jan;161(1):78-88.

    Lamb J, Pepler DJ, Craig W. Approach to bullying and victimization. Can Fam Physician. 2009 Apr;55(4):356-60.

    Centers for Disease Control and Prevention (CDC). Bullying among middle school and high school students–Massachusetts, 2009. MMWR . 2011 Apr 22;60(15):465-71. Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6015a1.htm (rev. 4/22/2011, cited 3/8/2012).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How Should I Counsel a Mother Using a Bedside Co-Sleeper?

    Patient Presentation
    A 4-month-old female came to clinic for well child care. The mother reported using a bassinet-style co-sleeper next to her bed for the infant to sleep in. She liked this because she could roll over at night and take the infant into her bed to breastfeed and return the infant to the co-sleeper easily. The mother was a non-smoker and non-drinker. The past medical history showed a full-term infant without prenatal or natal problems. The pertinent physical exam showed a smiling infant with growth parameters between 75-90%. The physical examination was unremarkable.

    The diagnosis of a healthy infant was made. The resident physician was not sure how she should counsel the mother about the co-sleeping arrangement. The attending physician tried to quickly look up the American Academy of Pediatrics (AAP) recommendations but could not find the relevant information during clinic. The attending did say that he himself did not recommend co-sleepers because he was afraid of entrapment in the area between the bassinet and the adult bed, in addition to having loose adult bedding around the infant. He did note that there were some co-sleeping products that wall off an area of the adult bed to make a separate sleeping area for the infant in the adult bed. This he did not recommend and knew that the AAP also did not recommend it. The following day, the attending had more time to review the AAP guidelines which does not make a recommendation for or against bedside co-sleepers.

    Discussion
    Infant sleeping practices are different around the world, but need to provide a warm, safe sleeping environment with as little inconvenience and cost for the family. The AAP recommends that infants use a crib, bassinet, playpen, portable crib, or play yard with a firm mattress with no loose bedding (including pillows, stuffed animals, sleep positioners such as wedges, etc.). “Room-sharing without bed-sharing is recommended” by the AAP to prevent suffocation, strangulation, and entrapment of the infant in an adult bed. The AAP’s extensive technical report with specific recommendations for safe infant sleeping environments are available (see To Learn More below).

    Learning Point
    Co-sleepers that are located in the adult bed are not recommended by the AAP. Bedside co-sleepers that are located separate from the adult bed but next to it are neither recommended or not recommended by the AAP on the basis that there is not enough data to make a recommendation. The AAP also does not recommend bed rails for infants. Bedrails are placed along the side of the bed and are intended to prevent a larger child such as an older toddler, preschooler or school age child from falling off the side of the bed. Car seats and other sitting devices are also not recommended as places for infants to sleep.

    The U.S. Consumer Product Safety Commission and ASTM International are currently working on standards for bedside co-sleepers but these recommendations have not been published. Consumer Reports, an independent, non-profit consumer advocacy organization, does not recommend either co-sleepers that are located in the adult bed or beside the adult bed. They recommend a separate crib for infants and children up to ~4 years of age.

    Questions for Further Discussion
    1. What are some common sleeping arrangements in your practice location?
    2. What parent recommendations do you offer for different sleeping arrangements?
    3. How common is sudden infant death syndrome (SIDS) and/or deaths from sleeping environment in your practice location?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: SIDS and Infant and Newborn Care..

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Arm’s Reach Concepts Recalls Infant Bed-Side Sleepers Due to Entrapment, Suffocation and Fall Hazards. Consumer Product Safety Commission. Available from the Internet at http://www.cpsc.gov/cpscpub/prerel/prhtml11/11187.html (rev. 4/5/2011, cited 3/2/2012).

    American Academy of Pediatrics Technical Report. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics. 2011:128;e1341-e1367.

    Bassinet Buying Guide. Consumer Reports. Available from the Internet at http://www.consumerreports.org/cro/babies-kids/baby-toddler/bassinets/bassinet-buying-advice/index.htm (rev. 1/2012, cited 3/2/12).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital