The identified TCs offer important insights into the relationship between trainee actions and how they conceptualise practice. At their heart, many appeared to represent ideals of practice that trainees should incorporate into their developing identities as they explore what it means to be a physician. Future research should explore how to incorporate TCs into assessment and the support of trainee development.

PurposePostgraduate training programs are incorporating feedback from registered nurses (RNs) to facilitate holistic assessments of resident performance. RNs are a potentially rich source of feedback because they often observe trainees during clinical encounters when physician supervisors are not present. However, RN perspectives about sharing feedback have not been deeply explored. This study investigated RN perspectives about providing feedback and explored the facilitators and barriers influencing their engagement.

Bhat and Goldszmidt discuss how healthcare providers can struggle with enacting intraprofessional collaboration when faced with systemic barriers.

CLINICIAN'S CAPSULEWhat is known about the topic?Children's pain in the emergency department (ED) continues to be under-recognized and sub-optimally managed.What did this study ask?We sought to evaluate the frequency of caregiver/child acceptance of analgesia offered in the ED.What did this study find?Of the 743 children who presented to the ED with a painful condition, 408 (54.9%) were offered analgesia. If offered in the ED, analgesia was accepted by 91% (373/408) of the caregivers/children.Why does this study matter to clinicians?This study suggests that caregiver/child refusal of analgesia is a not a major barrier to optimal pain management and highlights the importance of ED personnel in encouraging adequate analgesia.

Introduction: The suboptimal management of children’s pain in the emergency department (ED) is well described. Although surveys of physicians show improvements in providing analgesia, institutional audits suggest otherwise. One reason may be patient refusal. Our objectives were to determine the proportion of caregivers that offered analgesia prior to arrival to the ED, accept analgesia in the ED, and identify reasons for withholding analgesia. Our results will inform knowledge translation initiatives to improve analgesic provision to children. Methods: A novel survey was designed to test the hypothesis that a large proportion of caregivers withhold and refuse analgesia. Over a 16-week period across two Canadian paediatric EDs, we surveyed caregivers of children aged 4-17 years with an acutely painful condition (headache, otalgia, sore throat, abdominal pain, or musculoskeletal injury). The primary outcome was the proportion of caregivers who offered analgesia up to 24 hours prior to ED arrival and accepted analgesia in the ED. Results: The response rate was 568/707 (80.3%). The majority of caregivers were female (426/568, 75%), aged 36 years or older (434/568, 76.4%), and had a post-secondary education (448/561, 79.9%). Their children included 320 males and 248 females with a mean age of 10.6 years. Most (514/564, 91.1%) reported being “able to tell when their child was in pain”. On average, children rated their maximal pain at 7.4/10. A total of 382/561 (68.1%) caregivers did not offer any form of analgesia prior to arrival. Common reasons included lack of time (124/561, 22.1%), fear of masking signs and symptoms (74/561, 13.2%) or the seriousness of their child’s condition (72/561, 12.8%), and lack of analgesia at home (71/561, 12.7%). Analgesia was offered to 328/560 (58.6%) children in the ED and 283/328 (72.6%) caregivers accepted. The most common reason for not accepting analgesia was child refusal (20/45, 44.4%). Conclusion: Most caregivers do not offer analgesia to their child prior to arriving in the ED despite high levels of pain and an awareness of it. Despite high rates of acceptance of analgesia in the ED, misconceptions are common. Knowledge translation strategies should dispel caregiver misconceptions, and highlight the impact of pain on children and the importance of analgesia at home.

Spontaneous bacterial peritonitis is a common complication of cirrhosis with high risk of deathBacterial infection of ascites fluid, most commonly from Escherichia coli or Klebsiella pneumoniae, causes the condition. 1 Its prevalence in patients with cirrhosis is 10.8% in North America, and nearly 25% of patients die despite appropriate antibiotic treatment. 2 2 The presentation varies and patients may not have abdominal pain or fever Spontaneous bacterial peritonitis is often a trigger for cirrhotic decompensation, which can manifest as isolated hepatic encephalopathy, gastro intestinal bleeding, renal failure, increasing ascites volume or any vital sign abnormalities, including hypothermia. 1,3 Given its highly variable presentation, the current guideline recommends that every patient who presents urgently to hospital with cirrhosis and ascites be tested for the condition. 1 3 Prompt diagnosis is required to reduce risk of death A paracentesis that shows ascites fluid with a polymorphonuclear leukocyte count of 250 cells/mm 3 (0.25 × 10 9 /L) or greater confirms the diagnosis. In 1 study, delaying paracentesis by 12 hours resulted in a 2.7-fold increase in odds of death. Clinicians should perform paracentesis as soon as possible. 4 Empiric antibiotic treatment requires consideration of local resistance patternsIn North America, antibiotic resistance in spontaneous bacterial peritonitis is 17.8%, with methicillin-resistant Staphylococcus aureus the most common resistant organism. 2 Empiric treatment in low-resistance areas is a third-generation cephalosporin, and in high-resistance areas is piperacillin-tazobactam. 1 5 Clinicians should prescribe albumin within 6 hours of diagnosis to confer a mortality benefit Albumin has a number needed to treat of 6 patients to prevent 1 death, and of 4 patients to prevent 1 case of renal failure, if given within 6 hours of diagnosis of spontanous bacterial peritonitis. 5 The latest guideline recommends that, in addition to fluid resuscitation, albumin be given to all patients with the condition. 1 Recommended dosing is albumin 1.5 g/kg on day 1 and 1 g/kg on day 3. 1

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