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Emergency care is a highly complex, cognitively demanding specialty that is often challenging because providers work in time-, resource-, and information-constrained settings while caring for patients whose illnesses are still evolving. In the United States alone, there are approximately 145 million annual visits to EDs and many more to urgent care settings. The pressures of clinical practice continue to increase with demands on productivity in the face of decreasing reimbursement and a steadily rising volume of patients. All these factors unfortunately have “contaminated” the “art” of medicine (ie, arrival at a diagnosis after careful and comprehensive clinical examination) with the “knee jerk” aspect of indiscriminate ordering of tests to arrive at the diagnosis. The diagnostic process is even more complex in the context of pediatric emergency care not only because of the spectrum of physiological, anatomical, and psychological differences compared with adults but also because many clinicians are uncomfortable with pediatric patients, are inadequately trained, or work in settings that do not have population-specific management resources. The dangers of over- or under-diagnosis, over- or under-testing, or over- or under-treatment is the risk of patient harm. Injury to patients due to diagnostic mishaps is currently recognized as the most important yet understudied aspect of patient safety (ie, “the blind spot” in the patient safety movement.) The National Academies of Science, Engineering, and Medicine has highlighted the importance of making a timely and accurate diagnosis.

The endeavour of my co-editors and me in revising the Atlas of Pediatric Emergency Medicine is to continue to empower the clinician with a readily accessible and highly relevant resource to make a timely and accurate diagnosis.

Instead of the dense prose of traditional textbooks, this Atlas features a consistent format organized as a Clinical Summary, Emergency Department Treatment and Disposition, and Pearls (“must-know” clinical essentials) for each topic. Side by side with this easy-to-read text is a wealth of images illustrating how these clinical problems look in real life in an emergency setting. By using a high-yield text, we have been fortunate to include more than 2000 images in this edition, greatly enhancing the original work. All 21 sections have been updated with many newly added entities that are applicable to the practice of pediatric emergencies. We have updated the Atlas with the most current imaging techniques available in the emergency setting. Chapter 21 on emergency ultrasound as well as other sections where point-of-care ultrasound (PoCUS) is applicable have been updated because the impact of ultrasound in pediatric emergency medicine care delivery has exponentially increased since the second edition of our Atlas. While PoCUS helps answer a focused clinical question, our reliance on additional imaging remains a crucial part of arriving at the most likely diagnosis. Thus, many entities are presented with CT and/or MRI images. We continue to remain cognizant and enthusiastically supportive of the medical and lay communities who are radiation conscious and cautious. Hopefully, advances in ultrasound technology, such as contrast-enhanced sonography and elastography, will play greater roles in the pediatric ED in the future.

Working in the environment of the ED, we have accumulated a plethora of clinical pathology that enhances and finely tunes our visual diagnostic skills. Armed with a camera and a consent form, we were able to build a library of educational material in the form of clinical pictures, radiographic images, and fascinating stories. With these assets, we prepared the first edition of the Atlas of Pediatric Emergency Medicine (2006) and have been humbled and extremely pleased by the enthusiastic response of our readers. Based upon that response, we published the second edition (2013), also translated into Spanish (2014). Nationally and internationally known experts in pediatric emergency care have contributed their expertise to enhance the impact of this third edition.

This Atlas is written for anyone who has the privilege of taking care of acutely ill and/or injured children. It is designed with the end-user in mind. We hope our experience and images will aid all dedicated practitioners in their efforts to hone their visual diagnostic and differential diagnosis skills and help clinicians to avoid the pitfalls that occur when the “art” is lost.

We are committed to keeping the art of visual diagnosis off the endangered species list and keeping it as the highlight of our clinical day. Our trainees are being schooled in processing flow and survival mode ideation. The following quotation by Sir William Osler has always influenced our approach at the bedside while caring for patients: “Don’t touch the patient... state first what you see; cultivate your powers of observation.” The familiar old adages “A picture is worth a thousand words” and “I cannot define an elephant but I know one when I see one” underscore the benefits of learning from photographs. The student of visual diagnosis is not only more likely to make the right diagnosis but is also more likely to avoid costly errors. We urge our fellow physicians to treasure this art.

Ars longa vita brevis (Art is long while life is short). With this quote, Hippocrates reminds us how much there is to learn in a short period and thereby (hopefully) inspires us to be humble, scholarly, and better clinicians.

Binita R. Shah, MD, FAAP
Prashant Mahajan, MD, MPH, MBA
John Amodio, MD, FACR
Michael Lucchesi, MD, MS

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