A joint statement published in 2009 by the American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee, and Emergency Nurses Association Pediatric Committee spelled out the need for reform in emergency care when it comes to caring for children.
The bottom line is this: if your child has an emergency and you have the luxury of time and choice of where to go, go to an ER at a Children’s Hospital or a pediatrician-staffed emergency room. Collect $200 and pass go. Learn from my mistakes.
Driving the joint statement was concern from both pediatricians and ER physicians about inconsistent care for children in Emergency Departments (EDs) that do not normally specialize in the care of children. The statement outlines strategies to prepare EDs around the country to care for children based on some sobering statistics…
Of the 119 million separate ED visits in 2006, nearly 20% were children. However, pediatricians or pediatric emergency medicine doctors cared for the minority of those children treated. With less than 800 board certified pediatric emergency room physicians in the US, it’s the exception more than the rule that the person in the white coat in an emergency room caring and advising you during your child’s visit is specially trained/boarded to care for your child. One survey reported that only 6% of EDs had the proper equipment ready to care for children of all ages. Another concern is that about ½ of the EDs cared for fewer than 10 pediatric patients a day, making children the small minority of whom they help. When staff, physicians, and the flow of emergency room are unaccustomed to children, care for children may falter. Some EDs may simply be ill prepared as they lack the experience.
This post and my point is not to trash very capable, compassionate ER doctors. My son received phenomenal care at an adult ER when he broke his leg. Further, my position isn’t simply because I blog for a children’s hospital. No one told me, hinted, or suggested I write this. This comes from my heart. This is simply to assert there are differences in care. And often as parents, we have a choice.
The joint statement outlines the way to prepare Emergency Departments with materials, training, and staff to properly care for kids. “It is imperative that all hospital EDs have the appropriate resources (medications, equipment, policies, and education) and staff to provide effective emergency care for children. “
Speaking of pediatric specific EDs, Dr Suzan Mazor a pediatric ER doc and toxicologist says, “We know enough to do less. As pediatric emergency physicians, we trust our exam and our questions for families and can avoid unnecessary testing. Outside EDs are likely not going to harm your kid, but may put your child through more blood work, intervention, and testing than is needed.”
Pediatricians work hard to intervene only when necessary. Another less is more nod here.
Hear my tale, learn from my mistakes:
In April of 2009 we traveled to a hotel north of San Diego for a medical conference. One morning while working off my up-all-night-in-hotel-room-with-screaming 4-month-old-hang-over, our 2-year-old F got up before me and joined my brother-in-law in the adjoining room. O and I were sleeping when I awoke to hear F’s cry.
Like every parent, I can discern that cry from about 2.5 miles; I think there is a little protected neuronal space in the brain reserved for all parents to hone their child’s cry. I’m not kidding.
My brother-in-law said he’d not been looking at F while making some coffee for about 2 minutes when F started to complain about neck pain. Then the onest of crying-screaming-grabbing his neck started. And it got louder and louder.
When I got to him, F poured into my chest and refused to let me touch him on the left side of his neck and chest. He was seemingly stabilizing himself in the bend of my own neck, his head tucked deep inside mine. F is not a massive cuddler (much to my disappointment), so this was delightful for the first few moments until I realized something was really wrong.
Mom mode, check. Internal freak-out, check. Most of my training and doctor skills now out the window in the face of worry, I started to triage and try to figure out what had happened. When he continued to cry, cling to me for dear life and refused to move for about 10 minutes, I got more suspicious we needed help. I started to suspect a collarbone injury as we pieced together the story. My brother in law had left him on the hotel bed while stepping away. Hadn’t heard a thud or fall but F immediately started to complain about neck pain when he returned after being unwitnessed. He was on sitting on the floor. Had F fallen off the bed, broken his collarbone, and then refused to move?
That was my mommy theory. Not a very good pediatrician story, it turns out. This is exactly why doctors don’t care for their own children…we get blinded by emotion.
I paged the husband, already at his conference, and piled into the car just after calling the hotel manager to find the nearest ER with x-ray. Now F had his pediatrician mom and pediatric radiologist dad driving down the highway in search of a diagnosis. In the car seat, he refused to turn his head and look at me.
Diagnosis shift. Now I was thinking of torticollis, a spasm in the neck.
We checked into the ER that was about 10 minutes from the hotel. We let them know we were both physicians when we checked in. When we met the ARNP and Emergency MD in the ER, they acted concerned but nervous that we were physicians. They asked what we, his parents, thought we should do. “What studies do you want?”
We were there for help, not to guide care.
I reflected my opinion that it was likely torticollis, but I was unsure. The ER physician suggested that we needed to do a CT scan of his head and neck because it was an unwitnessed fall. At this point, F had not even been examined. No one had even touched him.
We refused. We were worried they were just scared of caring for him. Instead of examining him and making a plan, it seemed they were treating us, not our son.
When we refused the head CT, they suggested stabilizing his neck with a C-collar and putting him on a backboard and transferring him by ambulance to a Children’s Hospital ED. They refused to allow us to transfer him by private car. Although I understood their position to protect themselves (and F), I knew we didn’t need to transfer by ambulance. So we signed out AMA (against medical advice). Unnerving and something I never thought I’d do in my lifetime,
Vancouver General Hospital’s ER refuses to admit children – there’s a Children’s Hospital less than 10 minutes’ drive away and ALL children are seen there, unless they need immediate attention. I’m very grateful for that – I have absolute faith that they know what they’re doing in Children’s. Thank you for including the quote from Susan Mazor though – until that point your article wasn’t making it really clear WHY pediatric staff are better qualified to care for children.
Your experience at the San Diego ER sounds like that scene from Airplane:
SMS: How are you going to treat my child?
Dr: I can’t tell.
SMS. You can tell me. I’m a doctor.
Dr: No, I mean I’m just not sure.
Your point about the ER doctors treating you and your husband is valid. Dr Friday is used to freaked out parents. She dealt with your emotions and she knew that freaked out parents don’t think clearly so she didn’t rely on you for a diagnosis. The grownup ER doc isn’t used to freaked out parents. If two pediatricians bring their child in, he could easily feel like the “third opinion.”
We’ve had 3 ER experiences with our kids, 2 of which were in adult ERs at large, reputable hospitals on the Eastside. After the first horrid experience, we asked Children’s triage for advice. They sent us to the second hospital as they supposedly have a Ped ER doc and transfer appropriately. Unfortunately, we were berated and chastized for bring our newborn to a virus infested ER in the middle of the night in winter and sent home for our minor concern. Our child got sicker and was admitted for a week when we finally went to the Children’s ER. At the Children’s ER, the same presentation go us seen on arrival, before I’d checked in or filled out paperwork. Someone came ask if I had an insurance card after they’d paged the fellow on call who was waking up at 3am to come admit my baby. World of difference.
I’m glad you posted, and the fact that you work at Children’s hospital is significant. Most parents I know assume that the ER at Children’s is for children who are seen by especially clinics at the hospital, in cases of emergency. So I thought the convention was to go to the local hospital and have them transfer you if you “really” need a specialist. When I arrived at Children’s that night, I felt I was unfairly taking resources from the oncology patient, the fall/head trauma patient, the cystic fibrosis patient…My kid needed more care than I expected but he was the healthiest kid on the floor during our entire stay. Maybe it’s because I grew up when St Jude’s put “children’s hospital” on the map for most people. Or just the fact that you have to be referred and can’t just call up to make an appointment at all other departments besides the ED. I have a hard time thinking of a Children’s hospital as being by invitation only.
Pls excuse the typos:
especially = specialty
I have a hard time NOT thinking of a Children’s hospital as being by invitation only.
PS: do non-Drs call the ED triage before heading in? I do after a medical claim dispute where our insurance didn’t want to pay for a visit because it wasn’t an emergency.
WendySue, I completely concur with your post. Unfortunately, I had a somewhat similar experience with my son. My son was on antibiotics and getting a really bad rash. I took him to the hospital associated with his pediatrician’s office – however it is an adult hospital & ER. I thought maybe they would have the notion to confer with his physician. It appeared he had a multiforme rash – and they couldn’t tell me for sure what caused it. But they pumped him full of fluids (even though he was downing a pint of pedialyte in the exam room), then they took some blood and did some high-panel test just to tell me his monocytes were high. Duh, I told the doc he was on antibiotics for an ear infection! They treated the nausea he was having but wouldn’t treat the itching!!! AAAGGGHHH!!! I begged the doc, who I know has been an ER doc for a bajillion years, for some benadryl to give him some relief. He refused because my boy was barely one years old. Double AAAGGGHHH!!! Then they had me pay my $100 copay up front for useless care. Well, after 6 hours of being ignored and 30minutes of dealing with a human, I went home broke and exhausted and angry and my boy was still miserable and itchy. Hours go by and his erythema multiforme continuted to spread and get worse. I called his on-call doc and demanded he be seen by a pediatrician. I said I will take him back to the local hospital ER if someone from his office would come and see him or I was going to take him here to Childrens. His on-call doc said to take him straight to Childrens. So I showed up here in the ER, was abruptly triaged, was seen by 4 or 5 docs in the exam room. I could have pulled my hair out when each one of them asked if I had given him some benadryl… I didn’t know whether to laugh or cry. Anyhow, 2 hours and 4 or 5 doctors later and no labs to be had, my son got his benadryl, we were in and out of the Children’s ER in record time and me and my son finally got a good night’s sleep. His ear infection cleared up too! 🙂
I had to just say that Viki, your Airplane comment made me laugh out loud, thanks!
I too would only use a Children’s hospital and ED if needed, but the nearest one is 2 1/2 hours away from me, so in a true time-sensitive emergency, I will likely just go to my local community hospital ER.
Thanks for this information. What you say makes perfect sense. I never gave this much thought before, and we live near a hospital system that has a separate children’s hospital with a children’s ER (and I work for the med school associated with the hospital), so I’d have gone there automatically. But now I know to seek out a children’s hospital if we should need emergency services away from home.
This is great post, thanks for sharing! My question is would you recommend the same for “minor” ailments like suspected ear infection, sinus infection or high fever? We live 30-40 minutes from a Children’s ER or Urgent Care, but only 10 minutes from a “General” Urgent Care or ER and when one of my young kids (age 1 and age 3) need to be seen for something like this I often debate whether to make the drive or just go with whats close.
Dr. Swanson, I think this is a great post. I, too, thought Children’s Hospitals were for VERY sick children (read: cancer patients, serious trauma, etc.), and not for concerns for my otherwise healthy toddler. I know a LOT of people feel the same. When we recently took Will to the Children’s ER, I still worried that it would that way, as if we were being overly “dramatic” and taking up resources meant for more seriously ill kids. Once we were there, all of the staff made it clear that we were in the right place.
And I know your post really isn’t about this, but it’s also important to note that its the small little details about being seen at a Children’s Hospital that make the difference for our children. And although these details seem small, a sick child is already scared and miserable enough. It’s the little things that can make a huge difference in how they feel. The professionals we worked with at Children’s knew just how to make procedures (starting an IV, for example) easier on our son. Not that professionals in an adult ER wouldn’t try their best, but they just don’t have the same tools (smaller-sized equipment) or experience working with children. It was truly an art form watching them work. They were amazing with all sorts of interesting tricks to make the whole thing easier. And yes, we would have gotten “good” care elsewhere, but when you have access to the “best,” why settle for less?
Our rules are — if it is obvious and not likely to require general anesthesia then we go to the local hospital (300+ beds, 3 miles away). Otherwise, we go 35 miles to the children’s ER…
We’ve had 4 trips to the ER with one of my 6 year olds, 3 to the children’s and one to the local hospital. The local hospital trip was for staples for a head laceration. Although the care was reasonable, they did apply the local anesthetic to his hair instead of his scalp, leading to a miserable few minutes while they stapled him up. In that case, a short drive, and a short wait was worth it (especially since we had a wedding in just a few hours).
In the other cases, though a trip to the Children’s ER/ hospital is best. For us, it is not just the pediatric ER doc that is important, but also being seen by pediatric specialists. Our first trip to the ER was after our son had a prolonged tonic-clonic seizure. We were not only seen by the pediatric ER staff, but also by the pediatric neurologist, and when we were admitted we were admitted to the chidren’s hospital. All big advantages in my book.
Wendy Sue Swanson, MD says
Sorry for the late response. I think the answer to your question is unfortunately, “It depends.” Yes, an ear infection is minor but I’ll tell you that the care plan can differ–most children who are seen in urgent care/ER outside of a children’s facility will automatically be prescribed antibiotics….while the AAP guidelines and many pediatricians would advise waiting 48 hours first, using pain control, and seeing if infection goes away on its own. If not, then using antibiotics.
So yes, you’re likely to get good care in the urgent care close to home but it still may be different than that in a peds ER.
Further, knowing minor from serious is a tough distinction.
And no, to Katie’s point– in a good and well run ER at a children’s hosp, you’re not taking care away from sicker kids. With good triage and proper staffing, all children will be seen regardless of diagnosis and be seen at pace needed to ameliorate their suffering and problems. However, I’d be curious what an ED doc would say about this–they may disagree! Will do my best to get an answer for you…
Chris Johnson says
As a PICU doc I get most of my patients from an ER, either our in-house one or transferred from another hospital. The difference between pediatric ERs and more generic ERs in the care the children received is striking — the peds docs are used to doing this sort of thing. Children sent to me from non-peds ERs often have had some, well, unusual things done to them.
So the peds ER is best for the sicker kids, too.