You have read a great deal in the previous chapters about which problems a parent can appropriately observe at home, which are best handled with a call to the doctor for advice, and which need evaluation in an emergency department. If you do bring your child to an emergency department, you may find it a bewildering and even frustrating experience. This is especially the case if you do not understand how these places work, how they differ from a doctor’s office or a free-standing walk-in clinic. In our final chapter you will learn some of that useful information. It will allow you to make the best use of the facility to get the care your child needs.
As of 2012 there were nearly five thousand hospitals in America with emergency departments that cared for children. Only about 10 percent of those, however, were in hospitals with the ability to provide advanced pediatric care. About half of those, 250 in all, were found in specialized children’s hospitals. That is probably not a significant consideration if your child has an easy, straightforward problem. But if your child has a more complicated or challenging problem and you have access to a children’s hospital (most are in large cities), then it makes sense to take your child there for care. This is because the doctors in a dedicated children’s facility will be experienced in treating all manner of children’s ailments. They also will have ready access to whatever special tests or expert advice your child’s case might require.
Children’s hospitals do account for a disproportionately large number of emergency department visits by children. Even though only 5 percent of emergency departments who see children are located in dedicated children’s hospitals, they cared for nearly 30 percent of all children whose parents brought them to one of America’s emergency departments. So it appears parents recognize the difference. On the other hand, nearly a third of children cared for in emergency departments across the country are seen in facilities that do not even have the capacity to care for those children if they are sick enough to require admission to the hospital; if the child needs to come into the hospital, the emergency department has to transfer the child to another facility. If your child is quite sick, it seems best to avoid that situation if possible.
I do not mean to imply that a general hospital cannot give good care to children. For families living in smaller communities, access to a dedicated children’s emergency department is limited, and the great majority of general emergency departments do a good job taking care of children with uncomplicated problems. But it is something to consider if you live near a children’s hospital and have a choice in where to go. You can find where children’s hospitals are by looking at the list of the National Association of Children’s Hospitals and Related Institutions (www.childrenshospitals.net).
By their very nature, emergency departments are very inefficient and expensive places to deliver care. This is true for patients of all ages. As we have seen, this is because they need to be ready at all times to handle critically ill or injured patients, even if those categories of patients do not appear very often. Emergency departments always must be prepared for worst-case scenarios. This requires the immediate availability of specialized equipment and a host of staff trained and experienced in using it. The staff must have quick access to expensive x-ray and laboratory equipment that is maintained and ready to use around the clock. These considerations mean that all emergency departments have a very high fixed cost, an expense that is independent of the number of patients they are seeing at any given time.
Many facilities have tried to deal with this situation by having a separate walk-in or ambulatory clinic affiliated with the emergency department. Often these clinics are open evenings and weekends, when doctors’ offices are generally closed. The idea is to find a middle ground between the sophisticated and expensive capabilities of the emergency department and the more simple environment of a physician’s office. If a child who is quite ill comes to a walk-in clinic, the emergency department is nearby to take over the case. The concept makes sense. For some of the scenarios you have read about in this book, the advice “Go to the Emergency Department” could also apply to one of these facilities.
If you take your child to the emergency department, what can you expect to happen? They can be confusing or even chaotic places. Even the waiting rooms, where you can expect to spend quite a bit of time unless you are lucky, are often complicated. There is something else to consider—the high potential for miscommunication. These are often high-volume places, where there is considerable emphasis on through-put, on getting the children seen, treated, and back out the door. When a harried doctor meets parents who have been waiting a long time, often hours, just to get in to see the doctor, both may already be cranky before the interview even starts.
Once you are through the emergency department door and registered with a clerk, the first medical person you and your child will meet is a nurse. The waiting patients are typically sorted by how sick they appear to the nursing staff. It is not first-come-first-served; the sickest get seen first. This is called triage, a term derived from a French word meaning to prioritize patients into thirds: the critically ill, the seriously ill, and the not-so-ill. This is how it should be.
The triage nurse typically has only a few minutes, sometimes even less than a minute, to spend with the patient. The nurse will ask you a few questions, glance at your child, and make a quick assessment of how ill your child looks. The nurse will also pay attention to the things you say, no matter how your child looks. For example, if you tell the nurse your child has been vomiting blood, that will likely move you up on the list.
Sometimes at this point the nurse will check your child’s temperature, pulse rate, and breathing rate; sometimes this happens later. If your child is in one of the more-serious tiers of the triage pyramid, the nurse will hustle him to the examination area. If, however, like most children, your child is in the not-so-ill third of the triage pyramid, you will wait to be seen, these days sometimes a very long time.
When you and your child are called back to the examining room, a nurse will again ask you a few questions. You and your child will then wait some more. Since the typical emergency department has many more examining rooms than it has doctors, families wait in one of these rooms until the doctor gets to them. Finally the doctor will come to the examining room door, look at the brief note written by the nurse—which consists of statements like “fever for three days,” “coughing for a week,” or “vomiting since yesterday”—and then whisk into the room.
You should realize this doctor you are meeting nearly always has other things on her mind besides your child. The doctor in a busy emergency department is typically juggling the problems of several other patients or children in other rooms at the same time she is evaluating your child. For example, she may be thinking about one child sent off to the radiology department for x-rays, about another with blood-test results pending, and perhaps a third awaiting evaluation by a surgeon about possible appendicitis. It is a difficult thing for an emergency department doctor to approach your child with a mind totally cleared of other things—there are built-in competing issues. In a very busy emergency department, it is often nearly impossible to have even a brief interview with a doctor that is not interrupted by others calling the doctor—who for the moment is your child ’ s doctor—away to the telephone or out into the corridor for some discussion or other.
It is not an ideal system, but it is what we have. It usually works, but it is easy to see how this built-in pressure and chaos can sometimes lead to problems.
After the doctor has spoken with you and examined your child, she may be able at that point to figure out what is wrong and decide what to do—give you a prescription for an antibiotic for an ear infection, for example. If the doctor needs tests to determine what to do, that means, depending upon the circumstances, a technician might take a blood sample, a nurse could obtain a urine sample, or you and your child might be sent to the radiology department for x-rays. Generally you and your child will then wait in the examining room for the results to come back. If things are crowded and the examination room is needed for another patient, you might be asked to go back out to the main waiting room.
One of the key reasons for the inefficiency of getting medical care in the emergency department rather than from your usual physician is that the emergency department doctor does not know you and your child. You are strangers to each other. You are also meeting each other in a stressful, typically busy place, one where there rarely is time for leisurely conversation. A situation like this is hard-wired for doctors getting more tests than your regular physician might order. This is the one and only time the emergency doctor is going to see you and your child, so the understandable tendency is to get more tests to look for more-serious problems, even if the doctor thinks they are very unlikely.
Another consideration is that most of the time, what the emergency department doctor knows about your child is what you tell her. Medical delivery systems are becoming more and more integrated, especially as electronic medical records become more common, but it is unusual for the doctor to have immediate access to your child’s complete past medical record. If she does have such access, and this is something many are striving for, emergency department care instantly becomes more organized and integrated with your child’s total health picture. But we have a long way to go before we get to that goal.
If you take your child to an emergency department, what sort of doctor will you meet? As all parents know, a doctor is not a doctor is not a doctor; that is, we are not interchangeable in what we know and what we can do. For most children their regular doctor, if they have one, is either a family doctor or a pediatrician. Some emergency departments, especially those connected to children’s hospitals, will have pediatricians in their emergency departments. They often even have highly-trained pediatricians who are experts in the specific specialty of emergency pediatrics. Many smaller emergency departments, especially those found in the communities across rural America, are staffed by family physicians. The doctors in the majority of emergency departments, however, are trained in a relatively new specialty known as emergency medicine. What is that, and what might it mean for your child? To answer this important question, you need to know something about how we train physicians.
An aspiring physician, after graduating from college, first goes to medical school, a process that takes four years to complete. There are currently 141 medical schools in the United States, along with 29 osteopathic schools. There were once key distinctions between those categories, but these days they teach essentially the same curriculum and their graduates are eligible for the same specialty training afterward.
The new medical (or osteopathic) graduate is not ready to practice medicine; he must first complete what is known as residency. This is a period of anywhere from three to six years or more, depending upon the specialty, during which he is given increasing responsibility to manage patients on his own. At the end of that training, he takes an examination. If he passes, he is then called board-certified in that specialty. Pediatricians complete a three-year residency exclusively devoted to the care of children. Family medicine doctors do a three-year residency that is more broad-based because they expect to care for patients of all ages. The strictly pediatric portion of their training is generally around six months or so. Their pediatric experience necessarily concentrates on common problems in children.
Pediatrics is a very old medical specialty, dating back to the 1920s. Family practice, once called general practice, has also been around for a long time. As emergency departments grew in size and complexity, there emerged a brand-new medical specialty to staff them—emergency medicine. Like family doctors, emergency medicine physicians are trained to take care of patients of all ages. However, the focus of their skills is on the problems that bring people to the emergency department. They spend a great deal of their training time learning how to manage potentially life-threatening conditions.
The great majority of people who seek care in an emergency department—85 percent or so—do not have such a problem. They have something that they feel cannot wait, but it is not life-threatening, although they may not know this. Emergency department doctors are experienced in handling a wide variety of acute problems, including problems children have. But the way these physicians are trained inevitably means they will not be the best at dealing with every ailment your child might develop because that is not their focus. They do a good job managing many of the serious things you have read about in this book, but they are not pediatric specialists.
For a parent, this means that if your child has a complicated and specifically pediatric problem that is not a true emergency, unless you are in a dedicated pediatric facility, you will not be seeing a pediatric expert in the emergency department. Most of the time that does not matter much, but sometimes it does. It is certainly something for you to consider when you are deciding whether or not to make a late-night trip to the emergency department.
There is another kind of healthcare provider that a parent may often meet in the emergency department—what we call a midlevel provider. Over the past decades our medical delivery system has included people who are not physicians. There are two main categories of these: nurse practitioners and physician assistants. Both evolved out of the recognition that we have a shortage of primary care physicians. Experts differ over the question of whether or not we actually have a physician shortage in America. Many believe the real issue to be not that we do not have enough physicians, but that we have a poor distribution of doctors—too many subspecialists and not enough primary care doctors like family doctors, pediatricians, and internal medicine practitioners. Whatever the politics of the matter, physician assistants and nurse practitioners emerged to fill this gap. They function in similar roles, but they are not trained in the same way.
A physician assistant is someone who has gone through a specific training program aimed at teaching her how to help physicians by learning to care for patients, including children, with common conditions. The first training programs used former military medics, building upon what they had already learned in the service. A physician assistant has completed a two-to-three-year training program, usually following a college degree. What a graduate of such a program can do varies from state to state. In some places, a physician assistant can function independently of a physician; in other places, physician supervision is required.
A nurse practitioner is somewhat different. These individuals are already trained and certified as nurses. After nursing school they receive several years of additional training to allow them to act in an expanded role beyond nursing. For children, there is a special category called pediatric nurse practitioner, or PNP. Such an individual cares only for children. PNPs are widely used in office pediatric practices. Although they usually have some oversight by physicians, their particular skills often allow them to function in a very independent role when taking care of children.
Many emergency departments employ physician assistants, nurse practitioners, or both. Although some physicians continue to have reservations about this arrangement, it makes sense because many of the people seeking care in the emergency department have straightforward, uncomplicated problems that do not require sophisticated medical knowledge to diagnose and treat. A fishhook stuck in a finger, a cut in a hand, or uncomplicated wheezing are examples of these. But parents should know that if they take their child to the emergency department, they may not necessarily see a doctor. As I noted earlier, sometimes that does not matter, but sometimes it does.
What does all of this mean if you decide to take your child to the emergency department? You will be meeting a healthcare provider who does not know your child. He typically will not have any access to previous medical records that will help him know what has happened to your child in the past. All he will know about your child is what you can tell him. So you should think hard about how best to do that. The odds are you will spend some time in the waiting room, which is a good opportunity to organize your thoughts.
Conversation has been the cornerstone of medical care since the time of Hippocrates, the founder of Western medicine over two thousand years ago. For much of that time, talking and listening to patients was in fact all the doctor did; the idea that a physician should actually examine a sick patient is an innovation barely a hundred years old. This notion of talking with but never examining a patient appears ridiculous to us, but actually it is based on a great truth—in most cases, doctors decide on what is probably wrong with a patient and what to do about it based upon nothing more than a conversation with the patient. Of course this conversation is more important in some cases than in others. After all, a broken leg is still a broken leg, no matter the circumstances of how it happened. The majority of the time, however, the conversation between physician and patient is where everything starts.
The most useful way you can prepare for the doctor to see your child is to get clear in your own mind the details of your child’s problem. It is a good idea to write things down: When did the problem start? Did it change over time? Did you do anything about it, and did that help? Has your child had a similar problem before, and how did that go? The doctor you see is likely busy and will very much appreciate your effort to sort things out. It will also allow him to give your child the best care.
There are several key expectations you should have during your trip to the emergency department. Foremost among these is that you should always understand what is going on. Insist that the doctor explain, in ways you can understand, what the problem is, what needs to be done about it, and what to expect later. Make sure you know what is being done and why. Make sure you know if further doctor visits will be needed afterward. If possible, ask the emergency department to send to your regular doctor a record of what happened there. Many emergency departments do this routinely, but it is always good to ask.
The goal of this book has been to give you, the parent, a working knowledge of how doctors evaluate many common acute problems in children, how we decide things. It is not difficult for any parent to develop some ability to do this, even if the specifics require medical training. Of course this book is not intended to replace medical evaluation, and you should not be practicing medicine on your children. Still, most parents can understand some key principles that will help them decide what to do if their child is sick in the middle of the night.
Good luck, and realize that children are amazingly resilient creatures. They heal very well and grow up to have children of their own.