It's been a crazy couple weeks. I'm on vacation now, so I'm hoping to get a few of these cranked out so that I don't miss any for a while. Apologies for not keeping up with my self-imposed schedule!
I'm on my Emergency rotation this month, and after having only worked a handful of shifts, I've learned a ton. I've also seen a wide variety of anxious and worried patients and parents. However, I've also seen families who are frustrated by a perceived lack of help.
I encourage all parents, if they think there is a problem, to first call their pediatrician. This is not idle advice... half the things I see in the Emergency Department can be seen in a pediatrician's office, not only faster, but generally cheaper for both the family and the insurance company. I also recognize that there is a trend among primary care physicians in general to refer their patients to the Emergency Department if anything is concerning to them, rather than working it up themselves. This isn't necessarily a bad thing--it can just be very frustrating for the parents.
Let's go through some cases to see who is best treated in the Emergency Department (henceforth referred to as ED), and what expectations for them are.
Patient 1: 3 week old infant comes in with a fever to 101. Otherwise looks healthy.
Should the patient come to the ED? Yes, Absolutely. Infants are not good at localizing infection because their immune system--what helps them fight off disease--is not developed yet. Virtually all their protection comes from mom--either from that protection crossing the placenta prior to delivery, or in the breastmilk afterward. So, these babies are at risk of getting serious infections, and sometimes the only outward sign of those serious infections is fever.
What should you expect in bringing this child in? Because we cannot easily identify the source of the infection, we check the major areas where infections can hide: the urine, the blood, and the spinal fluid. This means collecting urine, drawing blood, and doing a procedure called a lumbar puncture to get the fluid from around the spinal cord. The child will then have to be admitted to the hospital to await the results of those tests.
Patient 2: 3 1/2 year old girl with a few red spots on her back. Otherwise looks and feels healthy. No fever.
Should the patient come to the ED? This one can probably be treated best at the pediatrician's office. If the child has a fever and it's after hours, it's reasonable to bring her in, but without a fever, the spots are either bug bites, hives, or maybe a viral rash. In any case, there isn't a whole lot that the ED is going to do for you other than reassure you that these things are not serious, and that might be better conveyed by your local pediatrician.
What should you expect if you do bring the child into the ED? Long wait times. We have kids that are legitimately sick, so they get priority. I will not fault you for bringing your child in if you are worried, but again, you're probably going to be seen faster and have a better relationship with your pediatrician in the office.
Patient 3: 14 year old who nearly passes out on the toilet, and has gained weight and been overly tired for a year.
Should the patient come to the ED? This is a soft call. Passing out is something that raises red flags for us in the pediatric population, but in this case, there was no actual passing out. So either we're going to say he's sick with some virus, dehydrated, or something along those lines, or we're going to say that maybe he was straining a little too hard on the toilet and that's why he suddenly felt lightheaded.
What should you expect if you do bring this child in? A lot of reassurance. Maybe a few tests if something in the history raises a red flag for us. However, you should NOT expect us to magically cure your child or figure out what is wrong with him, nor should you expect us to be able to expedite your wait to get in to see a specialist. We can rule out any life-threatening causes of the passing out, but we are not going to solve the mystery as to why he has been tired so long, especially if you've already been seen recently by a pediatrician. That is not the purpose of the ED.
Patient 4: 8 year old who has had headaches on and off for months at various times of day. They go away with ibuprofen/Motrin/Advil, but usually come back.
Should this patient come to the ED? This patient was a little complex, but as he only had a minor headache when he came in, there really wasn't anything we could do for him. Since it was a chronic problem, and the headaches were going away, this is really a patient that should be seen in a general pediatrician's office.
What should you expect if you do bring this child in? Again, a lot of reassurance. While there is some diagnostic testing we can do, unless the child is getting worse, vomiting with the headaches, or they do not resolve with medication, the testing really isn't needed on an urgent basis, so we're probably going to refer him back to his primary pediatrician. If you don't have a primary pediatrician, we will gladly give you some numbers for some.
The bottom line? I won't fault you for bringing in your kid to the ED if you are worried something is wrong. But please, if the problem has been going on for a while, and your child doesn't appear to be getting worse, please call your primary pediatrician and have your child be seen there. You will probably get in and out faster anyway (since waiting times in the ED for non-urgent problems can be several hours, even after you are initially seen).
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