If you could name 1 peds ED for a student to get the best rotation experience, where would you name?

[theWUbear]

Post-match this year I still have requirements to finish out the year with month long rotations in April and in May. I have exhausted the amount of adult EM my school will allow me for the year.

I have the idea of doing one month in the best pediatric ED for teaching experience that will have me for the month. Sick kids, high volume, students and residents very active, good didactics all come to mind. Anyone have recommendations? CHOP comes to mind as a layman to PEM thinking of a possible top pediatric location. I asked my ED's PEM faculty and they suggested Lincoln Hospital in the Bronx. Wondering what everyone thinks, nation-wide.

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[Jlaw]

Post-match this year I still have requirements to finish out the year with month long rotations in April and in May. I have exhausted the amount of adult EM my school will allow me for the year.

I have the idea of doing one month in the best pediatric ED for teaching experience that will have me for the month. Sick kids, high volume, students and residents very active, good didactics all come to mind. Anyone have recommendations? CHOP comes to mind as a layman to PEM thinking of a possible top pediatric location. I asked my ED's PEM faculty and they suggested Lincoln Hospital in the Bronx. Wondering what everyone thinks, nation-wide.

Lincoln is really a learn by immersion type place...teaching is hit or miss and didactics are a miss. Also don't think its really a peds hospital, they just have a peds pod in the ED. For pure peds the ones I have heard good things about are CHOP, Children's Mercy KC, Boston Children's, Cohen's (NSLIJ)

 

[alpinism]

Post-match this year I still have requirements to finish out the year with month long rotations in April and in May. I have exhausted the amount of adult EM my school will allow me for the year.

I have the idea of doing one month in the best pediatric ED for teaching experience that will have me for the month. Sick kids, high volume, students and residents very active, good didactics all come to mind. Anyone have recommendations? CHOP comes to mind as a layman to PEM thinking of a possible top pediatric location. I asked my ED's PEM faculty and they suggested Lincoln Hospital in the Bronx. Wondering what everyone thinks, nation-wide.

Whatever you do stay away from Peds EDs at Children's Hospitals as well as those run by Pediatrics/PEM fellowship trained faculty.

Philadelphia, Cincinnati, and Boston may have great Pediatrics programs but they have horrible Peds EDs.

If you don't believe me look at the evidence (from the busiest Children's Hospital Peds ED in the country).

It seems like the last few months, Annals of Emergency Medicine keeps bringing down the hammer on peds EM:

http://www.annemergmed.com/article/S0196-0644(12)00700-7/abstract

Retrospective study over a 12 month period looking at the number of critical procedures performed by the various docs in a high volume academic peds ED (I believe it's Cincinnati Children's).

Some of the interesting findings (to me):

• 194 total resuscitations out of ~90,000 visits (0.22% of patients)
• 61% of faculty did not perform a single critical care procedure
• 63% of faculty never performed a single successful intubation
• Faculty, on average, go 1095 shifts for every one chest tube they perform
• PEM fellows performed only 3 critical procedures in a year!
• PEM felllows averaged 2.5 intubations per year (ouch)
• 27% of critical procedures were performed by non-EM docs (lame)
• No wonder they miss out on procedures. Here is their resuscitation team for critical children: PEM physician, nurse team leaders, peds or EM resident, several bedside nurses, RT, PEM fellow, surgery resident, surgery fellow/faculty, anesthesiologist, neonatology fellow, pediatric critical care staff, pediatric cardiology staff.

I give credit to this research group for shedding light on a topic that I think most everyone recognizes, but never discusses in polite company. It takes a lot of guts to publish a paper that questions the value of the training your hospital and specialty provides.

Steven Green provides an accompanying editorial with some interesting ideas to improve PEM training. These ideas are pretty inflammatory (which he recognizes). One idea is to redefine what a peds ED is. He says greatly increase the "urgent care" portion, staffing it with midlevels and "urgent care pediatricians." Have the "critical care" area staffed solely by PEM providers, and reduce the number of fellows and train them mostly in the critical area.

The other idea (with "profound philosophical implications" as he puts it) is to concede that PEM docs don't see enough of these procedures to actually be competent in them, and to simply concede them to a team of specialists. This already happens to a large extent, but his idea would be to give in entirely, making PEM completely a cognitive specialty.

 

[alpinism]

I'd recommend looking at busy inner city hospitals with combined adult and peds EDs.

 

[KinesiologyNerd]

8 weeks of rads and derm sounds way better to me.

 

[DeadCactus]

You presumably have a full residency of EM ahead of you. Do something else, either to broaden your exposure or to do something fun. A month of medical spanish and salsa dancing in South America is going to do way more for you than your Nth month of EM as a student. Derm, radiology, and anesthesia are excellent suggestions if you can't leave the country. Spending money to do an away rotation in an ED (even a pediatric ED) after you've already maxed the ED exposure your school will let you have is a terrible decision.

 

[namethatsmell]

On a related note for EM applicants, give residencies extra points when more than half their peds training occurs outside of the tertiary peds hospital. It's a sign that the EM leadership understands the points made above (which are so spot on). Spending a little time at a peds mothership ED as a resident can be helpful, but you'll learn so much more (and do more) if your program gives you more time at a high-volume community peds shop.

 

[RustedFox]

You presumably have a full residency of EM ahead of you. Do something else, either to broaden your exposure or to do something fun. A month of medical spanish and salsa dancing in South America is going to do way more for you than your Nth month of EM as a student. Derm, radiology, and anesthesia are excellent suggestions if you can't leave the country. Spending money to do an away rotation in an ED (even a pediatric ED) after you've already maxed the ED exposure your school will let you have is a terrible decision.

b-b-but... I learned SO much from my Scandanavian Pediatric Oncology rotation...

... said no one, ever.


Dude, go have fun post-match. Don't be a boner.

 

[Tenk]

Go do whatever has the least amount of work.

 

[normtheniner]

Post-match this year I still have requirements to finish out the year with month long rotations in April and in May. I have exhausted the amount of adult EM my school will allow me for the year.

I have the idea of doing one month in the best pediatric ED for teaching experience that will have me for the month. Sick kids, high volume, students and residents very active, good didactics all come to mind. Anyone have recommendations? CHOP comes to mind as a layman to PEM thinking of a possible top pediatric location. I asked my ED's PEM faculty and they suggested Lincoln Hospital in the Bronx. Wondering what everyone thinks, nation-wide.

Brenner's Childrens at Wake Forest in Winston-Salem, NC sees pretty high volume. We get a pretty decent amount of Peds ED time during residency as well.

 

[theseeker4]

I agree with the comments to go with easy, fun, and/or interesting rotations. One of my last rotations 4th year was forensic pathology. Very interesting (no, did NOT make me want to become a pathologist) and the kind of thing you will never again get a chance to see. Performing the autopsies also helped with my gross anatomy a bit, and most days ended by noon. I wish I had done a dermatology rotation, since I am very weak with rash identification, and that would have helped a bit. Definitely do Rads if you haven't already, hopefully at a site that is known for letting you leave early and skip most days.

Seriously, take the opportunity to relax 4th year as much as you can.

 

[Cinclus]

I wish I had done a dermatology rotation, since I am very weak with rash identification, and that would have helped a bit.

Eh, my derm rotation wasn't super helpful. It mostly consisted of me freezing AKs off of people. But I am able to identify actinic keratoses...

 

[dchristismi]

I spent a month doing a facial plastics rotation that I set up in my hometown with an ENT who had a fellow, and both enjoyed teaching. Saw a bunch of Mohs repairs with crazy flaps, fancy cosmetics and got to practice with 7-0 fast absorbing gut. I didn't honestly do *that* much, but it was fascinating, and something I'd never really get to see otherwise. (minimally invasive facelifts, anyone?) Learned some neat tricks and now I can honestly say that I did train with a facial plastic surgeon when patients ask.

 

[Arcan57]

Whatever you do stay away from Peds EDs at Children's Hospitals as well as those run by Pediatrics/PEM fellowship trained faculty.

Philadelphia, Cincinnati, and Boston may have great Pediatrics programs but they have horrible Peds EDs.

If you don't believe me look at the evidence (from the busiest Children's Hospital Peds ED in the country).

Calling Cincy Childrens' a horrible Peds ED is a bit strong. Nobody is going to let a MS do advanced procedures on kids. Any peds hospital is going to offer plenty of bread and butter peds, most of which will be seen in a Fastrack type area. There's no where that sees a huge volume of acutely ill children. Tertiary peds hospitals will skew towards chronically ill kids who are managed at the subspecialist attending level. The community will have less people to elbow out of the way so you can watch, but you're still not going to be calling the shots or intubating there either.

 

[alpinism]

Calling Cincy Childrens' a horrible Peds ED is a bit strong. Nobody is going to let a MS do advanced procedures on kids. Any peds hospital is going to offer plenty of bread and butter peds, most of which will be seen in a Fastrack type area. There's no where that sees a huge volume of acutely ill children. Tertiary peds hospitals will skew towards chronically ill kids who are managed at the subspecialist attending level. The community will have less people to elbow out of the way so you can watch, but you're still not going to be calling the shots or intubating there either.

I get what your saying but while med students might not normally be doing procedures, the PEM fellow/attending apparently also aren't either. It's kinda hard to learn PEM from someone who has next to no practical/procedural experience themselves. At 90K visits per year you should be getting at least a half dozen intubations per year not zero like most of their faulty. That either means they're missing all their tubes or consulting anesthesia/ENT every time.

On a more realistic level, at Cincy you'd probably just be standing in the back of the room with 20 other people during a code before some specialist swoops in to do any critical procedures. At a busy community/county shop you'd at least get the chance to do compressions/bag and maybe put in an IV/IO and then assist with any critical procedures. That being said I'd be much more worried about not being able to see your own patients and do your own basic procedures (repairing your own lac vs calling plastics).

 

[BigRedBeta]

Children's Healthcare of Atlanta - and specifically Scottish Rite (Egleston is the hospital associated with Emory so it likely will be easier to get a spot there, since they're used to having students). The group at SR is private practice and so fellows and residents are rarely, if ever, seen. The SR ED is one of the busiest in the country.

 

[Arcan57]

I get what your saying but while med students might not normally be doing procedures, the PEM fellow/attending apparently also aren't either. It's kinda hard to learn PEM from someone who has next to no practical/procedural experience themselves. At 90K visits per year you should be getting at least a half dozen intubations per year not zero like most of their faulty. That either means they're missing all their tubes or consulting anesthesia/ENT every time.

On a more realistic level, at Cincy you'd probably just be standing in the back of the room with 20 other people during a code before some specialist swoops in to do any critical procedures. At a busy community/county shop you'd at least get the chance to do compressions/bag and maybe put in an IV/IO and then assist with any critical procedures. That being said I'd be much more worried about not being able to see your own patients and do your own basic procedures (repairing your own lac vs calling plastics).

If you're trying out peds EM for the procedures you're on the path to disappointment. While I think the article clearly demonstrates that pediatric EM fellows have a difficult time getting enough procedures in the ED to obtain competence, I think you're completely ignoring the fact that only 147 intubations occurred in 1 yr. You're interpreting that as all these tubes were stolen by someone else, but in fact it's just really uncommon to intubate kids. If you're being fed off stories of attendings who practiced before H. flu and strep vaccines essentially wiped out obstructive pharyngeal infections or before BiPap, magnesium, and an awareness of the risks of post-intubation management made the intubated asthmatic a rarity then I can understand the indignation. Having spent 4 yrs rotating there, the tubes in the ED rarely made it above fellow level. Sick neonates tubes tended to rotate between Cinci EM and peds residents, trauma airways tended to be either EM residents or PEM fellows. Let's assume that these practitioners sucked at airway and missed 20% of tubes (actual figure probably 5% or less). That leaves 30 tubes a year that make it up to attending level. There are 48 attendings listed under faculty at Cinci. For each of these faculty to get 6 tubes a yr the intubation rate would have to essentially double and it would mean nobody but the attending ever got a shot at a tube.

Honestly, outside of Level 1 trauma centers I can forsee a future where exposure to critical procedures during (non-peds) EM residency becomes an issue. While I intubated some trauma patients and airway obstructions, most of my tubes in residency came from respiratory failure (typically flash pulmonary edema from CHF) or to facilitate a work-up in an aggressive, combative patient. With the efficacy of BiPap and aggressive nitro gtt for the former and ketamine for the later I'd estimate that 30-50% of my intubations during residency came on patients I wouldn't intubate today. This is slightly offset by liberalized IV fluids leading to earlier intubation in septic ED patients, but that would only add back maybe 5% to the total number of tubes.

If you are training at a place that has you intubating 5-10 patients a shift as a rotating MS-3, feel free to ignore the last paragraph as it obviously doesn't apply to you.

 

[Arcan57]

double post

 

[Arcan57]

.

 

[alpinism]

If you're trying out peds EM for the procedures you're on the path to disappointment. While I think the article clearly demonstrates that pediatric EM fellows have a difficult time getting enough procedures in the ED to obtain competence, I think you're completely ignoring the fact that only 147 intubations occurred in 1 yr. You're interpreting that as all these tubes were stolen by someone else, but in fact it's just really uncommon to intubate kids. If you're being fed off stories of attendings who practiced before H. flu and strep vaccines essentially wiped out obstructive pharyngeal infections or before BiPap, magnesium, and an awareness of the risks of post-intubation management made the intubated asthmatic a rarity then I can understand the indignation. Having spent 4 yrs rotating there, the tubes in the ED rarely made it above fellow level. Sick neonates tubes tended to rotate between Cinci EM and peds residents, trauma airways tended to be either EM residents or PEM fellows. Let's assume that these practitioners sucked at airway and missed 20% of tubes (actual figure probably 5% or less). That leaves 30 tubes a year that make it up to attending level. There are 48 attendings listed under faculty at Cinci. For each of these faculty to get 6 tubes a yr the intubation rate would have to essentially double and it would mean nobody but the attending ever got a shot at a tube.

Honestly, outside of Level 1 trauma centers I can forsee a future where exposure to critical procedures during (non-peds) EM residency becomes an issue. While I intubated some trauma patients and airway obstructions, most of my tubes in residency came from respiratory failure (typically flash pulmonary edema from CHF) or to facilitate a work-up in an aggressive, combative patient. With the efficacy of BiPap and aggressive nitro gtt for the former and ketamine for the later I'd estimate that 30-50% of my intubations during residency came on patients I wouldn't intubate today. This is slightly offset by liberalized IV fluids leading to earlier intubation in septic ED patients, but that would only add back maybe 5% to the total number of tubes.

If you are training at a place that has you intubating 5-10 patients a shift as a rotating MS-3, feel free to ignore the last paragraph as it obviously doesn't apply to you.

Fair enough, I forgot about all the peds residents (who technically are stealing tubes from EM residents/ PEM fellows even if they are few and far between).

And yes, peds tubes are rare anywhere you go, which is all the more reason why you don't want to be fighting with peds residents and PEM fellows over the few tubes that do come into your ED. Look, I'm not saying that you should be doing tons of procedures during a PEM rotation, but rather enough to become competent, which clearly is not the case at most Children's Hospitals including Cincy (I'm not signaling them out specifically). If the fellows are only averaging 2.5 per year its likely the EM residents are doing the same if not less. The problem is not just that peds tubes are very uncommon but also that there are too many cooks in the kitchen (EM residents, Peds residents, PEM fellows, and faculty). Personally speaking, as a med student or resident, I'd rather go somewhere with a large volume of sick kids and no peds residents/PEM fellows for the reasons stated above.
Obviously no one in the US is intubating 5-10 per day but I know multiple NYC residents working at EM run peds EDs who average almost 1 tube per month (0-17 year olds).
In addition they are far more likely to do lac repairs, abscess drainages, ortho reductions, etc... rather than consult everything like PEM fellows and Peds faculty.

I'm sure Cincy is a great place to train and I'll take back my previous comment that they have a horrible Peds ED.

 

[fahimaz7]

A busy site that doesn't have pediatric EM fellows fighting for the cases and isn't a quaternary referral center with super complex congenital kids 24/7.

We had a few residents head to Boston Children's, only to tell us that they had very little autonomy and there were too many other residents, students, fellows, etc to get any good exposure.

 

[link2swim06]

Meh....they are just little adults.

But for real. Critical care is basically the same as adults (except for babies). A 10 year is more similar to a 25 year old, than a 25 year old is to a 95 year old.

 

[Radz123]

Radiology resident here. I think it would be extremely beneficial to any physician but especially an ER physician to do a rotation in Interventional Radiology. People have no real idea what IR does or what's involved (completely understandable) which often leads to conflict and patient mismanagement. Also radiologists are generally nice people which makes procedural learning much more pleasant. Doing a month in IR would leave you will skills in obtaining venous access and performing ultrasound guided procedures that you'd use for the rest of your life.

 

[emergentmd]

Doing one month of a busy PED EM will unlikely make you a more prepared or better EM doc when residency starts. You have worked hard for 4 yrs, got into your speciality. Relax and take a break before you really get busy.

 

[wysdoc]

Post-match this year I still have requirements to finish out the year with month long rotations in April and in May. I have exhausted the amount of adult EM my school will allow me for the year.

I have the idea of doing one month in the best pediatric ED for teaching experience that will have me for the month. Sick kids, high volume, students and residents very active, good didactics all come to mind. Anyone have recommendations? CHOP comes to mind as a layman to PEM thinking of a possible top pediatric location. I asked my ED's PEM faculty and they suggested Lincoln Hospital in the Bronx. Wondering what everyone thinks, nation-wide.

St. Paul Children's (St. Paul, Minnesota) is a bustling ER with high acuity.

 

[BigRedBeta]

As a PICU attending, the Cinci data didn't surprise me, but it's really more how peds pathology and peds respiratory failure presents itself. Walk around any PICU from November to March and you're going to consistently see 40-50% of the patients vented. Bronchiolitis typically peaks in severity around day 4 of illness...but the respiratory distress will start on day 2 which is when they show up in the ED. So it's just a matter of timing when they show up in the ED vs when they need a tube. Critical Care is the one "stealing" the tubes.

Of note, the majority of peds residents don't want the experience of intubating bigger kids. Being aggressive may help you jump the line but I knew I was headed to PICU fellowship and everyone of my attendings in the ED knew it...I still only got 2 intubation attempts during residency in the ED (at a program that provided tons of time to residents in the ED - IIRC I did something like 50+ 12 hour ED shifts as an Intern).

I do agree with the sentiment that the big name childrens' hospitals function more as quaternary (even quintenary) referral centers these days. They are overrun with fellows and aren't the best spots for younger trainees who desire any modicum of autonomy. Even in certain fields they aren't good training places for fellows, and the ED can be one of those places. I did fellowship at a place consistently ranked in the top 10 of both Parents Magazine and USNWR and probably had 7-10 times where I was called down to the ED to intubate, and about half of them the PEM attending abdicated to me to manage the airway.