Peds ED vs adult ED

[mercaptovizadeh]

Compare the two. I am in the peds ED (off service resident), saw 1.5 patients/hr last night, felt somewhat overwhelmed. Do I need to expect the same on adult ED in terms of inefficiency? Is conscious sedation a sludge that slows down things in ways that the adult ED does not?

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[RuralEDDoc]

Depends on the acuity. The vast majority of Peds visits are low acuity, essentially urgent-care visits, and a seasoned Emergency Physician should be comfortable seeing at least 2.5 pediatric PPH for all comers. My usual Peds visit is 3 minutes for H&P and then discussing normal/abnormal and reassuring the parents for another 7 (oh your one month old hasn't pooped in two days? Ok, lets talk about normal bowel habits, etc). Add five minutes for documentation and discharge and I can see 4 kids per hour at my current site. This is contrary to my usual adult visit, which is a patient with ESRD and Lung cancer in DKA and respiratory failure. Over 2 adult PPH is difficult. Very. very different scenarios.
If you're at an academic quaternary-care center and half of your Peds visits are transplant kids or kids with cancer, then ya, 1.5 per hour will keep you busy, especially as a resident. A septic 6 year old with a heme cancer deserves a lot of time and careful attention. Much of that time will be spent coordinating care with specialists.
Regarding conscious sedation, this is very system dependent. Some hospitals make it damn near impossible to do conscious sedation and the set up takes 15 minutes of your time, then the sedation time and procedure. A single procedure will take you an hour with all the hoops to jump through. Learn tricks to avoid conscious sedation when you can do so and still have good outcomes:
1. Place L.E.T. on all lacerations as soon as they hit the door
2. Use relatively high-dose single agent Pain control (eg 2mcg/kg intranasal fentanyl); doesnt meet criteria for conscious sedation but controls pain and also relieves anxiety
3. Distract kids with Sponge Bob, Dora, etc, on a phone or table
4. Use dermabond whenever possible. Combine stitches, dermabond, and steri strips in any acceptable way to properly close a wound
5. Use regional anesthesia whenever possible. This works extremely well for facial lacs. Getting the block is the hard part, then the stitches are easy
6. Just be prepared to use conscious sedation on all three year olds. They are strong as f*%k and are difficult to distract.

 

[emergentmd]

Compare the two. I am in the peds ED (off service resident), saw 1.5 patients/hr last night, felt somewhat overwhelmed. Do I need to expect the same on adult ED in terms of inefficiency? Is conscious sedation a sludge that slows down things in ways that the adult ED does not?

If you can't handle 1.5/hr in a Peds ER, you will not survive in an adult ED.

RVU and complication in Peds ER << Adult ER

Conscious sedation is conscious sedation no matter kids or adults.

 

[Angry Birds]

Adult ED is a zoo compared to the Peds side.

 

[emergentmd]

MY last Pedi ED shift 1st 5 pts - Sore throat, skin rash, cough, wheezing, wrist pain. No real thought, No workup

Adult (my Last 5 pts tonight) - Chest pain, Intoxication, Back pain, Chest Pain, Abd Pain. 3 work up, 2 no real thought.

Zoo is about right. Tonight is chronic pain night, last night was gun/knife club.

 

[Perrotfish]

Do you see all patients acuities? In the Peds ED I rotated through residents generally only saw triage category 3 (of 5) and above. Most of the patients I saw either needed a procedure, were medically complex, or were sick enough to at least consider admission. The standard clinic Peds patients (1 year olds with colds, etc) were still the majority of the patient volume, but they were seen exclusively by staff.

 

[Docinthetrenches]

Peds can be busy but it's mostly stable patients with more minor problems that can wait to be seen. Of course at a large tertiary care facility with trauma it might be different. Adult is usually MUCH busier and in general patients are sicker and need more procedures (the main reason adult EM pays more than peds em). Conscious sedation is a PITA no matter where it is done. There is so much paperwork and charting and often you need another doc or PA to help with it. It slows you down regardless of how much more you can bill for the procedure. Of course some things are very rewarding to fix under sedation like reducing dislocations, cardioverting, etc. In peds I found most places use the Papoose board more liberally for things that are really not that painful (like lac repair after lidocaine infiltration, etc) since there is a real risk doing conscious sedation on anyone - some may say the board is more "brutal" but its safer. Adults dont' do well on papoose boards.