How often do kids get really sick?

[DeadCactus]

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I was listening to EMCrit and he mentioned the "Upstairs care, downstairs moto" in allusion to his CC training. The point being I can appreciate the argument for how providing a more fluid transition between ED care and IM/CC care could provide a benefit in the severely ill patient with multiple medical conditions.

But it made me wonder if you see the same sort of benefit with the Peds/EM or Peds EM training. I'm pretty sure just about every shift in the ED has an adult trying very diligently to spiral down the toilet with multiple uncontrolled medical conditions. But how often do you a see a kid with that complicated of medical need? How often does the extra training in pediatric illness actually enhance care?

 

[dotcb]

If you compare the percent of adults at a level 1 tertiary center going to ICU setting vs. the percent of peds at a level 1 tertiary center going to an ICU bed, I would estimate the adult percent is 5-6+ times as high. In other words, you have to see a lot of sick kids to see a really sick one.

I'm EM trained, and I do think there is value to being PEM trained if you want to work at a tertiary peds center.

 

[Rendar5]

I was listening to EMCrit and he mentioned the "Upstairs care, downstairs moto" in allusion to his CC training. The point being I can appreciate the argument for how providing a more fluid transition between ED care and IM/CC care could provide a benefit in the severely ill patient with multiple medical conditions.

But it made me wonder if you see the same sort of benefit with the Peds/EM or Peds EM training. I'm pretty sure just about every shift in the ED has an adult trying very diligently to spiral down the toilet with multiple uncontrolled medical conditions. But how often do you a see a kid with that complicated of medical need? How often does the extra training in pediatric illness actually enhance care?

There's a reason Pediatric EM and Pediatric ICU training exists.

 

[dchristismi]

As an EM-trained community doc who had a heavy emphasis on pediatrics in residency and gets called by the nurses to see the sick babies, I definitely think there's a place for PEM guys.

But that is not at my community hospital.
My rate for Adult ICU admission is more than 20x my rate for PICU admission. If not more than that.

However... I also don't have a large percentage of chronic kids, transplant kids, cancer kids, etc. These populations definitely exist, and they tend to congregate around the meccas and make a point to travel to the meccas when they get sick.

 

[deleted65604]

But how often do you a see a kid with that complicated of medical need? How often does the extra training in pediatric illness actually enhance care?

In the past year, I've taken care of 3 ICU-type peds. One was a severe head injury that was pretty bad off. He ended up dying a few weeks later in the PICU. That made me quite uncomfortable. The sobbing parents/grandparents at the bedside and the 30 people in the waiting room brought a sense of urgency and scrutiny that I've never felt before. The second was a septic kid that we couldn't ever get stable enough to fly out (and the weather was too bad to get to the PICU. They ended up bradying down repeatedly and ultimately dying. A 6 hour long emotional roller-coaster for the parents. The third was a pediatric drowning with asystole. We did CPR for 2 hours when the child finally warmed up and got some vitals, but again, didn't last long. Another 6 hours of @#!*% for another family who will never recover from that trauma.

These three experiences made my grateful for every last minute I spent in that inferno called a PICU in residency (8 weeks). It also made me appreciate PALS. You will forgive yourself for not being on your game and missing something on the 88 year old demented nursing home patient. You will never forgive yourself for providing anything less than perfect care for a sick kid.

Pediatric ER people usually work in centers with pure pediatric ER's, with a PICU upstairs. My experience from being in the PICU, is that the peds EM people just call the PICU team for all critical patients. They don't mess around with sick kids too long in the ER. They want them out of their ER ASAP.

 

[Socrates25]

In the past year, I've taken care of 3 ICU-type peds. One was a severe head injury that was pretty bad off. He ended up dying a few weeks later in the PICU. That made me quite uncomfortable. The sobbing parents/grandparents at the bedside and the 30 people in the waiting room brought a sense of urgency and scrutiny that I've never felt before. The second was a septic kid that we couldn't ever get stable enough to fly out (and the weather was too bad to get to the PICU. They ended up bradying down repeatedly and ultimately dying. A 6 hour long emotional roller-coaster for the parents. The third was a pediatric drowning with asystole. We did CPR for 2 hours when the child finally warmed up and got some vitals, but again, didn't last long. Another 6 hours of @#!*% for another family who will never recover from that trauma.

These three experiences made my grateful for every last minute I spent in that inferno called a PICU in residency (8 weeks). It also made me appreciate PALS. You will forgive yourself for not being on your game and missing something on the 88 year old demented nursing home patient. You will never forgive yourself for providing anything less than perfect care for a sick kid.

Pediatric ER people usually work in centers with pure pediatric ER's, with a PICU upstairs. My experience from being in the PICU, is that the peds EM people just call the PICU team for all critical patients. They don't mess around with sick kids too long in the ER. They want them out of their ER ASAP.

I agree completely. Let me first get out the obligatory "yes we care about adult patients too" political-correctness, but the bottom line is that we would walk thru fire to save kids whereas with adults not so much.

Its completely different resuscitating a 3 y/o drowning victim from a friends swimming pool compared to a 60 y/o MI. It just is, and it should be that way.

 

[Socrates25]

However... I also don't have a large percentage of chronic kids, transplant kids, cancer kids, etc. These populations definitely exist, and they tend to congregate around the meccas and make a point to travel to the meccas when they get sick.

There's a fair number of chronic kids who see multiple specialists at big childrens hospitals, some of them getting admitted several times per year, and the parents still insist on living in rural backwaters. Frankly, its ridiculous.

I'm sorry, but if your kid is syndromic with all kinds of weird upper airway anomalies, you have the peds ENT clinic on speed dial, and he has to get admitted everytime they get a viral URI, then you need to move your ass to a reasonable distance from the big academic medical center and get the hell out of the country. No offense.

 

[Birdstrike]

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[Stitch]

Just my take as someone peds trained and someone who gets nervous when that 45 year old parent comes into our peds ED complaining of chest pain. 😱

It depends on how you look at it. As others have eluded to, kids can and often do get quite sick. Our 40 bed PICU is always busy and many come through the ED, either as acute traumas or chronic disease. On the other hand, if you take a cross section at any given time and compare it to an adult ED we probably do get more BS/acute care (sore throat, URI). It's sorting through these to find the sick kid that gets tough, because many kids look 'great' until they code.

I think it's hard for non peds people to deal with a coding child, but I always tell the EM residents rotating with us that while there's a world of difference between a kid and an adult, there's not much difference between a coding kid and a coding adult. Yes, the differential diagnosis is different but it still comes down to your ABCs which you all are trained very well to handle. Try to take a step back and follow the algorhythms. Call a peds center if you need help, we're used to helping out when/if we can.

 

[michigangirl]

In the past year, I've taken care of 3 ICU-type peds. One was a severe head injury that was pretty bad off. He ended up dying a few weeks later in the PICU. That made me quite uncomfortable. The sobbing parents/grandparents at the bedside and the 30 people in the waiting room brought a sense of urgency and scrutiny that I've never felt before. The second was a septic kid that we couldn't ever get stable enough to fly out (and the weather was too bad to get to the PICU. They ended up bradying down repeatedly and ultimately dying. A 6 hour long emotional roller-coaster for the parents. The third was a pediatric drowning with asystole. We did CPR for 2 hours when the child finally warmed up and got some vitals, but again, didn't last long. Another 6 hours of @#!*% for another family who will never recover from that trauma.

These three experiences made my grateful for every last minute I spent in that inferno called a PICU in residency (8 weeks). It also made me appreciate PALS. You will forgive yourself for not being on your game and missing something on the 88 year old demented nursing home patient. You will never forgive yourself for providing anything less than perfect care for a sick kid.

Pediatric ER people usually work in centers with pure pediatric ER's, with a PICU upstairs. My experience from being in the PICU, is that the peds EM people just call the PICU team for all critical patients. They don't mess around with sick kids too long in the ER. They want them out of their ER ASAP.

As it's already been said, plenty of kids get sick.

You hit the nail on the head, Jarabacoa (and others). As a PICU intensivist and peds anesthesiologist, I appreciate your perspective (which is spot on, in my book). Every day my PICU gets many many calls from ED physicians at community hospitals who have a kid they need to move pronto. It becomes very clear who has done extra peds training or taken extra time to become well versed in PALS and the nuances of peds EM. Children who come to my tertiary care center for specialty care/follow-up live all over the state and even farther (as socrates mentioned, you wonder why, but it's the truth). When they do show up in the community ED, it's often because it was so bad that they couldn't make the trip to their primary facility. Which means you're stuck with the sick onc kid who is peri-arrest and needs to be tubed and go on pressors. or genetics kid. or cardiac kid. the list goes on. There are some kids out there living near your facility with some crazy diagnoses. This doesn't mean you need peds EM training to be an awesome community ED physician. You just need to have the tools to recognize a sick kid and the steps to get them stable and somewhere where there is PICU and peds specialty capabilities. Peds EM training is a must for those working in pure peds EDs in tertiary care centers, obviously.

My hat has gone off to many a poised, expert, community ED physician in their primary role of saving a kids life so they can get to my PICU/ED. By the same token, I've dealt with my fair share of extremely nervous, bumbling community ED docs when it comes to sick children-- who either let pride get in the way or don't trust their instincts. . This is by no means a knock on ED physicians. The same goes for some of my anesthesia and pediatrician colleagues with regards to other things.

Yes, kids do get sick. Not as often as adults, but when they do, it's usually bad-- and often reversible. Which means knowning how to manage it becomes extremely important. Hope you don't mind me eavesdropping on your thread. It peaked my interest. I have a lot of respect for so many community ED docs that I interact with on a regular basis. There's the ones that I used to hear over the phone as a fellow and be thriled that it was "Dr. X" that was calling about one of our frequent flyers-- because I know that person has got it all under control, and knows when they need additional advice.

 

[EM_Rebuilder]

Great points have been made above.

To the original OP.. it does happen. I have been finished with residency for 4 whole months; I did quite a bit amount of moonlighting the last two years of residency. My residency program had a dedicated peds ER and we had a PICU. It was mainly colds and coughs, but I did partake in some good sick kid cases and we did a month in the PICU.

On my own in my very short career, I have seen two really sick kids and both were intubated by me. The first coded and did not make it. The other one did well.

I was certainly more 'nervous' on both those kids compared to the NH septic 98 year old that I intubate weekly... but things went smoothly and I attribute that to good peds CC exposure...

 

[dchristismi]

I intubate about half a dozen kids a year, and have to throw out kudos to michigangirl and my accepting peds intensivists - I have always found them to be very gracious and helpful when I need them. I also think that the airway management is one of the easier parts: tube goes in, baby breathes. It's the toddler in status epilepticus, the gray baby, the scalded skin syndrome with diffuse sloughing, the sneaky sepsis/meningitis...lots of things to go wrong, and as above, when it goes badly, I am very thankful for all the peds experience I got in residency and the expert on the other end of the phone. And for the record, I really hate drownings.

I very distinctly remember speaking to a pediatric cardiologist one night with a neonate taching at 280, just praying that my adenosine would break it and I wouldn't have to shock this baby. (Mostly for the mom's sake, as we all know cardioversion is very safe. But it's awfully intimidating when the patient is 5 kg).

And the single worst day of my career as an attending... a 6 day old in septic shock and DIC, and the very nice intensivist who didn't mind my repeated updates as the baby crashed, burned and coded repeatedly. The chief complaint: Baby is cold. Sure enough, hypothermic, hypotensive, hypoxic, hypoglycemic...

And now that I'm thinking back over my worst kid cases in the last 4 years, I really am a $#&* magnet...

 

[michigangirl]

👍 You are the definition of the awesome ED docs I am so glad are looking out for kids in the community.

I intubate about half a dozen kids a year, and have to throw out kudos to michigangirl and my accepting peds intensivists - I have always found them to be very gracious and helpful when I need them. I also think that the airway management is one of the easier parts: tube goes in, baby breathes. It's the toddler in status epilepticus, the gray baby, the scalded skin syndrome with diffuse sloughing, the sneaky sepsis/meningitis...lots of things to go wrong, and as above, when it goes badly, I am very thankful for all the peds experience I got in residency and the expert on the other end of the phone. And for the record, I really hate drownings.

I very distinctly remember speaking to a pediatric cardiologist one night with a neonate taching at 280, just praying that my adenosine would break it and I wouldn't have to shock this baby. (Mostly for the mom's sake, as we all know cardioversion is very safe. But it's awfully intimidating when the patient is 5 kg).

And the single worst day of my career as an attending... a 6 day old in septic shock and DIC, and the very nice intensivist who didn't mind my repeated updates as the baby crashed, burned and coded repeatedly. The chief complaint: Baby is cold. Sure enough, hypothermic, hypotensive, hypoxic, hypoglycemic...

And now that I'm thinking back over my worst kid cases in the last 4 years, I really am a $#&* magnet...

 

[DeadCactus]

So this thread was born out of a long-term interest in going in Peds EM. But my interest is more in being the local peds expert in an all-ages ED than in staffing a dedicated tertiary pediatric ED.

So I guess the question is, are two more years of formal training overkill if I'm not having the really sick kids funneled to me in a pediatric ED? And would I see enough really sick kids to maintain and develop the skills from fellowship?

 

[dchristismi]

Aw thanks, michigangirl...

And deadcactus - I personally think it's overkill if you are planning to go community. In residency, I remember the emphasis on fellowship as the end-all-be-all. I thought I'd do one. I thought I'd stay in academics. Boy, was I wrong.

Look for residencies that emphasize pediatrics and remember that you get out what you put in. And there is that one other little thing... every year you're making $50K as a fellow, you're not making $250K as an attending.

 

[michigangirl]

Go to a program that has a busy tertiary care peds ED-- the peds ED that is a level 1 trauma center for kids, etc.-- and get the most out of your rotations through that ED. If being a community-based doc is your ultimate goal, then peds EM fellowship isn't necessary. Just need to be exposed to all the craziness while in residency- as I've said above, the key is to have the stabilization and call for guidance thing down. Septic shock is pretty much the same in a kid or an adult, just done in cc/kg of fluid. Knowing when and when not to intubate an peds asthmatic. Knowing when it's myocarditis or hypovolemia, the newborn sepsis algorithm-- these are all things you'll get from your residency. If you decide during residency that you want to see kids all the time, well, then you do the fellowship! Good luck!

 

[deleted109597]

Getting ready to start working at a peds ED part time, as having one in town means that your adult ED doesn't get any kids. So basically I'm doing it so I don't forget what sick kids look like. Thankfully, it's almost always doubled covered, and has an intensivist upstairs.

Not to hijack, but knowing what to do with sick kids is fairly important. Training means a lot. Had a "bounceback" at a rural for a 27 day old with "trouble breathing." Coughing up a storm, febrile. Started septic w/u. During the course of informed consent, the aunt said "why didn't they do this 4 days ago when we brought him in?" Short story, 23 day old, 103F measured in the ED, sent home after CBC/UA, told to take tylenol for fever. I thank God that the kid only had a viral illness, but between the stupid doc and the stupid parents (who hadn't followed up yet), this kid could have turned out very bad.

 

[michigangirl]

Getting ready to start working at a peds ED part time, as having one in town means that your adult ED doesn't get any kids. So basically I'm doing it so I don't forget what sick kids look like. Thankfully, it's almost always doubled covered, and has an intensivist upstairs.

Not to hijack, but knowing what to do with sick kids is fairly important. Training means a lot. Had a "bounceback" at a rural for a 27 day old with "trouble breathing." Coughing up a storm, febrile. Started septic w/u. During the course of informed consent, the aunt said "why didn't they do this 4 days ago when we brought him in?" Short story, 23 day old, 103F measured in the ED, sent home after CBC/UA, told to take tylenol for fever. I thank God that the kid only had a viral illness, but between the stupid doc and the stupid parents (who hadn't followed up yet), this kid could have turned out very bad.

I don't know much about EM training, but I would hope that a fever in any child less than 2 months would have automatically initiated a full sepsis workup and referral as necessary if the hospital doesn't have a pediatric floor capable of taking care of that child-- by any physician who has trained in either EM or pediatrics. This is the only two groups of people that I would expect this to be routine knowledge. Don't need peds EM fellowship to know this! Just need to know basic guidelines for urgent care pediatrics!

 

[WilcoWorld]

I don't know much about EM training, but I would hope that a fever in any child less than 2 months would have automatically initiated a full sepsis workup and referral as necessary if the hospital doesn't have a pediatric floor capable of taking care of that child-- by any physician who has trained in either EM or pediatrics. This is the only two groups of people that I would expect this to be routine knowledge. Don't need peds EM fellowship to know this! Just need to know basic guidelines for urgent care pediatrics!

Not to derail this thread, but I wouldn't tap a 1-2 mo old who looked otherwise well and had a negative work up. Less then a month, sure, but from 1-3 months I'll skip the LP if the kid looks great.

 

[Stitch]

I don't know much about EM training, but I would hope that a fever in any child less than 2 months would have automatically initiated a full sepsis workup and referral as necessary if the hospital doesn't have a pediatric floor capable of taking care of that child-- by any physician who has trained in either EM or pediatrics. This is the only two groups of people that I would expect this to be routine knowledge. Don't need peds EM fellowship to know this! Just need to know basic guidelines for urgent care pediatrics!

Wow, that's totally scary. I used to wonder why pediatricians were so aggressive at workups in infants with viral illnesses. Then I did my residency and started to see all the neurologically devastated kids with swiss cheese for brains because someone waited and didn't do a proper workup.

Not to derail this thread, but I wouldn't tap a 1-2 mo old who looked otherwise well and had a negative work up. Less then a month, sure, but from 1-3 months I'll skip the LP if the kid looks great.

Absolutely agree. It used to be 3 months, then people backed off to 2 months, and now that 5-8 week range is pretty negotiable. Definitely have a low threshold to tap, and I'd at least do blood and urine, but if they have good follow up and the parents aren't idiots, standard of care is moving closer to the 4 week mark. But, as you say, less than 4 weeks is a red flag that's inexcusable.

 

[WilcoWorld]

Wow, that's totally scary. I used to wonder why pediatricians were so aggressive at workups in infants with viral illnesses. Then I did my residency and started to see all the neurologically devastated kids with swiss cheese for brains because someone waited and didn't do a proper workup.



Absolutely agree. It used to be 3 months, then people backed off to 2 months, and now that 5-8 week range is pretty negotiable. Definitely have a low threshold to tap, and I'd at least do blood and urine, but if they have good follow up and the parents aren't idiots, standard of care is moving closer to the 4 week mark. But, as you say, less than 4 weeks is a red flag that's inexcusable.

I agree that the threshold should be low. The planets of clinical impression, labs, birth history, follow up and reliable parents must all align for fevers under 3 months to be going home. I also should clarify that a "work up" includes cultures and a differential. A CBC & urine dip aint gonna cut it.

Also, the case that McNinja described is just plain scary.

Lastly, to Michigangirl - no disrespect intended - I just wanted to make sure I wasn't unaware of some important peds knowledge. I see about 1/3 kids, which is the reason I've been reading this thread closely.

 

[DeadCactus]

Getting ready to start working at a peds ED part time, as having one in town means that your adult ED doesn't get any kids.

Is that a pretty attainable goal or more of an exception?

As best as I can guess at this point, my ideal is working in an academic center splitting time between a regular ED and a tertiary peds ED. Is straddling the fence like that readily achievable?

 

[michigangirl]

There were at least three attendings in my tertiary care center's peds ED who split their time equally between the two. They brought a lot to the table. So it's possible.

No disrespect felt-- my bad, I was being very general. When I said full sepsis workup I meant relative to the clinical picture and age. Like Stitch said, the 5-8 week window is definitely negotiable for the LP, but low threshold is the key. But obviously the 27 day old had all the pickins for disaster based on the story.

 

[Birdstrike]

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[Apollyon]

Getting ready to start working at a peds ED part time, as having one in town means that your adult ED doesn't get any kids.

This is flagrantly untrue, but you say it with such authority that people will take it as gospel. At least it wasn't true when I was a resident in NC, when I was in practice in SC, or in practice in HI. In all places, all with a pediatric hospital or a peds ED in town, the community locations were/are still 10-20% peds.

 

[deleted109597]

This is flagrantly untrue, but you say it with such authority that people will take it as gospel. At least it wasn't true when I was a resident in NC, when I was in practice in SC, or in practice in HI. In all places, all with a pediatric hospital or a peds ED in town, the community locations were/are still 10-20% peds.

I counter that with my own personal anecdote. In 4 months I have seen exactly 1 child at my primary site, and average 20-28 patients per shift. He didn't live in that town, and had broken his arm basically across the street. At the county site they still see less than 5% peds. When I was at Birmingham and Cincinnati in medical school, I never saw any children at the adult hospitals. I do remember 1 child coming in because "the wait was too long", but I didn't see them.
Some towns are different, and size of the city certainly determines this. But in general, if people know there is a children's hospital, they go there with their children.

 

[deleted109597]

Is that a pretty attainable goal or more of an exception?

As best as I can guess at this point, my ideal is working in an academic center splitting time between a regular ED and a tertiary peds ED. Is straddling the fence like that readily achievable?

Like all jobs, it depends. I would argue that it is easier at a community-type children's hospital than it is at a huge research center. I knew plenty of people who did the same at WakeMed, and while it wasn't a dealbreaker with my current job, it was nice to know going into it that they a)took non peds-EM people, and b)needed warm bodies.
All you need to do is ask some place, the worst they could tell you is no.

 

[EM_Rebuilder]

This is flagrantly untrue, but you say it with such authority that people will take it as gospel. At least it wasn't true when I was a resident in NC, when I was in practice in SC, or in practice in HI. In all places, all with a pediatric hospital or a peds ED in town, the community locations were/are still 10-20% peds.

Agreed.

In my town, the 'private hospital' has a dedicated Pediatrics ED; not sure what there volume is but I would guess 20K+ per year.

My hospital, which is the county/teaching hospital (no EM), does not have a dedicated Peds ED, but we still see 10-15%+ at least... and the hospitals are essentially across a major street from each other. We have a PICU; they have a PICU as well.

 

[deleted109597]

Using the EMRA data, at my residency (Pitt), they had 20% peds visits, for 19K out of 100K visits. There is no peds ED there.
At my current job (a residency training program), there is a peds site in town that sees 40K kids per year. The main resident site sees 4.5K kids out of 50K visits, or less than 10% peds. At the community site there isn't any data because we have so few kids. We don't even have people who can admit pediatric patients, which may be the significant cause of the bias (ie, their PMD telling them it is not worth their time to visit that hospital.) Similarly, we don't have OB/GYN coverage, and the city is remarkable about their ability to self triage to the 3 hospitals that do. While every town is different, as mentioned above, I have objective data that where I've been they see signficantly fewer kids if there is a peds hospital in town.
At Mississippi (UMMC), they list 30K kids (out of 88K visits) for 34% peds. They're counting their peds ED in that, so I can't separate the two (if they're physically separate to begin with, which I can't seem to determine).
Duke doesn't list any of their data on EMRA.

 

[Apollyon]

Using the EMRA data, at my residency (Pitt), they had 20% peds visits, for 19K out of 100K visits. There is no peds ED there.
At my current job (a residency training program), there is a peds site in town that sees 40K kids per year. The main resident site sees 4.5K kids out of 50K visits, or less than 10% peds. At the community site there isn't any data because we have so few kids. We don't even have people who can admit pediatric patients, which may be the significant cause of the bias (ie, their PMD telling them it is not worth their time to visit that hospital.) Similarly, we don't have OB/GYN coverage, and the city is remarkable about their ability to self triage to the 3 hospitals that do. While every town is different, as mentioned above, I have objective data that where I've been they see signficantly fewer kids if there is a peds hospital in town.
At Mississippi (UMMC), they list 30K kids (out of 88K visits) for 34% peds. They're counting their peds ED in that, so I can't separate the two (if they're physically separate to begin with, which I can't seem to determine).
Duke doesn't list any of their data on EMRA.

Gently, you're perseverating to prove your point, but also subtly moving the goalposts. As I said, you sound dogmatic saying "you won't see kids in the community when there's a peds hospital", and now you say "significantly fewer" - which can be A LOT more than "none", as a drop from 20% to 5% is indeed significant, but, even in a 30K community ED, that is 600/year, or almost 2 per day. Where you being hyperbolic? That is because you wrote with authority, as I stated above. That you've seen a solitary kid raises a few questions: Are you physically near the children's hospital? Is there good to very good public transportation? Are the parents that good? I ask these because one unifying factor that seems to bind these cases together is if the parents can't get to the children's hospital. Hell, two community hospitals (well, one hosp and one standalone ED) have between 5 and 10 deliveries per year, and neither one has Ob/Gyn or Peds.

 

[Hamhock]

Gently, you're perseverating to prove your point, but also subtly moving the goalposts. As I said, you sound dogmatic saying "you won't see kids in the community when there's a peds hospital", and now you say "significantly fewer" - which can be A LOT more than "none", as a drop from 20% to 5% is indeed significant, but, even in a 30K community ED, that is 600/year, or almost 2 per day. Where you being hyperbolic? That is because you wrote with authority, as I stated above. That you've seen a solitary kid raises a few questions: Are you physically near the children's hospital? Is there good to very good public transportation? Are the parents that good? I ask these because one unifying factor that seems to bind these cases together is if the parents can't get to the children's hospital. Hell, two community hospitals (well, one hosp and one standalone ED) have between 5 and 10 deliveries per year, and neither one has Ob/Gyn or Peds.

You're point is made. Let it go.

HH

 

[deleted109597]

Gently, you're perseverating to prove your point, but also subtly moving the goalposts. As I said, you sound dogmatic saying "you won't see kids in the community when there's a peds hospital", and now you say "significantly fewer" - which can be A LOT more than "none", as a drop from 20% to 5% is indeed significant, but, even in a 30K community ED, that is 600/year, or almost 2 per day. Where you being hyperbolic? That is because you wrote with authority, as I stated above. That you've seen a solitary kid raises a few questions: Are you physically near the children's hospital? Is there good to very good public transportation? Are the parents that good? I ask these because one unifying factor that seems to bind these cases together is if the parents can't get to the children's hospital. Hell, two community hospitals (well, one hosp and one standalone ED) have between 5 and 10 deliveries per year, and neither one has Ob/Gyn or Peds.

The peds hospital is about 2 miles away as the crow flies. There is plenty of public transportation in this town.
My authority is that at my site, I and the rest of the people there simply don't see peds patients period. As in fewer than 1 child per day in a place that sees about 100 patients per day. So while I may be hyperbolizing for some areas, it is true for me. If you want to make it less of an "offensive" statement, then sure, I will say that having a peds hospital nearby simply cuts your pediatric visits between 1/2 and 3/4 what it would be based on the data I've already posted. And since most EM residents feel that pediatric experience is what they are least comfortable with, I would argue having less is more of a hindrance in feeling comfortable.

 

[deleted65604]

I would agree with Dr. McNinja, a peds hospital will really cut down on your peds ER visits within a certain radius at other hospitals. I dont' know what the affected distance radius would be, but I feel it greatly at my current job. I just worked a moonlighting shift at a rural ER and saw about 20% kids, compared to my regular gig where I see virtually none, being close to a peds ER.

Having 5 kids myself, I would take them to a peds ER rather than a regular ER if I had the choice.

 

[The White Coat Investor]

The problem with Peds EM fellowships is you spend two more years training then end up with a paycut.

 

[michigangirl]

The problem with Peds EM fellowships is you spend two more years training then end up with a paycut.

So this applies to EM as well? It's the truth-- unfortunately if your passion is practicing pediatric medicine it means a paycheck that's not as pretty as adult medicine. Which means that those of us who commit ourselves to pediatric medicine just really love it.

 

[Hamhock]

So this applies to EM as well? It's the truth-- unfortunately if your passion is practicing pediatric medicine it means a paycheck that's not as pretty as adult medicine. Which means that those of us who commit ourselves to pediatric medicine just really love it.

I think Active is saying (please AMD, correct me if I am wrong): after a PEM fellowship, you end up with a paycut, but minimal more clinical acumen in the PED that makes an "outcomes" difference (at least in what really matters for EM docs).

Yes, a PEM fellowship will give you academic and intellectual opportunities, but it will not make you a better PEM doc (especially if you are EM-trained...very offensive, but it's my post and opinion...and outcome research supports me).

Peds EM is EM...not fancy Peds. If you want to make a difference is the academic world: do a PEM fellowship. If you want to be the best PEM doc you can be - then be the best EM doc you can be (not Peds doc).

Kids are just small adults!!

Flame away!

HH

(BTW: I very recently trained at a place with a PEM fellowship...when Peds cases went downhill, there was an "alert" sent to the department: sick kid. Who do you think took over then? It was not the Peds folks...or even the PEM-trained folks...it was us: EM. Yes, I am being ornnery here. However, I am so against the idea that Peds folks rule small adults, that I will expose myself.)

HH

 

[UnderwaterDoc]

Kids are just small adults!!

Holy crap, I'm grabbing some popcorn for this one.

 

[michigangirl]

I think Active is saying (please AMD, correct me if I am wrong): after a PEM fellowship, you end up with a paycut, but minimal more clinical acumen in the PED that makes an "outcomes" difference (at least in what really matters for EM docs).

Yes, a PEM fellowship will give you academic and intellectual opportunities, but it will not make you a better PEM doc (especially if you are EM-trained...very offensive, but it's my post and opinion...and outcome research supports me).

Peds EM is EM...not fancy Peds. If you want to make a difference is the academic world: do a PEM fellowship. If you want to be the best PEM doc you can be - then be the best EM doc you can be (not Peds doc).

Kids are just small adults!!

Flame away!

HH

(BTW: I very recently trained at a place with a PEM fellowship...when Peds cases went downhill, there was an "alert" sent to the department: sick kid. Who do you think took over then? It was not the Peds folks...or even the PEM-trained folks...it was us: EM. Yes, I am being ornnery here. However, I am so against the idea that Peds folks rule small adults, that I will expose myself.)

HH

I'm not gonna flame away because I have NO idea where you practice or the context of your comments based on your experience. Some kids ARE basically small adults. Like the 14 year old healthy trauma. Or even the 12 year old kid. Where's the line?Up for debate. What I do know-- if a sick (and I mean SICK, like a hypoplast s/p BT shunt that looks like crap ) baby shows up in your peds ED where there is a peds EM fellowship and they need help, and they call the adult ED-- I am PRAYING that there is for some weird reason no PICU in that hospital. Because if there is and they are not the first call I'm just gonna say 😱

 

[Rendar5]

Adults are big kids, not vice versa =p.

once you hit the peri-pubescent period, EM's almost completely the same (with sepsis presenting a bit differently but all other things presenting the same). toddler and baby medicine is different enough that the extra training proves valuable. When the **** hits the fan on that age range, it's nice to have the peds EM doc come over to help out (our peds ED is a 20 second dash from our critical care ED).

I will say that at my institution though, the peds EM people, even if they trained as peds initially, generally act more like EM physicians than peds physicians in their approach to patients.