Importance of peds exposure in residency?

[holabuster]

I am curious to hear the views of residents and attendings on the importance of peds exposure during residency. I know that "no one is really comfortable with sick peds" and that this is a weakness in exposure of programs overall but how little exposure is too little?

The reason I ask is because I really loved two programs except for what appears to me to be unacceptably poor peds exposure. But I'm not sure if I'm overblowing this.

Specifically, I'm talking about Cook County and St. Luke's Roosevelt. Did anyone catch that Cook County has really poor peds exposure? Only 5k volume. It's so low they are dissolving the peds ED and merging it with the adult side. They do go to UChicago and Northwestern once each for peds.

At St. Luke's, you have only 1 shift a month throughout the third year, which I don't imagine is enough to keep skills up. Low volume and acuity peds place.

How are these not deal breakers if you want to be a competent ED doc that can see both adults AND kids?

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[goodoldalky]

It is very important and also quite variable between programs. All programs will teach you to intubate but not all programs will make you comfortable with peds.
I have no knowledge about those two programs but you have to see a lot of kids to see a few sick ones.
To me, it seems like you have already answered your own question...

 

[Erek94]

It's so low they are dissolving the peds ED and merging it with the adult side.

Yea I also wonder how they're going to change the intern peds experience month at county now that this is happening. I basically got an "I don't know yet" when I asked about it. I feel like you'll be ok handling any peds that come your way graduating any program. Some programs will just make you more comfortable than others.

 

[EM/CC_23]

It seems like a significant number of programs have a PICU month +/- a few weeks in the NICU and/or peds anesthesia to improve comfort with the sickest kids. I subjectively felt that it could be hard to know how useful this experience is, because the experience likely depends on how much autonomy is given to the EM residents in that particular children's hospital. I rotated for a month with some pgy-3 EM residents in a PICU at a big children's hospital, and the central lines and intubations on THEIR patients were 100% taken by the pgy-4 peds fellows, and the rare resuscitation was managed by the attending and nurses alone (with the residents and fellows observing!). Because of this, a question I asked residents on interview days was: when you are doing your peds time (including PICU or whatever), what's the relationship like between you and the peds residents/fellows in terms of taking care of the sick patients? They sometimes gave an answer like "we work together" or "we rotate who gets the sick patient" or "it depends on the situation," and other times they would say things like "there are no peds fellows, and the peds residents generally run in the opposite direction when there is a sick kid, so we get to do everything every time." I also got the sense that the programs that send their residents to smaller community pediatric EDs or PICUs (where there are no other residents) might get pretty solid peds experience.

 

[deleted547339]

I think you're slightly mistaken. Plenty of EM folks are comfortable with sick kids. It's the kinda-sick kids that make your head spin. Or, beyond just sick, it's the weird kids that are concerning (think congenital). I think most EM attending who trained at a good program feel OK with a septic kid. Fluids (IO if necessary), tube, abx +/- LP, ship. That's not the problem. It's the kinda sick kid.

Edit: And to answer your original question, peds exposure is hugely important.

 

[holabuster]

Thank you guys so much for your thoughts. Wish I had asked some more detailed questions about the interactions with peds residents/fellows.

I double checked my numbers regarding the peds rotations. At Cook, you do 1 peds ED shift at home (errr...currently non-existent) intern year, plus 1 away each year (UChicago, Northwestern, UChicago, UChicago). You see some peds at the community sites. No longitudinal. No PICU/NICU.

At St. Luke's, you do 2x PED months intern year, 1.5 PED months PGY2, and basically 1 shift in the PED each month of PGY3. No PICU. 1/2 block NICU.

Do you think this is enough exposure at Cook and St. Luke's? It appears not, especially since longitudinal peds seems key to me, but would value the advice of the residents/attendings around here.

 

[WilcoWorld]

I saw A LOT of kids in residency, many of whom were sick (congenital heart disease, oncology and the like), most weren't (gastro & viral respiratory stuff, tho both of those can die on you too!).

I think that Peds exposure during residency is important, but (like adults) what's really important and beneficial is remaining humble and following up on as many head-scratchers as you can in your first few years out. Call the parents of that febrile 4 month old you sent home without testing, read the discharge summary of the "septic" 2 month old you LP'd and admitted. You're not going to come out of residency 100% sensitive and specific for pediatric disease - the best you can do is to zero in on it through continued refinement. Once you get to perfect it'll be time to retire.

 

[filhodeinferno]

I think you're slightly mistaken. Plenty of EM folks are comfortable with sick kids. It's the kinda-sick kids that make your head spin. Or, beyond just sick, it's the weird kids that are concerning (think congenital). I think most EM attending who trained at a good program feel OK with a septic kid. Fluids (IO if necessary), tube, abx +/- LP, ship. That's not the problem. It's the kinda sick kid.

Edit: And to answer your original question, peds exposure is hugely important.

I agree. It's the kid with some congenital heart malformation, genetic disease, or inborn error of metabolism that comes in where I don't really ever feel comfortable about the case. You find yourself thinking "is this just a viral illness, or is it something different because this kid has XYZ zebra disease?" Sometimes I'm relieved when I've got a good excuse to just admit those ones.

Anyway, as a resident, I think peds can be monotonous, often needing to see 100 or more viral URIs before you see something really bad. For that reason, a lot of peds exposure is needed.

 

[DO2016EM]

I am curious to hear the views of residents and attendings on the importance of peds exposure during residency. I know that "no one is really comfortable with sick peds" and that this is a weakness in exposure of programs overall but how little exposure is too little?

The reason I ask is because I really loved two programs except for what appears to me to be unacceptably poor peds exposure. But I'm not sure if I'm overblowing this.

Specifically, I'm talking about Cook County and St. Luke's Roosevelt. Did anyone catch that Cook County has really poor peds exposure? Only 5k volume. It's so low they are dissolving the peds ED and merging it with the adult side. They do go to UChicago and Northwestern once each for peds.

At St. Luke's, you have only 1 shift a month throughout the third year, which I don't imagine is enough to keep skills up. Low volume and acuity peds place.

How are these not deal breakers if you want to be a competent ED doc that can see both adults AND kids?

Yeah, the peds exposure is why I ranked Cook a little lower than I had originally placed it. The program overall was great and will train you very well, but I felt the intern year didn't offer much (too many IM floor months) and, as you talked about, the peds experience was lacking. The good news is you get to go to some of the best children's hospitals for a Peds EM month each year (NW and U of C), however, I'm not sure I like being a "guest" at another institution. Would prefer a program with its own Peds ED or children's hospital.

 

[BoardingDoc]

I felt the intern year didn't offer much (too many IM floor months)

Too many IM floor months? Plural? As in they not only have more than zero, but apparently more than 1? Shoot me in the face.

 

[alpinism]

Too many IM floor months? Plural? As in they not only have more than zero, but apparently more than 1? Shoot me in the face.

Not only that but you also do a month of Short Stay Medicine and a month of Infectious Disease.

Cook County is basically still a PGY2-4 EM program disguised as a PGY1-4.

Anyway they've got my vote for the 2nd worst EM curriculum out there after Kern Medical Center in Bakersfield.

Kern's Curriculum:
PGY-1: 2 months IM wards, 1 month general surgery wards, and 1 month pediatric wards
PGY-2: 1 month pediatric wards and 1 month neurosurgery wards

 

[WilcoWorld]

Not only that but you also do a month of Short Stay Medicine and a month of Infectious Disease.

Cook County is basically still a PGY2-4 EM program disguised as a PGY1-4.

Anyway they've got my vote for the 2nd worst EM curriculum out there after Kern Medical Center in Bakersfield.

Kern's Curriculum:
PGY-1: 2 months IM wards, 1 month general surgery wards, and 1 month pediatric wards
PGY-2: 1 month pediatric wards and 1 month neurosurgery wards

I dunno, short stay medicine might actually be pretty helpful in EM's future with all of the Obs Units we now run.

1 month on the Neurosurg ward though? Shoot me in the head...oh wait, maybe not in the head.

 

[Hercules]

As other posters have stated, Peds is highly variable and probably one of the most important aspects of a program. All programs will get you comfortable with trauma and sick adults. I'm sure every graduating resident thinks they are comfortable with Peds but some are a lot better prepared than others. I had an awesome pediatric experience which I think was pretty ideal and what I would recommend to those evaluating programs. I had a longitudinal exposure (we did 2-3 shifts at our pediatric ED each month while in the adult ED), a PICU month with dibs on all CVLs, intubations, and resuscitations (the PICU fellow even took me down with him to do a chest tube on a 2 year old that wasn't my patient), and a 2 week NICU rotation where you were basically there for neonatal airways. I thought the NICU rotation was a little overkill at the time, but when I had to deliver and intubate a 22 wk premie my 1st or 2nd year as an attending in my community ED it was definitely nice to have several of those airways under my belt.

 

[DO2016EM]

Too many IM floor months? Plural? As in they not only have more than zero, but apparently more than 1? Shoot me in the face.

Yeah, it's two months of IM floors. You're in the ED 3.5 months, I believe, during intern year. However, years 2-4, you get a ton of ED time.

 

[cofcemt]

As noted by several others, experience is key. I have seen more sick kids at the small community shop I split my time at, than at the children's hospital. Luckily I came from a program that integrated adult and peds in the same ED, so 15-20% of our volume was peds any day of the week. I think this was way more beneficial than doing a month of peds then a shift here and there in peds like many programs do.

I felt comfortable with sick kids when I graduated, but it's still a whole different ballgame when your by yourself at night without backup. I did a 2 week peds anesthesia rotation at the end of my residency as an elective and it made me feel both humbled and much better about the <2 yo intubation.

Also would echo someone above that said the ones that make me most worried are the moderately sick, but discharged kids.

 

[goodoldalky]

I agree. It's the kid with some congenital heart malformation, genetic disease, or inborn error of metabolism that comes in where I don't really ever feel comfortable about the case.

Those are easy... transfer

 

[holabuster]

Thanks everyone for your thoughts. Would love to hear where residents/attending/whoever received strong peds training or which programs they believe would provide it.

 

[RustedFox]

As noted by several others, experience is key. I have seen more sick kids at the small community shop I split my time at, than at the children's hospital. Luckily I came from a program that integrated adult and peds in the same ED, so 15-20% of our volume was peds any day of the week. I think this was way more beneficial than doing a month of peds then a shift here and there in peds like many programs do.

I felt comfortable with sick kids when I graduated, but it's still a whole different ballgame when your by yourself at night without backup. I did a 2 week peds anesthesia rotation at the end of my residency as an elective and it made me feel both humbled and much better about the <2 yo intubation.

Also would echo someone above that said the ones that make me most worried are the moderately sick, but discharged kids.

I don't want to seem like I'm minimizing the rotation you did; it sounds awesome. - I find, however - that the 1-2 year old tubes are the easiest to do, technically. The kids are anatomically correct; that is to say that they haven't had a lifetime of poor diet and nonsense to turn them into no-neck, fat, bearded, snaggletoothed, screwball airways.

Sad commentary on our American society, eh ?

 

[DeadCactus]

Mechanically easy intubations, but some experience helps a lot with the psychological part.

 

[gman33]

Peds is only one part of your training.
I wouldn't let that make or break your selection of a program.

Choose a program based on the overall quality of training, location, and where you think you will be happiest.

We did dedicated peds blocks, but we also saw peds at all of our training sites.
As with anything else that makes you uncomfortable, try to see that type of patient whenever possible.
So if you hate seeing kids, see them every chance you get.

Same with weak and dizzy, drug seeker, whatever else bothers you.
Over time you will develop an approach to each of these patient types which will make you more comfortable.

 

[goodoldalky]

Peds is only one part of your training.
I wouldn't let that make or break your selection of a program.

Choose a program based on the overall quality of training, location, and where you think you will be happiest.

Just playing devils advocate, it sounds like gman had excellent peds training... I would consider peds training make or break. This is one of the few things in EM - you've got three years to learn it - some places will prepare you, some will not - and you don't get any do overs.

Location and happiness of course are important, but IMO.. Think long and hard about your peds training. You do not want to be putting a chest tube in a 2 year old the first time when you're a brand spanking new attending somewhere. You only get one chance to "learn" this stuff...

 

[cofcemt]

I don't want to seem like I'm minimizing the rotation you did; it sounds awesome. - I find, however - that the 1-2 year old tubes are the easiest to do, technically. The kids are anatomically correct; that is to say that they haven't had a lifetime of poor diet and nonsense to turn them into no-neck, fat, bearded, snaggletoothed, screwball airways.

Sad commentary on our American society, eh ?

No offense taken. That's why I only did 2 weeks. Intubated about 5-6 kids a day. Most were easy, but I went in on a lot of the cases with things like hypoplastic mandible, downs, facial reconstruction after trauma, genetic kids. Anatomy not so normal then.

It was a great rotation and just reassured me that I would be fine. Plus it was a sweet 7a-2p M-F rotation.

 

[Angry Birds]

They are just little adults.

 

[christmasindr]

Peds is only one part of your training.
I wouldn't let that make or break your selection of a program.

Choose a program based on the overall quality of training, location, and where you think you will be happiest.

We did dedicated peds blocks, but we also saw peds at all of our training sites.
As with anything else that makes you uncomfortable, try to see that type of patient whenever possible.
So if you hate seeing kids, see them every chance you get.

Same with weak and dizzy, drug seeker, whatever else bothers you.
Over time you will develop an approach to each of these patient types which will make you more comfortable.

For someone who is genuinely interested in taking care of kids, would you say it's better to pursue the pediatrics residency+EM fellowship path or EM+Ped fellowship route? Because it sounds like peds exposure doesn't seem to be something that programs like to focus on.

 

[Zebra Hunter]

I agree. It's the kid with some congenital heart malformation, genetic disease, or inborn error of metabolism that comes in where I don't really ever feel comfortable about the case. You find yourself thinking "is this just a viral illness, or is it something different because this kid has XYZ zebra disease?" Sometimes I'm relieved when I've got a good excuse to just admit those ones.

Anyway, as a resident, I think peds can be monotonous, often needing to see 100 or more viral URIs before you see something really bad. For that reason, a lot of peds exposure is needed.

I usually just call their heme/onc/neuro/endo/cards doc about those kids, and get recommendations and a same day/next day follow up if I end up discharging. I feel like those kids are pretty easy to manage because their care always ends with calling their specialist who always seem happy to help.

 

[hundreddaysoff]

For someone who is genuinely interested in taking care of kids, would you say it's better to pursue the pediatrics residency+EM fellowship path or EM+Ped fellowship route? Because it sounds like peds exposure doesn't seem to be something that programs like to focus on.

Depends on (1) whether you're also genuinely interested in taking care of adults and (2) what kind of practice options you want to have. Peds-specific training is certainly not required to take care of kids in regular EDs. If you are like me and can't imagine yourself happily working in any setting other than the ED, avoid the peds residency.

I like to think my program has pretty good peds training with tons of exposure, but I guess I won't really know until I'm an attending. We do one dedicated peds block per year, 2--3 other longitudinal shifts per normal EM block, and then we see all the kids in the regular ED on every overnight shift when the peds ED is closed. I like this setup and I actually feel like I'm getting a lot more exposure than I would if we had a shiny 24/7 dedicated peds ED.

 

[TheComebacKid]

I know it's a little late for those who have already submitted their rank lists, but for future generations... I think it's a a great asset to go to a place that has a dedicated children's hospital for pediatric exposure. Places that are level 1 pediatric trauma centers have a decent amount of volume and the acuity of sick kids is pretty high. Some of the cases that come into those hospitals are also really complex with weird glycogen storage diseases and congenital heart defects etc.

It's a trade off. Your big county programs like Cook County offer an unparalleled adult EM experience but don't have much in terms of dedicated academic pediatric centers where they do research and set up the infrastructure for high acuity peds exposure. Other programs like Loma Linda, WashU, Denver i.e. places that have a pediatric EM fellowship will arguably give you a more robust peds experience.

Also, longitudinal pediatric exposure seems important to me. I chose to rank a program that scatters peds EM shifts throughout the curriculum versus does 1 block of peds EM/year which for you may end up being only in January with RSV baby galore 24/7. I like the balance of seeing kids with ankle injuries in the spring and complicated URI's in the winter.

 

[normtheniner]

I know it's a little late for those who have already submitted their rank lists, but for future generations... I think it's a a great asset to go to a place that has a dedicated children's hospital for pediatric exposure. Places that are level 1 pediatric trauma centers have a decent amount of volume and the acuity of sick kids is pretty high. Some of the cases that come into those hospitals are also really complex with weird glycogen storage diseases and congenital heart defects etc.

It's a trade off. Your big county programs like Cook County offer an unparalleled adult EM experience but don't have much in terms of dedicated academic pediatric centers where they do research and set up the infrastructure for high acuity peds exposure. Other programs like Loma Linda, WashU, Denver i.e. places that have a pediatric EM fellowship will arguably give you a more robust peds experience.

Also, longitudinal pediatric exposure seems important to me. I chose to rank a program that scatters peds EM shifts throughout the curriculum versus does 1 block of peds EM/year which for you may end up being only in January with RSV baby galore 24/7. I like the balance of seeing kids with ankle injuries in the spring and complicated URI's in the winter.

I agree with this. Our place is peds trauma 1. We do several shifts a month in the Peds ED all three years in addition to a dedicated peds ED month during intern year. I like this style better because having built in peds shift every block keeps me from getting rusty of forgetting things I've already learned.

 

[goodoldalky]

For someone who is genuinely interested in taking care of kids, would you say it's better to pursue the pediatrics residency+EM fellowship path or EM+Ped fellowship route? Because it sounds like peds exposure doesn't seem to be something that programs like to focus on.

I would say the latter, for two main reasons. 1. You cannot take care of adults unless you go EM-->Peds EM. 2. As a general rule, Adult EM pays more than Peds EM.

However, doing an EM residency alone boards you to take care of adult and pediatric patients, no fellowship needed. The ONLY reasons to do EITHER pathway are: 1. You want to do academics, specifically PEM. 2. You want to work in a large urban children's hospital emergency department (in these places, most of the time attendings are PEM). Search the forum, there is a lot of discussion on this topic previously.

It is a lot of investment of time and you need to have an excellent reason for doing so.

 

[BigRedBeta]

PICU attending here. Obviously my bias is that peds is crucially important, and most of the data I've seen is that EM residencies don't give enough exposure to kids compared to relative volume seen once out in the community.

What I will say, is that while a peds resident and PICU fellow, I saw a lot of EM residents roll through the Peds ED, Peds wards, and PICU and your attitude as a resident really matters. Regardless of the amount of kids built into your schedule, if you're uninterested, distant, and impossible to find, you're not making the most out of the chances you do have. On the flipside, if you come in with the attitude that you don't have much time to pick all this stuff up, and you're willing to put forth the effort, even a limited exposure to peds can become incredibly useful. So you have to be vocal in getting the attending and fellow to meet your educational needs. The default in children's hospitals is always more supervision, that's why there is fellow coverage 24/7 in most PICU's and why the bigger centers have all moved to 24/7 inhouse attending coverage. Far too often EM residents resent the lack of autonomy and simply go through the motions, missing out on procedures, sick kids, and picking the brains of those with peds expertise.

 

[goodoldalky]

Agreed with above, peds exposure in your EM program should be among the most important factors, and highly variable between programs.

 

[Old_Mil]

For someone who is genuinely interested in taking care of kids, would you say it's better to pursue the pediatrics residency+EM fellowship path or EM+Ped fellowship route? Because it sounds like peds exposure doesn't seem to be something that programs like to focus on.

I would say EM + Peds EM.

Clinic medicine and chronic care is the antithesis of EM.

 

[christmasindr]

PICU attending here. Obviously my bias is that peds is crucially important, and most of the data I've seen is that EM residencies don't give enough exposure to kids compared to relative volume seen once out in the community.

What I will say, is that while a peds resident and PICU fellow, I saw a lot of EM residents roll through the Peds ED, Peds wards, and PICU and your attitude as a resident really matters. Regardless of the amount of kids built into your schedule, if you're uninterested, distant, and impossible to find, you're not making the most out of the chances you do have. On the flipside, if you come in with the attitude that you don't have much time to pick all this stuff up, and you're willing to put forth the effort, even a limited exposure to peds can become incredibly useful. So you have to be vocal in getting the attending and fellow to meet your educational needs. The default in children's hospitals is always more supervision, that's why there is fellow coverage 24/7 in most PICU's and why the bigger centers have all moved to 24/7 inhouse attending coverage. Far too often EM residents resent the lack of autonomy and simply go through the motions, missing out on procedures, sick kids, and picking the brains of those with peds expertise.

When I talked to the EM residents/attending, their indifference toward the peds training and exposure was a bit disappointing to me. The general consensus I got was that kids are not very sick anyway, so there's nothing interesting going on.

 

[alpinism]

When I talked to the EM residents/attending, their indifference toward the peds training and exposure was a bit disappointing to me. The general consensus I got was that kids are not very sick anyway, so there's nothing interesting going on.

Well to be brutally honest, the vast majority of kids aren't sick at all.

And the ones that are sick usually have some already diagnosed chronic medical condition (genetic defect, intrauterine toxicity, or premature birth).

Most people go into regular EM to take care of patients with acute life threatening illnesses or injuries.

Its easy to get frustrated when all you see is viral URIs and gastroenteritis all day.

 

[christmasindr]

Well to be brutally honest, the vast majority of kids aren't sick at all.

And the ones that are sick usually have some already diagnosed chronic medical condition (genetic defect, intrauterine toxicity, or premature birth).

Most people go into regular EM to take care of patients with acute life threatening illnesses or injuries.

Its easy to get frustrated when all you see is viral URIs and gastroenteritis all day.

Does that mean there's no point of pursuing a Ped fellowship for an EM resident?

 

[christmasindr]

I would say EM + Peds EM.

Clinic medicine and chronic care is the antithesis of EM.

Why clinic medicine? And don't you see a lot of patients with adult chronic care in EM?

 

[n2b8me]

Its easy to get frustrated when all you see is viral URIs and gastroenteritis all day.

It can feel like your skills aren't really being used when dealing with the bread and butter peds stuff that comes to most community practices... BUT I think I would be more 'frustrated' if most of what I saw was kids with serious chronic conditions coming in for exacerbations/complications of their illnesses. That sounds taxing.

 

[DeadCactus]

For someone who is genuinely interested in taking care of kids, would you say it's better to pursue the pediatrics residency+EM fellowship path or EM+Ped fellowship route? Because it sounds like peds exposure doesn't seem to be something that programs like to focus on.

This really comes down to whether you want to see adults too and where you want to work. The EM -> fellowship pathway lets you see adults, makes you more marketable, and generally means higher pay. The EM route also lets you finish in 5 years depending on where you go for your training. The Peds -> fellowship pathway lets you avoid adults and builds a CV better suited to an academic position at a stand alone children's hospital. This route is 6 years.

A third option is doing a combined emergency medicine and pediatrics residency at one of the 4 institutions offering it. This route is 5 years and lets you sit for the pediatric and EM boards opening up any work environment or fellowship in either field but does not let you sit for the pediatric emergency medicine sub-specialty board. Some ED's really want fellowship trained folks and some view the combined training as equivalent.

Roughly, the pediatric ED is 90% urgent care and primary care with 10% emergency medicine and 1% critical care. The EM trained folks tend to be more comfortable with the emergent and critical patients than their pediatric trained colleagues because of their somewhat translatable experience in adults. The pediatric trained folks tend to be more efficient seeing the other 90% (both in terms of being less likely to order fewer tests to reassure themselves the kid is healthy and in terms of making the most of the ED visit to do a little PCP style anticipatory guidance) and tend to be more comfortable with the congenitally ill kids.

Does that mean there's no point of pursuing a Ped fellowship for an EM resident?

Again, depends what you want. If you want to be the pediatrics guy at a shop or work in a dedicated pediatric ED, then additional pediatrics training is a good idea. If you just want to be more comfortable, then read and go to conferences. There's no need to give up years in a fellowship. The EM to fellowship route is less common as few people are interested enough to spend 2 years in fellowship to make less money and see a patient population they were seeing before.

 

[BigRedBeta]

Roughly, the pediatric ED is 90% urgent care and primary care with 10% emergency medicine and 1% critical care. The EM trained folks tend to be more comfortable with the emergent and critical patients than their pediatric trained colleagues because of their somewhat translatable experience in adults. The pediatric trained folks tend to be more efficient seeing the other 90% (both in terms of being less likely to order fewer tests to reassure themselves the kid is healthy and in terms of making the most of the ED visit to do a little PCP style anticipatory guidance) and tend to be more comfortable with the congenitally ill kids.

I agree with a most of this. I think the comfort level for adult EM providers with kids is highly, highly variable from what I've seen posted about here on SDN, what I've been called to the ED to help with while in smaller communities on locum tenens gigs, the phone calls I've taken requesting transport, and the kids I've physically transported. Under and overmanagement by adult providers is rampant, and what scares me more is when the level of concern/recognition of severity of illness is way out of proportion to the patient's actual condition. Now admittedly, my sample is limited to only that population that warrants transfer, whether to the pediatric wards or the PICU, but it's probably only 20-25% of the time that the management and the level of concern from the ED provider are both appropriate for the patient's actual problem. There's far more consistency when I take phone calls from hospitalists or PEM staff, although depending on the location, some Peds ED's are consistent only in overtreating everything.

 

[deleted547339]

I agree with a most of this. I think the comfort level for adult EM providers with kids is highly, highly variable from what I've seen posted about here on SDN, what I've been called to the ED to help with while in smaller communities on locum tenens gigs, the phone calls I've taken requesting transport, and the kids I've physically transported. Under and overmanagement by adult providers is rampant, and what scares me more is when the level of concern/recognition of severity of illness is way out of proportion to the patient's actual condition. Now admittedly, my sample is limited to only that population that warrants transfer, whether to the pediatric wards or the PICU, but it's probably only 20-25% of the time that the management and the level of concern from the ED provider are both appropriate for the patient's actual problem. There's far more consistency when I take phone calls from hospitalists or PEM staff, although depending on the location, some Peds ED's are consistent only in overtreating everything.

That's fair, but the vast majority of shipping hospitals are not staffed by EM trained folks.

 

[deleted109597]

Roughly, the pediatric ED is 90% urgent care and primary care with 10% emergency medicine and 1% critical care. The EM trained folks tend to be more comfortable with the emergent and critical patients than their pediatric trained colleagues because of their somewhat translatable experience in adults. The pediatric trained folks tend to be more efficient seeing the other 90% (both in terms of being less likely to order fewer tests to reassure themselves the kid is healthy and in terms of making the most of the ED visit to do a little PCP style anticipatory guidance) and tend to be more comfortable with the congenitally ill kids.

Agree with point 1. We are better at the sick kids (although sometimes worse at identifying sick vs not sick). However, and this may be personal practice dependent, as an emergency doc I order significantly fewer tests than the peds/peds EM trained folk. Most of it is being comfortable with "this is not an emergency" and not needing unnecessary testing to prove exactly what it is. Of note, there's a multiple virus/bacteria PCR panel that the pediatricians love to order so they can tell people they have a rhinovirus, or a coronavirus, whereas I'm ok with tell them it's a viral URI NOS. It's not like we have any disease specific treatment that comes from testing.
What's annoying is how long it has taken for peds folks to use ultrasound. I mean, sure, they like to order them, but I still haven't worked in a peds department that has a bedside machine.

EM docs are significantly better at procedures. Its not even close. In fact, peds=>peds EM people finish with the bare minimum after 6 years, and most EM folks are done by the second year. There's been a couple decent articles out about this.

While Peds EM might be a requirement at some hospitals (and any that train fellows), it's so far behind EM in numbers that it will never be completely full likely. And this isn't like the "well, if EM can staff Peds hospitals, than FM can staff EDs" etc. EM has a requirement for amount of peds exposure. And it's much higher than the FM requirement for emergencies.

 

[gman33]

No one is good at handling things that they don't see often.
Ask a pediatrician to manage an adult in septic shock or whatever and they likely will have no clue.
The last time they saw that was in med school.

I remember when an adult would present to the PEDs ED when I was a resident.
The staff and docs would lose their mind.
Even if it was nothing.

EM docs are primarily adult doctors. Yes I see kids, and yes I try to handle most of it.
Some of the stuff is out of my comfort zone.
I am trained to rule out life threats.
If I can't do that, they get seen by or sent somewhere so that can occur.
It's not over management in my mind.
It's just that they showed up somewhere that can't evaluate their condition properly.
I'd rather transfer 100 kids who needed nothing, then to send home the one who needed help.

We can have a bigger discussion of whether this is a good use of resources, but that's how I practice.
I'm also not taking the advice of someone over the phone who has no skin in the game to just send a kid home.