Is it truly pediatric "emergency" medicine?

[bougiecric]

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
• 61% of faculty did not perform a single critical care procedure
• 63% of faculty never performed an 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.

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[deleted109597]

It's tough. Truthfully, kids just aren't as sick as adults. However, sick kids are a nightmare.

Nobody is able to see enough sick ones to ever feel "comfortable" without lying to themselves, even if only a little bit.

I don't argue that his concept of conceding the critical patients to the critical care team is a good one. Sure, we recognize them as such, but then let the other guys take care of it.
No, I don't think it's applicable to adults though.

 

[dotcb]

2 words: peds glidescope

I haven't done a peds airway in 3 years despite full time practice at level 1 trauma peds/adult centers. Despite that, I feel I can do the majority of peds critical procedures - IV access, LP, chest tube, etc. With a peds glidescope, I feel I have a good chance of getting the airway too, if i needed to.

 

[eastcoastEM]

Hm, my buddy at a major PEM training center does 1-2 peds tubes a month. I saw 1-2 tubes in the 3 shifts I did in the same peds ed. I didn't think it was that rare.

 

[DeadCactus]

Interesting article. Supports my personal bias for the EM based route to Peds EM. While not the same, I think having sick adults around to help maintain critical care skills is a big plus...

 

[EMIM2011]

It's tough. Truthfully, kids just aren't as sick as adults. However, sick kids are a nightmare.

One more reason to have someone take care of them who actually is good at procedures etc.

No, I don't think it's applicable to adults though.

I agree, looking at it from a practical perspective. The reality, however, is that most EM folks do not provide critical care that is as good as the care provided by let's say intensivist. Many reasons for that....we just don't see that many super-sick patients as they do, we have to take care of the rest of the patients in the department and so on. Scot Weingart talked about that a few times as well. It always bothers me, for example, that most EM docs have no clue about ventilator management and other critical care stuff that we SHOULD know about when managing sick patients in the ED. Well, I guess it goes back to the "triage" thing...

 

[Arcan57]

Having pulled 20% of my residency there, I would agree that the peds EM fellows lack EM procedure experience. Chest tubes and central lines are usually delegated to the PICU or trauma team. Cinci Childrens is very guideline, best-practices driven so there is a lot of pressure to have the most experienced operator in the room doing the procedure (or taking the procedure at the first hint of difficulty). A decent proportion of their staff only work the non-critical areas and so are essentially peds moonlighting as peds EM. With subspecialty fellows in-house for almost any time-critical specialty and real-time PICU/trauma team activations there isn't really a need for cracker jack peds EM proceduralists.

I agree, looking at it from a practical perspective. The reality, however, is that most EM folks do not provide critical care that is as good as the care provided by let's say intensivist. Many reasons for that....we just don't see that many super-sick patients as they do, we have to take care of the rest of the patients in the department and so on. Scot Weingart talked about that a few times as well. It always bothers me, for example, that most EM docs have no clue about ventilator management and other critical care stuff that we SHOULD know about when managing sick patients in the ED. Well, I guess it goes back to the "triage" thing...

Triage? I'm not sure I catch your meaning

We stay proficient at that which we do routinely. Unless you're pulling shifts on the unit or are in a tertiary care center routinely working the resuscitation area you're not going to be intensivist-level in critical care. I loved Weingart's talk on push-dose pressors, but since I heard it I haven't seen a pt. w/ hemodynamically unstable a.fib that had a contraindication to cardioversion. And this is in a shop that sees 165pts/day and bills 10-12% crit care.

It's honestly been years since I saw a patient that I couldn't oxygenate using either AC or SIMV and playing around with the PEEP and FiO2 while keeping TVs somewhere around 7ml/kg. I agree that EM docs should know the basics of vent management (reasonable TVs and going up on PEEP if oxygenation is a problem) but most of the nuances of vent management are for patients with ridiculous pulmonary physiology (vanishingly rare outside of tertiary care centers or long-term unit players with the lung compliance of cardboard) or for weaning.

The other part of the equation is that most of us aren't working in an academic center. I'm sure Dr. Weingart's approach to using titrated phenylephrine and diltiazem for rate control in a.fib is infinitely more elegant than my own hamfisted management. But unless a patient is actively dying I can't sit at bedside for 20-30 minutes pushing drugs. In resuscitations, I'm the one putting in lines (using full sterile barriers and mandatory U/S)and intubating and then I have to enter all the orders into the computer afterwards. Most of my nurses have less then 3 yrs experience and are inconsistent in being able to put in anything larger than a 20g and have a minimum 1:3 ratio while being held to strick metrics regarding admit and discharge to depart times. This simply isn't an environment that allows for the nuances that having resident minions and dedicated resuscitation staff brings to the critically ill patient.

Considering that the national average for crit care hangs around 6%, the average ED doc is seeing 1-2 patients per shift that require >30mins of dedicated attention. The majority of those are going to be run of the mill (in no particular order) CHF requiring BiPap, DKA, normo to hypertensive a.fib w/RVR, bad asthma exacerbations and fluid responsive sepsis. Depending on what your hospital's push is, you may see some specialty stuff (last job loaded up on neutropenic fever and head bleeds). But with the exception of the EM/CC stuff and some very specialized shifts in academia, railing at "most EPs" for not being intensivists is like bitching out a community orthopedist for not doing acetabular fractures.

 

[Rendar5]

Agree with above, in the community ED, when ICU beds are available, we shouldn't be seeing ARDS, finely juggling pressors, jumping to APRV mode when SIMV fails, taking the neuromuscular blockade off an intubated asthmatic. Get them to the unit, and if they're really that critical (which is rare), tell the pulmonologist or intensivist that you need them to personally see the patient in the middle of the night (and in 8 months, I have yet to need to do that). We're resuscitationists by trade, but not intensivists. In my mind, it means our job is to stabilize enough for a hand-off to the right person.

EDIT: in my tertiary care academic residency, the Peds EM doc would intubate maybe every few months, but they'd still be more comfortable in a baby's airway than our regular ED docs., central line? PICU. But you know what, if they need a central line, they need to be upstairs.

 

[Stitch]

I have to agree for the most part. Critically ill children need an intensivist because intensivists manage them on a daily basis. That includes lines and chest tubes. That said, most peds EM physicians are perfectly capable of intubating a kid and doing the ABCs when they come up. The true art of peds EM in my opinion is the risk stratification. How do you pick out the one kid who's sick but looks ok. What do you do with a bronchiolytic who's definitely sick, but it's unclear how sick? The intermediate cases are the toughest. I know that all EM docs do this to some degree, but the pediatric disease spectrum is so different you really need intense familiarity with it. Managing that risk stratification and keeping a busy ED flowing are what's taught in fellowship, along with the initial critical care steps.

Just my thoughts. I see things from both sides now that I'm in CC.

 

[WilcoWorld]

I have to agree for the most part. Critically ill children need an intensivist because intensivists manage them on a daily basis. That includes lines and chest tubes. That said, most peds EM physicians are perfectly capable of intubating a kid and doing the ABCs when they come up. The true art of peds EM in my opinion is the risk stratification. How do you pick out the one kid who's sick but looks ok. What do you do with a bronchiolytic who's definitely sick, but it's unclear how sick? The intermediate cases are the toughest. I know that all EM docs do this to some degree, but the pediatric disease spectrum is so different you really need intense familiarity with it. Managing that risk stratification and keeping a busy ED flowing are what's taught in fellowship, along with the initial critical care steps.

Just my thoughts. I see things from both sides now that I'm in CC.

My thoughts exactly.

 

[The White Coat Investor]

In my limited (like everyone else's apparently) experience, seeing the airway (what the glidescope excels at) is easy in kids. The hard part is actually physically putting the tube in and keeping it there.

The problem with limiting the procedures to the specialists is that specialist availability is limited. Peds critical care procedures seem like the perfect thing to use a sim lab for to me. Rarely done, but very important, procedures. Pilots don't have enough planes poop out on them in the sky, so they do it in the simulator, over and over and over again. Perhaps there's something to learn there.