How EDs Work

It was morning in Honduras on my most recent medical mission.  I padded in my pajamas to the room where the coffee was supposed to be, but alas it wasn’t out yet.  I went back to my room, got dressed, back to the coffee table- still no joe. Somewhat miffed, I went to brush my teeth.  Finally on that third trip back, now really irritable, there was finally coffee!  Later that morning, I stood in the clinic doorway and greeted a family that was all smiles, though covered with dust from their three-mile walk from the open-air hut they called a home.  Makes my irritation over coffee pretty lame.

Anger over having to wait is a pervasive emotion in the Emergency Department too.  Families are already stressed about their sick child.  Then they have to wait for the doctor- sometimes an hour or two, sometimes more.  They really get steamed when  another kid passes them in the waiting room, being ushered back ahead of them.  What the hell’s going on??

Getting passed up touches on an under-current of frustration in our society.  While America is supposed to be class-less, everyone equally important, we see that’s not the case.  In court, the rich can afford better lawyers, and beat raps that would have us behind bars for years.  In the airport, there’s first class lounges and airplane seats, and there’s the rest of us in crowds and cramped seats, only a tiny bag of pretzels for our trouble.

But the ER is a true meritocracy. We treat emergencies first- kids who have real trouble breathing, compromised airways, or shock from dehydration or blood loss.  If we don’t see them first, they can get dangerously more ill, and even die. The front of the ER is called “triage,” a military term for sorting casualties to maximize lives saved- the most critical go first, the mildly injured wait, and the dead are dead.

You’ll sometimes see an apparently well child go ahead of you.  A kicker in Pediatric Emergency Medicine is that often the first signs of distress are subtle- mild trouble breathing, hidden signs of shock, before the quick and inevitable “crash.”  The child jumping to the head of the line may look okay from afar, but really isn’t.

Once a mom complained to me that at a previous Emergency Department visit, she waited for hours with her child.  When finally brought back, they passed the nurse’s station where the nurses and doctors were laughing and leisurely eating pizza, like they were at a Superbowl party. They didn’t seem to be busy with many other patients either.  Since hearing of this apparent outrage, I furtively eat my meals in our back conference room.

In defense of that ER crew, they may have just finished resuscitating a major trauma, having spent hours putting in tubes and lines, taking the patient to CT and back, giving blood and meds, and calling in surgeons.  Finally they get to eat a meal, and while they’re at their jobs, what’s wrong with some camaraderie after a stressful event?

As I mentioned above, I just returned from my annual medical mission to Honduras. In the mountains, when a mom’s child gets sick, she has nowhere to go- no ERs, no walk-in clinics, no medical care at all.  Once a year we show up at a local school house, and people walk miles to see us.  They wait hours in line in the hot sun. To make time go by, we have a station where the kids get crayons and paper and make pictures.  They pass around their creations and chatter with everyone around, having a better time than any tablet could provide.

To survive your visit to an ER, some patience and perspective is in order.  If a child is truly sick, they’ll be seen quickly.  If you’re not rushed right back, count your blessings- the triage crew has assessed your child as not being gravely ill.  If you get passed up by another, know that that kid is worrying us, but we haven’t forgotten you- the computer tracker assures that. Better still, if your child doesn’t have an emergency, like only having a fever, cough, or rash, see your doctor the next day.  If they have ear pain or a sore throat, give them ibuprofen or acetaminophen (Tylenol). And be thankful that, unlike coffee growers in the mountains of Honduras, you’ve got somewhere to go.

Is There A Doctor In The House?

This week’s guest columnist is Dr. Meighan Anderson, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

She’s 10 years old.  She has asthma and eczema, but hasn’t seen her regular doctor in a year- her pediatrician retired and mom hasn’t found a new doctor yet- life’s so busy!  Yet the girl has had several asthma flares requiring Emergency Department visits. The itching from her eczema is also making life miserable, with sleepless nights and scaly skin.  Visits to walk-in clinics have yielded treatments that haven’t worked.

Many kids don’t visit their regular doctor enough.  When they get sick, Urgent Care clinics are so convenient.  Sometimes the family’s moved and not found a new doctor locally.  Sometimes their doctor has retired, or doesn’t take the family’s new insurance.  We also hear a lot of “he’s never sick, he hasn’t needed a doctor,” in the ER.

Having your own doctor is more important than many realize, especially for kids with chronic conditons like our 10 year-old asthmatic.  For kids with these issues, only their doctor has reliable records of what has already been tried, what worked and what hasn’t.  Office-based doctors are better trained and more experienced with these conditions too, rather than Urgent Care or ER providers, whose focus is acute illness.    Finally, office doctors are where to go for vaccinations, school physicals, and specialist referrals.

The first step to find a doctor is your insurance.  If your child has medicaid, only certain practices accept that, though most pediatricians take some medicaid patients.  If you have private insurance, that company will provide a list of accepting doctors.  Office location is important too- shorter trips from your home are helpful with busy lives.  Then you need to decide what kind of doctor to pick.  If your child is newborn through teenage years, a board-certified pediatrician is best.  If your kid is a late teen, soon to be 18 years-old, a Family Practice or Internal Medicine doctor is better, since they can take care of him into his adult years.  They take care of parents too!

“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul.  Although the two cannot be separated.” -Plato

Though Plato wrote this over 2000 years ago, it’s still relevant.  Above we discussed finding your child a doctor- insurance accepted, location, and specialty (Pediatrics, Family Practice, Internal Medicine).  But is the physician right for your child’s body and soul?  And your soul too?

Cultivating the doctor-patient relationship is important to successful care.  One of the  determinants in this is a practice style called “shared decision making.”  This is where you and a doctor negotiate what is possible for care, rather than the doctor dictating what you should do, and you being expected to follow blindly.

What does shared decision making look like?  In some cases, there isn’t much sharing.  Technical issues are decided by the expert- the doctor.  For example, your child has a sore throat.  It could be a virus and resolve in a few days, or strep throat, requiring an antibiotic.  A strep test is done, it’s negative, and the doctor doesn’t prescribe an antibiotic, because it won’t help and may have side effects.

But what if your child always has a sore throat and it seems allergic?  With chronic illness like allergy, where lifestyle affects your kid’s illness, shared decision making is a must.  Should you go to an allergist, or would this be too much trouble, or does the thought of skin pin-prick allergy testing freak you both out?  Should you try some anti-allergy medication first?  Which one- inhaled, sprayed in the nose, or swallowed liquid, or a pill?  Which will your kid tolerate, and which is most effective?  Can you afford to tear up your carpet and put in hardwood floors for better dust control, and what about the smokers in the house?  Will they quit, can they quit?

All these questions should be explored with your doctor.  What is doable, what is best for your child, what can you and your kid tolerate, to optimize your child’s care?  Together you all decide on realistic goals and expectations.  In the old days, the doctor was always the boss.  These days, to deliver the most effective care, sometimes she’s boss, sometimes you are, often you’re co-captains of the team 

Is This Really “That”?

This week’s guest columnist is Dr. Babak Amrollahie, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

I recently saw a 4 year-old named Mary in the Emergency Department.  She vomited once while eating lunch, and was brought in by both parents for evaluation.  Mother appeared more concerned about the episode, and said “Mary is always happy and active, but she’s acting tired since she vomited.  I’m always with her, she’s not herself.”  However, the father said “Mary only vomited because she doesn’t like pickles, so she spit them out.  Then she ate some of my fries and finished her lemonade.”  At this point mom looked at me and said, “I’m worried about food poisoning.”

Most visits to the ER are not emergencies.  However, it’s reasonable for parents to be concerned about a symptom like vomiting.  Parenting isn’t easy, and when folks see their child in distress, it often sticks them right in the heart.  So how do we decide that this is a benign problem, which only needs us to reassure the parent; or decide that this could be a serious problem that requires more attention?

FIrst of course, we listen to the story of what happened.  This story is the “medical history,” which also includes asking about related symptoms, and the child’s past illnesses.  Then we examine the child, to match the story with what’s happening in the kid herself.

In Mary’s case, we have a girl who vomited only one time, which typically isn’t severe enough to worry about bad things like dehydration or appendicitis.  When I examined her, I saw a child who was active and playful, with plenty of moisture in her mouth, good circulation, and normal vital signs.  This confirmed that Mary was doing well.  I reassured mom that Mary’s condition was mild, that she was going to be okay, and mom was relieved.

Parents can do this exercise at home, and avoid a costly and time-consuming ER visit.  If your child is eating and drinking well, breathing normally, and active, they are probably not having an emergency.  However, if they are acting excessively tired, vomiting for several hours in a row, in severe pain, or having trouble breathing, then it’s time to see a doctor; if not your own, then in the ER.

Omar is a 9 year-old boy whose mother is concerned about a rash that appeared on his arm. It first appeared last week, and then went away a few days later.  It looked like a sunburn, according to mom, but she was worried that it was something else bad.

Mother had not discussed the rash with Omar’s pediatrician since “every time I call the office, they give me an appointment for the next 2 or 3 days.”  Like with Mary above, the first thing is to take a history: was the rash itchy, did it hurt, were there any accompanying symptoms like fever, cough, or diarrhea?  Mother thought it might be the sunscreen she applied, though she said “it’s not a new brand, he’s used this before.”

Next is the physical exam.  I checked Omar’s skin for lingering signs of the rash, and also did the basics- listened to his lungs and heart, felt his belly, looked in his mouth and throat.  There was no rash, and he otherwise was well, an active and polite 9 year-old boy.  Mom was happy to hear that Omar was fine, we discussed the possibilities of what caused his rash (sunscreen irritation versus sunburn on a patch she missed with the screen), and they went on their way.

Many parents come to the Emergency Department for questions that worry them, and often because they can’t get into their child’s doctor.  These worries can be profound- is this cancer, or in Omar’s case, is this a sign of a potentially bad allergic reaction in the future?  When parents have these questions that keep them up at night, they come to the ER.

Fortunately, the answer is most often benign.  And if the child looks fine in the basic ways- is eating and drinking, is breathing comfortably, is active, then the answer can wait until the next available appointment with your doctor.  If the child is truly sick, with persistent vomiting, shortness of breath, worsening fatigue, and you can’t get into your regular practice, then by all means, come in!

Is Chapped Lips An Emergency?

One of last year’s fun news stories was a 911 call from a man whose cat wouldn’t let him in his house.  After a three hour stand off, and after the police and 911 operator finished laughing themselves silly, an officer was dispatched and apparently talked the cat down.

Similar absurdities happen in Emergency Medicine.  Once when I worked in Baltimore, a mom brought her child in for chapped lips.  Thinking that no one would come to the ED for such a minor thing, I searched for the “hidden agenda,” some underlying worry explaining mom’s thinking.  Like if her Uncle Frim had lip cancer and she feared her son had it too. However, after an exhaustive history, there was no such issue: her son simply had chapped lips.

It’s sometimes difficult telling the public when to call 911 or not, and when to bring kids to the Emergency Department or not.  We want to encourage people to get emergency help so they don’t blow off potentially serious issues.  On the other hand, we don’t want the Emergency Department and EMS systems clogged with non-emergencies.

Most pediatric ED visits are not emergencies, but families come for many reasons. First, parents get scared for their kids.  They love their kids and when they get sick or hurt, parents sometimes rush for help rather than call their doctor for advice or wait for an appointment.

Often parents can’t get their kid seen in the office that day.  An appointment for next week doesn’t help when your child won’t stop vomiting, or needs x-rays.  Sometimes when the parent does call for advice, the mom is told to go to the ED, rather than office staff taking time to talk the situation through, giving advice that could keep the child home.

Sometimes when a child gets sick or hurt, a doctor’s office or school is worried about caring for a potential emergency.  They aren’t used to emergencies and don’t want to miss something, or get sued.

Almost daily we see kids in the Emergency Department who were in car crashes, seem fine, but the parents want them “checked out.”  You can’t fault this reasoning; they care about their kids and are worried.  However, when the “crash” involves cars backing into each other in a parking lot, and the child was strapped into a car seat, maybe an ED visit is overkill.  Unless the lot has cars speeding into their slots like the Indy 500 pit stop.

Too often the ED is used as a walk-in clinic, rather than for true emergencies.  The point of this blog is to inform you about what real emergencies are, what can wait to see the doctor, and what you can take care of at home.  So let’s review common issues appropriate for the ED, and things that are not emergencies.

Kids who are short of breath, tugging to breathe, belong in the ED.  Of course bring any children with possible broken bones, cuts that need stitches or won’t stop bleeding, or severe pain. When kids get lethargic (difficult to arouse), they need to get seen.  However, there are gradations of cuts and limb injuries, and lethargy: kids with fever get lethargic, but recover with anti-fever medicines.  If it isn’t obvious if it’s an emergency or not, call the doctor’s office.  If they can’t help, go to the column in this blog to the immediate right side of the page.  Click on your issue to read specifics about what is an emergency, and what can be handled at home.

Things that are commonly not emergencies: fever, coughing, rashes.  Fever doesn’t hurt kids- it doesn’t cook their brains and is rarely associated with seizures.  The height of the fever doesn’t correlate with how sick the kid is either: a child with a 104 temperature isn’t sicker than a child with 101.  Coughing also isn’t an emergency- kids cough when they get colds and if they aren’t otherwise short of breath, it can wait.  Again, see the column to the right.

This is a busy time of year for the Pediatric Emergency Departments, so use common sense when deciding to visit.  Use your doctor’s call line, or this blog when in doubt.  But if you still can’t decide, bring your child in. Better safe than sorry, but you can leave the chapped lips at home.

Non Emergencies in the Emergency Department

I walk into the room, introduce myself, and ask my usual lead-in question: “When did things first start going wrong?”  The mom answers “She started with this rash last night, and this morning it has spread all over.  Just look at it!”  The mom yanks up the toddler’s shirt and sweeps her hand to show me the extent of the child’s scourge.

And the child’s skin looks….normal.  I put on my reading glasses and peer closer.  Still, I am hard-pressed to identify anything that could be remotely called a rash.  The mom offers: “Its those bumps that worry me.”  Ah yes, I can see that the child’s skin has tiny bumps that at first you don’t notice, but alter the skin’s texture a little bit.  I straighten up, complete the rest of my history and physical, and inform the mom that no, the child does not have measles or chicken pox or flesh-eating bacteria, but a dry, irritated skin condition called eczema.  A change of soap, more lotion, and it should be fixed up in a few days.

Winter is a busy time in the Pediatric Emergency Department.  Bronchiolitis makes babies cough, influenza makes all ages feel and look miserable, and asthmatics wheeze.  Kids are kept indoors by the cold and cough on each other and spread the contagion.  Emergency Departments and doctor’s offices are filled to the brim with sick children.  And then everybody waits longer to see the harried practitioners.

The majority of theses illnesses involve coughs and fevers.  Fevers and coughs are not emergencies, and there are some simple things to know that can keep you from having to wait for hours in the Emergency Department or at your doctor’s.  Fever itself is not an emergency.  Fevers do not harm your child- they do not cook kid’s brains and they rarely cause seizures.  Fever is actually one of the body’s natural mechanisms to fight illness- fever is a good thing!  When your body senses that you are sick, it sets your brain thermostat higher.  The higher body temperature makes it harder for infection to grow in you, and your immune system can get on top of the infection.

What is more important with fever is how the kid is acting with the fever.  Certainly the child will be tired and miserable, but that is easily treated with medicines like ibuprofen (motrin, advil) or acetaminophen (tylenol, pediacare).  As long as your child is drinking some, breathing comfortably, and is mentally “with it,” your child is doing okay. Most fevers are caused by viruses that will pass in a few days without need for a prescription.

Likewise, most coughs are not emergencies.  Sure, coughs are irritating, particularly at night when everyone wants to go to sleep.  But as long as the child is breathing comfortably, then home remedies are as good (or better!) than any prescription.  Put your kid to bed with their his head elevated, get the vaporizer going next to the bed, put on some Vicks-Vaporub.  Give some ibuprofen or tylenol to ease that scratchy throat.  Don’t waste your money on cough syrups- science has shown over and over that they don’t work.

There is no prescription that reliably helps coughs either.  Everyday I get parents who ask for a prescription for colds.  As I tell them, no one has invented any medicine that helps dry up runny noses or suppresses cough.  Doctors sometimes prescribe anti-histamines, codeine, or other things, but these medicines rarely help and often cause more trouble than they are worth.  They can make a child more awake and antsy and irritable, and the kid still coughs!

So please don’t be like the mom above and rush to the Emergency Department when your child has a rash or a fever or a cough.  We are busy enough with the children who are lethargic or working hard to breathe, with kids with broken arms and head injuries and lacerated faces.  Long lines of the non-emergent just makes everyone wait longer, only to be told the things that could have been done at home.  If you are not sure, call your doctor to see if you should come to the office or come to the ER.  Do your part to keep non-emergencies out of the Emergency Department.



The ER Is NOT for Colds and Diaper Rashes!

It is a busy time of year for us in the ER business.  Besides the usual injuries and illnesses, people fill the ERs in the evenings with worries that are NOT emergencies.  The waiting rooms are clogged with milling crowds, often irate because of long waits, passing germs to each other, and most of those people could have stayed home and been fine. 

Why are our evenings so busy?  People get off work, come home to a sick child; now the doctor’s office is closed, so they bring the sick child (no matter how minor the illness) to the ER.  Also, there is something about when the sun goes down that increases people’s worries.  Minor illnesses are blown up to big worries in parents’ minds at night.  Doctors’ phone services are also to blame.  When some parents call their doctors at night, rather than go into a thorough conversation that can figure out the problem and help the family stay at home, the doctor or nurse just say “go to the ER.”

Here is a list of minor illnesses that should NOT be brought to an EMERGENCY department.  When families with these complaints check in, other childrens’ care will be delayed while we wade through these non-emergencies: rashes (especially diaper rashes!  In an Emergency Department?!), fever, cough and runny nose, sprains that the patient can walk on, car accidents that happened on a previous day, toothaches, pregnancy tests, diarrhea, vomiting only once or twice or less than a few hours, pink eye, pinworms, ear pain, sore throat.  All of the above should wait to see your regular doctor the next day.

Here are some of the emergency versions of the above: shortness of breath, fever with worsening fatigue, abdominal pain with worsening vomiting and poor drinking, fever in a baby less than 3 months old, injury with deformity or inability to walk, worsening headaches with any of these. 

This evening, do yourself and your ER workers a favor: call your doctor before coming to the crowded ER and waiting hours, if you are not sure if your child’s condition is an emergency. 

 Also, you can look to this blog to read about common illnesses and injuries, and how you can take care of things at home (look to the Categories column on the right side of this page).  All the entries here talk about what can be taken care of at home, and how, and what makes your child’s problem a real emergency.