Under ideal circumstances, every one of the nation's 5,000-plus emergency rooms would be staffed with pediatric emergency medicine specialists -- they receive three years of pediatrics training and three more years of education in child-specific emergency medicine. But only 50 to 55 specialists graduate annually, not nearly enough to go around. So who's on the job? "It depends on where you go," says Sigmund Kharasch, M.D., director of pediatric emergency medicine at Boston Medical Center. "Almost all children's hospitals and some community ones in large cities employ pediatric emergency medicine specialists, but more often, a board-certified emergency medicine physician mans the ER in community hospitals. In some hospitals, it may even be a moonlighting internist, who has little training in either kids or emergencies."
Board-certified emergency medicine doctors -- the type children are most likely to encounter in the ER -- spend, on average, just 13% of their training on pediatric care, even though kids make up 34% of their caseload, according to a recent survey of 118 emergency medicine residency programs by the Society for Academic Emergency Medicine.
The group also found that a third of program directors are "not very confident" or "definitely not confident" of their residents' exposure to resuscitation techniques for newborns, and about 1 in 10 have doubts about the ability of residents to handle pediatric trauma. "After my training, I did not feel comfortable treating very sick children," confesses Dr. Cohen, a father of three. "Much of what I learned was from studying the medical literature on my own and being on the job."
And if some emergency medicine doctors feel uneasy, imagine the knowledge gap of a physician who is only moonlighting in the ER. When Keisha Wade took her 6-month-old daughter, Zakyra Hall, to the ER at Henry Ford Cottage Hospital in Detroit because she was having trouble catching her breath, a doctor who lacked emergency medicine training examined her. He practiced pediatrics, although in a deposition taken for the case, he admitted to failing board certification in the specialty five times. And government documents show that he was released from active duty in the Air Force for "failure to exercise due care" in eight pediatrics cases while working at a military hospital in Maine.
Of course, Wade couldn't check out the doctor's track record at the time. According to her attorney, Brian J. McKeen of McKeen & Associates in Detroit, who won a $55 million malpractice lawsuit in the case, the doctor didn't perform a complete physical exam, run any tests, or take a detailed history even though the medical records state Zakyra was "gasping for air" and she had been admitted to the hospital's main campus the previous week. He just gave Wade instructions for medication and sent her home.
When Zakyra's condition worsened the next day, Wade decided to take her back to the ER; on the way, the infant went into respiratory arrest. By the time she reached the hospital, her brain had been deprived of oxygen for about 15 minutes, causing cerebral palsy and mental retardation. Doctors discovered that Zakyra had rickets, a deficiency of vitamin D, plus she likely had suffered from respiratory syncytial virus, an infection that can lead to apnea -- a condition in which breathing stops temporarily. "Zakyra will need constant medical care for the rest of her life," says McKeen. "At the trial, experts testified that if she had been treated properly, she would likely be a healthy 5-year-old now."
Doctors aren't the only ER staff who desperately need better training. Just 25% of nurses who care for children in New Hampshire hospitals are certified in Pediatric Advanced Life Support. Although no recent national figures exist, "25% is probably better than most states," says Dr. Kharasch. And even less qualified staff may handle triage (where kids are categorized by the severity of their illness), a task that was once reserved for registered nurses. "I'm investigating a case where an emergency medical technician triaged a 6-month-old baby as being low-risk," says McKeen. "The infant stopped breathing in the emergency room lobby. When I took the technician's deposition in the case, he was working as a carpenter."
Seven sizes of breathing masks hang on a child's examining room wall at Robert Wood Johnson University Hospital in New Brunswick, NJ. The Disney-themed room also stocks scaled-down resuscitation equipment, three sizes of blood pressure cuffs, and two sizes of ear speculums. The reason: "We care for newborns to teens. How could they use the same equipment as one another, let alone adults?" asks Thomas Bojko, M.D., director of operations and critical care. "For instance, the breathing mask has to fit snugly around the face so all the air can reach the lungs. Using the wrong size mask can be life-threatening."
But what seems obvious to Dr. Bojko is anything but at some community hospitals. "Some doctors who are transferring a child can't give me a blood pressure reading because they don't have a pediatric cuff," says Joseph Wright, M.D., a pediatric emergency medicine specialist at Children's National Medical Center in Washington, DC.
Last year, the American Academy of Pediatrics (AAP) issued updated guidelines for the care of children in the emergency department. They included a list of more than 50 kinds of kid-related equipment and supplies that ERs should stock. But no one's mandating that hospitals do so. So are they? It's questionable.
A survey sent to 101 ERs in 1998 and 1999 found that 43% lacked infant cervical collars, used in spinal injuries. Overall, though, most ERs claimed that much of the necessary pediatric equipment was on hand. Still, no one checked to make sure. In a similar study, doctors at Montreal Children's Hospital in Canada surveyed 737 Canadian ERs and visited 38 to verify the accuracy of the responses. The result: Eight of the nine types of equipment examined weren't as available as hospitals claimed. In the survey, 24% of hospitals admitted that they didn't have intraosseous needles (used for giving IVs to infants), but during the visits, 38% of hospitals lacked them; 11% indicated they didn't have infant blood pressure cuffs, but 16% were missing them.
When her son Jamie started vomiting, Stacy Berger took the 1-year-old to an ER near Palm Beach, FL. "We waited for five hours and there wasn't one toy," she recalls. What's worse is that the doctor rushed the exam. "He wanted to switch the antibiotic Jamie had been taking for an ear infection and send us home," says Berger. "But he had taken that drug before without problems. I felt there was something more." So Berger pushed -- and the doctor ordered a chest X-ray. It turned out that Jamie had pneumonia.
Miffed by the visit, Berger blasted the hospital in a survey. Shortly afterward, an administrator called for more details. "He assured me things were going to change," she says. They did: When Jamie returned to the ER over a year later, it was wonderful, Berger says: "The hospital had a pediatric ER filled with books and toys. Plus, the staff seemed more thorough."
Berger's strategy was a wise one, says Dr. Shook: "Improving emergency care is a battle for parents to join." If you're eager to make a difference in your area, here's your mission:
Check out the EMSC's Web site, www.ems-c.org, to see if your state has pediatric equipment or training guidelines. Inform your legislators of any shortfalls. Ask them to look into the matter and introduce bills to plug the gaps.
Chances are, she's in the know. Ask her about ways to improve the system locally.
Why? "Hospital administrators have no idea what's going on with children in their ERs," says a pediatrician who requested anonymity. "There is little energy or money left over after the needs of adults, and BS fills in the void of pediatric care." A few weeks after mailing the letter, call to request a meeting to address the issues. Getting nowhere? Threaten to alert the local news. And, if need be, do it. You can improve ER care -- even if it's one hospital at a time.