Let's keep discussions regarding care of children in EDs at a higher plane in
1998. EM and Peds EM are different specialties now than when we all started
years ago - whether we were doing it 20, 10, or even 3 years ago; whether we
were doing it while walking barefoot to school or a time when we never had a
day off in residency, etc, etc.. We all have anectdotes of mishandled cases -
by EPs and pediatricians alike. It gets everyone nowhere to harp on the bad
What I would like to know, is what is everyone is doing about raising the bar
with regard to the standard of pediatric care in their EDs? Do you call the
referring physician (pediatrician or EP) with f/u for less optimally handled
cases as well as the properly handled ones? If you do nothing but grouse
about "those guys", you have failed to improve the lot of the next child who
they may come in contact with. We all have been doing this long enough to
know (1) we are not perfect and (2) we all can benefit from a collegial, "Hey
doc, did you happen to consider...?" rather than an accusatory f/u like, "hey,
you dumb..., why didn't you..." - whether it is to our face or behind our
It is so ridiculous at times that I have some partners who think that some of
our pediatricians are waiting for us to make mistakes so they can swoop in and
say, " See, I told you so....those EPs don't know squat about kids" rather
than making themselves available to express their concerns or improve
standards of care.
Facts: (1) there will never be enough pediatricians or Peds EPs or $$ to hire
them - to see all the kids in EDs (2) the majority of experienced EPs out
there are doing a good job day in and day out caring for kids (3) Peds EPs
have expertise and insights that all EPs could benefit from and would welcome,
if NOT done in a pejorative manner. (4) almost all groups I have encountered
would like a Peds EM expert in their group to help them upgade their skills
and allow them to continue seeing children, often 30-35% of their practice.
I'm not sure the 3 year fellowship is going to help meet this "market demand".
So...we need to figure out ways to: (1) market the skills of peds EPs to
general EM groups without scaring the public or giving the impression that
EPs do not know how to take care of kids
(2) universally improve ED standards with regards to clinical pathways, nurse
staffing, and equipment so that in the majority of pediatric emergencies, kids
will receive a minimum standard of care that we all feel comfortable with.
Nursing is an element of this equation that is almost always overlooked. An
experienced peds EM nurse is invaluable.
Dr. Herman, siting your example regarding the dehydrated kid who arrived with
D5W: putting staffing EP vs Peds EP aside, a standard protocol, widely
distributed, clearly stating that all children with hypooperfusion or
dehydration needs boluses of crystalloid would be of much better service to
all children rather than discussing the merits of Peds EPs vs. EPs. We need
to figure out how to do this without appearing to create cookbook medicine.
How to raise the standard of care...for everyone?. APLS is one forum in which
we can do it. We need more of these courses..EPs appreciate them and Peds EPs
are critical faculty for these courses. As an EP and Peds EP, I feel that we
all spend too much time teaching PALS and not enough time promulgating APLS -
a much more germaine course to EM. The third edition is coming out in a few
months and is expected to be much improved.
Enough for now..
Have a good week everyone!
Mike Gerardi, MD
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