The Critical Child in the Community ED
The Critical Child in the Community ED
Authors:
Alfred Sacchetti, MD, FACEP, Chief Emergency Services, Our Lady of Lourdes Medical Center, Camden, NJ, and Assistant Clinical Professor, Emergency Medicine, Thomas Jefferson University, Philadelphia, PA
Khoshnood Ahmad, MD, FAAP, FACEP, Medical Director, Pediatric Emergency Department, K. Hovnanian Children's Hospital at Jersey Shore University Medical Center and Ocean Medical Center, Brick, NJ
Peer Reviewer:
Ron Perkin, MD, MA, Professor and Chairman, Department of Pediatrics, The Brody School of Medicine at East Carolina University, Greenville, NC
Editor's Note: The critically ill or injured child presents both a diagnostic and therapeutic challenge to any Emergency Department. Vascular access, airway management, fluid therapy, invasive procedures and medication selection all must be coordinated and delivered in a time-sensitive manner. In the best of circumstances all of these essential actions can be distributed and coordinated by a resuscitation team of emergency personnel, consultants, and critical care associates. Physicians in community EDs face a unique situation. This article will address the challenges that face the community-based emergency physician in the care of the critical child.
The Editor
Tertiary Care vs. Community Care
Emergency Departments, and more to the subject of this article, the facilities that house them, represent a spectrum of available resources. At one end of this spectrum are Tertiary Care Pediatric Centers (TCPC) such as children's hospitals or university-housed pediatric centers; at the other end are community hospitals.
The first difference between these sites appears in their accessibility. Tertiary centers, by their very nature are isolated geographically. This does not mean that they are not in populated areas; in fact, most tend to be positioned in densely settled metropolitan areas. However, they are relatively isolated from most of the population of the country. The vast majority of children in the United States live more than 100 miles from any TCPC. In contrast, community hospitals, as the name implies, are located in geographic communities that are within relatively easy traveling distance for most children. This distinction does ignore those rural residents who are not within close proximity to any medical facility, although children in these areas typically will live closer to a community hospital than a tertiary center. There also are fewer tertiary centers than there are community hospitals. As a consequence, critical children are much more likely to present for their initial care to a community ED than to a tertiary center, leading to most critically ill or injured children requiring stabilization in a community ED before a secondary transfer to a TCPC.
Interestingly, in a computer model of pediatric pre-hospital care, initial transport of a critically ill child to a community hospital provided more rapid stabilization than direct transport to a tertiary care pediatric center.1 In addition, community emergency departments appear to treat sicker children than tertiary care EDs. In a review of pediatric ICU admissions, children transferred from community EDs were more likely be endotracheally intubated and require blood pressure support compared to those admitted to the PICU from the tertiary care center's own ED.2 In another study, those patients transferred from EDs to PICUs from community hospitals tended to have better resource utilizations and shorter ICU lengths of stay than those transferred from hospital wards, implying that the care these children received was excellent.3
The second distinction between these two types of facilities can be found within the available support personnel. In a TCPC, there are multiple redundant resources to accomplish any stabilization procedure. If a critical child requires endotracheal intubation in a TCPC, an emergency physicianmost commonly a pediatric emergency physician, an anesthesiologist, a pulmonologist, an otolaryngologist and at least one intensivist plus their fellows or residents generally will be readily available. At a community hospital, particularly during off hours, the emergency physician may be the only clinician available to perform the intubation. It is this reliance on an isolated emergency physician that most distinguishes the community ED from the tertiary care center. As a result, the lower the capabilities of the housing facility, the greater the capabilities of the ED need to be. Expressed another way the ED capabilities are an inverse function of the hospital's capabilities. Despite this difference in resources, the community hospital ED is expected to produce the same patient outcomes as the TCPC.
Table 1. Recommended Supplies for EDs Caring for Children
Essential Pediatric Equipment
Patient warming device
Intravenous blood/fluid warmer
Restraint device
Weight scale, in kilograms only
Tool or chart that incorporates both weight and length to assist in determining equipment size and drug dosages
Pain-scale assessment tools
Blood pressure cuffs (neonatal, infant, child, adult-arm, and thigh)
Doppler ultrasonography devices
Electrocardiography monitor/defibrillator with pediatric and adult capabilities
Hypothermia thermometer
Pulse oximeter with pediatric and adult probes
Continuous end-tidal CO2 monitoring device
Endotracheal tubes (size 2.5 mm to 8.5 mm)
Feeding tubes (5F and 8F)
Laryngoscope and blades (sizes 04)
Magill forceps (pediatric and adult)
Nasopharyngeal airways (sizes 05)
Stylets for endotracheal tubes
Suction catheters (infant, child, and adult)
Tracheostomy tubes (sizes 2.5 mm5.5 mm)
Yankauer suction (adult and pediatric)
Bag-mask device with appropriate sized masks (infant, child, and adult)
Nasal cannulas (infant, child, and adult)
Nasogastric tubes (8 F18 F)
Laryngeal mask airway (sizes 1, 1.5, 2, 2.5, 3, 4, and 5)
Arm boards
Catheter-over-the-needle device (24-14 gauge)
Intraosseous needles or device
Intravenous catheteradministration sets with ability to regulate rate and volume
Umbilical vein catheters (3.5 F and 5.0 F)
Central venous catheters (4.0 F7.0 F)
Intravenous solutions to include: normal saline, dextrose 5% in normal saline, and dextrose 10% in water
Extremity splints, including femur splints (pediatric and adult sizes)
Spine-stabilization method/devices appropriate for children of all ages
Lumbar puncture tray with spinal needle (sizes 22-18 gauge)
Difficult airway kits to include jet insulator
Tube thoracostomy tray and chest tubes (sizes 8 F40 F)
Newborn delivery kit
Urinary catheterization kits and urinary catheters (6
To help determine what capabilities an ED requires to effectively treat children, the American College of Emergency Physicians, the American Academy of Pediatrics, and the Emergency Nurses Association issued a joint policy statement titled "Guidelines for Care of Children in the Emergency Department." This paper is designed to provide direction for any emergency departments caring for children and can be found on the websites of all three parent organizations.4 The Policy Statement is a consensus document that includes guidelines on staffing, performance improvement, patient safety, policies, equipment, and medications and provides an excellent blueprint to help any department prepare for an acutely ill or injured child. This document is particularly useful for institutions that possess no inpatient pediatric facilities. In these circumstances the ED must be able to function independently in its ability to care for children and may be forced to lobby for supplies or drugs that have no utility elsewhere in the hospital. Table 1 contains a summary of the supplies recommended in the guidelines and Table 2 contains a summary of the recommended medications.
Table 2. Recommended Medications for EDs Caring for Children
Essential Medications
- Activated charcoal
- Amiodarone
- Anticonvulsant medications
- Antidotes
- Antihistamines (H1 and H2)
- Antiemetic agents
- Antimicrobial agents
- Antipyretic drugs
- Atropine
- Bronchodilators
- Calcium chloride
- Corticosteroids
- Dextrose*
- Epinephrine (1:1000)
- Epinephrine (1:10,000)
- Inotropic agents
- Lidocaine
- Magnesium sulfate
- Naloxone hydrochloride
- Neuromuscular blockers
- Procainamide
- Sedatives
- Sodium bicarbonate*
- Topical, oral, and parenteral analgesics
- Vaccines
*Indicates medications with both pediatric and adult preparations
Modified from "Guidelines for Care of Children in the Emergency
Department"
In addition to equipment and medications, specific diagnostic studies may be limited in a facility with no pediatric inpatient service. For example, even if microsampling techniques are not required elsewhere in the hospital, they still need to be available to the ED. If the laboratory is not going to provide these services, then a capillary analysis device may be required for the ED.
Although all of the equipment contained in the Joint Policy Statement should be considered essential, a number of devices are worth emphasizing since they can mean the difference between a successful or failed resuscitation.
The Policy Statement requires some form of endotracheal (ET) intubation confirmation device, which may include either a colormetric cap for the ET tube or a quantitative waveform capnometer. For the community hospital, there is no justification for the use of any device other than a formal capnometer. These devices affix to the end of an endotracheal tube and sample the exhaled breath for carbon dioxide. Capnometers may measure the CO2 in line directly where the adapter attaches to the ET tube or they may suction off a small stream of gas from the adapter and measure the CO2 within the monitor itself. These two different variations are appropriately termed either "inline" or "side stream" capnometers. Both versions of the capnometers are equally effective for the needs of the emergency physician. Figure 1 contains a photograph of an inline capnometer in place on an intubated premature delivery in the ED.
Figure 1. Inline Capnometer in Place on Premature Newborn in ED
Capnometers also contain a monitor screen that presents a waveform of the exhaled carbon dioxide as well as a quantitative peak end tidal CO2 level.
As an endotracheal intubation confirmation device, waveform capnometers are more sensitive than colormetric devices. They can detect the lower levels of carbon dioxide that may be present during cardiac arrests and hypotensive states. They also are more responsive than other devices, providing definitive differentiation between esophageal or endotracheal intubation with a single breath in low or no flow states.
Capnometers also provide breath-to-breath feedback on the ventilatory status of an intubated child. Because the measured end tidal carbon dioxide level correlates very closely with the arterial pCO2, the resuscitation team can avoid both hypo- and hyperventilation. This feedback can be invaluable in an infant or neonate. If the child is being hand ventilated, then the individual doing the bagging can determine objectively if the child is receiving too high or too low of a minute ventilation. Once the child is placed on a ventilator, the physician can adjust the ventilator settings without the repeated time-consuming arterial punctures needed for arterial blood gases. In addition, continuous capnometry provides immediate notification if the ET tube is dislodged.
Laryngeal mask airways (LMA) are another potentially life-saving device that should be available to the ED. No physician, regardless of how talented, can be certain to successfully complete every endotracheal intubation. The LMA provides a viable alternative airway for even the smallest of children and as such should be readily available to any community ED. These devices need not be housed in the ED but should be readily available from the operating room or nursery if required. Full kits of disposable LMAs, including sizes 1, 1.5, 2, 2.5, 3, 4, and 5, are commercially available for under $100.
Vascular access in children can present another challenge to any ED treating children. In the stable child with difficult IV access, sub-cutaneous infusions are possible with hyaluronidase pre-injections.5,6 In children in extremis, intraosseous needle insertions will permit both fluid and medication administration. For those other children in whom intravenous access is preferred, a transilluminator or vein detector can be valuable. These devices permit location of veins not visible or palpable under normal ambient lights. Figure 2 depicts a transilluminator. In a transilluminator, a high-intensity visible light source is projected through a fiber optic cable. The tip of the cable is placed on the palmer surface of the child's hand or plantar surface of the foot, effectively transilluminating the extremity and outlining the venous collecting system. In the vein detector (see Figure 3), an infrared laser is projected onto the skin surface. The deoxygenated blood of the peripheral veins absorb the line and appear as dark lines through the patient's skin, regardless of the patient's skin color.7,8
Figure 2. Transilluminator in Place on Infant's Hand
Figure 3. Infrared Vein Viewing System Outlining Venous Plexus on Dorsum of Hand
Specific pediatric radiographic or ultrasound studies also may be limited in non-pediatric centers. In these circumstances the ED will need to have some form of an over and back arrangement with an institution that does provide pediatric disease-specific diagnostics. For example, ultrasound evaluation for intussusception is a procedure that many community hospitals may not perform, yet it may be an essential study for an emergency physician to differentiate a viral infection from an abdominal emergency in an infant.
In hospitals that do not provide such studies, it may be tempting to rationalize away the presence of a disease when faced with difficult access to a specific diagnostic study. This is more likely when the ED staff must invent a means to obtain the test de novo each time it is needed. Formalizing such processes in advance is the best way to avoid missing a diagnosis in a child because of lack of access to an infrequently used study.
Maintenance of pediatric clinical skills in a facility that has few pediatric ED visits can be source of anxiety for emergency practitioners. What most emergency physicians should realize is that critically ill children are relatively rare in all emergency departments. Even large pediatric centers routinely do not encounter children in extremis to the extent that general emergency departments encounter critically ill adults.9 More importantly, most of the clinical assessment and procedural skills used in the care of adult patients readily translate to the care of children.
Despite mantras to the contrary, children really are just small adults. Variations in vital signs exist and there are some minor anatomic differences that need to be kept in mind, but the similarities far exceed any age-related differences. When all is said and done, it is not as if children are tadpoles and adults are frogs. General emergency physicians routinely consider physiologic and physical differences between adult patients when making management decisions. The anatomy of a 36-week gestation woman is certainly different than that of a 25-year-old male; the cardiovascular system of an 80-year-old does not compare with that of a 30-year-old and most bipolar patients are more psychiatrically diverse than any adolescent. Given the wide variations in patient characteristics that general emergency physicians encounter, patient age should be regarded as another modifier in the management decisions to be considered. Emergency physicians certainly should not be intimidated by the unique anatomic or physiologic differences found in infants and small children.
Another critical aspect addressed in the "Guidelines for Care of Children in the Emergency Department" is simple steps to improve the safety of children in any emergency department. All children should be weighed in kilograms and the weight recorded in a prominent place on the medical record. If the emergent stabilization of the child does not allow for a weight, then a length-based system should be available to estimate the child's weight. Infants and children should receive a complete set of recorded vital signs and a process should be in place to identify any abnormal vital signs for age and the physician notified. The use of precalculated dosing guidelines should be available for children of all ages.
In addition, policies, procedures, and protocols should be developed and implemented. Table 3, modified from the "Guidelines for care of Children in the Emergency Department," includes a list of potential policies to be considered for pediatrics.
Table 3. Policies, Procedures, and Protocols for Children in the Emergency Department
- Illness and injury triage
- Pediatric patient assessment and reassessment
- Documentation of pediatric vital signs, abnormal vital signs, and actions to be taken for abnormal vital signs
- Immunization assessment and management of the underimmunized patient
- Sedation and analgesia for procedures, including medical imaging
- Consent (including situations in which a parent is not immediately available)
- Physical or chemical restraint of patients
- Child maltreatment (physical and sexual abuse, sexual assault, and neglect) mandated reporting criteria, requirements and processes
- Death of the child in the ED
- Do-not-resuscitate orders
The Lonely Emergency Physician
Community emergency medicine is unique in that it is the only practice environment in which a single physician is required to manage a dynamically changing department of patients. This solitary model requires the physician to multitask within the care of a single patient as well as between the management of other department patients. Limited options exist to delegate patient assessments, stabilization procedures, and even monitoring in these circumstances. Because of this, the care of a critical child in the community is much more aggressive than that required in a tertiary care center.
In a tertiary care center, a critical child may be observed by a team of physicians comprised of pediatric emergency physicians, intensivists, and hospitalists. This form of management is not available in the community ED. With only one physician available to perform any stabilization procedures or intervene if a child suddenly deteriorates, observation is not an option. The community emergency physician must make an estimation of the child's clinical course and complete any essential procedures if a worst-case scenario is anticipated.
Earlier initiation of procedures has a number of advantages in the care of these children. The most important advantage of early completion of the stabilization procedures is that it extends the number of clinicians in the department able to care for a child. With a critical child, a physician working in single coverage may be forced to hover in close proximity to the child. An infant with a tenuous respiratory status cannot be left simply with an ED or respiratory technician for observation. Such a patient would command almost continuous attention from the lone physician or a dedicated nurse. Instead, if the child is intubated endotrachealy with stable ventilator settings, then the physician would be free to attend to other issues either with the child or within the department.
This concept is termed management from a distance. The premise is to complete every indicated diagnostic and therapeutic procedure on the patient during the initial patient encounter. Once this is accomplished, the managing physician can respond to any diagnostic results or changes in status from any point in the ED. Obviously, this does not replace frequent direct evaluations of the critically ill patient. However, in the event of multiple simultaneous critical patients, the physician can at least manage one from a distance.
Another advantage of more aggressive care is that it facilitates the turnaround time of a transport team. The entire goal of the transfer of a critically ill child is to deliver that child as rapidly as possible to a pediatric intensive care facility where all the resources of the tertiary care center can be brought to bear on the child's problems. To this end, the more stabilizing procedures the transferring ED completes, the fewer that need to be completed by the transport team and the shorter the on scene time. For example, if there is a possibility that a lumbar puncture (LP) needs to be performed prior to administration of antibiotics, then the LP should be performed as soon as it is considered. Completion of the LP will prevent the transport team from being delayed on scene to complete the spinal tap.
In the situation in which the procedure is a potential stabilization procedure, a more aggressive approach lessens the risk that a transport team will need to attempt the procedure while in the ambulance should a child's status change suddenly. Almost any emergent procedure from vascular access to endotracheal intubation is more likely to be completed successfully in the ED than in a transport vehicle
In some circumstances, an emergency department may delay performance of a procedure out of fear. Physicians may justify holding off on attempting a procedure by arguing that the patient is likely to turn around if given just a little more time to be observed. It is understandable that any physician may be intimidated by a critical procedure in any patient; however, delaying the inevitable only will place the entire resuscitation at greater risk of failure. In fact, earlier attempts at procedures actually will lessen the risk of complications in emergency departments that have less confidence in their abilities. An excellent example can be seen in a comparison of conservative and aggressive approaches to endotracheal intubation in a child with respiratory distress who appears to be fatiguing (See Figure 4). The physician can attempt the procedure when the child is still adequately ventilating on his own, in which case the pH may be 7.25, oxygen saturation 94%, and the pCO2 60, leaving a sizable reserve should the procedure be more difficult than expected. If the intubation attempt takes 15 minutes to complete, the child's ventilatory status may deteriorate to a pH of 7.1, oxygen saturation to 85%, and the pCO2 to 80, which is not ideal but still is well within the physiologic range. However, if the physician delays until the intubation is unavoidable, the starting pH may be 7.0, oxygen saturation 85%, and the pCO2 90, leaving little margin for any difficulty with the procedure. If the procedure takes that same 15 anguished minutes, then the resulting pH at completion will be below 6.80, oxygen saturation 50%, and pCO2 greater than 100, parameters that could lead to cardiac arrest in an already stressed child. ` graphically contrasts these two approaches.
Figure 4. Graphic Representation of Physiologic Status Comparing Early and Delayed Initiation of Endotracheal Intubation Attempt
Every clinician's skills change over time. Surgical and endovascular organizations have developed guidelines linking outcomes with operator or hospital volumes implying that clinicians require a certain number of cases to maintain proficiency. Not only has this never been documented for ED procedures, but more recently, studies have begun to challenge the validity of this entire premise in those surgical and endovascular fields.11,12 Most community emergency physicians routinely treat pediatric patients and consider pediatric stabilization procedures part of their defining skill sets. But whether an ED has a large pediatric census, or rarely treats children, emergency physicians infrequently perform invasive procedures on critically ill children in their daily practices. Fortunately, the community emergency physician can extrapolate from their adult critically ill patients to their care of children. General emergency physicians who treat pediatric patients are well aware that a linear correlation does not exist between infants, children, and adults, but the overall approach to most critical procedures is age independent. As such, community emergency physicians should not be intimidated when contemplating any procedures in a pediatric patient.
This same aggressive management of stabilization procedures in critically ill children also should be applied to their medical management. Since the critically ill child must be transferred from the department, it is important for the treating physician to address as many medical issues as possible before the transport process. Volume status, electrolyte abnormalities, arrhythmias, pressor requirements, and seizure control all should be aggressively managed as part of the child's initial stabilization.
The obvious indication for such an approach to the critically ill child is rapid reversal of the presenting pathologic condition. However, there are a number of other advantages in this management style.
As with performance of procedures, the more rapid medical stabilization of a child frees the single coverage emergency physician to address other responsibilities. Early initiation of medical interventions identifies management problems by uncovering either failed treatments or additional complications. The earlier in the care of a child a treatment is attempted, the sooner its efficacy will be known. It is much better for a physician to realize that a medication is not going to be effective when there is still time to try another option with the child still in the department. Similarly, it is better for a complication related to a particular medical intervention to appear with the patient in the ED than between facilities in a transport vehicle.
Early aggressive medical management also will permit the treating emergency physician to engage a consultant further down the management pathway by identifying non-viable treatment options. For example, in a child with status epilepticus, if the emergency physician already has administered the maximum dose of lorazepam and phenytoin before the consult is reached, then the conversation can focus on newer medication options. The consultant in this case would not need to waste time leading the emergency physician through some of the earlier more basic treatment options that failed.
As with performance of procedures, successful medical stabilization also will shorten the turnaround time of the transport team.
In summary, the lack of observation as an option dictates a much more aggressive management approach to the critical child in the community ED.
Transfer of a Patient
At some point in the care of a child, a decision may be needed to transfer the patient to another facility with a higher level of care. The exact timing of such a decision will depend on the inpatient pediatric capabilities of the community hospital. Regardless of when the determination is made, at some point the emergency department clinicians must make arrangements to transfer the child.
The first logistical issue to be resolved is where the child is to be transferred. If transfer agreements exist with a tertiary care facility, then this decision is predetermined. If no such contracts are in place, then the emergency physician will need to select a facility to contact for the transfer. Obviously, the receiving facility must have the capabilities to care for the child's specific problem. Insurance coverage may play a role in the selection of the receiving hospital; however, the particulars of how facilities determine medical coverage and participation in a given insurance plan is a subject that not even Congress has been able to resolve and will not be discussed here.
Once a receiving hospital has been identified, the transfer process can be initiated. Multiple models exist for the transfer of patients from one emergency department to another medical center.
For receiving hospitals that serve as tertiary referral centers, a dedicated transport center frequently exists. The transferring physician contacts the center and presents the particular case to a nurse or physician. In other models, an emergency physician serves this role and is the initial contact for the receiving hospital. Regardless of who is the entry person, there is usually a step in the process in which a determination is made if an appropriate bed is available along with an accepting specialty physician. Sometimes, this can be the most time-consuming portion of a transfer, particularly during periods of limited capacity when multiple calls to multiple facilities may be needed to identify an available bed for a child.
In transfers of stable patients with isolated simple problems, a phone conversation with the transport center may be the only interaction between the transferring and receiving facilities. For example, a stable child with an isolated extremity fracture may need nothing more than the name of the accepting orthopedic surgeon and a hospital room number. Critically ill children will require a much more detailed interaction between the emergency physician and the accepting consultant.
Emergency physicians converse with other physicians from their hospital on a daily basis to arrange admissions or discuss patient care options. Although interactions with consultants from different institutions are similar, they are not identical. The first difference in speaking with a consultant from another institution is that unlike the medical staff at a home facility, the physicians from the tertiary center may have no knowledge of an outside emergency physician's competence. From the consultant perspective the EP's practice abilities can be anywhere from those of a third-year medical student to those of a professor emeritus. It should not be considered insulting if the accepting physician does a little prodding into abilities of the transferring physician. Remember, he or she needs to know what can be asked in terms of the management of the child to be transferred. Some emergency physicians may be comfortable with critically ill children and have appropriately stabilized the patient, but a given consultant also must deal with other physicians who will not complete even the most basic maneuver prior to calling for a transfer. At the same time, such conversations should not lead into a battle of egos or curriculum vitaes. The best way to establish the pediatric abilities in these circumstances is through management of the child. Actions truly do speak louder than words.
The presentation of the child to the consultant should be accurate and concise. This is not teaching rounds on the inpatient ward. The case presentation should not begin with the chief complaint, then work through the history of present illness and the physical exam and diagnostic studies. That all can be presented later if requested. Joe Zeccardi, the long-time chair of emergency medicine at Thomas Jefferson University in Philadelphia, always emphasized when presenting to a consultant to "lead with the diagnosis." There is no need to relay a story that takes them to a diagnosis, that work has been done by the treating ED team. Simply give the diagnosis to the consultant and move on from there. The diagnosis should be followed with a quick summary of the child's status and the ED care to that point. The consultant's time is valuable, but the emergency physician's time is even more valuable. The opening sentence should grab their attention and with some additional vital information they immediately can be taken to the point in the child's care where they can begin to contribute to management decisions. Such a presentation also limits questions about options that have been excluded and eliminates the need for unnecessary discussions. Many consultants will ask questions reflexively because of prior experiences with less sophisticated departments. By delivering a rapid-fire case summary, the transferring physician can take control of the conversation.
Consider the following presentation: "We have a 9-month-old male with septic shock, diffuse purpura, who is intubated, fluid resuscitated with 60 mL/kg of NS, started on a 10 mcg/kg dopamine infusion, who has a blood pressure of 60 systolic. We also have given ceftriaxone." In 15 seconds, a consultant has all the information he or she needs to become involved in the case.
Contrast this with the traditional medical presentation that would begin with a complaint of lethargy, discussion of recent poor feeding, include some comments about why the mother brought the child to the ED, what was attempted prior to the intubation, etc. This type of presentation is likely to get no further than the second sentence before the consultant would assume control and begin soliciting information through a series of questions.
Certainly, there will be cases where the diagnosis is unclear. In those instances, lead with a simple description of the child's status and organ system failure. A statement such as: "We are managing a critically ill child with refractory hypotension for which we are unable to determine the cause." This could be followed with the stabilization procedures and child's current condition. It is very likely that if the diagnosis is not clear to the ED team, it will be equally unclear to a consultant.
In some cases, the emergency physician may have optimized the child's stabilization and need only present the case and work out the logistics of the transfer. In other instances, the emergency physician may need additional management direction from the consultant. In these circumstances, it is best to asked specific questions of the consultants regarding the exact information needed. Avoid open-ended questions such as "What should I do next" This is likely to lead into discussions of pathophysiology or their hospital's protocols.
It is important to remember that the patient is still the responsibility of the transferring emergency physician. The consultant is making recommendations not dictating orders. If a suggestion seems questionable, do not be intimidated from asking for a justification. This is especially important if the contact at the transferring hospital is a not an attending. It is entirely appropriate to ask for a resident or fellow to obtain input from an attending if it seems warranted.
EMTALA and HIPAA
The Emergency Medicine Transfer And Labor Act (EMTALA) rarely will present a problem for transfers of critically ill children from a community ED to a tertiary care center. Since the child is moving to a higher level of care for services that are unavailable at the community hospital, the transfer will meet EMTALA criteria.
The Health Insurance Portability and Accountability Act (HIPAA) is never an issue in relating sensitive medial information from the transferring ED to the receiving tertiary care facility. Although, no legal rulings have addressed the specifics of communications, most facilities believe it is not necessary to obtain patient consent to transfer this information.
More important to the transferring hospital is the right to contact a receiving hospital for follow-up on a transferred patient. Again, no official opinions have been issued on this topic. However, many attorneys believe that it is important for the transferring facility to receive timely feedback on their patients for both educational purposes and to immediately institute corrections for possible management errors in the future. If a community ED failed to recognize a reversible problem in a child, and the receiving hospital was prohibited from providing immediate follow-up, then a second child presenting with the same condition would be at risk for suboptimal care. In addition, the more timely the feedback, the more effective it will be for the ED staff. For this reason it is reasonable to call the receiving facility and ask for follow-up on transferred patients either the day of the transfer or at any point during their hospitalization.
Conclusion
Any physician practicing community emergency medicine will encounter critically ill children. The unique characteristics of stabilizing these children without the immediate resources of a tertiary care center present additional challenges to the single coverage emergency physician. However, with aggressive solid emergency medicine care, excellent outcomes can be expected for these children.
References
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8. Schuman A. Best new products for pediatricians 2009. Contemporary Pediatrics 2009;26:56-60.
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The critically ill or injured child presents both a diagnostic and therapeutic challenge to any Emergency Department. Vascular access, airway management, fluid therapy, invasive procedures and medication selection all must be coordinated and delivered in a time-sensitive manner.Subscribe Now for Access
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