May-June 2010 | Health

(Little) Emergencies

Here's the 411 on where to go for a pediatric 911.

With four children under age 10—including a daredevil who once took a ride on a ceiling fan that then dropped on his head—Heather Brugger has been to most of the pediatric emergency rooms at least once in the Bethesda area.

She recalls one visit in particular to Children’s National Medical Center in Washington, D.C., three years ago. “I could cry thinking about it,” the Bethesda resident says. One of her sons, then 4, was having trouble breathing from asthma. At the time, he also was prone to falling and had muscle weakness on one side of his body. Previous doctors had been baffled by the symptoms, she says.

At Children’s, they controlled the boy’s breathing, then called a pediatric neurologist into the ER. He suspected a rare movement disorder, dopa-responsive dystonia, and put her son on a medication used for patients with Parkinson’s disease. The medication ended up helping him regain his mobility.

“Because of that emergency room visit, my son has no trouble walking now, no cane, no walker,” Brugger says. “[The doctor there] changed his life.”

Children’s is just one of several area hospitals with emergency centers that cater specifically to kids under 18. Others include Suburban, Shady Grove (which will treat those under 21), Holy Cross and Montgomery General.

Dr. Kathy Shaw, who chairs the American Academy of Pediatrics’ Committee on Pediatric Emergency Medicine, says Montgomery County residents are fortunate. “Most children do not have the opportunity to go to a pediatric emergency department,” says Shaw, who also runs the emergency medicine division at The Children’s Hospital of Philadelphia.

In a true emergency, you’d call 911 and an ambulance would bring your child to the nearest hospital. But when there’s time to make a choice, Shaw suggests discussing options ahead of time with your pediatrician.

Meanwhile, here’s a look at what you need to know about five local pediatric ERs.

Children’s National Medical Center Emergency Medicine and Trauma Center

111 Michigan Ave. NW, Washington, D.C.

Number of patients seen in 2009: 85,000
Number of beds: 35 in main emergency room, with as many as 40 more at night

The care

Children’s ER is staffed 24/7 with pediatricians who specialize in pediatric emergency medicine. This specialty requires three additional years of training, including 12 months of supervised work in an ER that sees at least 20,000 pediatric patients annually, according to Dr. Gail McGuinness, a spokesperson for the American Board of Pediatrics in Chapel Hill, N.C., which certifies doctors in the specialty.

“If a kid goes into the ER with an upper respiratory tract infection, it probably doesn’t matter a whole lot [if the child is seen by a general pediatrician], because general pediatricians take care of that,” she says. “But if someone came in critically injured or ill, having an individual with more experience and training in the care of children and emergencies could be beneficial.”

Also on site or on call are some 400 pediatric subspecialists, including pediatric cardiologists, pediatric neurologists and pediatric plastic surgeons.

This makes Children’s essentially a one-stop shop for kids. While other pediatric ERs may transfer patients with severe or complex problems, Children’s can fully treat even the most serious or life-threatening emergencies. Children’s is a Level 1 Pediatric Trauma Center, meaning ambulances bring the most serious injuries there.

Many of Children’s ER physicians are also researchers, which “provides a process of continual improvement,” says Dr. Stephen Teach, a Bethesda resident who worked in Children’s ER for 13 years. For example, hospital research found many families with an asthmatic child waited until a severe flare-up of the disease before coming to the ER for care, Teach says. Children’s now offers those families follow-up appointments in the ER to help them better manage the asthma, prevent flare-ups and reduce ER visits.

The check-in

Walk-ins go to a welcome desk, supply an ID and receive a photo badge. Next stop is the ER lobby, where patients generally wait only a few minutes before being screened by a nurse, who ensures a doctor immediately sees urgent cases, according to Dr. James Chamberlain, a Gaithersburg resident who’s chief of emergency medicine at Children’s.  If it’s busy, non-urgent patients wait another 10 to 15 minutes on average to see another assessment nurse, who does an in-depth screening before an evaluation by a physician. From the door, you’ll wait, on average, a little under an hour to see a doctor, he says.

The two-step screening process, started in 2006, helps identify those with a painful or urgent problem faster than in previous years. “When we had the one-step process,” Chamberlain says, “sometimes you’d wait up to 30 minutes to see that first nurse—and we thought that was unacceptable.”

A call to your family’s pediatrician can further shorten the process. The pediatrician can phone a hotline at Children’s, and although the most serious cases are still taken first, the call enters your child into the wait queue while you’re en route. You also can ask your pediatrician if your child needs to be seen right away or if it can wait until morning, when waits may be shorter, Chamberlain says. “With the nature of pediatric diseases, there’s a peak in the afternoon and early evening.”

The comforts

Since Children’s only treats children, your little one won’t be exposed to a ranting drunk with a cut forehead, as in the typical adult ER.

And while its space resembles any busy hospital, it does have crayons and paper in the lobby as well as TVs in the rooms, a mobile video player and a stash of giveaway toys, coloring books, Dora and Diego stickers and popsicles that staff can access in the treatment area.

“If at all possible, you should request a child-life specialist,” says Ellen Good, who is president of the Child Life Council and manages the child-life department at Yale-New Haven Children’s Hospital in Connecticut. At Children’s, these family advocates regularly visit the ER and provide support and offer diversions. If they’re not available, parents should be advocates for their children themselves, Good says. “For example, if a nurse or doctor is poking your child continuously to find a vein, you have the right to say, ‘No, please stop,’ ” she says. Ask that someone else help, like a phlebotomist who specializes in drawing blood.

Suburban Hospital Pediatric Center

8600 Old Georgetown Road, Bethesda
Number of patients seen  in 2009: 6,239
Number of beds: three ER beds plus  four inpatient beds in the unit for kids  who are admitted

The care

Pediatricians staff Suburban’s pediatric center 24/7. They do not currently have a board-certified specialty in pediatric emergency medicine, as the doctors at Children’s do. But they do have ER experience and regularly treat the kinds of problems typically seen in an ER, such as asthma flare-ups, fevers and broken limbs. If a child is critically ill, emergency medicine physicians from the main ER may provide support.

There are no pediatric subspecialists at Suburban’s hospital campus, but there are pediatric neurologists, pediatric cardiologists and others who have privileges at Suburban and can come for a consultation. Usually, however, if a patient requires pediatric subspecialty care, Suburban will consult with Children’s, Georgetown or Johns Hopkins, which have programs with pediatric subspecialty expertise.

The check-in

At sign-in, urgent cases are immediately sent back to a treatment room. Depending on how busy the ER is, less urgent cases may stay in the main ER waiting area before they see a nurse for a primary evaluation. After that evaluation, the patient will either go for X-rays or go back to the pediatric center to wait for the doctor. During 2009, the average wait time between sign-in and being seen by a pediatrician was just under one hour, according to Suburban’s spokesperson, Ronna Borenstein-Levy.