Wanted: Emergency Care Just For Kids

By MARK SHWARTZ

SPRING 2003 - It's four o'clock on a Tuesday afternoon, and the Emergency Department at Stanford University Hospital is already filled to capacity. A sign reading "Closed to Ambulances" has been posted near the front desk to alert staff that all but the most serious trauma cases will be temporarily diverted to other hospitals.

In the narrow hallway leading to the patient treatment area, the scene is reminiscent of afternoon rush hour, as doctors and nurses dart in and out of tiny exam rooms, gingerly avoiding wheelchairs and gurneys that roll by.

Children are treated alongside adult patients at Stanford's Emergency Department, which sees about 8,000 pediatric cases per year.

More than 39,000 people are treated in Stanford's Emergency Department every year -- 8,000 of them children. To make a child's experience less traumatic, the Hospital recently decorated a handful of exam rooms with colorful paint and stencils, and, thanks to a donor, added a small play area, creating a kind of temporary pediatric ward.

On this day, nearly all of the pediatric beds are occupied. In Room 17, Paul Johnson is recovering from a fractured wrist that occurred during a schoolyard accident.Minutes earlier, Paul's screams could be heard up and down the corridor as he underwent the painful procedure of having his wrist re-set. Now the 7-year-old is resting comfortably with his mother at his side.

In the next room, 16-month-old Thomas Segovia clings to his mother, who tries her best to comfort the distressed child. Earlier in the day, Thomas' right eye had mysteriously swollen shut, so his mom brought him to the emergency room. That was three-and-a-half hours ago. A round of blood tests revealed that Thomas may be suffering from a rare and potentially serious eye infection, so the decision is made to admit him to Lucile Packard Children's Hospital for further observation.

Meanwhile, in Room 13, a young couple keeps watch over their 1-month-old son, who is having trouble breathing, while across the hall in Room 15, a new mom cradles her infant, who also has respiratory problems.

"We see a fair number of children every day," says Eric L.Weiss, M.D., the attending physician. "We treat the whole gamut of cases -- from ear infections to serious traumas."

Weiss recalls how, earlier that morning, two Palo Alto girls riding their bicycles to school were rushed to the emergency room after being struck by a car. One later died from head injuries.

"You can't help but have strong feelings when something like that happens," says Clement Yeh, an intern who was on duty when the girls arrived. Now, nearly nine hours later, Yeh and his colleagues are about to examine an unconscious teenage boy injured during a soccer match. The boy recovered and eventually was released.

A Dedicated Pediatric Team

The emergency department is pretty much organized chaos," says Robert L. Norris, M.D., chief of emergency medicine at Stanford Hospital. "Sometimes it's like we're on roller skates when we're in there working."

And the situation is expected to worsen, as forecasters project that, in the next decade, the number of pediatric patients at Stanford Hospital could increase from 8,000 to a 12,000 a year. To solve the problem, Norris has joined forces with the Lucile Packard Foundation for Children's Health to spearhead a $16-million fundraising effort to enhance pediatric emergency services at Stanford. The goal is to hire a dedicated pediatric medical team, reduce emergency room waiting times and, in the long term, construct a child-friendly pediatric area for emergency services. Donors already have contributed $8 million, and Norris is optimistic that the additional $8 million will be raised.

To date, the only dedicated pediatric emergency department in the Bay Area is at Children's Hospital of Oakland -- a facility that primarily serves Alameda and Contra Costa counties. But if the fundraising campaign is successful, then Stanford Hospital will have its own pediatric emergency program to serve the Peninsula, the South Bay, and outlying communities such as Gilroy and Santa Cruz.

"The care we are able to provide right now, given our current situation, is excellent, but it pains me to have to take care of kids in this type of environment," Norris says, noting that, for a child, an emergency visit can be an overwhelming and frightening experience.

"It's a common saying that children are not just little adults. They have special needs," he explains. "When they come here, they're in pain, they're afraid and they're getting medical care from somebody who's probably a stranger -- not a family doctor they know and trust."

Children who are injured or sick have a tendency to appear stable, then decline very quickly. Adds Norris: "A child can be going into shock and look pretty good, and then suddenly get really, really bad. That's the kind of situation a pediatric physician or nurse can anticipate."

Pediatric emergencies also involve a wide range of developmental concerns that rarely come into play when treating adults, notes Harvey J. Cohen, M.D., Ph.D., chief of staff at Packard Hospital and chair of the Stanford University Department of Pediatrics.

"Trauma of the spleen is one example," Cohen says. "With an adult, you're likely to remove the damaged organ, but a baby needs a spleen for development of the immune system. Also, if you suspect that a child has any kind of serious infection, it's essential that you diagnose it rapidly to avoid complications."

Rapid Growth

Stanford long has been considered one of the premier emergency centers in Northern California. Built in 1976, the Stanford Emergency Department now handles an average of four new adults and one new pediatric case per hour, nearly three times the number it was originally designed to accommodate.

"Clearly, the volume of people we see has outgrown what our physical plant will allow, so we need bigger space,"Norris says. Equally troubling is the fact that the department has no attending pediatric physicians, nurses, or counselors on staff to comfort and reassure anxious children and their families.

"Adult patients usually arrive on their own, but a child will come in with mom and dad, maybe some siblings, and they have needs, too, in terms of communication, care, and comfort,"Norris says. "That is the nature of pediatric medicine."

The average length of stay for pediatric patients in the Stanford Emergency Department is 3.6 hours. Children and their families spend much of that time in a large, adult-oriented waiting room surrounded by strangers.

"We need a waiting environment that is appropriate for families -- away from where a bleeding or intoxicated adult might be sitting," Norris explains. "After all, the emergency department is the front door to Packard Hospital for many of the patients who get admitted, and this is not the first impression we want people to have."

The vision is to have an emergency department where all patients enter the same door but are immediately directed to separate areas -- one for adults and one for kids.

"Because we are fortunate to have Stanford Medical Center next door to the Children's Hospital, our plan is to have a separate section for kids in the main Stanford Emergency Department," adds Cohen. "That means separate waiting rooms, examining rooms, and a pediatric triage area. In the meantime, our most important objective is to hire additional clinical staff dedicated to children and their families."

Expertise and Desire

A nationwide search is now under way to find a director trained in both pediatrics and emergency medicine. The director will help shape and provide medical direction to the pediatric emergency services team. A nurse educator also will be hired to coordinate the team of pediatric caregivers and help train emergency department staff on the nuances of caring for children. Other new staff would include two attending pediatric emergency physicians, a pediatric social worker, and a child life specialist -- all of whom would be available during the peak evening hours.

Emergency room physician Eric L. Weiss, M.D., examines the x-rays of 7-year-old Paul Johnson, whose wrist was fractured in a schoolyard accident.

"We'll want to have people with a special desire and expertise in taking care of children," Norris explains. "For example, we're looking for a child life specialist whose expertise is preparing children for frightening or potentially painful procedures or diagnostic tests. Child life specialists get down to the kids' level to explain things. It's remarkable what they can do."

The pediatric services will be designed to reflect what Norris refers to as the Packard Brand of Care: "You walk through Packard Hospital and you have a different feel -- carpeted floors instead of tile, for example. The staff there is trained to deal specifically with children and families. I would be very pleased to have that sort of feel and quality of care for our pediatric patients." Norris predicts that such a well-staffed, user-friendly facility could reduce the average length of stay for pediatric emergencies by as much as one hour.

"Through the momentum of this fundraising campaign, we have the opportunity to develop truly comprehensive pediatric emergency care, " says Norris. "If you believe -- and I do believe this -- that the speed with which a person gets better has a lot to do with his or her emotional state, then being treated by pediatric trained caregivers in a comfortable and less intimidating environment will definitely improve a child's wellness. That is our ultimate goal for the children we treat."