If you build it, they will come
New pediatric ER earns high marks from families

BY MARK SHWARTZ

SPRING 2006 -- Like most children, Melissa Wallace isn't particularly fond of emergency rooms.

But her most recent visit to the emergency department at Stanford Hospital was an entirely new experience. Instead of sitting in a crowded waiting room surrounded by adult patients,Melissa, age 15, was immediately escorted to the hospital's new children's emergency wing and given a private room where she could relax and watch a movie while being treated by pediatric emergency specialists.

Stanford's new pediatric emergency services opened in December. An estimated 11,000 children are expected to visit the facility this year, and that number could double within a decade.

Lying in her hospital bed, the San Jose teen focuses her attention on a large, flat-screen computer playing a DVD of The Little Mermaid, one of her favorite films since childhood. Hours earlier, during a high school soccer match, Melissa had collided head-on with another player and was rushed to Stanford emergency.

"All I remember is blood everywhere," she says, watching the animated film while emergency pediatric resident Renee Hsia, MD, carefully stitches the large gash on her forehead. At Melissa's bedside is her mother, Christine Wallace.

"Dr. Hsia has been so gentle, and the movie is a great diversion," Christine says. "The whole atmosphere is much nicer. It doesn't feel so sterile."

Melissa Wallace of San Jose gets stitched up after she collided with another player during a high school soccer game.

Melissa agrees. "I like it here, especially the movies," she says. "We opened our doors on December 1, 2005, and the difference has been like night and day," says Bernard Dannenberg, MD, director of the new pediatric emergency services. "Now one of the biggest complaints we get from patients is, 'Doctor, can you move your head, I can't see the computer screen,'" he quips.

A Growing Need

Bernard Dannenberg, MD, and pediatric intern Amanda Sanford, MD, discuss the patient case load as evening approaches.

An estimated 11,000 children are expected to visit Stanford's emergency department this year, and that number could double within a decade. The projected rise in pediatric cases prompted members of the hospital staff and the general community to call for a new emergency facility designed specifically for children, to ease long waits and overcrowding in the main emergency department and provide a dedicated staff with expertise in pediatric emergency medicine. In fact, much of the funding for the new facility and added personnel came from contributions by local individuals.

For parents like Mary Goulart, who makes frequent emergency room visits with her chronically ill child, the new pediatric wing is a vast improvement.

"It's dramatically different," says Goulart, whose son, Joshua, was born with a life-threatening heart condition. "The first thing you notice is the physical layout. It's more family friendly and comfortable. There's a separate pediatric waiting room filled with toys, video games, and movies. That's good, because when you're with other families, everyone is more understanding when children are screaming and vomiting. It's also nice to have a private room that's quiet and has a separate bathroom."

Mary Goulart with son, Joshua.

Located in a refurbished section of the emergency department, the new pediatric facility boasts six private examination rooms, including two isolation rooms with negative airflow to prevent serious communicable diseases from spreading throughout the hospital. Each private room is equipped with an iMac, wireless Internet, children's DVDs, and a large selection of iTunes—all donated by individuals, as were many of the other child-friendly touches. For example, unlike the adult emergency section, which was built in the 1970s, the remodeled pediatric wing is colorful and bright, and, thanks to individual donors, the walls are decorated with original prints by popular children's illustrators, such as Eric Carle.

The new wing also features a resuscitation suite with two critical care beds and state-of-the-art pediatric emergency equipment, including child-size gastric tubes, airway kits, and special medications.

"We try not to treat adults and kids in the same manner," explains Dannenberg, who was recruited to Packard in 2004 as the first Davies Family Endowed Director of Pediatric Emergency Medicine. "Children with cancers, congenital anomalies, and chronic illnesses are frequent visitors and should be treated according to their special needs."

Patients and their families have access to computers, movies, and toys in the new pediatric waiting room, separate from the adult area.

Communication between family and staff is a major problem during emergencies. "For example, it's important to tell parents that the lab work will take an hour so they're not sitting around wondering what's happening," says Dannenberg, one of only a handful of doctors in the United States with training in pediatrics and emergency medicine.

"In the adult emergency department, as much as the staff tried hard, we always felt like we were in the wrong place," Goulart says. "But in the new facility, it's clear that the family is an integral part of the experience. The staff is just phenomenal. They'll ask us, 'What do you think? You're the ones who know your child best.'"

A Pediatric Team

The new program also includes a part-time pediatric emergency physician -- Sangeeta Chona, MD, and an associate director, Ewen Wang, MD, who supervises teaching. "Dr.Wang took care of Joshua during his last visit," Goulart recalls. "A week later, she called to ask how things were going. I was really floored, because you don't expect an ER doctor to make a follow-up call."

The Davies Family endowment also enabled the hiring of pediatric nurse educator Paula Miller, RN, who brings more than three decades of nursing experience to the position, including 24 years in children's intensive care medicine. "Right now, we have a dedicated pediatric emergency team on duty seven days a week from 3 p.m. to midnight," she says. "However, every child who comes to the emergency department is taken to the new pediatric facility, no matter what time of day or night. Eventually, I'd like to see us go 24/7 with more pediatric emergency nurses and doctors working every shift."

Child life specialist Colleen O'Connor comforts Sanum Hamidi of Fremont after a painful procedure to reset the girl's fractured wrist.

Another new member of the team is Colleen O'Connor, the department's first pediatric emergency child life specialist. "This is a concept taken from Packard Hospital," Dannenberg explains. "Colleen distracts the kids during painful procedures, works with siblings, and serves as a liaison between the parents and the staff."

On a typical day, O'Connor can be seen bouncing from room to room, lending her cell phone to an anxious dad or offering to watch the kids while mom moves her car. On one evening in February, O'Connor uses gentle teasing to prevent a toddler from running out of the pediatric visiting room. "Where are you going? Where are you going?" she calls to the little boy, who then bursts into laughter, turns around, and rejoins his father in the visiting room.

"I have graduate degrees in applied developmental psychology and theater, and both come in handy," she says. While on duty, O'Connor wears a yellow plastic necklace filled with bubble juice. "If a kid is shy or afraid, I blow bubbles," she says. "It's a great distraction, especially when the doctor is doing an exam."

She has used the ploy so often that she's earned a nickname -- the Bubble Lady. "Sometimes I color with the kids or read them a book if they need to be relaxed," O'Connor says as she enters a room where 5-year-old Sanum Hamidi is being treated for a painful wrist fracture.

"Sanum loves I Spy books, so I read one to her to distract her while the doctor works on her arm," O'Connor says. "I try to explain medical procedures to kids in an easy way they can understand."

Kathryn Marinos of San Bruno enjoys a quiet moment with her 1-month-old son, Andrew, who was suffering from a respiratory infection.

As the evening wears on, the exam rooms begin filling up with children of all ages from throughout the Bay Area. In Peds Room 1, Kathryn Marinos holds her infant son, Andrew, who is just 25 days old and has breathing problems. "I drove all the way down from San Bruno because I wanted to come to this emergency room," Marinos says. "I've been in hospitals all over the world, and as far as emergency rooms go, this is one of the best."

Meanwhile, in Peds Room 3, Rahel Woldegiorgis of San Jose plays with her 8-month-old daughter, Mahder, who has been admitted with diarrhea and a rash. "It's much better than when I visited here last July," Woldegiorgis says. "I love this private room. It wasn't like this when I was a kid."

Rahel Woldegiorgis and her daughter, Mahder, of San Jose, await treatment for Mahder's diarrhea and severe rash.

A half-hour later, Mahder and Rahel leave Room 3 and high school student Mitchell Yoshikawa is brought in after dislocating his shoulder during the third quarter of a basketball game. Mitchell and his father drove all the way from Morgan Hill, because the emergency department at the local hospital was too crowded. Fortunately, the shoulder had spontaneously slipped back into its normal position. After a brief examination, Dannenberg makes his diagnosis. "Mitchell is going to get a sling, play the fourth quarter, and go home," he jokes.

"The majority of our cases are common colds and other respiratory infections. If that's all they have, there's no reason for them to wait around in the emergency department to be treated. The art of pediatric emergency medicine is to do a thorough exam and determine if the child needs additional treatment or hospitalization,” says Dannenberg.

Future Needs

Bernard Dannenberg, MD, examines Mitchell Yoshikawa of Hollister, who came to Stanford from a high school basketball game in Morgan Hill after suffering a dislocated shoulder.

Long wait times are still a big problem for families and staff. "The kid doesn't want to be here, the mom is worried, and I have to make them feel better," Dannenberg says. "We have a much nicer facility now, but we'd like to improve wait times. Emergency rooms are full of infectious people, so the longer they have to wait, the worse off they are."

Dannenberg believes that with an investment in high technology, the visitation process can be greatly streamlined. "We're in the heart of Silicon Valley, but everything at the hospital is still done with paper," he says. "Right now, the average time it takes to get medical information from other hospitals is measured in hours, not minutes. I'd like to see as quickly as possible a paperless emergency department."

He also would like more funding to establish a research fellowship in pediatric emergency medicine to train the next generation of specialists and conduct long-term studies that lead to improvements in patient care and family services.

Pediatric resident Nancy Barnett, MD, and pediatric emergency nurse Amanda Lema, RN, look over an X-ray during the evening rush.

At the same time, the demand for additional staff is expected to grow. Today, children make up about 29 percent of all emergency visits to Stanford Hospital, up from about 23 percent last year.

"I would like to thank all the donors for their initial support and their steadfastness in seeing the project through," Dannenberg adds. "We've completed the first step, and now we have to build on that for the future."