Saturday, April 21, 2007

Getting Professional Help: Improving Sick Kid Visits to the Emergency Room

Well, after Regurgapalooza 2007 went on two days longer than we last reported, we found ourselves facing an Emergency Room sick visit for the third time in Ranger's short life. Ranger's pediatrician and her entire practice (4 physicians total) were fully booked on Thursday as a modern plague of bodily-fluid erupting youngsters has overtaken our community in recent weeks. The pediatrics nurse recommended we take Ranger to the ER as his symptoms were acute and indicated dehydration. Our experiences with the ER visit and his subsequent hospitalization have prompted another tips list.

#1- Know which facility you prefer before you ever encounter an emergency. If your community, physician, and insurance allow you selection from different facilities, research while healthy and know where you're headed when an emergency occurs.

Not all emergency medical facilities are created equal. It's good to find out what wait times to expect, quality of care, and reputation for working with infants/children. Friends working in the medical profession have told me of two seemingly identical hospitals in the same community where one has a much higher in hospital infection rate. This kind of information is good to know in advance.

It's also good to know if a hospital specializes in pediatrics. In our community, only two of the three hospitals accept pediatrics inpatients. The hospital without pediatrics will see children in the ER, but can't admit them, so for illnesses which might require hospitalization it's counterproductive to go there. One of the two hospitals with pediatrics is allied with a respected regional children's hospital and can offer a higher level of specialization.

We used to live in a town where the ER wait for any condition was at least 4 hours (they didn't seem to apply triage principles but instead plodded through a first-come, first-served practice). Some friends went to ER with a newborn running 105 degrees, and after over an hour of waiting and staff indifference they called their old family physician in a nearby community. He met them at the ER in their old community in 45 minutes and saw the burning up baby immediately. It was definitely worth a 45 minute drive for the prompt and caring attention they received at the smaller hospital. Even if they had to wait the regular 40 minute ER wait time, they would still see a doctor MUCH sooner in the far-flung hospital where people really cared about their child's well-being. We made a mental note to visit their small town hospital should we ever need emergency care.

Ask people with kids or grandkids about their families' recommendations and experiences. There's a lot of emotion in hospital stories, so try and keep an eye on the facts.

#2- Contact your pediatrician's/physician's office before you leave your house- even though you'll probably just get an answering service. Sometimes they have a better alternative (our pediatrician recommends a partner after-hours pediatrics clinic for less critical concerns). Sometimes they can grease the wheels at the ER and get you in faster (it's not how things work here, but I know it's worked in for friends in other communities).

#3- Gather necessary items before you leave:

  • Payment (Insurance Info/Card, Funds for Copay/Deductible)
  • Vitals (Your wallet, cell phone, phone numbers of anyone you might need to call)
  • Records (Regular Physician Contact Info, List of Medications/Treatments, Any Records of Symptoms/Temperatures)
  • Icky (Vomit catcher (see the 1st anonymous comment on our barf management strategies for a great, quick DIY solution and make one now while no one is barfing), Ziplock and bring the most recent dirty diaper if a stool sample may be needed (helpful for infants/toddlers with abdominal symptoms or vomiting))
  • Comfort: Kids' entertainment, Jeremiah of and recommends bringing favorite books and a pillow with a distinctive or colorful case (lest the hospital think you're taking their pillow home). A blanket or washable toy can also handy.
  • Sustenance: Food/drink for kids and grown-ups (or at least funds for the vending machine).
  • Upkeep: Diapers and wipes (the local ER usually doesn't have these on hand), a change of clothes, SOCKS, shoes, jacket or sweater, backup outfit in cases of fluid eruption.
  • Containment: Do you need a stroller to keep your child from making the occasion into a meet and greet? Will your child need a place to lay down?
  • Is there a chance of hospital admission? If so, you may want to shove a few more things in your car (we'll post this list separately soon).
#4- Don't be grouchy.
While we're all for medical self-advocacy for our families and ourselves, we've observed many families entering the ER with chips on their shoulders. It does you no good with staff to be combative, angry, or negative. Politeness and respect can be a great assets.

You're obviously having a bad time and feel the situation needs professional assistance (otherwise you wouldn't be in the ER).

An ER is a demanding and unpredictable work environment. The people there are working hard in a somewhat chaotic environment. If you can keep your cool as a patient's parent and do your best to help the process, your positive attitude will set you apart from other patients. This always seems to get us preferential treatment in the local ER. It's okay to ask questions and make requests, but if you can do it in a way that recognizes the demanding job of the medical professionals, they are more likely to hear your concerns and respond with consideration.

#5- Have Your Information Ready
Anyone who has spent time behind a desk or cash register knows that people are rarely prepared- even for incredibly routine, predictable processes. This is compounded when people are under duress, they tend to forget more things- slowing processes to a crawl.

If you are visiting an American hospital, have your identification, your insurance information, your supplemental payment (deductible, copay, etc.), your emergency contact information, and your regular physician information on the ready when you get to the registration desk. I guarantee it will speed the registration process.

Not only can you prepare for the registration desk, you can also predict most of the questions in the nurse's initial interview. If you can, write a list while you wait.
  • Does the ill party take any medications? Make sure to include asthma inhalers and any other prescribed items regardless of their delivery format (pill versus inhalation). Most people require further questions to disclose these non-pill, non-liquid items. Also include any regularly consumed supplements (vitamins, herbal remedies, etc.) and any recently consumed over-the-counter products (pain relievers, cough syrups, etc.). You'll probably surprise the interviewer with your broad definition of medication. If anyone in your family regularly takes medication, it's a great idea to have a written list in your wallet to supply in case of medical emergency that includes drug name, reason prescribed, and exact dosage.
  • What's in the patient's past? Does the ill person have allergies, prior hospitalizations, chronic illness, known conditions, surgeries, or family history which may be relevant to their current condition and/or treatment methods?
  • Organize and describe the events that have lead you to the ER. Chronological, succinct presentation is usually the best method of delivering this information. What symptoms brought you to the ER? When did they appear? Have they changed over time? How? When? To what degree?
  • Input: How has the patient been eating and drinking? Does it vary from their normal routine? If so, how? For how long has there been variation in consumption? Were any new foods, beverages, or conditions recently introduced?
  • Output: Number of dirty and wet diapers for infants and toddlers. Number and type of recent eliminations for older kids. How does this vary from regular habits? Is there a change in odor, color, or consistency?
  • Environmental factors: Has your child done anything unusual or experienced anything significantly different recently that might be relevant. A friend of mine while in vet school experienced allergy symptoms which might have been quite mysterious had she not had her first up-close contact (a horse proctological exam) with a large animal earlier that week. Her physician soon diagnosed her allergy to large animals (thank heavens her specialty is birds). While a toddler, our infant godson kept experiencing mysterious rashes- often after seeing a specific relative. It turned out that he has an incredibly severe allergy to tree nuts, and the relative wore a lotion with almond oil that was causing a rash reaction.
#6- Don't freak out, especially when they bring out the needles.
Being worried about your child is fine, but being utterly distraught will cause your child greater anguish and will probably cause you more delays.

If you're taking a sick non-verbal kiddo in, expect bloodwork at the very least (though you may also have x-rays and/or other labwork). And the phlebotomists have to draw that blood with a needle. And the veins are very small, so it may take a couple tries. Deal with that now. It's no fun (they stuck dehydrated Ranger 7 times yesterday to find a viable vein), but it has to happen. This is how doctors diagnose illness; this is how they know what to treat; this is how your kids get better.

So, when the nurse or phlebotomist comes into the room realize they are thinking "Oh *&%#, not a baby/toddler/little kid and parent!" Greet them as you would a friend doing you a huge favor. Offer to help (if you feel able). Let them know you aren't combative (many parents are), and they will relax (last night not withstanding, we usually have great luck with blood draws). When Ranger was a newborn we overheard a couple alternately threaten and beg a phlebotomist not to draw their very sick baby's blood. He had to insist that this was the very thing they had come to the ER for to get them to eventually agree. By the time he got their begrudging permission to draw the blood, their baby was completely freaked out from her parents' outbursts. If you don't want your child fully examined, stay home. Don't terrorize your child with your own fear, pain, and guilt.

A child hears panic and anger in a parent's voice and doesn't know its source or direction (I recently yelled at some teenager thugs harassing. cornering, and physically threatening strolling birds at the zoo and made Ranger burst into tears). Focus on deep breathing, staying calm, and reassuring your child throughout the process. We sing Ranger some of his favorite songs and keep telling him that is just part of making him feel better. He's not verbal enough to understand, but after saying it a few times, I know I don't feel as guilty about subjecting him to that pain. The kids will cry out when stuck, but they recover far more quickly when the parents take a more casual and reassuring stance.

#7- Ask Questions
There's nothing wrong with asking questions. Typically helpful questions are nature of the diagnosed illness, expected duration of illness, your responsibilities for treatment, the warning signs of complication or illness progression, risks of treatment, and future prevention of condition (if possible).

#8- Anticipate and Accommodate Your Child's Specific Needs
This may seem obvious, but Jenni and Jeremiah of Z Recommends give a prime example of how a parents' knowledge of their child can greatly improve the quality of care through attention to detail: If a child sucks their thumb, it's nice for parents to [request] the IV stick in the non-thumb sucking hand. Nurses don't usually think about that.
Ranger is much calmer when he sees a procedure done on someone else first, so we tend to ask the doctors to cursorily shine the lights in our eyes, ears, and mouths first if he seems tense. However, he must brave the rectal thermometer alone.

Jim just called. Ranger woke up feeling much more himself this morning and is now completely bored with being quiet and sitting still. Please forgive my poor editing and proofreading, as I'm posting this in haste.

I will soon post here a to link to general checklist/worksheet of things parents may need for an ER visit which also includes a worksheet of standard ER questions.

Please feel to add your own best practices in the comments.

Next: What to Pack for the Hospital When Your Child May Be Admitted


Anonymous said...

random medical question -- is it best to have the mother's dr. or the baby's dr. to do the circumcision. does it really matter.

adrienne said...

Random answer-
We can only speak from limited family experience, but we feel like our pediatrician was our best choice. She regularly performs circumcisions while my OB rarely does. Our hospital also offered a "hospitalist" doctor who could perform the circ- who we suspect is also very practiced in the procedure.

Anonymous said...

Hi Adrienne and Jim - Sorry to hear the little guy has been so sick.

Part of our background prep has also been to provide grandparents with signed forms giving our consent for them to seek medical treatment for the girls. We don't usually send the girls to their grandparents if they are seriously ill, but kids can get really sick really fast.

With our consent forms and copies of our insurance cards, the girls could begin treatment before we get tracked down or can get to the hospital from out of town. The consent forms includes a lot fo the info you mention (previous illness, medications, allergies, Dr.'s name, etc.).

Mike said...


My wife and I are about 1 month out from our first child arriving on the scene and this article was a very nice reminder that we're going to have to deal with some not-so-fun things soon.

Man, why can't it all just be laughs and toys and fun!! :P

But thanks for a great article that we'll use to start preparing.

Needles... *shudder*

Anonymous said...

just a quick response to the question about circing: before you decide, check out another great blog:

Anonymous said...

As an ER physician, I was so happy to read your blog. Your comments, esp. under #'s 4 and 6 are so true. As in any situation, you will really be treated much better if you treat us well. Hopefully the care of the child is not affected by the parents, but we will go out of our way to assist appreciative parents with any requests. It is so refreshing to take care of parents who act appreciative and understanding instead of mistrustful and angry. Understand we don't want you to have to be in the ER anymore than you want to be there. Thank you so much.