Summary: It is very likely that children will become ill or injured during a time when your doctor's office is closed. Most of these conditions can be managed at home without the assistance of your child's physician. Call 911 for obvious emergencies, but in most instances when your child becomes ill, it will be difficult to determine if your child's condition is really an emergency. Knowing more about childhood emergencies can be helpful. It is preferable to have your child seen by your physician or call your physician to discuss your child's condition. If your physician is unavailable, or you believe that you cannot wait, then you should seek emergency care for your child. Having an emergency plan discussed with your physician ahead of time can be very helpful in deciding when and how to seek emergency care. Understanding a few facts about emergency rooms can be helpful in anticipating and better understanding your first encounter in an emergency room.
Children frequently become ill at inconvenient times, such as when you are about to go to work or when your doctor's office is closed. In fact, in a week, your doctor's office is open for only about one-fourth of the week. During the other three-fourths of the week (evenings, nights, Sundays and holidays), your doctor will not be available in the office. Actually, it is very likely that your children will become ill when your doctor's office is closed. Sometimes, it is obvious that your child is having an emergency and 911 should be called. In other situations it may be more uncertain.
As a parent, you will need to make a decision of whether to wait for your doctor's office to open or to take your child immediately to an emergency room. It is difficult for parents to accurately determine if a true emergency exists. On one hand, most parents are reluctant to use the emergency room unnecessarily, and on the other hand, parents should seek medical attention early to prevent complications from occurring. It is difficult for parents to choose between these extremes. Some medical insurance plans threaten their patients with high personal expenses or non-coverage if a patient is seen in an emergency room without a true emergency. I know of several medical insurance plans that have made their patients sign statements agreeing to pay for the emergency room bill on their own if the doctor does not find the case to be a true emergency. This is very unfair to patients since it is very difficult to determine whether something is a true emergency until the patient is examined by a doctor. Even physicians cannot be correct all the time, since in many instances, serious emergency conditions are hidden and difficult or impossible to identify early. It is a good idea to call your doctor through the answering service. You can discuss your child's condition over the phone. If your physician advises you to take your child to the emergency room, it is almost impossible for the insurance company to deny coverage since you are following your doctor's instructions.
Determining whether an emergency is present is very difficult. This cannot be explained in a simple paragraph. With this understanding, it's a good idea to start somewhere. If you are not sure what to do, you should call your doctor to seek advice by discussing your child's condition over the phone. If your doctor is not willing to do this, you should consider finding another doctor.
Let's start by looking at three common reasons for which children are brought to an emergency room; fever, seizures and trauma. Only sometimes are these true emergencies. To determine whether these conditions are more likely to be serious emergencies, you will need to review more details on these topics in the fever, seizures and broken bones chapters, respectively. Very briefly, fever, seizures and trauma are usually not emergencies unless they are associated with other signs and symptoms.
Fever in children is more serious when it occurs with fussiness, irritability or lethargy (being poorly responsive and weak). Seizures are more serious when they are longer (greater than 2-3 minutes), they recur or when they occur after a drug overdose. Seizures that involve only part of the body (partial seizures) are less dramatic than those involving the entire body (generalized seizures); however partial seizures are more often due to serious problems. Seizures are more concerning when they occur for the first time or when they occur without fever. Seizures are less serious when they occur with high fever in the age group from 6 months to 6 years and the child otherwise is active, alert and playful. Seizures are usually followed by drowsiness. This drowsiness should gradually resolve. If drowsiness persists or if the child was drowsy or lethargic before the seizure, this is potentially more serious. Trauma is often serious when a car is involved, or a high speed accident (bicycle, skateboard, etc.) is involved, or there is persistent pain. The presence of visible deformities (it looks crooked), significant swelling, or loss of function or sensation are also serious. In the absence of these symptoms, emergency care is often sought because someone thinks that a bone might be broken. But this is rarely urgent in the absence of significant pain, swelling, deformity or loss of function/sensation since an x-ray can always be ordered through your doctor's office. It does not have to be done through a hospital ER. Many office physicians order hospital x-rays or refer their patients to private x-ray facilities not affiliated with a hospital.
Difficulty breathing is usually an emergency. Abdominal or pelvic pain can be an emergency depending on the cause and the degree of pain. Serious conditions such as appendicitis or twisted internal organs are difficult to distinguish from minor conditions such as constipation or stomach flu. Testicular pain is an emergency. Chest pain is often an emergency in adults, but it is only rarely an emergency in children. Unfortunately, this is difficult to sort out easily.
Vomiting and or diarrhea is more likely to be an emergency if it is severe, is associated with abdominal pain or if fluids taken by mouth are not keeping up with fluid losses.
Severe pain in general is an emergency since it is unreasonable for anyone to endure pain unnecessarily. It doesn't matter if the pain is in the ears, eyes, head, neck, back, chest, abdomen or extremities. Perhaps the cause of the pain may not be very serious (such as an ear infection), but if the pain is severe, it is a legitimate emergency to seek pain relief measures from a physician. Often, the degree of pain is of less concern than the cause of the pain. For example, slight chest pain could be due to pneumonia or a collapsed lung.
Other miscellaneous conditions which are often emergencies include loss of function or loss of sensation of part of the body, sudden weakness, significant tingling, rapid changes in vision, confusion, agitation, cyanosis (bluish or purplish color to the skin), pale color to the skin, dramatic skin rashes, swelling, suicidal behavior, severe depression, etc. A complete list is not possible. Call your physician or seek emergency care if you are concerned or unsure. Calling a hospital emergency room will not be helpful in most instances since most hospital ER’s have policies against providing medical advice over the phone to patients whom they have not seen recently. Drug overdoses may be an emergency. Most cities have poison information centers that can recommend treatment over the phone or referral for emergency care. Most poison information centers can be accessed by calling 911.
Have an emergency plan:
There may be a time when your child has an emergency. You might not have enough time to call your doctor. Even if you are able to call your doctor, he/she might not be able to return your call in time, since doctors may be talking to other patients, attending to a separate emergency or the doctor's pager or phone may be malfunctioning. In such instances when you must make a decision without the assistance of your doctor, you should use your emergency plan.
You should discuss this with your doctor prior to an emergency so you will know what to do. Ask your doctor if there is an urgent care center or hospital emergency room that you should go to. Make sure that your doctor's recommendation is covered by your insurance plan. In most cities, there are several different emergency rooms that are available. Ask your doctor to recommend the best one in your area. If you are likely to be in a different part of town, ask about this area as well.
Most cities have children's hospitals which specialize in children's care. In most instances, children's hospital emergency rooms are staffed by pediatricians or emergency physicians with specialized pediatric training. If a specialist is required (such as surgery or cardiology), it is more likely that a pediatric specialist (such as a pediatric surgeon or pediatric cardiologist) will be available in the children's hospital compared to a general hospital. Children's hospitals treat children almost exclusively. Thus, their experience level with children is greater than that compared to a general hospital. If your young child requires specialty care such as a surgeon, would you prefer the surgery to be done by a surgeon who usually performs surgery on adults at a hospital which cares for mostly adults or by a specialty surgeon who performs surgery only on children at a hospital which cares for children exclusively? Ask your doctor if there is a children's hospital in your area that he/she recommends.
Hospital Emergency Rooms (actually, it's an emergency department):
If you ever have to go to an emergency room, it's a good idea to understand some facts about emergency rooms. First of all, the "new" terminology is "emergency department", NOT "emergency room." Unfortunately, the abbreviation E.D. does not sound nearly as good as "E.R."
"E.R." sounds so good that they even used these letters for a TV program. This program would not have been as popular if it were called "E.D." The term emergency room originates from generations before us when the hospital wards were large and emergency care areas in the hospital were small. In those days, there was a physician "on call" for emergencies, which means that when an emergency patient arrived in the ER, the physician would be called in, perhaps from home nearby or perhaps from another part of the hospital. These physicians were usually young physicians in training or general practitioners. The emergency room in today's hospitals is no longer a room. Modern emergency departments have many patient rooms and specialized care units within them.
In today's emergency departments, nationwide 911 emergency ambulance dispatching systems are vast and complex. Most emergency departments are staffed 24 hours a day, by full-time physicians specializing in emergency medicine. Larger emergency departments are staffed by multiple physicians on duty together. Hospitals have shifted their emphasis from inpatient (patients cared for in the hospital) hospital wards to complex outpatient care (patients cared for without the use of overnight hospital beds). It is common for home care to include IV's, nebulizers (aerosol medication delivery units), orthopedic hardware, blood tests and even home ventilators. Much of this equipment and the support needed for management is beyond the scope of most clinics and offices. Emergency departments provide evaluation and management services as an outpatient for complex problems that in the past, required inpatient hospitalization. Emergency medicine is now a recognized specialty of medicine and most emergency departments are staffed by physicians board certified in emergency medicine instead of general practitioners.
Emergency departments are often used to train nurses, paramedics and physicians. It is very likely that you may first be greeted by a medical student, intern or resident. A resident is a physician (he/she has already graduated from medical school with an MD or DO degree) who is in a training program, usually in one of the specialties such as internal medicine, surgery, pediatrics, obstetrics/gynecology, psychiatry, family medicine or emergency medicine. Interns are newly graduated physicians in their very first year of training. A first year resident and an intern are the same. The term "intern" and "internist" are often confused. An intern is a first year resident. An internist is a fully trained physician specializing in adult internal medicine.
Residents in training and medical students MUST be supervised by attending physicians. An attending physician is a physician credentialed by the hospital's medical staff. Basically, this means that the hospital's Chief of Staff and other hospital physician leaders have granted this physician privileges to practice medicine within the hospital. An attending physician is not necessarily board certified. Better emergency departments are staffed by attending physicians who are board certified in a specialty appropriate for acute care medicine (most often, they are board certified in emergency medicine). For a physician to become board certified, they must apply to determine if they qualify to take the board certification exam. Most applicants qualify to take the exam by completing accredited residency training programs in their specialty. If they qualify to take the exam, based on their training and/or work experience, they must then pass the exam to become board certified.
Most emergency departments are capable of evaluating patients of all age groups with nearly any type of medical condition. Some emergency departments specialize in certain services. Knowing the capabilities of the emergency departments in your area would allow you to seek emergency care in the best qualified facility.
Most emergency departments are staffed by well-qualified nurses and physicians. Despite this, don't expect to be treated exactly the same way as your child's regular physician. ALL physicians are different, even if they are all board certified in the same specialty. Physicians practice differently, they have different personal and medical preferences, they explain things differently, they have different styles, etc. Emergency physicians differ from your child's regular physician in several ways that are described in the table below. Understanding these differences will help you to better understand a future encounter in an emergency room.