Millions of children require some level of emergency care each year, and according to the American Academy of Pediatrics, significant barriers limit access to appropriate services for a large number of these patients.

For instance, not all children have access to pediatric hospitals, and studies have shown that access to them can significantly reduce mortality and length of hospital stays for sick or injured children. A study published in the January 2006 Journal of Pediatric Surgery analyzed almost 80,000 pediatric trauma cases and revealed that close to 90 percent of injured children nationally were treated at adult hospitals or in children's units at adult hospitals.

Peter Glaeser, MD, medical director of the emergency department at the Children's Hospital of Alabama in Birmingham, said one problem is that physicians in Alabama and other rural states have little training in pediatrics and emergency medicine.

"Fifteen percent of doctors in emergency rooms in Alabama are trained and certified in emergency medicine. They are practice trained in treating children," Glaeser said. "At Children's Hospital, our ER staff members all are trained in pediatric emergency medicine, so we're the experts in taking care of children. The problem is that kids are taken to emergency rooms in their locale."

Glaeser said one of the challenges facing physicians who aren't trained in pediatric medicine is understanding what is normal for children at each development stage. "Each age has specific norms in vital signs and the ways a child interacts," he said. "Unless a doctor sees a lot of children, he may not know what normal is and could miss the fact that the child is going into shock, for example."
A number of children also are treated at facilities that lack the recommended pediatric equipment and supplies. "In most emergency rooms, 20 to 30 percent of the patient volume is children," Glaeser said. "While there is a list of recommended pediatric equipment for all emergency rooms, surveys show that most don't have the needed equipment or if they do, the staff doesn't know how to use it."

Pediatric emergency physicians are trained after medical school through a pediatric emergency residency followed by a three-year fellowship, Glaeser pointed out. "A doctor who is trained just in emergency medicine gets four months of training in pediatric emergency medicine. A doctor trained in internal medicine gets no training in pediatric emergency care," he said.

Children's Hospital's emergency department is the only one in Alabama with the ability to take care of pediatric trauma cases and is designated a Level 1 trauma center by the state. "We're the only game in town and in the state when it comes to treating critically ill or injured kids," Glaeser said.

Kathy Monroe, MD, is a professor of pediatrics at UAB and affiliated with Children's Hospital. She said another advantage for children being treated at a children's hospital is having a staff that is comfortable with the needs of children. "For example, we have nurses who are experts in obtaining IVs in the small veins of children," she said. "Also, the entire staff — including doctors, nurses, transport personnel and radiology staff — is able to communicate with children on their level of understanding."

New guidelines have been set by the American Academy of Pediatrics and the American College of Emergency Physicians that call for more pediatric services and medical expertise, as well as supplies and equipment that are appropriately sized for children, but Glaeser said other problems still remain.

"There are problems on the pre-hospital side that still need to be addressed. Paramedics and emergency medical technicians continue to need additional pediatric training," he said. "That's somewhat peripheral, but the work done in the field affects what we do and it can have a huge impact on the outcome." One example is the ongoing debate about whether pediatric patients should be intubated in the field. "Studies now show that these patients do no better if they're intubated in the field," Glaeser said.

Monroe said she would like to see improvements in pediatric patient care that focus on injury prevention and educating parents on how to keep their children safe. "My research is in the area of injury prevention, and our records indicate that most of the injuries we see could have been prevented with education or simple preventative measures," she said.



June 2007