Ask Us Anything About… When to take your child to the ER

Barbara Schindo – Good afternoon. You are watching Ask Us Anything About when to Take your Child to the Emergency Room. I’m Barbara Schindo. According to the National Institutes of Health, about 30 million kids go to the emergency room every year. And we know that trips to the emergency room can be stressful and frightening, can cause a lot of anxiety. But with the right information, we can help reduce some of that anxiety, prepare you and your family for any potential trip to the emergency room and, hopefully, help you have a more positive experience. So joining me today to talk about what parents should know when you need to take your child to the emergency room, our Doctor, Kathie McCans, who is the division chief of pediatric emergency medicine, and also April Squares, who is a registered nurse and clinical staff leader at Penn State Health Children’s Hospital in the pediatric emergency department. So thank you both for joining me today. We appreciate your time. And we also welcome your questions for April and Dr. McCans. If you have any questions about when to take your child to the emergency room, please feel free to put your questions in the chat right below this video, and we will get an answer for you. And we can do that whether you’re watching now live or if you’re watching this on playback. So to get started, we’ll first mentioned that Penn State Health Children’s Hospital is the only level one Pediatric Trauma Center in South Central Pennsylvania and the only hospital that has a dedicated pediatric emergency department. So let’s start with you, April. Talk a little bit about, you know, what exactly does that mean? And why does that make this, the emergency department at Penn State Health Children’s Hospital different than a typical emergency room?

April Squares – Sure. So coming to a dedicated pediatric emergency department means that you’re going to have access to a bunch of different specialties who have pediatric providers. In addition to that, all of our nurses, physicians, and PCs are pediatric specifically trained. And we also have access to child life therapy, music therapy, and other resources to help ease your transition into the emergency department. We know it can be a scary time for your child. So we have a bunch of resources as soon as you walk in the door to help make that trend a little bit easier for you.

Barbara Schindo – Okay. Thank you, April. And now, we’ll start with Dr. McCans. I know there is, there’s probably a lot of curiosity about different types of injuries. You know, I was telling you both before we started here that I have a lot of girlfriends that have young kids, and they get very anxious when something happens and are thinking, you know, “When do I need to take [inaudible] department. So Dr. McCans, we’ll start with some of these potential injuries or illnesses and when it might be necessary to go to the emergency department. So let’s start with a fever. Let’s say your child has a fever that may be a low-grade fever or high-grade fever. You know, when should a parent start thinking about making a trip to the emergency room versus just calling your pediatrician?

Dr. McCans – That’s a great question and one that I really, am fairly passionate about because fever is your friend, particularly in young children. It is their body’s way of responding to any infection, whether it’s a minor cold or something potentially more serious. So the first thing people need to really know is don’t be afraid of a simple fever. It is your child’s way of fighting infection. It actually helps to kill off viruses and bacteria. And so it really is a good thing. There’s really only one reason that we treat a fever and that is to help a child feel better because when children feel poorly, they may not drink or eat or they may be very fussy and irritable and it’s stressful for the child and the family. So it’s always a good idea to call your pediatrician. If your child is otherwise acting well but has a fever, they’ll talk you through it. They will help triage whether the child can come in and be seen in their office, whether that needs to happen on the same day or can wait a day or two. They’ll provide you instructions on supportive care. I always say that fever becomes an emergency if there’s fever and additional symptoms that are causing concern. So if the fever, if there’s a fever and the child is struggling to breathe, or has an all-over body rash, or is really ill-appearing, according to the parents, can’t be aroused or it’s just too sleepy, and that’s what’s scary. So fever and additional symptoms that are causing concern, from severe vomiting and diarrhea and the child is not urinating, the family feels they’re becoming dehydrated. Those are the additional symptoms that make the fever an emergency and it’s really not a temperature which, in and of itself, makes this an emergency. It’s really the fever plus other symptoms or their family sense that things are really going poorly and it’s not safe because an emergency is really defined by the lay person’s perception that this isn’t safe to stay at home with that, a person needs urgent or immediate care.

Barbara Schindo – I’m glad you brought that up about, there’s not a specific temperature that would cause the emergency because I would think a lot of folks might think, you know, a 103 fevers is much more dangerous or scary than a, you know, a 99 or 100. But you’re saying there may be circumstances where a fever that high is totally treatable at home.

Dr. McCans – Right. So I mean I’ve seen children with 104 fevers who are running around and playing. That is not a child who has a dangerous fever. And fever really starts at 100.4. If it’s less than 100.4, in pediatrics, we don’t really consider that a true fever, which is also something people don’t realize. And children tend to have higher fevers that last longer than older children or adults, most likely, in part because they are using fever as their primary immune response since they may not have been exposed to very many viruses or bacteria that can make us sick, and they may not have antibodies, and certainly in children who were immunized. Those things that historically cause serious problems for young children are much less common because they already have immunity provided by those vaccines they’ve received.

Barbara Schindo – Okay. And what about, you know, injuries at home, like an accident or a fall, where it might appear that your child has a head injury? At what point would it be necessary to take your child to an emergency room if that happens at home?

Dr. McCans – So if the child appears ill or out of it, has significant symptoms like repeated vomiting, has a seizure, seems like they are altered by the head injury, that is an urgent and emergent problem that care should sought. If it is, the child seems completely fine, but struck their head, talking to your pediatrician is likely a good idea if you’re worried. If there’s just a simple bruise, particularly, on the forehead, talk to your pediatrician. It’s really about the fact that the child had a head injury of some sort, banged their head, and now what is happening. So if they’re out of it, if they’ve had a seizure, if they look ill, if the family again feels like this isn’t right, my child’s not doing well, that’s when I think they need to seek care. And how concerned they are to guide whether they call their pediatrician for guidance, or come directly to the emergency department. And certainly, if the child is having a seizure, severe bleeding, or seems to have neurologic symptoms, is very out of it. That’s even an indication that they should consider calling 911 and having an ambulance transport the child to the emergency department.

Barbara Schindo – Okay. Thank you, Dr. McCans. You are watching Ask Us Anything About when to Take your Child to the Emergency Room with Dr. Kathie McCans and April Squares from Penn State Health Children’s Hospital Pediatric Emergency Department. We welcome your questions for Dr. McCans or April. If you have any questions, please put them in the chat right below this post and we will get an answer for you. So let’s talk a little bit about what to expect when you get to the emergency room. Let’s say, you know, something happens at home or your child is ill and you either made the decision or spoke with your pediatrician and they say, you know, “It’s time to go to the emergency room.” April, can you talk a little bit about, you know, what should the family expect when they get there? You know, what happens once you get to the emergency department?

April Squares – Sure. So you’re going to enter the emergency department. You’ll be registered with the child’s name and birth date, and then shortly after arrival, you’ll be triaged by one of our pediatric specifically trained triage nurses. It’s at that point that your child’s initial vital signs will be taken. We’ll go over some brief health history and really get into the details of the reason that you’re there for your visit. The triage nurse will determine the acuity of your child’s needs, and that takes into account their symptoms, their risk of worsen symptoms, and then you are placed in an acuity line based on the reason for your visit. So depending on our volume, sometimes that means that you will go back out to our waiting room. Sometimes that means you’ll go right back to a room and sometimes that means you may be placed in alternate areas. Our biggest goal is to make sure that we see every child within an appropriate timeframe based on their symptoms. So that may mean that you are assessed by a physician or a resident in a non-traditional space. During times of high volume, that may mean that you’re seeing in a stretcher, in one of our hallway beds, that you’re seeing in an internal waiting room. But again, the true intention of that is that so we can see you as soon as possible based on the symptoms that your child is brought in for. From there, you’re typically placed into a regular pediatric ED room. You’ll have studies done. You may have had those studies done while you were waiting. If your child is there and needs an X-ray, sometimes the X-ray techs will get you from the waiting room to expedite that care while you’re waiting for a pediatric room. Once you’re in the room, you’ll be treated by a pediatric specifically trained nurse and a physician who is trained in pediatric emergency medicine. And then from there, we’ll provide the care that you need. Once some of that is done, you may also be asked to move back to an internal waiting room while we finish your evaluation and your treatment. And again, that’s just so we can expedite care through all of the patients that we need to see.

Barbara Schindo – Is there anything, you know, parents or guardians, family should know about preparations? Is there anything specific they should bring along with them or they should know or have before they come?

April Squares – Not necessarily, especially in a true emergent situation. We have everything that you may need during your stay, just please speak up. And remember that you are your child’s strongest advocate. So if you have a gut feeling that something is wrong, definitely speak up at any point during your stay, whether you’re in the waiting room, in a room speaking with a physician, your voice truly matters. So —

Dr. McCans – So I would say it’s helpful if a family has a child who is on medications, if they keep a list of the child’s current medications and dosages in kind of in their pocketbook or something or their wallet. Something that would be going with them in an emergency, not that you should ever take time in an emergency to seek and find information. But if it is maybe more urgent than emergent, ensure you have that particularly if you’re going to an emergency department that is not connected with your child’s primary care. Through electronic medical records, we do often have access to a lot of information that we did not use to have. But if we can know for sure medications the child is on and dosages, being sure that all the care providers have access and information regarding that the child is allergic to certain things, again, we’d have access to that if your child has been cared for at the Hershey Health System in the past. But if you get unaffiliated care or you’re traveling some time, and you’re going to an ED that doesn’t know your family, having that information is really helpful as well as if you’ve been referred to the emergency department from another provider for care that can’t be provided at that location. If there’s test information or in particular radiology, like having it on a disk and bringing that with you to us, will save some time, and us starting either the process over or electronically, trying to obtain that information.

Barbara Schindo – So, Dr. McCans, you mentioned, you know, if you may get referred to the emergency department from another provider, let’s say, you know, talk a little bit about, for example, if you go to an urgent care or your pediatrician’s office, particularly, if you’re at an urgent care and you’re there with your child, and then, you know, the staff at the urgent care says, you know, we think you need to go to the emergency room, instead. You talk a little bit about, you know, what should the expectation for parents and kids be if they’re in that type of situation? You know, if they feel like, you know, the urgent care doctor says we think you need a, you know, we think you need a higher level of care because that might, you know, cause some parents to panic, but what should they know about the expectation from moving from, you know, an urgent care to the pediatric emergency department?

Dr. McCans – So certainly, so, you know, urgent cares have really expanded the availability of medical care rapidly to a lot of people but it is uncommon to have dedicated pediatric providers in urgent care settings. I am not aware of any dedicated pediatric urgent cares in South Central Pennsylvania. I could be wrong. And there are other places where there are pediatric urgent cares, but I don’t think there’s any in our area. And so that urgent care provider, I think is making a recommendation to go to the emergency department because they also have your child’s best interest at heart, and they want the child to get the best possible care, but since they may be less experienced in caring for children, what they perceive is necessary may not be accurate when the child is being evaluated for by pediatric providers. And I think a common thing for that is, that the child maybe did bang their head and has some symptoms of a concussion. And families are told, “Well, you need to go to the emergency department for your child requires a radiologic study, a CAT scan of the head,” and then you come to the emergency department. We evaluate the child fully, and we feel that that’s not necessary. In pediatrics, we really try to limit radiologic studies of children that aren’t going to have a significant effect on their care because there’s risk, long-term risks associated with that. So if the referral has been made by a non-pediatric provider, it may be that they are really in an abundance of caution on making the recommendation. They are, but we may view what’s necessary or appropriate differently. And then, I think, again, to keep in mind that along each step people are making recommendations because they truly want the best possible outcomes and care for your child. And then we, typically, are discussing with the family why we think what we think, why it’s necessary, what the risks and benefits are, and then working with the family to come to a plan that is acceptable to everybody.

Barbara Schindo – And Please excuse my cat. He’s obviously curious about this, too. I apologize. Thank you for that, Dr. McCans. You’re watching Ask Us Anything About when to Take your Child to the Emergency Room with Dr. Kathie McCans and April Squares from Penn State Health Children’s Hospital’s Pediatric Emergency Department. And April, I had wanted to ask you this question as well when you were talking about what to know when you are bringing your child to the emergency room, is there ever a circumstance where a parent or guardian should call ahead and let an emergency room know they are coming? Is that necessary? Or just by nature of it, is it not necessary?

April Squares – It’s usually not necessary. Sometimes if you call your pediatrician beforehand, your pediatrician will call in and give us a heads up that you’re on your way but otherwise, it’s not necessary to give us a advance notice that you’re coming in.

Barbara Schindo – Okay. And is there anything, anything additional that either of you wants to add to the question about, you know, what does staff, what does emergency room staff need to know about my sick child or my child’s condition? You know, is there anything in particular that parents should be prepared for there?

Dr. McCans – If you think that, if your child has special needs, it’s really important to share with the emergency department things that help that child be more comfortable. When I think of children with significant developmental delays or children with autism, sometimes they have very specific things that we would not be able to predict. That either makes it easier or harder with that child. And so families are proactive about saying this is what, my child’s most sensitive or that sort of thing. We will often ask parents that when we realize the child has some neurocognitive differences. But if any provider doesn’t ask, parents should be very proactive about things that they uniquely know about their child that will help us make it a comfortable and positive experience for the child. And generally, if the child has that experience, so does the family.

Dr. McCans – I’m actually glad you brought up, you know, kids and adolescents with special needs. Can you guys talk a little bit about, you know, what makes a dedicated pediatric emergency department, you know, different in that area because I know Penn State Health Children’s Hospital’s Pediatric Emergency Department has some specific resources for kids with special needs who may need them?

April Squares – Dr. McCans did you want to speak to that?

Dr. McCans – Sure. So I really think it’s having that full spectrum of providers that are experienced with taking care of children as well as the additional sub-specialty physician who, whether or not they’re available in person, in the moment, or available to us via a phone call to help support a child’s need. And additionally, we have access to child life, not 24 hours a day, but they’re here for a significant number of hours every day, as well as music therapists who, they really are wonderful and engaging all our children, but especially those with special needs. And then we have some equipment that can be helpful for children with special needs available to us. I always forget there’s this distracting machine that has lights and strobes. I forget what it’s called all the time but for a child that finds that sort of stimulation soothing, well, we can bring that in the room. And by virtue of the fact that we have frequent contact with our child life therapists, in particular, they have taught many of us how to bring some of those same skills to the child who is there when child life is not present. And we also have, again, a variety of supplies to the generosity of the health system available to make it easier for children. We routinely provide children who are anxious with stress balls or homemade stress balls, which again an ED that’s not seeing this large number of children just may not have those supplies that help distract children as well as the expertise of people dedicated to trying to make the experience as comfortable and positive as possible.

Barbara Schindo – Okay. Thank you very much, Dr. McCans for that. And thank you very much to both of you for joining us, April Squares and Dr. McCans from Penn State Health Children’s Hospital. If there’s a question, for those of you watching this at home, if there’s any questions that we did not answer here, if you have any follow-up questions for April and Dr. McCans, there’s still an opportunity to do that. Please feel free to put any questions or comments in the chat below this post, and we will still be able to get an answer for you even if you’re watching this on playback. Thank you again to both of you for joining us and thanks for watching.

April Squares – Thank you.

Dr. McCans – Thank you.