Not only is it winter, but it is also holiday season. ED visits spike at this time of year. Dr. Joseph Ravera is Director of Pediatric Emergency Medicine at the University of Vermont Children’s Hospital. He talks to us about common holiday and winter-related illnesses and injuries, how to prevent them, and provides details on the new pediatric ER at the UVM Medical Center, set to open in 2019.
What is the status of new pediatric ER at the UVM Medical Center?
Ravera: It is in the final stages of development. It will have seven dedicated pediatric beds, including critical resuscitation bays where we can take care of very sick children. We hope to have it up and running by this summer, or at the very latest next winter.
Why is it important to have a separate pediatric space?
Ravera: As you can imagine, pediatric emergency equipment is very differently sized in adults. There’s a phrase in pediatric medicine that “children aren’t just little adults.” You need different size IVs, and different size breathing tubes and feeding tubes. Having that in a centralized space is helpful. Also, if you have nurses who like to work in pediatrics, it helps them get into a groove if they focus only on pediatrics for a couple weeks or a month, as the medical problems are a little bit different.
Possibly the biggest boon, especially to patients, is that in some cases there can be a separate triage line. I don’t want to promise this, but ideally when the pediatric emergency department is up and running, when a child under 21 comes in they’ll be put in a separate line to go to the pediatric emergency department; thus, taking them out of the general adult population, which can help if there’s less volume of children.
You have also launched a new residency program. Tell us a about that.
Ravera: Yes, we have hired a residency director: Dr. Rich Bounds, a fantastic program director from the University of Delaware – Christiana Care Health System. We also have Dr. Mark Bisanzo from UMass, who has been here now for almost five years. He’s our assistant program director.
We’re interviewing 10 days this winter for six spots a year, and this is going to be a win, not only for the UVM Medical Center, but for the whole UVM Health Network. These are the doctors who we hope will go on to staff CVPH, Alice Hyde, Elizabethtown, our other affiliates, when they graduate.
It’s important to remember that the vast majority of emergency care in Emergency Departments in this country for children is not provided by a pediatrician, nor a pediatric emergency medicine physician; it’s provided by general emergency medicine physician, so strong training in pediatrics is important for them as they go out to some of our community sites.
When should somebody go to the ED versus urgent care?
Ravera: If your child appears critically ill, and you’re thinking about calling an ambulance, come to the ED. I’d always rather have you come to the emergency department. Come to the department and have it seen and evaluated. Better to be safe than sorry, particularly when it comes to children.
That said, the first line of defense is your pediatrician. A lot of pediatricians have good after hours call. So, if you can call and speak with either the pediatrician or a nurse and go over the symptoms, they can help triage you out to urgent care versus the emergency department.
Remember that urgent care is very good at realizing what they need to transfer quickly. If you walk in, and you have something that they think is out of their scope of practice, they’re likely going to transfer you to the emergency department. I would say there are certain procedures that an urgent care cannot do, particularly when it comes to deeply sedating children, so if you think that this is a bad cut that might need 10-15 stitches in a three-year-old, and they might need some sedation that’s probably better done in an emergency department. A broken bone that needs to be set is better done in an emergency department, but minor cuts and broken bones can certainly be handled in urgent care.
If you’re worried come to the emergency department. If you have time, I would check-in with your pediatrician, go over the symptoms, and ask your pediatrician: “Do you think we can go to urgent care?”
What are some common issues you see in the ER?
Ravera: We see the whole gamut – one of the reasons why I love working in emergency medicine. We get everything from coughs and colds to sprained ankles and cuts. In Vermont, we have a very active, hard-charging population that trickles down to our one-year-olds. Once they can walk, they’re running. So, the vast majority of what we see tends to be orthopedic injuries, cuts, and scrapes.
What are common winter-related illnesses or injuries that you see?
Ravera: I think the most important thing to remember is winter is our prime season for viruses, particularly respiratory viruses. The most famous one is RSV, which stands for Respiratory Syncytial Virus. There’s no specific treatment for viral infections. Antibiotics won’t help. Mostly, it’s just a question of time. The vast majority of children with viral infections get better and don’t even need to come to the hospital. A very small subset must come to the ER, and an even smaller subset are admitted to the hospital, and an even smaller subset get critically ill.
The one piece of advice I will give is that vaccines are crucial, particularly the flu vaccine. Even if it only gives partial protection. The flu is not only miserable, but in some cases very serious and life-threatening. Children with chronic illnesses, such as cystic fibrosis or congenital heart disease, are at high risk even with just a simple respiratory virus. That’s why things like keeping your child or children out of daycare if they are sick with a runny nose and fever may be life-saving to a kid in daycare with a chronic medical condition.
In terms of the injury side: helmets, helmets, helmets, helmets, helmets! If you’re going down something wear a helmet.
it’s also wood stove season, it’s time to get the fire going. Fire safety is key. We probably see two or three kids a year with pretty significant burns, particularly to the hands, because they’re cruisers and they’re just ready to get up. They don’t realize how hot a wood stove actually can get once it gets going. Always take that extra second to either put a gate up. If you’re going to run the wood stove, make sure someone has an eye on the little ones.
What toy or gift-related injury prevention advice do you have?
Ravera: Most toys these days are pretty safe. Be cautious with anything that shoots a projectile. The old phrase is you could put someone’s eye out, and sadly we have seen that before. If you are going to buy something that shoots a projectile like a BB gun, I would strongly recommend adult supervision and eye protection. That means every time you shoot it. It only takes one stray BB to leave a kid with permanent vision loss, or severe, decreased vision in one eye.
What should you do if you are outside and you or someone you know gets injured?
Ravera: It’s a really complicated question because it kind of depends on where you’re at. One of the subspecialties of emergency medicine is wilderness medicine, for which we have a strong department here led by Dr. Sarah Schlein.
There might be a situation where you need to make some sort of splint to get someone out. If you’re anywhere in the front country probably the best thing to do is shelter in place and have someone get down to a ski patroller, or get down to where you can get cell phone reception and call 911, particularly if it’s a severe injury. Then, let the professionals with their equipment get you to an ambulance and to the hospital.
Any other advice that you want to share?
Ravera: Always remember that the emergency department can be a busy, crowded, and stressful place. Mondays by far are the busiest day. I’m not saying that to deter anybody from the emergency department, but if you’re coming on a Monday, be prepared for a longer wait.
A lot of things affect the wait time. One of the biggest complaints we get is wait times and believe me physicians are just as frustrated. I promise anyone who comes to the emergency department that we will see and evaluate you. That’s actually a federal law. We can’t not evaluate you, but we do apologize if there is a long wait, and we do try our best to see everyone as quickly and as safely as possible.