Thread by @AnishaKMD

Let me paint a picture of #peds #emergency care for you.

Let's say your 3 year old bonks his head on the coffee table right before dinner. Nothing horrible, but needs stitches. You take him to urgent care. They tell you that they can't fix it, and you need to go to the ER.

1/

You get to the ER. It's 8 pm, the waiting room is about half full, and you think - "Ok, this may not be so bad. Maybe we will be home by midnight."

But a few hours later, all that's happened is that a nurse has taken his vitals. Your 3 yo is exhausted and so are you.

2/

Meanwhile, here's what's going on in the back.

There are no ICU beds. There are 2 kids in the ER who need the ICU. One is a bit sicker than the other, so the ICU is making room.

In the meantime, 1 nurse is dedicated to this very sick child needing constant monitoring.

3/

Another nurse stayed 2 hours late to help. A kid who broke a bone needs sedation to get it back into place, and that nurse is completely dedicated to safely sedating this child.

This means, of the nurses we have, 2 don't "have assignments." They are 1:1 with patients.

4/

So, 4 additional children stay in the waiting room while these nurses are 1:1 with kids (instead of the usual 1:3 assignment).

There is another child with a severe injury who needs sedation. The first nurse doing the sedation really does have to go home.

5/

So, 1 more nurse's rooms are closed in order to sedate the second child and fix this injury. This nurse is now taken out of an assignment for 1-2 hours.

Meanwhile, it's now 2 AM. Reinforcements aren't coming until 7. We just want to try and take care of kids.

6/

Children are also coming in via ambulance as transfers from other hospitals for specialized care. They come in through the ambulance bay, so you don't see them in the waiting room.

But it's now 3 AM, you & your toddler are half asleep, and wonder if it's worth it to stay.

7/

Because of all this, the waiting room doesn't move much unless something serious happens out there. Which it can at any time, and it does from time to time.

Then we run to make sure a kid is ok.

8/

While other floors "cap" the beds they have based on staffing, we can't. It's not the job of the ER. Ours is to keep:
- the kids waiting for the PICU safe
- the kids who need procedures safe
- the kids coming in as transfers safe, and
- the kids in the waiting room safe.

9/

So, while your kid's forehead laceration could be fixed reasonably quickly in theory, in practice it is dependent on many more factors -- time of day, ER staffing, ICU staffing, provider availability, number of transfers -- than one would expect.

10/

One of the differences between emergency medicine and being on a floor is the cognitive load. I didn't realize quite how different it was until I was a fellow.

Each additional child we see requires fresh eyes, new thinking, & a new relationship.

11/

On the floor, you often have half or more of the same patients as yesterday. Of course you're admitting/discharging as well, but new kids aren't being seen at a rate of a few per hr.

Now it's 5 AM & of course you're frustrated - I would be too! We are trying to get to you.

12/

But please, please continue to be kind to the staff who truly are trying desperately to care for every kid who needs us.

Your kindness helps us focus on what's important - keeping the kids safe - and not on folks' frustration and how it's directed.

We're not superhuman.

13/

It takes a second to recover from being yelled at. (We're lucky that in the peds ER that folks are less likely to be assaulted). What we want to be doing is focusing on caring for your kid, not on whether our staff is safe.

14/

And hopefully, soon, your kid's laceration has a couple of stitches & he's eating a popsicle.

We're trying to make this better, but the pandemic & the current respiratory virus surge of rhino/entero is causing many kids to breathe hard.

15/15