A third of those family physicians who regularly treat children can expect to encounter at least 1 pediatric seizure in their office during the year. Two thirds or more are likely to encounter children with seriously high fevers, dehydration, allergic reactions, or asthma attacks. Concern about office preparedness for these emergencies is warranted.
Our data suggest that family physicians’ practices may not be appropriately equipped. Having an oxygen tank is of little use if there is no mask to administer it. We do not recommend intubation in the office setting. Most emergency medicine experts agree that the key to airway management in out-of-hospital settings is positive-pressure ventilation through use of a bag-valve-mask, but the correct size is required. Similarly, there must be quick and sure means to administer fluids and IV drugs in the proper doses. The intraosseous needle may be the safest and fastest way, but less than 1 in 7 family physicians had this item. Doses for children vary greatly and quick information aids (such as the Broselow tape, which indicates drug dose and device size according to body length) may not be available. Familiarity and skill with these 2 items could be acquired in PALS training.
It is puzzling that family physicians think it less important to provide emergency care to critically ill children in their offices than do pediatricians. It may be that they think it is not appropriate for them to treat such emergencies or that such emergencies do not happen often enough to be of concern. Perhaps most of their data are anecdotal, and they simply have seen little information on the incidence, variety, or severity of pediatric office emergencies. Might they generalize their proficiency with adult emergencies to those of children? Some may believe that training in Advanced Cardiac Life Support provides sufficient skill to handle pediatric emergencies, but the techniques, doses, and device sizes for infants and young children are quite different from those for older children, adolescents, and adults.
Our study provides evidence that family physicians and pediatricians should assess the likelihood of children with serious medical emergencies presenting in their offices. As Trachtenbarg14 recently suggested, they should evaluate their own unique patient mix and be prepared accordingly. Both family physicians and pediatricians should evaluate the likelihood of seeing more pediatric emergencies because of managed care. Our study may help them judge their need for continuing training. Many states have developed specific training programs through the Emergency Medical Services for Children (EMS-C) program,* funded by the federal Maternal and Child Health Bureau. PALS training courses are commonly available. Our current and future work involves promoting and conducting such training.
Conclusions
Though no primary care office can be as well equipped as a hospital emergency department, the cost of basic equipment should not be prohibitive. It can cost less than $600 to prepare an office.15 In terms of time, PALS training is a 2-day course with refreshers every 2 years, and a mock emergency in the office can take less than an hour. Emergencies are by no means as common as ear infections; however, they do occur, and the consequences of being unprepared are serious. Family physicians need many skills. These data demonstrate that preparedness to stabilize and resuscitate children in emergency office encounters should be part of their repertoire.
Acknowledgments
Our study was funded by the North Carolina Office of Emergency Medical Services, Division of Facilities Services, Department of Health and Human Services, through a grant from the US Department of Health and Human Services. We thank Bob Bailey, Director of the North Carolina Office of Emergency Medical Services, for his assistance and support. We thank also Zoe Yetman (East Carolina University) for her attention to detail in managing the survey and Matthew Curry and Kevin Gross for reviewing the final manuscript.
Related Resources
- Emergency Medical Services for Children
- Maintained by the EMSC program, which is primarily supported and jointly administered by the U.S. Department of Health and Human Services’ Health Resources and Services Administration and the U.S. Department of Transportation’s National Highway Traffic Safety Administration. The site offers information on education and training, national and state activities, funding opportunities, and family education resources for injury control and prevention. http://www.ems-c.org
- American Academy of Pediatrics‹a comparison of APLS and PALS training and telephone numbers for both programs. " target="_blank">http://www.aap.org/profed/nrp/aplscom.htm>
- The components of the 14-hour APLS course may be found at " target="_blank">http://www.aap.org/profed/nrp/aplsccreq.htm>
- American Academy of Family Physicians (AAFP)‹Pediatric Advanced Life Support: A Review of the AHA Recommendations by Inis Jane Bardella, M.D. This article summarizes information from the PALS program but does not serve as a replacement for completing a PALS course. http://www.aafp.org/afp/991015ap/1743.html
- AAFP CME page‹Location and dates of PALS courses http://www.aafp.org/afp/calendar/cmecours.html