CHOP ER Article

1. 10 Children’s View
From top: Sickle cell disease-related pneumonia brought Nikaury, 3,
to the ED; Mitchell, 10 weeks, visits for pink eye; CHOP’s newest
ambulance joins the fleet; Jakir, 9, injured his lip playing basketball.
24 in the
EMERGENCY
DEPARTMENT
hours

2. Children’s View 11
very year, more than 85,000 children visit the Emergency Department (ED)
at The Children’s Hospital of Philadelphia.
The ED is so many things: a 24-hour refuge for urgent problems, a training
ground for new pediatricians, a regional referral center for lesser-equipped
community hospitals, and a safety net for families who don’t know where else to
go. It is a place that touches so many children and families, often at the scariest
moments of their lives.
Nationwide, hospitals admit about 6 percent of children from emergency
rooms. At children’s hospitals, it averages 10 percent. CHOP’s admission rate is
18 percent — nearly the highest in the nation. The admission rate reflects the fact
that CHOP’s patients face, on average, more severe illness, explains Kathy Shaw,
M.D., division chief and director of Emergency Medical Services. “We get the
sickest children referred to us from community hospitals, we’re a Level
I trauma center, and we’re in an inner city where there’s a burden of
illness,” she says.
Starting at 8 a.m. on Nov. 7, 2011, we spent 24 hours
in the ED to find out what happens in a typical day. As we
learned, the ED doesn’t have the running, shouting action of
TV hospital dramas — although our day held moments
of that — but it does treat many children every day
with potentially life-threatening problems. There
were 279 children brought in that day. These are
their stories. >>
E
By Eugene Myers
and Julie Sloane

3. 12 Children’s View
Patient Snapshot: 279 Patients seen … 40 ED patients admitted to the Hospital … 3 Trauma cases
requiring the resuscitation room … 81 Patient beds in use … 316 Prescriptions written … 20 Children
arrived by ambulance … 1 Child arrived by helicopter … 179 Calls to the Poison Control Center
Lily, 14 months
8 a.m. The doctors and nurses on team 1 discuss each patient
one by one: There is a 6-year-old boy with severe breathing
problems, a 9-year-old girl with abdominal pain, and a 3-month-
old baby with fever and possible seizures.
Rounds are an institution between every shift change —
8 a.m., 4 p.m., midnight. The incoming team of physicians
and nurses forms a circle with the outgoing team, introducing
themselves by first name and role. Good communication not
only prevents medical errors, but introductions also help patient
families know who is taking care of them.
Each team is led by an attending physician and staffed with
seven to 10 nurses, fellows, nurse practitioners and residents. As
many as seven teams operate simultaneously, each caring for as
many as 10 patients. On this morning, team 1 is led by Joel
Fein, M.D., who has been at CHOP since his residency in 1988.
He checks in on a 12-year-old girl with suspected appendicitis
and a pained expression. “She doesn’t want surgery,” says the
girl’s mom. “If you do need it,” Fein says with a smile, “you’ll
want it sooner rather than later. Trust me.” By mid-morning, her
appendicitis has been confirmed and she is taken to surgery.
10:15 a.m. A resident presents the story of 2-year-old
Ramisha to team 2 attending Mirna Farah, M.D. Ramisha
(pictured on opposite page) has had a fever for nine days, the
resident explains, and has been getting them every few weeks
since she returned from a family trip to Bangladesh six months
ago.
“Let’s think of the possibilities of what she might have,” says
Farah. They rattle off a long list and look online for information
about diseases particular to Bangladesh. Then Farah goes to
examine Ramisha herself. Every patient in the ED gets examined
by at least two doctors, including an attending, who guides the
others and makes the final call on all treatment.
Bright-eyed and alert, but cranky from her fever, Ramisha
hugs her mother close and cries. Farah waves her red, lighted
stethoscope like a toy to distract Ramisha while listening to her
lungs and looking in her ears. Finding no other visible problems,
Farah orders a battery of tests that will last the entire morning.
“Nine days is too long,” Farah says to Ramisha’s family. “If we
don’t find anything, we’ll admit her.” Around 4 p.m., they do just
that.
11:15 a.m. “It’s wheezin’ season,” says sort nurse Bonnie
Rodio, R.N., a 36-year CHOP veteran, watching the waiting
room begin to fill. Rodio’s job is to rate the urgency of each child’s
problem the moment they arrive, prioritizing the most urgent
cases.
Fall, with the return to school and exposure to viruses, cold
air and decaying vegetation, always brings a spike in asthma.
While it’s a common condition, asthma is also the top reason kids
ONE DAY BY
THE NUMBERS

4. Children’s View 13
Ramisha, 2
From left: Kidney
transplant patient Michael,
10, came to the ED with
a severe headache; Sabir,
17, receives a cast for his
fractured hand; Team 1
rounds at 4 p.m. as Mark
Zonfrillo, M.D. (center,
in green), takes over for
Joel Fein, M.D. (far left).
in emergency rooms need to be admitted, so it is taken very seriously.
This day, in fact, will bring 66 kids in respiratory distress. Even with a
whole team dedicated to respiratory problems, these patients overflow
into all the teams. Come winter, the ED will see more flu and infections;
its busiest day ever was in October 2010, when the H1N1 virus drove
more than 500 kids to CHOP’s ED.
12:27 p.m. Joel Fein flips through the results of a teen mental
health screen, given to a 14-year-old boy. It is a computerized survey Fein
co-developed with CHOP psychologist Guy Diamond, Ph.D., to screen
all teens 14 and older in the ED for problems like depression, drug abuse
and suicidal thoughts. “These are questions a child would be asked in
primary care, but many don’t get primary care,” says Fein. About 20
percent of the time, the doctors find something worrisome on the survey.
Happily, today’s patient reports nothing wrong.
2:30 p.m. Fourteen-month-old Lily (pictured on opposite page),
normally a steady walker, wobbles her way down the hallway, with the
medical team and her parents hovering to catch her before she tumbles
over. This unsteadiness, called ataxia, is what has brought her family here
from Ocean City, N.J. Ataxia can be a sign of a brain tumor, and the
team very much hopes that is not the case with Lily. (Fortunately, the
next day Lily’s ataxia was found to be post-viral, and she went home.)
4 p.m. As team 1 holds rounds (pictured below), Joel Fein passes the
reins to Mark Zonfrillo, M.D., a pediatric emergency specialist who has
been at CHOP for five years. Most of the attendings also do research
outside of their clinical hours. In addition to the teen mental health
screening, Fein is deeply involved with programs to address and prevent
youth and family violence. Zonfrillo, too, spends about half his week
with CHOP’s Center for Injury Research and Prevention.
continues >>

5. 14 Children’s View
On the Move
The First Step in Any CHOP Experience? Getting There.
They might be one of the most important groups at CHOP
that patients never see. But for the baby fighting for her life in
a community hospital who needs to be rushed to CHOP, the
Emergency Transport Team is essential.
The Transport Command Center is a small room nestled
in the Emergency area. Inside, six or seven people sit in a row,
working the phones, which ring just about nonstop, around the
clock. An average of 1,200 calls go in and out each day.
This team coordinated the transport of 7,400 children to
CHOP last year — 3,000 through the Hospital’s own ambulances
or aircraft and 4,400 more from those of other hospitals. Most of
these children come from other hospitals that can’t offer the same
level of specialized pediatric care. They commonly come from any
of 150 hospitals in the region but can also arrive from across the
country and around the world.
The Transport Command Center may dispatch a helicopter
or one of CHOP’s three dedicated ambulances — more than 90
percent arrive by ambulance — making its nurses, paramedics,
respiratory therapists and, when needed, physicians quite well-
traveled. The team also works to make sure CHOP is prepared to
receive patients.
“It’s like the air traffic control of the Hospital,” says Nick
Tsarouhas, M.D., director of Transport. “Any child who needs to
get here, outside of a private residence, we’re somehow involved.”
– Julie Sloane
5 p.m. “Foreign body” reads the screen next to 20-month-old
Elias’ name. “Kids swallow things all the time,” says Zonfrillo.
CHOP’s Poison Control Center gets more than 40,000 calls a
year about kids under 6 (see box on page 16). “Most of the time
it’s harmless, but there are certain things we worry about, like
pins or button batteries. Those can actually be fatal.”
Elias’ mother watched him swallow a nickel, which another
hospital confirmed by X-ray, but nine days later, she still hasn’t
seen it emerge. “I’ve been digging through his diapers like I was
digging for gold!” she says earnestly. “I want that nickel out!”
Zonfrillo orders another X-ray and smiles as he looks at the
screen. “That’s what I thought,” he says. “It’s gone. It must have
come out in a diaper when Elias was at day care.”
6:45 p.m. Monday is the ED’s busiest day, and 2 to 11
p.m. its busiest hours, but the pace of the day seems to slow.
Attending Joe Zorc, M.D., in charge of keeping statistics for the
ED, guesses why: The Eagles are on. “There’s not necessarily a
correlation with when Philadelphia sports teams play,” he says,
smiling, “but it’s a pretty safe bet.”
Elias, 20 months
A 6-day-old baby arrives by helicopter for heart surgery.

6. Children’s View 15
continues >>
8:30 p.m. Without warning, a voice comes over the Haste
System, a loudspeaker controlled by Philadelphia Emergency
Dispatch. “Trauma alert.” An 8-year-old boy has been hit by a
car. He will arrive in 15 minutes. The resuscitation room, with
its three operating room-like bays to handle critical emergencies,
comes to life.
Within a few minutes, the Haste System calls out a second
trauma alert: 16-year-old male, GSW. Murmurs erupt among the
staff: “GSW.” Gunshot wound. More of the staff peel off into the
resuscitation room. CHOP receives only about 30 gunshot wounds
each year, but the teams have held many simulations to prepare for
this scenario. There is a precision to the frenzy, everyone quickly
donning gowns, gloves, masks and face shields. Trauma surgeons
and X-ray technicians arrive, the blood bank is called, the operating
room is notified, security guards man the door. About 50 people
fill the resuscitation room.
Zonfrillo calls out to the team in a loud, calm voice: “Get
ready to do a chest film. We’re going to need to roll the patient
quickly to look for wounds out the back. Who’s going to do that?
Who’s going to be cutting the patient’s clothes off?”
8:46 p.m. The paramedics briskly roll in a gurney with the
8-year-old from the motor vehicle accident and recite his story.
CHOP allows families to observe everything in the resuscitation
room, so the boy’s father is met by a child life specialist to serve as
his guide. It takes just seven minutes to assess the boy, who appears
fine but for a broken leg. He leaves for a CT scan before heading
to a normal patient room in the ED.
8:49 p.m. The boy with the gunshot wound arrives, and
while someone cuts off his clothes, others focus on ABC: airway,
breathing, circulation. The doctors call out their findings. “Airway
intact. Two wounds on the lower right quadrant of the abdomen.
Breath sounds equal and bilateral.” The boy is awake and alert.
They roll him to the side and find no exit wounds. He got lucky.
The CT scan will show the bullet went through his abdomen
superficially. He is going to be all right.
9:03 p.m. In the midst of the action, a third trauma arrives.
(“I have been here for five years, and only one other time have I
seen all three trauma bays in use at once,” Zonfrillo would say
later.) A third attending arrives to lead the case. The paramedic
calls out the story: A 2-year-old boy was climbing a dresser when
a TV fell on him. He has been lethargic. A similar frenzy descends
on the little boy, cutting off his clothes, checking his breathing,
drawing blood. A nurse notes that the boy is moving all of his
arms and legs equally. In the haste of getting him to the Hospital,
the boy is still wearing one red fuzzy Elmo slipper. He improves
quickly and, finding no obvious injuries, the team decides to watch
and wait. Hours later, the news is good: He is fine.
Above: Paramedics arrive with a trauma
patient. Right: Staff in the resuscitation room
spring into action.
16 Attending physicians … 2 ED fellows … 18 Residents … 63 Registered nurses … 6 Nurse practitioners …
7 Respiratory therapists … 4 Child Life specialists … 4 Social workers … 13 Techs … 76 Patient care assistants
ONE DAY BY
THE NUMBERS
Staff Snapshot:

7. 16 Children’s View
Help for Toxic Times
The Poison Control Center at CHOP Keeps Communities Safer
When a curious child finds out the hard way that the pretty
blue liquid in the shower tastes nothing like raspberry, most
parents know to call the Poison Control Center for free and
speedy help. But what most don’t realize is that for 23 counties
in Pennsylvania and all of Delaware, the 24/7 Poison Control
Hotline [phone]) is staffed entirely by CHOP.
The Poison Control Center at CHOP responds to
more than 80,000 calls per year, from homes, workplaces
and other hospitals. While more than half the calls are
about children under age 6, the Center has been helping
people of all ages for 25 years. It frequently receives
calls about chemical exposures in the workplace or
elderly people who take the wrong medications. Many
of the calls, in fact, come from other hospitals seeking advice
on perplexing overdosing and poisoning cases.
Every hotline call is fielded by a poison information
specialist who is a nurse or pharmacist, and a board-certified
toxicologist is always on call. Most incidents can be handled
over the phone. Not only does hotline advice frequently
prevent unnecessary trips to the emergency room, but also
studies show that every dollar spent on poison control services
saves $7 in related healthcare spending.
The Center, with a staff of 17, is supported by both
state and federal grants as well as funding from CHOP. In
recent years, as government funding for poison control has
been eroding nationwide, many centers have been forced to
close. The CHOP-based Poison Control Center has remained
open, and the Hospital is seeking to preserve this important
community resource through additional private donations.
Evening in the Emergency waiting room
10:40 p.m. William, 17, and his parents are
worried about swelling, pain and inflammation down
his right leg. There’s real cause for concern, since
William is being treated at CHOP for cancer in the soft
tissue of his leg. Fortunately, an ultrasound scan shows
no sign of a blood clot; Zonfrillo’s diagnosis is cellulitis,
which can be treated with an antibiotic. William is
especially relieved because this means he can participate
in a walk-a-thon the next day, sponsored by his school
to raise money for his treatments.
Midnight “Attention, attention. Rounds are
now beginning in team 1.” An announcement on the
intercom signals another change in shift. A seven-year
CHOP veteran, Manoj Mittal, M.D., takes over from
Zonfrillo as attending physician.
3:10 a.m. Sixteen-year-old Justin (pictured
on opposite page) broke his arm playing basketball.
Because his bones may still be growing — something
adult orthopedists don’t usually see in patients — his
community hospital decided to send him to CHOP.
Justin is sedated — he won’t feel or remember any
of this painful procedure. An X-ray machine displays a
real-time image of Justin’s arm as his bones are realigned.
His father waits right outside the room. He’s no stranger
to CHOP or the ED: His other son was once treated
here, and he credits CHOP with saving his daughter’s
life. He trusts CHOP doctors to take good care of
Justin, too. When he re-enters the room, his son’s arm is
bandaged, propped on a pillow. A nurse asks Justin how
– Sara Barton

8. Children’s View 17
How You Can Help
The Emergency Department sees 85,000 patients
every year, saving children’s lives every day. If you are
interested in making a gift to help further that mission,
please contact Mary Cooney at [email protected]
or 267-426-6468.
Above: Justin, 16, with his father
Below: Fellow Maya Jones, M.D., listens during rounds.
1. Breathing difficulties … 2. Fever … 3. Abdominal pain … 4. Headache … 5. Rash
he’s feeling. He groggily raises the thumb on his good hand:
He’s okay. Justin’s father tenderly rests a hand on his son’s
forehead. It’s been a long night for both of them, but soon
they’ll be able to go home.
5:17 a.m. Environmental Services takes advantage of
a temporary lull in the ED to clean, but there’s plenty of
activity in Zakee’s room. The 4-year-old boy broke into his
anti-seizure medication and drank way too much. Cynthia
Jacobstein, M.D., the attending in team 2, examines him
and questions his mother; meanwhile, a nurse calls Poison
Control for more information on the drug he took.
Ten minutes later, Zakee gags. A nurse gently turns
him on his side as he coughs up the orange medicine. The
team works together efficiently to suction out his mouth
and quickly clean him and the area. Now out of immediate
danger, Zakee rests comfortably.
6:05 a.m. The ED seems to be “running a special”
on appendicitis, as one staffer notes. There are five
appendicitis patients in the ED right now, four of them
transferred from other hospitals within the last two hours.
Children regularly arrive to the ED from other hospitals
via ambulance, helicopter and even airplane (see Page 14).
The synchronicity in such a short period is unusual, but the
cases are in the best possible hands: One of Manoj Mittal’s
research specialties is appendicitis.
Because there are so many simultaneous appendicitis
cases, Mittal suggests extra care be taken with their
medications; the charge nurse already had the same thought
and has assigned a different nurse to each patient to avoid
any potential mix-ups.
8 a.m. Mittal and his team hand off their patients and
their histories to new caretakers. The departing physicians
and nurses may never learn the outcomes for the children
they helped, but they’ve touched and improved many lives
throughout the night.
Now, sunlight is the only thing filling the ED
waiting room — the start of another day. The story for the
next 24 hours will be much the same, but it will feature
different players, different problems to be solved, different
emergencies.
The ED doors slide open. A mother and child walk in.
They head past the empty rows of seats toward the nurses’
station.
Q
ONE DAY BY
THE NUMBERS
Top 5 Reasons for Visiting the CHOP ED on November 7–8, 2011