Pediatric Emergencies in the Office: Are Family Physicians as Prepared as Pediatricians?

There was no pediatric emergency condition that family physicians were statistically more likely to encounter than pediatricians. Pediatricians were significantly more likely to see severe croup (75% vs 48%), seizure (62% vs 33%), dehydration (85% vs 64%), and serious febrile illnesses (82% vs 65%). The average pediatric practice saw at least 4 of each of these child emergencies in the course of a year.

Family physicians saw fewer children with medical emergencies than did pediatricians. The mean EOS score was 3.8 for family physicians versus 4.9 for pediatricians (P <.001).

Emergency Preparedness

Table 3 shows emergency preparedness, as measured by the immediate availability of resuscitation items. The items are listed in increasing order of availability.

Ninety-six percent of all practices reported that they had oxygen immediately available; 88% had resuscitation drugs; and 86% had intravenous (IV) fluids. However, 27% had no appropriate way of administering IV fluids or drugs (no child-sized IV catheter or intraosseous needle). Family physicians were significantly less likely than pediatricians to have child-sized IV catheters, a pediatric bag-valve mask, an oral/nasal pediatric airway, or suction and pediatric catheters. Family physicians were also less likely to have available an intraosseous needle, a pediatric laryngoscope and endotracheal tube, a Broselow tape, or continuous pulse oximetry. In regard to having resucitation items, both family physicians and pediatricians were certain about the availability of oxygen, IV fluids, and continuous pulse oximetry. No family physicians or pediatricians responded “don’t know” on any of these items. Physicians were most uncertain about whether they had a Broselow tape (34% chose the “don’t know” responses) and an intraosseous needle (17% chose “don’t know”). Family physicians were significantly less likely than pediatricians to know whether they had a Broselow tape (43% vs 20%, respectively), an intraosseus needle (24% vs 5%, respectively), and suction and pediatric catheters (14% vs 5%, respectively).

Of those who encountered respiratory emergencies, a fifth of the physicians had no child-sized mask for administering oxygen. Family physicians were less likely to have one than pediatricians (30% did not vs 4%, respectively).

Family physicians were substantially less prepared for child emergencies, according to the inventory of immediately available items. The mean EPS was 5.7 for family physicians versus 8.6 for pediatricians (P <.001). Four-fifths of all physician offices had never conducted a mock or practice pediatric emergency. Only 6% of family physician offices had conducted a mock emergency versus 40% of pediatric offices (P <.001). Approximately one third of all physicians had taken a PALS training course during the previous 2 years. Less than a fifth of family physicians reported taking PALS training, compared with half of the pediatricians (P <.01).

There is a positive relationship between PALS training and preparedness. Those who had PALS training were significantly more likely to have a Broeslow tape available than those who did not (58% vs 21%, P <.001) and also were more likely to have an intraosseous needle (62% vs 24%, P <.001). Those who had PALS training were more than twice as likely to have practiced for a pediatric emergency (30% vs 13%, P <.01).

Beliefs About Preparing for Pediatric Emergencies in the Office

Family physicians and pediatricians differed in opinion on the importance of providing emergency care to critically ill children in their offices. Family physicians thought it less important to provide this service than did pediatricians. Family physicians rated providing care to critically ill children in their offices between “not very important” and “somewhat important.” The mean importance score for family physicians was 2.8 versus 3.5 for pediatricians (P <.001), with 4.0 being “very important.”

Physicians of both specialties attached less importance to providing care to critically ill children than being prepared to do so but differed by specialty on this dimension as well. Pediatricians thought it was more important to be prepared for these events (mean for family physicians = 3.4 vs 3.7 for pediatricians, P <.05), but the difference may not be clinically relevant. Each rated being prepared to stabilize a true pediatric emergency between “somewhat important” and “very important.”

Discussion

Although our study was conducted in only one state, we know of no reason the North Carolina experience would be unique. In contrast to the few previous studies, we asked about specific types of emergencies. We found that family physicians encounter a smaller variety of office pediatric emergencies than do pediatricians, but none of these events are unusual for either, and many are common for both. Only respiratory or cardiac arrest might be considered rare for family physicians (annually experienced by less than 5% of practices), but the 2% of family physicians in our sample would equal 40 cases per year in North Carolina. One in 10 family physicians treated a child with a foreign body in the airway, which would be more than 200 occurrences for family practice offices yearly in the state.