While at the 2023 American Academy of Pediatrics National Conference & Exhibition, Steven Selbst, MD, spoke with Contemporary Pediatrics® about current trends in pediatric emergency medicine, and highlighted the ongoing mental health crisis.
Interview transcript (edited for clarity):
What trends are you observing in pediatric emergency department care?
Steven Selbst, MD:
I think we have seen over the years how emergency medicine has changed in pediatrics. Gary Fleisher was pointing out, he one of the early leaders in emergency medicine, I worked with him in the 1980s. Back then we saw a lot of kids with life-threatening infections, meningitis, epiglottitis, severe pneumonia. A lot of those have disappeared fortunately, because we have vaccines. Most of my residents haven't seen meningococcemia ever. That was one of the things we feared the most, so that has changed. I think what we see more now certainly much more mental health emergencies. Every emergency department in the country has children who are boarding for days sometimes, because they need inpatient hospitalization for a mental health issue and there's no place for them to go. So they end up staying in the emergency department, that's changed dramatically. I think other things that have changed the management of asthma, I remember years ago, it was all giving shots of epinephrine to kids who have asthma. The kids would be miserable, as you can imagine coming to an ER getting 3 or 4 shots of epinephrine. Now, it's albuterol and it works quite well and it actually makes the kids a little hyper and a little happy. So it's very different personality change for the kids with asthma. We've talked about how poisonings have changed. It used to be that iron poisoning was the leading cause of death in children for a toxin. But then through advocacy and through government, we made a change and iron is now in little blister packs, and you can't get a whole bottle of 100 of them at one time. You have to open them up and it's harder for kids to do that. So we no longer see iron poisonings as a cause of death. Now we're seeing more drugs of abuse. Gummies, marijuana, marijuana, gummies, THC gummies that kids get into and think they're candy. So we still have challenges ahead but they're really very different. I think the whole issue on pain management, we focus much more on pain management than we're used to. And we're much more careful with sedating patients for procedures and give them topical anesthetics to make things less painful. We have child life workers, to help the kids adjust to the emergency department and a procedure and be able to make it an ouch-less procedure as much as possible. Then I think also, we've gotten better at just our management. We have protocols now to manage sepsis that we try to follow on a national basis and try to order fewer tests and not waste money on things that aren't necessary, but try to get the best care for the kids following the evidence-based protocol.
What are the most common admissions you are seeing in children that are related to the mental health crisis?
A lot of suicides, suicidal ideation, attempted suicide, or planning a suicide, and severe depression. The pandemic certainly made that worse, but now the pandemic is over and we're still seeing so many kids who come in with severe depression and no place to turn and are trying to take their lives. So that's our most important one. Every once in a while we see a child that is truly psychotic, and it's hallucinating. I think that's not as common but we still see that every once in a while. We're fortunate at our hospital we have a great social work department and they're incredibly helpful in helping us to talk to the family and talk to the child and find out what's best. We make a decision together whether this child needs to be hospitalized as an inpatient, or whether intensive outpatient therapy would be adequate for that patient. So with the help of the social workers, we make that decision and then they help us to find placement for that child. But as I said, it doesn't happen immediately. It happens a day or 2 later or sometimes even longer. We also have a great psychiatry department. They're overwhelmed and they don't always get involved in all the patients, they can't possibly see all the patients who come through the emergency department. But, they will come down and help us because we have a lot of patients who are out of control and are acting out and throwing things and banging things and the psychiatry department helps us to manage those patients and give them the proper medications that they need to keep them from hurting themselves or hurting others.