5 good reasons why you may need to spend HOURS in Acute Care
The last time I asked for a show of hands of who wanted to spend one single second more than is absolutely necessary in emergency or acute care, despite my dramatic attempt at trying to upsell the charm of the place and the INTERESTING PEOPLE (ahem) WHO WORK THERE, the results were as you would expect. Zero hands raised. We all have busy lives with carefully measured out schedules, and so when the need for unexpected acute medical care presents itself we hope for the best to solve the problem as fast as possible. Healthcare marketing jumps right on the bandwagon, advertising minimal wait times and quick in and out care. Sometimes this works just great and is exactly what is needed, but sometimes it isn’t, and I want to present to you a few situations in which hanging around for a bit in emergency or urgent care really is to your benefit. Let’s see if I can convince you.
Remember what croup is? It’s the shortened version of the word laryngotracheobronchitis (lol), a primarily viral respiratory infection where the tissues in and around the vocal cords get inflamed and swollen, causing noisy breathing, a seal-like or bark-like cough, and sometimes respiratory distress. What gets rid of croup mostly is time, but symptoms can be managed in some situations by giving steroids to decrease the inflammation and for serious cases a breathing treatment called “racemic epinephrine” is given to help shrink the swelling as well. When this medicine is given, the results are often rapid and profound, and the child breathes much easier and everyone is happy. Sounds like we’re done, right? Welllllll, not so fast because the effect of this medicine wears off after 3-4 hours or so and some children will immediately relapse into noisy difficult breathing again. Believe me, it’s much better all the way around to do this while you’re still under medical care, so usually we have patients hang around in observation for this amount of time to ensure that they won’t rebound, and if they do, treat accordingly with another aerosol. So if your child winds up getting a dose of racemic epinephrine, expect to hang around for about 4 hours afterwards to see if they pass the test to go home.
Many people assume that xrays or head CT scans are automatically necessary if a child has a head injury—such as a fall down stairs or collision in sports. That used to be common practice, but not anymore. Practice guidelines have been established and studied and validated by the PECARN group, a national, multi-center research collaboration, that specifiy that many kids with head injuries do NOT need imaging and do just as well with 4-6 hours of observation to check for signs of worsening, such as protracted vomiting or mental status changes. When this data was published it changed practice significantly and decreased the number of head CT scans (and thus radiation to children) by quite a bit. If, after the observation period, a child is doing well and starting to feel better, a discharge home can happen without a trip to radiology and a radiation dose. But! For the stated period of time there’s some restful hanging around in acute care to experience.
These can have rapid onset and can be quite serious, from drops in blood pressure to airway compromise. Many medicines are given depending on the exact symptom constellation, but the mainstay of treatment is epinephrine as mentioned above in #1. This time it’s typically given as an intramuscular injection, but the rebound concern remains, so while most of the time the symptoms improve dramatically after medicine administration, there’s a chance that they will reappear after the medicine wears off, so guess what? Allergic reaction/anaphylaxis patients end up hanging around for several hours in acute care. And that’s a good thing because they can be watched closely and rapidly treated if need be. People can die of this condition, so it’s not to be taken lightly.
What’s worse than a child who is having a ton of vomiting and diarrhea? I’ll tell you. One who is dehydrated and also gets sent home prematurely, even after IV fluids, and continues to have so much vomiting that they can’t stay hydrated. So, in order to avoid that miserable scenario, we like to hang on to kids who are dehydrated to make sure that they will be able to successfully hydrate themselves by mouth at home. An added bonus is if they urinate in the process as well.
I hope I don’t have to do too much convincing on this one. After a child gets sedation medicine for a procedure (like setting a broken bone or having a complex laceration repaired), even after their eyes are open, they need to be fully awake before they go home. And by fully awake, I mean several things, not just alert and talking. It means that the child has tolerated something to drink without vomiting, and in some cases can get up and walk. All of these are indications that the sedation medicine has fully worn off, and in some people it happens more quickly than in others. It’s absolutely ok if your child is one who takes a little longer to get back to being fully operational, but just know that you’ll be hanging around for a bit until she/he gets there. It’s a safer way to go rather than bringing home a drowsy child.
For the best patient care regardless of setting, safety is always the top priority.
As such, not every outpatient scenario is well suited to in and out care. Rushing through patient management when the situation demands time and observation is a mistake at best and dangerous at worst. My advice today is to take a deep breath and adjust your frame of mind if you end up in acute care with a diagnosis that requires you to hang around. It’s for your and your child’s safety, and there’s good reason to do it.