The emergency department at Children's of Alabama has undergone a rapid evolution in the past twenty years. In 1983, the "ED" as such was staffed primarily by nurses. Pediatric residents were assigned to the ED for portions of the day only; during some hours the in-house ward team (which also covered the PICU) would be called down to the ED to evaluate the sickest patients. A surgery moonlighter was present during the evening hours. Total unscheduled walk-ins visits to the ED and acute medical clinic numbered approximately 40,000 per year. There were only three attending ambulatory pediatrics faculty, available in-house 8:00am until 8:00pm, who shared responsibility for the outpatient clinics. They would come to the ED for consultations as needed. No research activity was possible.
Today, there are approximately 65,000 patient visits annually to our ED. Approximately 13% of patients seen in the ED are admitted to the hospital. We have a staff of twenty pediatric emergency medicine faculty and ten pediatric emergency medicine fellows. We currently have nine full time pediatric certified nurse practitioners who provide 20 hours of coverage per day. At least one (and often more) attending/fellow will be present in the ED 24 hours a day with double to quadruple coverage for 16 hours of the day. An active program of teaching, research and publication is in place.
We feel that our large ED patient volume, while it can be stressful to manage at times, is also one of the greatest strengths of our pediatric residency program, providing housestaff exposure to a wide spectrum of clinical problems. It also provides the house officer the opportunity to acquire skills that are otherwise difficult to teach: recognition of the sick patient; development of a focused, problem oriented history and physical exam; the ability to juggle more than one patient at a time and set clinical priorities; the judgment to know when consultation and referral are indicated; and the difficult art of making timely decisions with incomplete information and multiple distractions.