In Good Hands

If a hospital’s emergency department (ED) is called its “front door” because of the large number of patients who arrive there, then the door at Monroe Carell Jr. Children’s Hospital at Vanderbilt must be well-oiled because of its frequent use

 

The people behind that door are both highly trained and immensely compassionate. They’re not just caring for a potentially sick or injured child, they must also console and reassure frightened parents who often just need to know what’s not wrong.

“The Pediatric Emergency Department is where families bring their children seeking help with sickness or injury, but many times this is the first place that they experience the services of Monroe Carell Jr. Children’s Hospital at Vanderbilt,” said Kate Copeland, MSN, RN, CPN, administrative director of Emergency Services. “We feel it is a privilege to care for children and we are dedicated to this mission.”

About 55,000 pediatric patients pass through each year, where they are triaged and examined in the ED’s 35 patient care areas and two trauma bays.

While there are thousands of hospitals in America that care for children, there are only about 250 that care exclusively for children. As a regional comprehensive pediatric facility, Children’s Hospital is the only Level 1 pediatric trauma center—the highest level of care—within 150 miles, providing specialty services for children from Alabama to Kentucky and all over Tennessee.

On any given day the pediatric emergency team may care for a child struck by an automobile, a patient having an asthma attack, a victim of child abuse, a newborn with a fever and worried parents, or a victim of a near-drowning episode.

“When you enter our pediatric emergency department you are greeted by a professional who only takes care of children and their families every day and who understands the differences in their care,” said Cristina Estrada, M.D., associate professor of Pediatrics and director of the Division of Pediatric Emergency Medicine. “Children are just not small adults—they differ in their disease processes, anatomically, physiologically and most important psychologically.”

Besides the board-certified pediatric emergency room providers, Children’s Hospital also offers sedation tailored just for pediatric patients and Child Life specialists, staff trained in child development who can calm fears and meet the unique needs of children, teens and families in the hospital setting.

And Children’s Hospital’s emergency physicians have a strong relationship with the area’s more than 300 community pediatricians in private practices. “We loop back with them to communicate about their patient’s emergency department course,” Estrada said. “We’re here 24/7 if you need us.”

The front door’s always open. Come on in.

 

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Paul Melchoirre is a quintessential toddler—he loves to get dirty, hates to wear shoes and is gregariously talkative to anyone who’ll listen. He loves people and is very comfortable in new settings or ones that can be frightening for some children—like hospitals.

The tiny 2-year-old Nashville boy has a chronic heart condition that has resulted in about 10 trips to the Pediatric Emergency Department (ED) at Monroe Carell Jr. Children’s Hospital—seven in his first year of life.

Paul has hypoplastic left heart syndrome (HLHS), a complex and rare congenital heart defect where the left side of the heart is critically underdeveloped and can’t effectively pump blood to the body. The right side of the heart does all the work, pumping blood to the lungs and the rest of the body.

Children with HLHS have at least three open heart surgeries throughout the first years of life. Paul has already undergone two and had the third this summer.

“He’s living life with half a heart, but he has a tremendous quality of life,” said Colleen Melchoirre, Paul’s mother.

“We spent a lot of time at the Children’s ED during his first year,” Colleen said. “We are ‘err on the side of caution’ type of people, and 95 percent of the time we had him there we were just worried. If he had a virus or a cold, his oxygen saturations (the amount of oxygen in your red blood cells) could be really low.

“It took us awhile to realize that lower oxygen saturations are OK for Paul when he’s sick,” Colleen said. “We were just so nervous, and we wanted to make sure he was OK. The ED staff was always so sweet and kind. They were there without judgment and a valuable resource to us. The staff is tremendously validating and always made us feel like it was OK to be there.”

Colleen said that finding out that your child is not critically ill is as important as finding out they are.

“Sometimes it’s only an emergency in your head. If these highly skilled professionals aren’t concerned about his mortality, then I’m not concerned,” she said. “Vanderbilt has allowed us to place our anxiety on them and not Paul.”

But one of their trips to the ED, on Christmas Eve morning of 2013, turned out to be more than just a validation that Paul was OK. Despite the family being “hypervigilant” about hand hygiene and Paul getting a shot to prevent respiratory syncytial virus (RSV), which causes infection of the lungs and breathing passages, he got the virus and was acutely ill. His pediatrician’s office sent him directly to the ED.

“I’m pretty level-headed and a good hospital mom, and can answer questions calmly and accurately, but that day was like an out-of-body experience,” Colleen said. “All of these people were working on him in the ED, and I lost my marbles. They asked me the last time he ate. I couldn’t answer.

“A nurse gently took me out of the room and got me water. He said ‘we’ve got this. He’s going to be OK.’ I will never forget that, and I remember after that moment feeling so much better because we were in the most lovely and competent hands.”

The staff in the Pediatric Emergency Department stabilized her small son and saved his life. He spent a few days in the Pediatric Intensive Care Unit (PICU) and then in a regular hospital room, and then was able to return home.

Colleen remembers that some of the ED staff came to the PICU to check on Paul during his hospital stay. “They were the first line of intervention. They did the right thing. They always do the right thing. Our family is so thankful to have a world- class facility like Vanderbilt’s in our back yard. It’s such a source of comfort.”

 

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Hanna Von Haefen is a busy Father Ryan High School sophomore in Nashville with afternoons and weekends filled with school activities, friends and school and travel soccer. “She goes 90 to nothing all the time,” said her mom, Molly Von Haefen.

A slight sore throat the morning after a concert in October didn’t stop the 16-year-old. Two days later she developed a fever, and visited her pediatrician’s office for a strep and mono test, both of which were negative.

Her pediatrician prescribed some steroids to help with the swelling and pain, but the throat pain continued to worsen. A second strep and mono test a week later were also negative. “He was like ‘it’s probably a virus,’ and I was like ‘whatever,’” Hanna said, recalling three trips to the pediatrician over two weeks. Her pediatrician finally gave her an antibiotic and suggested she see an ear, nose and throat (ENT) doctor.

On a Sunday, the day after her last pediatrician’s appointment, her condition began to worsen. She couldn’t eat or drink and her throat hurt so badly she couldn’t talk or swallow her saliva.

“I lay in my parents’ bed, spitting in a cup, watching one Gray’s Anatomy episode after another and crying all day long,” she remembers. “It was like this indescribable insane pain—like when you have strep throat times 10.”

Molly, her mother’s intuition kicking in, drove Hanna to the Pediatric Emergency Department (ED) at Monroe Carell Jr. Children’s Hospital at Vanderbilt. They gave her IV fluids and some morphine for the pain and sent her for a CT scan of her neck—the scan showed a quarter-sized peritonsillar abscess on the back of her tonsils, a collection of pus that forms near an area of infected skin or other soft tissue. It’s usually a complication of tonsillitis. Her pediatrician had not been able to see the abscess because of its location. In the ED, Hanna’s tonsils were numbed with a spray and the abscess, which the doctors described as “like a very tough balloon,” was lanced to allow the pus to drain.

“It basically felt like someone was tugging on my tonsils,” Hanna said. “But it didn’t hurt, and I’m not afraid of needles. Sticking needles in the back of my throat didn’t scare me one bit. Everybody there was super nice, especially the doctor, (Christopher Jackson, M.D.). He explained the whole procedure and how he was going to cut it open.” Hanna said.

Molly said because her daughter was not critically ill that she felt “silly” taking Hanna to the emergency room for a sore throat, but after seeing her get instant relief, was happy that she did.

“Whether this is a life or death situation or not, this is where we want you to bring your child,” said Cristina Estrada, M.D., associate professor of Pediatrics and director of the Division of Pediatric Emergency Medicine. “We’re not just a place to bring really sick kids. We understand all the differences that children face when they have an illness. Children are far different than adults in the way they combat disease and in the way their family deals with disease processes.”

After seven hours in the Emergency Department, Hanna was sent home with a strong antibiotic to fight any remaining infection. She recovered quickly and was back at school a day later.

Future pediatric patients could find a “Dr. Hanna Von Haefen” chatting with them when they’re sick or injured. She hopes to volunteer at Children’s Hospital soon to see if she’s cut out for becoming a doctor.

“I want to be a doctor really bad. One of the doctors told me that night that the first time he opened up someone’s stomach, he passed out. If that’s going to happen to me, I want to find out before I’m a doctor,” she said, laughing.

 

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EllieLou Dillard, like many infants, isn’t extremely fond of having her diaper changed. It’s not unusual for her to squirm and cry when her mom, Kimi, changes her diaper.

But a routine morning diaper change in January turned into a nightmare for the single Gallatin, Tennessee, mother and nursing student when 7-month-old EllieLou flipped herself off a changing table and injured herself.

“She was fussy being up there on the changing table,” Kimi said, recalling the frightening incident. “Her changing table was actually a dresser with a pad on the top and I assumed she’d stay put when I turned around for a split second to grab another shirt for her. She frog kicked herself off the changing table.”

The changing table was situated next to a door. She flipped herself off the table backward and landed on the back of her head. EllieLou suffered a black eye on the way down when she hit a trash can.

“I was shocked. I called the pediatrician’s office, sobbing,” Kimi said. “They told me to take her to Vanderbilt.”

Buckled safely in her car seat, Kimi drove her to the Emergency Department at Monroe Carell Jr. Children’s Hospital at Vanderbilt, where EllieLou was examined and monitored for four hours. Kimi and EllieLou were sent home with instructions to watch her closely.

It’s common practice for a child who falls but shows no signs of broken bones or a concussion to be thoroughly examined, but not X-rayed or scanned, said Cristina Estrada, M.D., assistant professor of Pediatrics and director of the Division of Pediatric Emergency Medicine.

“Radiation exposure through unnecessary CT scans and X-rays is a real threat to our young patients,” she said.

But soon after Kimi and EllieLou returned home, the infant began projectile vomiting. “My heart sank, I freaked out, and we drove back to the ER in the afternoon,” Kimi said. During their second visit, this one longer than the first, EllieLou was taken for a CT scan that showed a mild concussion, but thankfully no broken bones or significant head trauma.

According to the Centers for Disease Control and Prevention, falls are the leading cause of non-fatal injuries for all children ages 0 to 19. Every day, approximately 8,000 children are treated in U.S. emergency rooms for fall-related injuries. This adds up to almost 2.8 million children each year.

Kimi, alone and scared at Children’s Hospital, remembers the expert care that EllieLou received, but also the compassion of the nursing team. “I’m a single mom. I was stressed and scared because she was sick, and nurses who weren’t even our nurses would come and check on me so I could go to the bathroom or get some water. They knew there was nobody there to help me. They were really great and so supportive and I really, really appreciated it.”

Kimi wrote the Emergency Department a note after their visit, thanking the team for their support and care. “They have a really great team down there,” she said. “I’ve learned that nurses put up with a lot, and I wanted them to know how much I appreciated them. They were so busy that night—it was like a carnival going on. They don’t get thanked enough.”

EllieLou is now almost 1. Kimi said that she learned an important lesson the day of EllieLou’s tumble—to keep a hand on her at all times while she’s being changed. “It happened in 1 to 2 seconds. I was standing right in front of her. The saddest thing about it is I kept thinking if I had just been facing the other way (toward her) when she kicked herself off, I could have caught her.”

 

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Jackie Gervasio of Clarksville, Tennessee, was in dire condition when she arrived at the Pediatric Emergency Department at Monroe Carell Jr. Children’s Hospital at Vanderbilt on April 13 in a diabetic coma.

“She was at death’s door,” said Cristina Estrada, M.D., associate professor of Pediatrics and director of the Division of Pediatric Emergency Medicine.

Jackie’s condition was a double shock for her mother, Coleen. She didn’t know how critically ill she was, and she had only found out a few hours before that her 14-year-old daughter had diabetes.

Jackie, an eighth grader who is developmentally delayed and has hypertonia (increased tightness in her muscles), seemed fine at a Friday afternoon picnic with classmates, but by Saturday morning was sluggish, pale and complaining of stomach pain. She had also gotten up during the night and drained six juice bags—”they were totally dry and completely flattened out like there was never anything in them,” her mother said.

Jackie saw a doctor on Sunday morning in Clarksville. He gave her some antibiotics and told her to come back on Tuesday. By Sunday night, she took Jackie to Gateway Medical Center in Clarksville because she had stopped eating and drinking and wasn’t talking. Once the hospital evaluated her condition, they transferred her by air ambulance to Children’s Hospital.

“When my son and I took Jackie to Gateway, I told them she’s usually lively and perky. This isn’t my Jackie,” Coleen said. “They put her on a table so fast and started taking her clothes off. I said ‘is there a problem?’ I thought she just had a virus. Then they asked me if I knew she had diabetes, because she was in a diabetic coma. I was totally dumbfounded. I said ‘you’ve got to be kidding. She was just fine yesterday.’”

As Jackie was airlifted, Coleen rode with a friend to Nashville. When Coleen arrived at the Pediatric Emergency Department, Jackie had already been intubated and stabilized and was about to be transferred to the Pediatric Intensive Care Unit (PICU).

“There was a doctor that we called the Elephant Lady (the doctor was Estrada) because she had an elephant on her stethoscope,” Coleen said. “When she came in, I was crying, and I said ‘I can’t believe this is happening.’ She said ‘we’re going to take great care of Jackie. It might take a while, but she’s going to be OK.’ I asked her what I could have done to make sure this didn’t happen, and she told me not to worry about it, that she was in a great place where kids are the top priority. She was right.”

She stayed intubated for two days in the PICU, and was given insulin, but remained very ill. Twenty pounds lighter, she was discharged from Vanderbilt after eight days, but will remain a patient seeing a pediatric endocrinologist to manage her diabetes.

Coleen said her first impression of Vanderbilt—the Pediatric Emergency Department—remains vividly etched in her memory. And she is grateful that the physicians in both the ED and the PICU included her in their decisions about Jackie’s care.

“The doctors at Vanderbilt let me have my say in everything. It was a new experience for me. They really wanted to know what I thought.”