Our pediatric census started to rise last summer right around the time a new class of interns arrived. Of course, this has happened many times before and was usually associated with seasonal illnesses combined with parental anxiety.
The 2015 H1N1 influenza virus was a classic example of many weeks of increased pediatric visits, prolonged wait times, and more admissions. This made sense. The virus had an unusual propensity for causing some kids under 5 to become seriously ill. This made many parents anxious, and almost every fever generated a trip to our children's emergency center. The increase this year, however, did not make sense. Usually, our pediatric census goes down in the summer.
Our elevated peds census persisted into the fall. Most of the children presented with respiratory or gastrointestinal symptoms, and many of them were sick enough to be admitted. The acuity nearly doubled during this time.
The timing could not have been worse for our residency program. Interns in July are often delicate. Many if not all are terrified of being a doctor for the first time. We often schedule our interns for a lot of shifts in our peds ED because its census is reasonable in the summer, the patients are not that sick, and charting is comparatively easier than adults with multiple comorbidities. This allows them to see a lot of patients and get used to the complexity of EMR charting. Unfortunately, this intern class ran into a gauntlet of sick kids, and a few seemed overwhelmed.
As I write this in October, we are seeing about 40 percent more kids than we usually do this time of year. We didn't initially understand why this was happening, but I had learned something interesting earlier this month at the ACEP Scientific Assembly in San Francisco.
I met with Russell Horowitz, MD, the director of emergency and critical care ultrasound at the Ann & Robert H Lurie Children's Hospital of Chicago and an associate professor of emergency medicine at the Feinberg School of Medicine at Northwestern University. He said they had seen an overwhelming increase in the census and acuity for several months. And he said his pediatric EM colleagues around the country were saying the same thing.
While still in California, I met with a past residency graduate doing an emergency pediatrics fellowship in North Carolina. He said they were seeing an incredibly high number of kids with increased acuity and heard it was happening around the country. After getting home, I contacted another residency graduate doing his pediatric emergency medicine fellowship in Texas. It was the same story: more pediatric patients with higher admissions.
A Google search yielded two articles about the rising number of children requiring medical attention. The Chicago Tribune (Oct. 5, 2022; https://bit.ly/3WVOU0v) and the New York Times (Oct. 11, 2022; http://bit.ly/3Aa66FT) described situations where more children needed medical care, and a few days later, NBC News led their evening broadcast with this story. Now it was national news.
A Surge of Sick Kids
Unfortunately, we were seeing this surge of sick kids when there were fewer pediatric inpatient beds than before the COVID-19 pandemic. Many hospitals avoid inpatient care for children because it does not generate enough income. As the overall patient census dropped significantly in most hospitals at the start of the pandemic, they cut costs by decreasing the number of less profitable inpatient beds for kids. This is true for my small city in South Carolina. And it appears that more children are getting sick because they are immunologically naïve.
A similar situation occurred during the last international pandemic, the Spanish flu of 1918. John Barry explained in his book, The Great Influenza: The Story of the Deadliest Pandemic in History, that this virus caused so many deaths in the United States because it was the first time that many Americans from different areas came together in large numbers.
We did not frequently travel great distances at that time because of the difficulty and expense, but thousands of young men gathered from faraway places to prepare for World War I. Unfortunately, none had been exposed to the viral illnesses of the others, and this allowed the influenza virus to run rampant.
Many of the immunologically immature members of our society were sequestered over the past few years, and the viruses they usually traded with each other did not infect them. Then schools and day care centers opened, and kids were suddenly bombarded with viruses on their developmentally delayed immune systems. Couple this with parents reading nonstop terrible news on their social media feeds, and every time junior got even mild symptoms, an emergency formed in their minds.
The irony is that I preach to anxious parents that their kid's fever is a good thing. Kids get five to seven fever illnesses each year. This is normal and helps their immune system grow like the rest of their bodies. To emphasize the point, I ask parents if they remember the last time they had a fever. Very few can do this. Parents don't get sick a lot now because they were exposed to the same viruses growing up.
My guess is that the volume of pediatric ED patients will eventually recede. It might not be until spring, but there will be regression to the mean. The vast majority of children in our nation are healthy and resilient. The overflow of kids in our EDs will eventually be an interesting anecdote in the legacy of the pandemic that currently affects nearly every aspect of our professional lives.
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Dr. Cookis the program director of the emergency medicine residency at Prisma Health in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (http://emergencyultrasound.com). Friend him atwww.facebook.com/3rdRockUltrasound, follow him on Twitter@3rdRockUS, and read his past columns athttp://bit.ly/EMN-Match.