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The adult patient in the pediatric emergency department
PEDIATRICS/ORIGINAL CONTRIBUTION pediatric emergency medicine, training
"-['he Adult Patient in the Pediatric Emergency Department From the Divisions of General Pediatrics and Emergency Medicine, The Children's Hospital of Philadelphia and The University of PennsylvaniaSchool of Medicine, Philaddphia.
M Douglas Baker, MD Gary R Schwartz, MD Stephen Ludwig, MD
Receivedfor publication June 24, I992. Revisionreceived October 13, 1992. Acceptedfor publication October28, i992.
Study objective: To establish the frequency of use of pediatric emergency departments by adult patients and the spectrum of disease with which they present.
Design: Prospective, descriptive study and unblinded survey. Setting: Children's Hospital pediatric ED. Type oJ"participants: Seventy-two adult patients presenting to a pediatric ED during a two-year period and 31 pediatric emergency medicine fellowship directors. Interventions: For each patient, we recorded demographic information, chief complaint, interventions by physicians, diagnosis, condition, and disposition after initial care. Pediatric emergency medicine fellowship training program directors were surveyed by telephone regarding their experiences with adult patients and the extent of adult emergency medicine training within their programs. Main results: Of the 72 adult patients evaluated, one third (22} were treated for trauma and the remaining 50 for medical illness. More than 40 different diagnoses were encountered, including stroke and myocardial infarction. Twenty patients (27.8%) required hospitalization, four (5.6%) in intensive care settings. Of the 31 fellowship directors surveyed, 27 (87.1%) indicated that adult patients had been managed in their EDs during the previous year. All but one reported that their fellowship programs incorporated between one and four months of adult emergency medicine in their curricula. Conclusion: Adults frequently present to pediatric EDs for both minor and serious illnesses. Training in adult emergency medicine should be a part of all pediatric emergency medicine fellowship programs. [Baker MD, Schwartz GR, Ludwig S: The adult patient in the pediatric emergency department. Ann EmergMsdJuly 1993;22:1136-1139.]
JULY 1993
22:7
ANNALS OF EMERGENCY MEDICPNE
113 6/ 29
ADULT PATIENT
Baker, Schwartz & Ludwig
INTRODUCTION
As the American Board of Pediatrics and the American Board of Emergency Medicine have worked together to develop subspecialty certification in pediatric emergency medicine, many questions have been debated about training issues. How much training in general emergency medicine does a pediatric emergency medicine specialist need? How much basic pediatric training would benefit an emergency physician preparing for a career in pediatric emergency medicine? The answers to these questions at present are unclear. The importance of pediatric emergency physicians' familiarity with common adult emergencies has been assumed by pediatric emergency medicine fellowship training program directors. Adult emergency medicine training has been recommended as part of all pediatric emergency medicine fellowship training programs. 1 Although this recommendation empirically seems to be appropriate, actual experiences with adult patients in pediatric emergency departments have, to our knowledge, not been documented formally. This study was designed to substantiate the advisability of incorporating training in adult emergency medicine into pediatric emergency medicine fellowship training programs by describing the experience with adult patients in our own ED. Also, we sought to summarize the experience of other pediatric emergency medicine training centers with regard to their clinical and training experiences with emergencies in adults.
Emergency Medicine Fellowship Match. 2 Those directors were asked to estimate the number of adult patients treated each year in their facilities, to state whether protocols for management of adult patients existed in their facilities, and to describe the type of adult emergency medicine training that their pediatric emergency medicine fellows routinely receive. RESULTS
During the 24-month study period, 72 adult patients (0.01% of all visits) were evaluated in our ED. One patient presented twice, for different complaints. The age range was 19 to 70 years (mean, 35 years). Forty-two patients (58.3%) were younger than 36 years, and 55 patients (76.3%) were younger than 44 years. Thirty-four visits (47.2%) were by hospital employees, whereas 27 (37.5%) were by parents or visitors, eight (11%) by patients brought in error by prehospital personnel or by family, and three (4.2%) by passers-by who collapsed on hospital grounds. Women outnumbered men 52 to 19. The chief complaints and presumptive diagnoses of these patients varied greatly (Tables 1 and 2). Twenty-two traumarelated diagnoses accounted for 30.6% of the total and generally consisted of minor injuries. Medical illnesses were more varied in both nature and severity. Thirty-six patients (50%) required transfer to adult EDs for further evaluation. Table 1.
Chief complaints of 72 adult patients MATERIALS AND METHODS
From December 1989 through November 1991, all adults presenting to the ED of The Children's Hospital of Philadelphia were enrolled prospectively in our study. A patient was considered to be an "adult patient" if he or she was older than 18 years and not routinely followed medically in any Children's Hospital of Philadelphia clinic. At the time of admission to the Children's Hospital of Philadelphia ED, a data sheet was generated. The information collected included the patient's age, sex, and reason for being within the building. Also, we recorded their chief complaint, interventions by Children's Hospital of Philadelphia staff, length of stay in the ED, presumptive diagnosis, condition, and disposition after inttial care. For those patients transferred to adult medical facilities, we attempted to obtain the diagnosis established at the receiving institution and eventual outcome of the patient's disease. Finally, we surveyed by telephone the directors of the 38 pediatric emergency medicine fellowship training. programs listed as participants in the 1991 Pediatric
30/ 1137
Chief Complaint
No.
Syncope 19 Chest pain 10 Fall 8 Respiratory distress 8 Laceration/puncture wound 6 Abdominal pain 4 Musculoskeletal pain 4 Toxic exposure 4 Gunshot 3 Pregnancy 3 Needle stick 2 Seizure 2 Skin foreign body 2 Vomiting/dehydration 2 Altered consciousness 1 Assault 1 Burn 1 Dysphagia 1 Hematuria 1 Hives 1 Rash 1 Total 84* *Tetal exceeds72 because12 patientshad morethan one diagnosis.,
% 22.6 11.£ 9.5 9.5 7.1 4.8 4.8 4.8 3.6 3.6 2.4 2.4 2.4 2.4 1.2 1.2 1.2 1.2 1.2 1.2 1.2
ANNALS OF EMER6ENCY MEDICINE 22:7 JULY 1993
ADULT PATIENT
Baker, Schwartz& Ludwig
Of these, 20 (27.8%) required overnight hospitalization, including four ICU admissions (5.6%). Seventy-one patients (98.6%) recovered from their illnesses. One 54-year-old patient died from complications of her massive stroke, subsequent to admission to the receiving adult center. Fifty-four patients had documented times in the ED. The mean length of stay was 37 minutes (range, ten to 200 minutes). Many interventions were provided in the ED (Table 3). Most were noninvasive and required skills familiar to trained pediatric emergency physicians. The directors of 31 programs participating in the 1990 Pediatric Emergency Medicine Fellowship match 2 were Table 2.
Presumptive diagnoses of 72 adult patients
1.2 1.2
Trauma-Related Diagnosis
No.
%
Laceration Contusion Gunshot Head trauma Muscle strain Needle stick Skin foreign body Eye foreign body Puncture wound Thermal burn Subtotal Medical Illness Diagnosis
5 3 3 2 2 2 2 1 1 1 22
7.0 4.2 4,2 2,8 2.8 2,8 1.4 1.4 1.4 1.4 30.6
Vasovagal episode Asthma Allergic reaction Chemical conjunctivitis Seizure Alcohol intoxication Angina Hypoglycemia Myocardial infarction Appendicitis Oellulitis Costochondritis Dehydration Dehydration, anemia Dizziness Drug overdose Gastroenteritis Hypertension Labor Paronychia Pharyngeal foreign body Premature labor Supraventricular tachycardia Stroke Syncope Urinary tract infection Varicella Viral syndrome Subtotal Total
10 4 3 3 3 2 2 2 2 1 1 1 1 1 1 1 I 1 1 1 1 1 1 1 1 1 t 1 50 72
13.9 5.6 4.2 4.2 4.2 2.8 2.8 2.8 2.8 1.4 1.4 1.4 1.4 1.4 1,4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 69.5
993 JULY 1993 22:7
ANNALS OF EMERGENCY MEDIC/NE
contacted by telephone. Of these, 2 7 programs ( 8 7 . 1 % ) were in free-standing pediatric centers and four programs (12.9%) were in combined pediatric/adult facilities. Twenty-six programs (83.9%) had official policies concerning adult patients; 17 (65.4%) allowed ED evaluation and nine (34.6%) denied it. Twenty-eight programs (90.2%) had an established age cut-off above which patients were not admitted routinely to the KD. Table 3,
Patient intervention in the ED Intervention
No.
%
Physical examination Vital signs Parenteral medications IV fluids Supplemental oxygen Continuous monitoring Blood tests EC6 Radiographs Wound repair
72 60 28 22 22 19 14 14 5 5
1O0 83.3 38.9 30.6 30.6 26.4 19.4 19.4 6.9 6,9
Table 4.
Maximum age of patient routinely admitted to the ED in 28 pediatric EDs surveyed Age (yr)
No.
%
No limit 16 17 18 19 20 21 22
3 2 1 11 4 1 6 3
9.7 6.4 3.2 39.3 12.9 3,2 19.4 9.7
Table 5.
Categories of adult disease encountered
in 28 pediatric EDs
surveyed Disease Type
No.
%
Chest pain Pregnancy Minor trauma Major trauma Ingestion Myocardial infarction Other Stroke Syncope. Seizures
21 21 20 14 10 18 7 6 6 5
75.0 75.0 71.4 50.0 35.7 35.7 25.0 21.4 21.4 17.9
1 1 38/ 3 I
ADULT P A T I E N T
Baker, Schwartz & Ludwig
Most commonly (11 programs, 39.3%), this age cut-off was 18 years (Table 4). Twenty-seven programs surveyed (87.1%) indicated experience managing adult patients within the previous year. Chest pain, pregnancy, and traumatic diseases were seen most commonly (Table 5). No programs reported keeping accurate records of the number of adult patients seen in their EDs. However, estimates of annual total visits by adults ranged from five to 500 (mean, 80). All but one training program surveyed reported to have formal adult emergency medicine rotations incorporated as part of their standard curriculum. Eighteen programs (58.1%) offered two months of adult training during the two-year training period; nine (29%) reported one month; and three (9.7%) reported either three or four months. Seventeen programs (54.8%) also had one or more faculty members among the ED staff who had either adult medicine training or practice experience. DISCUSSION
Like other pediatric specialists, pediatric emergency medicine physicians are trained primarily to provide specialized care for children. In fact, in most pediatric emergency medicine fellowship programs, more than 90% of total training time is spent in pediatric rotations. This emphasis is well-placed, as most patients managed in pediatric EDs are children. Nevertheless, many if not all pediatric emergency fellowship graduates can expect to manage adult patients during their careers. Our data indicate that even in EDs located in free-standing pediatric centers, adult patients are encountered, often for management of myocardial infarction and other diseases atypical of pediatric patients. Worrisome among the list of diagnoses of adults seen in our ED were angina, myocardial infarction, and stroke. Serious complications of pregnancy, seizures, and complicated major trauma also have been reported to have been encountered in pediatric EDs. There are many reasons why pediatric emergency medicine fellows might profit from rotations in general hospital EDs. Contact with diseases and disorders seen primarily in adult patients is only one of these. Pediatric emergency medicine fellows also might benefit from exposure to different protocols and procedures commonly used in adult medicine and incorporate applicable portions into theirown general practices. Rotations in general emergency medicine also allow pediatric emergency medicine fellows beginning their careers to broaden their, exposure to others in the field.
32/ 1139
Both our experiences and those of others confirm the need for formal training of all pediatric emergency medicine fellows in the management of common adult diseases. Although most pediatric emergency medicine fellowship programs surveyed reported some provision of such training for fellows, the amount and extent of such training are variable. The potential exists for significant morbidity among adult patients who are managed in pediatric EDs. It is incumbent on pediatric emergency medicine training directors to ensure that their fellows are properly exposed to adult emergency medicine. This topic should receive continued scrutiny by the Pediatric Emergency Medicine Fellowship Curriculum Subcommittee. CONCLUSION
Our data indicaie that adult patients often present to pediatric EDs for treatment for a variety of diseases. Pediatric emergency medicine staff need to be prepared to effectively manage these patients. Pediatric emergency medicine fellowship training programs should critically review the adult emergency medicine training that they provide their trainees. REFERENCES 1. Curriculum Subcommittee,Section of EmergencyMedicine,AmericanAcademyof Pediatrics: Pediatric emergencymedicine (PEM)fellowship curriculum statemenl:.Pediatr Emerg Care 1991;7:48-53. 2. Pediatric EmergencyMedicine SpecialtyMatch: List of Participating Programs, 1991. Washington, DC, National Resident Matching Program.
Address for reprints: M DouglasBaker,MD The Children'sHospitalof Philadelphia 34th Streetand Civic CenterBoulevard Philadelphia,Pennsylvania19104
ANNALS OF EMERGENCY MEDICINE
22:7
JULY 1993
"-['he Adult Patient in the Pediatric Emergency Department From the Divisions of General Pediatrics and Emergency Medicine, The Children's Hospital of Philadelphia and The University of PennsylvaniaSchool of Medicine, Philaddphia.
M Douglas Baker, MD Gary R Schwartz, MD Stephen Ludwig, MD
Receivedfor publication June 24, I992. Revisionreceived October 13, 1992. Acceptedfor publication October28, i992.
Study objective: To establish the frequency of use of pediatric emergency departments by adult patients and the spectrum of disease with which they present.
Design: Prospective, descriptive study and unblinded survey. Setting: Children's Hospital pediatric ED. Type oJ"participants: Seventy-two adult patients presenting to a pediatric ED during a two-year period and 31 pediatric emergency medicine fellowship directors. Interventions: For each patient, we recorded demographic information, chief complaint, interventions by physicians, diagnosis, condition, and disposition after initial care. Pediatric emergency medicine fellowship training program directors were surveyed by telephone regarding their experiences with adult patients and the extent of adult emergency medicine training within their programs. Main results: Of the 72 adult patients evaluated, one third (22} were treated for trauma and the remaining 50 for medical illness. More than 40 different diagnoses were encountered, including stroke and myocardial infarction. Twenty patients (27.8%) required hospitalization, four (5.6%) in intensive care settings. Of the 31 fellowship directors surveyed, 27 (87.1%) indicated that adult patients had been managed in their EDs during the previous year. All but one reported that their fellowship programs incorporated between one and four months of adult emergency medicine in their curricula. Conclusion: Adults frequently present to pediatric EDs for both minor and serious illnesses. Training in adult emergency medicine should be a part of all pediatric emergency medicine fellowship programs. [Baker MD, Schwartz GR, Ludwig S: The adult patient in the pediatric emergency department. Ann EmergMsdJuly 1993;22:1136-1139.]
JULY 1993
22:7
ANNALS OF EMERGENCY MEDICPNE
113 6/ 29
ADULT PATIENT
Baker, Schwartz & Ludwig
INTRODUCTION
As the American Board of Pediatrics and the American Board of Emergency Medicine have worked together to develop subspecialty certification in pediatric emergency medicine, many questions have been debated about training issues. How much training in general emergency medicine does a pediatric emergency medicine specialist need? How much basic pediatric training would benefit an emergency physician preparing for a career in pediatric emergency medicine? The answers to these questions at present are unclear. The importance of pediatric emergency physicians' familiarity with common adult emergencies has been assumed by pediatric emergency medicine fellowship training program directors. Adult emergency medicine training has been recommended as part of all pediatric emergency medicine fellowship training programs. 1 Although this recommendation empirically seems to be appropriate, actual experiences with adult patients in pediatric emergency departments have, to our knowledge, not been documented formally. This study was designed to substantiate the advisability of incorporating training in adult emergency medicine into pediatric emergency medicine fellowship training programs by describing the experience with adult patients in our own ED. Also, we sought to summarize the experience of other pediatric emergency medicine training centers with regard to their clinical and training experiences with emergencies in adults.
Emergency Medicine Fellowship Match. 2 Those directors were asked to estimate the number of adult patients treated each year in their facilities, to state whether protocols for management of adult patients existed in their facilities, and to describe the type of adult emergency medicine training that their pediatric emergency medicine fellows routinely receive. RESULTS
During the 24-month study period, 72 adult patients (0.01% of all visits) were evaluated in our ED. One patient presented twice, for different complaints. The age range was 19 to 70 years (mean, 35 years). Forty-two patients (58.3%) were younger than 36 years, and 55 patients (76.3%) were younger than 44 years. Thirty-four visits (47.2%) were by hospital employees, whereas 27 (37.5%) were by parents or visitors, eight (11%) by patients brought in error by prehospital personnel or by family, and three (4.2%) by passers-by who collapsed on hospital grounds. Women outnumbered men 52 to 19. The chief complaints and presumptive diagnoses of these patients varied greatly (Tables 1 and 2). Twenty-two traumarelated diagnoses accounted for 30.6% of the total and generally consisted of minor injuries. Medical illnesses were more varied in both nature and severity. Thirty-six patients (50%) required transfer to adult EDs for further evaluation. Table 1.
Chief complaints of 72 adult patients MATERIALS AND METHODS
From December 1989 through November 1991, all adults presenting to the ED of The Children's Hospital of Philadelphia were enrolled prospectively in our study. A patient was considered to be an "adult patient" if he or she was older than 18 years and not routinely followed medically in any Children's Hospital of Philadelphia clinic. At the time of admission to the Children's Hospital of Philadelphia ED, a data sheet was generated. The information collected included the patient's age, sex, and reason for being within the building. Also, we recorded their chief complaint, interventions by Children's Hospital of Philadelphia staff, length of stay in the ED, presumptive diagnosis, condition, and disposition after inttial care. For those patients transferred to adult medical facilities, we attempted to obtain the diagnosis established at the receiving institution and eventual outcome of the patient's disease. Finally, we surveyed by telephone the directors of the 38 pediatric emergency medicine fellowship training. programs listed as participants in the 1991 Pediatric
30/ 1137
Chief Complaint
No.
Syncope 19 Chest pain 10 Fall 8 Respiratory distress 8 Laceration/puncture wound 6 Abdominal pain 4 Musculoskeletal pain 4 Toxic exposure 4 Gunshot 3 Pregnancy 3 Needle stick 2 Seizure 2 Skin foreign body 2 Vomiting/dehydration 2 Altered consciousness 1 Assault 1 Burn 1 Dysphagia 1 Hematuria 1 Hives 1 Rash 1 Total 84* *Tetal exceeds72 because12 patientshad morethan one diagnosis.,
% 22.6 11.£ 9.5 9.5 7.1 4.8 4.8 4.8 3.6 3.6 2.4 2.4 2.4 2.4 1.2 1.2 1.2 1.2 1.2 1.2 1.2
ANNALS OF EMER6ENCY MEDICINE 22:7 JULY 1993
ADULT PATIENT
Baker, Schwartz& Ludwig
Of these, 20 (27.8%) required overnight hospitalization, including four ICU admissions (5.6%). Seventy-one patients (98.6%) recovered from their illnesses. One 54-year-old patient died from complications of her massive stroke, subsequent to admission to the receiving adult center. Fifty-four patients had documented times in the ED. The mean length of stay was 37 minutes (range, ten to 200 minutes). Many interventions were provided in the ED (Table 3). Most were noninvasive and required skills familiar to trained pediatric emergency physicians. The directors of 31 programs participating in the 1990 Pediatric Emergency Medicine Fellowship match 2 were Table 2.
Presumptive diagnoses of 72 adult patients
1.2 1.2
Trauma-Related Diagnosis
No.
%
Laceration Contusion Gunshot Head trauma Muscle strain Needle stick Skin foreign body Eye foreign body Puncture wound Thermal burn Subtotal Medical Illness Diagnosis
5 3 3 2 2 2 2 1 1 1 22
7.0 4.2 4,2 2,8 2.8 2,8 1.4 1.4 1.4 1.4 30.6
Vasovagal episode Asthma Allergic reaction Chemical conjunctivitis Seizure Alcohol intoxication Angina Hypoglycemia Myocardial infarction Appendicitis Oellulitis Costochondritis Dehydration Dehydration, anemia Dizziness Drug overdose Gastroenteritis Hypertension Labor Paronychia Pharyngeal foreign body Premature labor Supraventricular tachycardia Stroke Syncope Urinary tract infection Varicella Viral syndrome Subtotal Total
10 4 3 3 3 2 2 2 2 1 1 1 1 1 1 1 I 1 1 1 1 1 1 1 1 1 t 1 50 72
13.9 5.6 4.2 4.2 4.2 2.8 2.8 2.8 2.8 1.4 1.4 1.4 1.4 1.4 1,4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 69.5
993 JULY 1993 22:7
ANNALS OF EMERGENCY MEDIC/NE
contacted by telephone. Of these, 2 7 programs ( 8 7 . 1 % ) were in free-standing pediatric centers and four programs (12.9%) were in combined pediatric/adult facilities. Twenty-six programs (83.9%) had official policies concerning adult patients; 17 (65.4%) allowed ED evaluation and nine (34.6%) denied it. Twenty-eight programs (90.2%) had an established age cut-off above which patients were not admitted routinely to the KD. Table 3,
Patient intervention in the ED Intervention
No.
%
Physical examination Vital signs Parenteral medications IV fluids Supplemental oxygen Continuous monitoring Blood tests EC6 Radiographs Wound repair
72 60 28 22 22 19 14 14 5 5
1O0 83.3 38.9 30.6 30.6 26.4 19.4 19.4 6.9 6,9
Table 4.
Maximum age of patient routinely admitted to the ED in 28 pediatric EDs surveyed Age (yr)
No.
%
No limit 16 17 18 19 20 21 22
3 2 1 11 4 1 6 3
9.7 6.4 3.2 39.3 12.9 3,2 19.4 9.7
Table 5.
Categories of adult disease encountered
in 28 pediatric EDs
surveyed Disease Type
No.
%
Chest pain Pregnancy Minor trauma Major trauma Ingestion Myocardial infarction Other Stroke Syncope. Seizures
21 21 20 14 10 18 7 6 6 5
75.0 75.0 71.4 50.0 35.7 35.7 25.0 21.4 21.4 17.9
1 1 38/ 3 I
ADULT P A T I E N T
Baker, Schwartz & Ludwig
Most commonly (11 programs, 39.3%), this age cut-off was 18 years (Table 4). Twenty-seven programs surveyed (87.1%) indicated experience managing adult patients within the previous year. Chest pain, pregnancy, and traumatic diseases were seen most commonly (Table 5). No programs reported keeping accurate records of the number of adult patients seen in their EDs. However, estimates of annual total visits by adults ranged from five to 500 (mean, 80). All but one training program surveyed reported to have formal adult emergency medicine rotations incorporated as part of their standard curriculum. Eighteen programs (58.1%) offered two months of adult training during the two-year training period; nine (29%) reported one month; and three (9.7%) reported either three or four months. Seventeen programs (54.8%) also had one or more faculty members among the ED staff who had either adult medicine training or practice experience. DISCUSSION
Like other pediatric specialists, pediatric emergency medicine physicians are trained primarily to provide specialized care for children. In fact, in most pediatric emergency medicine fellowship programs, more than 90% of total training time is spent in pediatric rotations. This emphasis is well-placed, as most patients managed in pediatric EDs are children. Nevertheless, many if not all pediatric emergency fellowship graduates can expect to manage adult patients during their careers. Our data indicate that even in EDs located in free-standing pediatric centers, adult patients are encountered, often for management of myocardial infarction and other diseases atypical of pediatric patients. Worrisome among the list of diagnoses of adults seen in our ED were angina, myocardial infarction, and stroke. Serious complications of pregnancy, seizures, and complicated major trauma also have been reported to have been encountered in pediatric EDs. There are many reasons why pediatric emergency medicine fellows might profit from rotations in general hospital EDs. Contact with diseases and disorders seen primarily in adult patients is only one of these. Pediatric emergency medicine fellows also might benefit from exposure to different protocols and procedures commonly used in adult medicine and incorporate applicable portions into theirown general practices. Rotations in general emergency medicine also allow pediatric emergency medicine fellows beginning their careers to broaden their, exposure to others in the field.
32/ 1139
Both our experiences and those of others confirm the need for formal training of all pediatric emergency medicine fellows in the management of common adult diseases. Although most pediatric emergency medicine fellowship programs surveyed reported some provision of such training for fellows, the amount and extent of such training are variable. The potential exists for significant morbidity among adult patients who are managed in pediatric EDs. It is incumbent on pediatric emergency medicine training directors to ensure that their fellows are properly exposed to adult emergency medicine. This topic should receive continued scrutiny by the Pediatric Emergency Medicine Fellowship Curriculum Subcommittee. CONCLUSION
Our data indicaie that adult patients often present to pediatric EDs for treatment for a variety of diseases. Pediatric emergency medicine staff need to be prepared to effectively manage these patients. Pediatric emergency medicine fellowship training programs should critically review the adult emergency medicine training that they provide their trainees. REFERENCES 1. Curriculum Subcommittee,Section of EmergencyMedicine,AmericanAcademyof Pediatrics: Pediatric emergencymedicine (PEM)fellowship curriculum statemenl:.Pediatr Emerg Care 1991;7:48-53. 2. Pediatric EmergencyMedicine SpecialtyMatch: List of Participating Programs, 1991. Washington, DC, National Resident Matching Program.
Address for reprints: M DouglasBaker,MD The Children'sHospitalof Philadelphia 34th Streetand Civic CenterBoulevard Philadelphia,Pennsylvania19104
ANNALS OF EMERGENCY MEDICINE
22:7
JULY 1993