Abstract:Formal pediatric emergency medi-cine training did not exist in Australiain the late 1980s, so I venturedoverseas to gain experience andknowledge from the then leaders inthe field. I completed my fellowshipand returned to an emergencydepartment (ED) in Australia as theonly pediatric emergency medicine–trained attending. This articledescribes my experiences in trans-forming an ED run solely by residentsinto one with now 14 full-time con-sultants and our own fellows.Imbedded in this story is the experi-ence of one of our first fellows whocame from Switzerland, where evenemergency medicine was not yet arecognized specialty. On his returnhome, he too transformed his ED.

Keywords:pediatric emergency medicine;training; Australia; Switzerland

*Emergency Department, Royal Children'sHospital, Parkville, Victoria, Australia;†University of Melbourne, Australia;‡Murdoch Children's Research Institute,Parkville, Australia; §EmergencyDepartment, Children's Hospital, Zurich,Switzerland; tKantonsspital,Schnaffhausen, Switzerland.Reprint requests and correspondence:Peter Barnett, MBBS, FRACP, MSc, FACEM,MSpMed, Royal Children's Hospital,Parkville, Victoria 3052, Australia.Peter.Barnett@rch.org.au

1522-8401/$ - see front matterCrown Copyright © 2012 Published byElsevier Inc. All rights reserved.

12 VOL. 13, NO. 1 • RETURNING TO THE PED AS TH

Starting Anew:Returning to the

PediatricEmergency

Department as theFirst and Only

Trained PediatricEmergencyMedicineSpecialist

E FIRST PEM SPECIALIST / BARNE

Peter Barnett, MBBS, FRACP, MSc,FACEM, MSpMed⁎†‡,

Sergio Stocker, MD, Pediatrician FMH§tt

y interest in pediatric emergency medicine (PEM)began when I was a medical student and did my

Melective during my final year (1983) in the emergencydepartment (ED) at the Hospital for Sick Children in

Toronto. Dr Jim Fallis was the ED director, a surgeon who hadturned his hand to emergency medicine (EM), and “Tex” Kissoon

TT AND STOCKER

RETURNING TO THE PED AS THE FIRST PEM SPECIALIST / BARNETT AND STOCKER • VOL. 13, NO. 1 13

was the fellow. After completing my basic trainingin pediatrics, I decided to specialize in PEM. Emer-gency medicine was then a new specialty inAustralia, and PEM had no formal training avenuein Australia. My parents (both physicians) had donetheir specialty training at the University of Texasand had loved their time and experience inGalveston. I wanted to do the same. So in 1988, Ilooked through the PEM fellowship program listpublished in Pediatric Emergency Care and wrote (yes,e-mail was not generally used at this point inhistory!) to several centers in the United Statesand Canada. In October of 1988, I flew to the UnitedStates and was interviewed at PEM programs in 6US cities: Seattle, Atlanta, Philadelphia, Washing-ton, Boston, and Cleveland. Back then, the processfor securing fellowship was done via a telephonematch between programs and the candidates theywanted. This occurred between 8 and 10 AM onemorning. Unfortunately, for me this was 3 to 5 AMmytime. Eventually, I got a call from Boston asking meto join their program, and I accepted.

Before leaving for Boston, I did a 9-month-longterm in pediatric critical care and then worked as a“fellow” in the pediatric ED (PED). This was a newposition because the ED did not have any leader atthat point and no one was solely interested in PEM.Thus, I educated myself as best I could. In 1990, wehad 4 registrars (equivalent of second- or third-yearresidents), who ran the ED. These were the mostsenior physicians on duty both day and overnight.We saw approximately 60 000 visits, and most of thework was done by residents rotating from otherhospitals (for 3 months) who may not have seen achild before coming to the Royal Children's Hospital(RCH). Oh how things have changed!

In May 1990, I left with my wife and son for Bostonfor the first of July start. Our fellowship yearincluded 5 other outstanding people from all overthe US. They are now in various parts of the US, but Istill see them at meetings: Nate Kuppermann, BrianBates, Marvin Harper, Doug Nelson, and YJ Sue. My2-year fellowship consisted of rotations within theED and in various other places around BostonChildren's Hospital and other hospitals. In my firstyear, I spent time in orthopedics, pediatric criticalcare, toxicology, adult EM (Massachusetts General).I did things I had never done before. I learned aboutconscious sedation, trauma management, suturing,fracture management, and the differences betweenthe Australian and US systems. Gary Fleischer,Grace Caputo, the late Michael Shannon, MarkBaskin, and all the PEM fellows were an unbeliev-ably supportive group. We did not do overnightsduring our first year, but the evening shifts finished

at 2 AM. I would walk home to Longwood Towers andset the alarm so as to be back for teaching rounds at7:15 AM (I missed some of these!). Research was animportant part of this fellowship, and we learned theins and outs of clinical research.

During my first year, I decided that I wanted tostay an extra year and embarked on a Masters ofScience in Epidemiology at the Harvard School ofPublic Health, completing this over the next 2 yearsand graduating in 1993. My second and third yearsas a fellow allowed me to complete my clinicaltraining and research and learn more about how anED was run, behind the scenes as well as on the unit.

When I left Australia in 1990, I was notguaranteed a position when I finished my fellowship.I spoke several times to the then professor ofpediatrics about coming back to Australia. My wifeand I seriously considered staying in the UnitedStates because I knew that things would be verydifferent for me when I returned home. The royalChildren's Hospital decided that the fellow positionin the ED that had been created would be turnedinto an attending's position. Now with 2 children, weset off to start anew back in our home town.

When I returned, the ED was in the same area ithad been for the last 30 years, nothing had changed.Patients were seen first by a clerk, then saw a triagenurse who decided if the problem was urgent ornonurgent, and then sent them to the ED or the“general clinic.” The general clinic was our non-acute ambulatory care area staffed by a separateteams of physicians and nurses. There was noconsultant working in the PED. The ED's backupwas a group of community pediatricians who had, astheir area of interest, behavior or school issues; sothe ED largely looked after itself. We did have an EDcharge nurse, and to her credit, she had forgedahead with the nursing staff, but she was initiallyvery reluctant for me to take charge of the medicalside. I had a tiny office, approximately 6 × 6 ft, in theback of the ED. I spent my early days working duringthe days in the ED, helping out and seeing thedifficult patients. Previously, medical subspecialistsand surgical specialties dealt with all “nongeneralpediatric” issues. For example, the orthopedicregistrars performed all the forearm reductionsunder a Bier block. They were given a 1-hourtutorial in how to perform a Bier block and thenwere let loose. I took it upon myself to learn thistechnique (this was not a common procedure inBoston) and learned from the orthopedic registrarshow the reductions were performed. Over the next12 to 18 months, I perfected this technique. Iremember one Sunday afternoon being called by theED staff and asked if I could come in and help out

14 VOL. 13, NO. 1 • RETURNING TO THE PED AS THE FIRST PEM SPECIALIST / BARNETT AND STOCKER

because the orthopedic registrar was in the operat-ing room and they had at least 4 patients waiting fortheir fractures to be reduced. I spent the next 3 to 4hours doing this, showing that PED staff couldperform these procedures well and safely.

In 1994, Gary Fleisher was invited to talk at theAustralasian Emergency Medicine Conference inMelbourne, and I was also asked to speak on PEMtraining. This was the first recognition by theCollege of Emergency Medicine that my specialtyexisted and that there were physicians in Australiawho were trained in this specialty.

Over the next few years, and with the advent ofEM consultants in general EDs, the hospital realizedthat the PED had to be its own entity, so a directorwas appointed to run the ED and the programseceded from the Centre of Community ChildHealth in 1996. The first director was an emergencyphysician with training in PEM obtained in theUnited Kingdom. Thus, after he was appointed, weslowly changed the mix of trainees in the ED. When Ifirst started in 1993, we had 4 senior residents on arotating roster (one on at any time over the 24-hourperiod) and from 12 to 19 residents (more duringthe winter when we were busier). We beganemploying EM trainees into these resident positions.In 1998, we appointed our first fellow; he was anadult EM trainee. He is now in charge of a smallerPED after being an attending at RCH for approxi-mately 10 years.

We introduced an education program for oursenior residents and fellow in 1998. Each Wednes-day morning they were taken off the floor and hadlectures and presentations from department andexternal staff. This education program has contin-ued, and recently, we have been able to addtraining for our fellows in management and othernonclinical issues.

ISSUES I HAD TO DEAL WITH WHEN IGOT HOME

Trauma care was a major issue for the hospital.Trauma centers had not yet been established inVictoria in the early 1990s, but most majorpediatric trauma was coming to RCH. Because wedid not have adequate senior physician coverage inthe ED after I returned, the pediatric intensive careunit (PICU) consultants decided that all traumashould be managed by them and that patientswould bypass the ED and go straight to the PICU.This involved transferring a severely injured childup 2 floors in a lift to reach the PICU. Because thePICU had very senior staff and the ED had only 1

consultant and no fellow, we were not in a positionto argue. This process continued until we had alarger number of consultants and fellows within theED, some 3 to 4 years after I returned. Currently,all trauma is first stabilized in the ED, and onlythen are patients transferred to the computedtomography scanner, operating room, or pediatricintensive care unit (PICU).

It took several months to a year to convinceother specialists around the hospital that mycolleagues and I were able to care for theirpatients. An example that comes to mind werediabetic patients in ketoacidosis; insulin was not tobe started in the ED and could only be commencedon the inpatient ward as decided by the endocri-nology consultants. This practice was based on thefact that inpatient beds were easily available andpatients could be transferred to the ward quickly.Unfortunately, this put the onus on the ward staffto manage patients who may not have been thatstable and in an environment not well suited foracute patient management. Over the next fewyears, this practice was changed. Because therewas little issue with inpatient bed availability in theearly 1990s, many patients were being directlyadmitted to the ward for simple problems thatcould be well managed in the ED and sent home(eg, many asthmatics, children with mild tomoderate dehydration, patients with burns of justa few percent).

Nitrous oxide was not used in the ED when Iarrived home. I had used it a bit in the United States,but after much research and its use in otherchildren's hospitals in Australia, we introduced itat RCH for simple procedures; initially, placement ofintravenous catheters or for sedation while suturing.The anesthesiology department was very protectiveof this resource, and we had to allow for their buy infor this to get implemented in the ED. Nitrous oxideis now used around the hospital, including the ED.Another advance was the introduction of ketaminefor procedural sedation. Our use of this drug cameabout by involving the anesthesia department in itsuse with the first patients, involving them inpractice guideline development, and then showingthem that we could use it well without their help.This took several years. Currently, the challengesurrounds the use of propofol; we are still workingthis one out.

The ED had its own protocols for the managementof various emergency conditions. These were allwritten by the related specialty units with someinput from the ED. I updated these, and we alsobegan a guideline development group within the EDand general pediatrics, which continues to this day.

RETURNING TO THE PED AS THE FIRST PEM SPECIALIST / BARNETT AND STOCKER • VOL. 13, NO. 1 15

These tools are nowWeb-based rather than on paperin the old “guideline folders.”

Emergency Department Staff DevelopmentAs we developed our department, we started

attracting pediatric trainees into our fellow posi-tions. Over the next few years, the College ofPhysicians began to recognize the need for a PEMfellowship. I was on the College committee, whichestablished a program for the College of Paediatrics(then within the College of Physicians). Thisprogram consisted of 3 years in advanced trainingincluding 18 months in an accredited PED, 12months of adult EM (to gain experience in traumaand technical procedures), and 6 months of PICU.The first graduates of this program were in 2001.

In 1999, we were approached by a Swisspediatrician who wished to train in PEM. SergioStocker was our first overseas trained fellow. Hestarted in 1999 and stayed with us for 3 years. Hecame with strong pediatric skills and good Englishbut little surgical experience. His personal talefollows at the end of this article.

Since Sergio, we have trained physicians from theUnited Kingdom, Ireland, Scotland, 4 more fromSwitzerland, Costa Rica, Canada, Singapore, Bah-rain, and of course, Australia (from both colleges—Physicians and Emergency Medicine). We havegrown from only 2 attendings in January 1996 tonow 11 full-time equivalents of attending coverage,3 fellows each year, and hopefully, next year ourfirst PhD student. Our research enterprise hasgrown enormously in the last 5 years with our firstNational Health and Medical Research Council(NHMRC) grant of over $800 000 for a multicenterstudy on rehydration in bronchiolitis.

We are about to move into a new hospital inNovember 2011 and with the prospect of hopefullyadding more attending staff. We are still not doingnight duty (my sympathy to a lot of you who are),but we have coverage from 8 AM to midnight 7 daysper week.

I have enjoyed my time leading the developmentof PEM both in our hospital as well as for Australiaand New Zealand. I am currently the chair of theJoint Training Committee in PEM, which evaluatesPEM training for both colleges. We are a small groupof specialists within each of these colleges, but weare working toward credentialing our trainees forboth colleges.

Recently, several of our overseas fellow traineeshave returned to their home cities, where they areeither the first or one of just a small group of PEMattendings. They have been keen to take back the

many things that they have learned. From my ownexperience of starting anew, now almost 20 yearsago, I have given them these suggestions: (1) makesure that your medical director (if you have one) isbehind you as well as your hospital administrator,(2) take 1 step at a time—find something that youknow you can change and that will work, (3) involvesubspecialties in a collaborative manner to startwith and then show them you are capable to managetheir patients.

ONE OF OUR PEM TRAINEES RETURNS TOSTART ANEW IN SWITZERLAND

In February 1999, my wife, our 2 children, and Iflew from Zurich to Melbourne. I had been luckyenough to get a position on a local salary as a fellowin PEM at RCH. At the time, I was a consultant ingeneral pediatrics at the Children's Hospital ofZurich. I had 7 years of training in pediatrics, andI always enjoyed working in the ED. In our hospital,which has been the biggest pediatric tertiary carehospital in Switzerland, the ED functioned like allothers in the country. The patients were “triaged” aseither a medical or surgical patient and then wereseen by the respective registrar (trainees withexperience between a couple of months to severalyears) in surgery or medicine. The ED was staffed by1 registrar each during the day, 1 during the night,and 1 person each on call. That was the roster overthe year, Monday through Sunday, summer andwinter. The registrars usually changed on a weeklybasis. There was no consultant physically presentin the ED. They were available on call and camein only if it was deemed essential. This meant thatthe registrars were pretty much on their own mostof the time and dealt with the patients as best asthey could, treating approximately 22 000 childrenper year.

In the ED at RCH, there were trainees ofdifferent levels, registrars training in PEM, fellowsand consultants from 8 AM to midnight, caring forall patients regardless of whether they had amedical or a surgical problem. The ED staffingreflected varying patient volumes during the dayand volume variations during different days of theweek and seasons. They used a triage system(Australasian Triage Scale [ATS]) that triaged thepatient according to their medical needs. Perhapsbest of all was that there were PEM trainedphysicians (consultants) who could offer patientmanagement advice and hands on help at almostany time. I felt pretty much confident caring forchildren with medical problems. During my 3-year

16 VOL. 13, NO. 1 • RETURNING TO THE PED AS THE FIRST PEM SPECIALIST / BARNETT AND STOCKER

training at RCH, I learned a lot about treatingsurgical patients and gained experience with allsorts of procedures (suturing, Bier block, fracturereduction, plastering, nitrous oxide and ketaminesedation, critically ill patients, intubation, severehead trauma, pediatric emergency transport ser-vice, and lots more). I also learned a lot about howto run and organize an ED. Last but not least, Ilearned much about the Australian work-life-balance and that one can do an excellent jobin medicine without working 70 hours or moreper week!

I went to Melbourne with the idea of gettingsomething changed at home, at the Children'sHospital of Zurich. I wanted to become head ofan interdisciplinary PED, set up like the ED atRCH. I did not have any promises from “home”about my future position, and it was quite clearthat the head of the surgical department wouldbe reluctant to have a pediatrician manage hispatients in the ED. I asked to have a few thingsmade clear about this before I came back home andinsisted that my position in the ED would be welldefined before I returned. The head of the medicaldepartment got a bit upset with my impertinenceon this issue, but he agreed to organize a think tankincluding staff of all relevant hospital departmentsto have my ideas discussed.

In February 2002, we flew back to Zurich, nowwith 3 children. On April 1, 2002, I started myposition as head of the new department of EM,being the first pediatrician in Switzerland withformal training in PEM. The fact that I began asthe head of department, and even had a “day off,”(1 nonclinical shift per week) cost me some goodwilland friendship with other department heads. Istarted with 7 registrars, coming from both themedical and surgical departments, working in thedepartment for 3 to 6 months. Their rostered hourswere based on the timing of patient presentation.Each physician treated any patient, irrespective oftheir underlying problem (medical or surgical); ifnecessary, we got other specialists involved. Werelied much more on clinical experience with me asthe consultant in the ED and were able to reduce(unnecessary) blood tests by 60%. Between 6 PM

and 8 AM, and on most weekends, the registrarsstill had to rely on the help of on-call consultantsfrom the medical and surgical departments.

The work we did was convincing, and after 1 year,I was able to employ my first consultant. Thisallowed us to cover additional shifts during the busyevening hours. Over time, we introduced various“Australian” protocols, such as nitrous oxide forprocedural sedation, Bier blocks for fracture re-

ductions, and last but not least, the ATS. Needless tosay, every step forward had to be discussed withvarious units of the hospital in a deliberate fashion.

A Few Examples of What We ChangedWith the help of the Victorian ATS protocols,

we began to teach nurses and physicians aboutthe basics of ATS. At that time, it was prettymuch learning by doing. A survey among all pediat-ric clinics in Switzerland showed that everybodywas interested in patient triage, but almost no onehad a formal triage system. Staff from all thepediatric clinics met in Zurich, and we discussedvarious triage protocols from different countries anddecided that we wanted to continue with the ATS.Regular meetings in different hospitals helped tosuccessfully introduce the ATS. We also had a nursewho had trained at RCH to teach ATS in Switzer-land. The ATS has now become standard practice inalmost all PEDs in Switzerland.

Children with stable supraventricular tachycardiawere usually sent to the PICU for conversion by acardiologist. We began to cardiovert children in theED, the first couple of times under careful observa-tion by the cardiology consultant. They saw that wewere able to do this procedure well and evenpossessed other “tricks” (eg, ice bags or valsalvamaneuvers) that could be used before adenosine.

Another great success was the introduction ofnitrous oxide for brief painful procedures. Beforethis, many children had to undergo general anes-thesia for minor procedures (eg, laceration repair,reduction of dislocated joints). Of course, theanesthetists tried to prevent the use of this“dangerous gas in the hands of paediatricians” inthe ED. I had learned to use nitrous at RCH, andbecause they could not provide us with anyevidence that it really was dangerous, we startedto use it widely in our ED, and other PEDs didas well. We were so very proficient with nitrousthat we have been invited to give lectures andteaching sessions on various occasions in Germanyand Austria.

At the end of 2005, we had 5 consultants (3 ofthem fully or partly trained in Australia) sharing4 full-time positions. We could cover every weekdayfrom 8 AM to midnight, and the weekends, from10 AM to 10 PM. Today we have 6.5 full-timeconsultant positions, covering 3 shifts per dayduring the week and 2 per day on weekends,treating approximately 28 000 children per year.The department became a role model for otherpediatric and even adult hospitals. Registrars arenow really keen to work in our ED because they

RETURNING TO THE PED AS THE FIRST PEM SPECIALIST / BARNETT AND STOCKER • VOL. 13, NO. 1 17

know that they will learn a lot in an extremelysupportive setting.

The change in our department has been enor-mous, and no one wishes to go back to the way thatit was. Unfortunately, the rate of pay for theseemergency pediatricians has not followed the

progress seen in the rest of the hospital, and thisstill needs to be addressed. Looking interestinglyat the development of my own 5 children, I amproudly watching the ED (my other baby) grow,being convinced that PEM, one day, will be awell-recognized specialty in Switzerland.