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Presented by the El Paso County Medical Society and hosted by Kathrin Berg.

Our children, you got to love them.

They have very different emergencies at very different ages.

But when do you know when you have to go to the E.R., when do you call 911?

We're going to talk about that specifically tonight.

This program is underwritten by the El Paso Children's Hospital.

And we also want to thank the El Paso County Medical Society for bringing the show to you now for over 28 years.

I'm Kathrin Berg, and this is the El Paso Physician.

Neither the El Paso County Medical Society, its members, nor PBS El Paso shall be responsible for the views, opinions or facts expressed by the panelists on this television program.

Please consult your doctor.

Thank you for joining us today.

We're talking about pediatric specialized emergency care.

Why specialized?

It's not just that somebody gets sick.

They have to go to the E.R..

Kids get into all kinds of trouble, and it's summertime in their home.

So we have a lot to speak about today.

We are filming in the classic Turner home.

I don't know if you've noticed that the last several times that you've been watching this program, but this is where the El Paso County Medical Society is housed in, is a Henry Trost building, and it's just fun to be here.

So let's get to all of this.

I would like to introduce Doctor Alfredo Maldonado.

Maldonado I did this last time too.

You are the medical director of the El Paso children's, pediatric E.R.

and then we have Miguel Arroyo, who is the attending physician of the El Paso Children's Hospital.

Also pediatric E.R.

Thank you so much for being here.

And my big first question.

El Paso Children's has its E.R., obviously specialized in pediatrics.

Right.

So I would like to let the audience know that you've got an E.R.. We just take them to the ER But when is it that you have to go to a pediatric E.R.?

And what is the specialized differences versus going to an E.R.

that happens to also serve children?

Does that make sense?

Sure thanks for having us today.

--Sure So it's interesting that the majority of kids that are seen in emergency rooms in this nation or seen in general, emergency medicine, departments, or what?

It's kind of the healthcare.

And part of that is that there's very, much less, pediatric ER's around the country.

And so just by virtue of there being many more general E.R.

's most of the kids get seen in general E.R.

's 'Pediatric E.R.

's' are specific because we are, specifically designed, to treat ill children.

And, that goes everywhere from having the physician seeing them take pediatric emergency medicine training the nurses, radiology techs, everything really is geared towards kids.

And, partly sometimes it might not seem like you know, 'an E.R.

is an E.R.'

right?

And in many ways adult E.R.

Departments are trained to see kids from birth to death, right?

Right.

We focus in on a very narrow spectrum, with our pediatric patients and as such, with our, our training, it's, all of our training is really dedicated to, carrying the emergency care of pediatric patients, and, you know, so in terms of our training, for our pediatric E.R.

physician, we complete that E.R.

residency with pediatrics, or emergency medicine.

And then, there's another three year fellowship dedicated solely to pediatric emergency.

Okay, compared to the, the, the general E.R.

physician who in their residency, maybe those 2 or 3 months of pediatric training, and it's a lot of stuff, you know, it's it's doing procedures and over and over and over again on children, it's, resuscitation on children.

So.

And even though they're trained to treat children, with, pediatric emergency room physician, that's the only thing that we care about in training for.

I imagine your equipment is very specialized, right?

You don't just put, you know, little ones into a big ol' hunk of machine And I remember just talking a little bit about that last time, with, with budgeting and with because there's always the, the, administration of any hospital and so specifically getting the equipment that you need for, for the little ones, which is great.

--And sometimes you know, the general emergency medicine department may not have the need for, very small, you know, EK tubes or things like that as often.

So the supply and know you have to get to the expiration date.

And if we see that as opposed to pediatrics emergency room and we see those patients all the time and we use that much more frequently, it's it's easier to justify the cost of extra stocking everything that you need.

That's pediatric specific.

- -I like the way that you explained it.

And I know that here on the border, we have - Every pocket of America has different needs.

But we have some specific issues here on the border.

We have the socioeconomic barriers.

We have sometimes transportation barriers.

In the time that you've been here, what have you seen is specific to our borderland when it comes to pediatrics?

Yeah, I think some of the barriers that I've seen being here and you kind of limit to kind of transportation issues, and luckily in our E.R., we have, you know, taxi vouchers that we can provide families.

Great.

Because, you know, El Paso is growing and it's becoming larger.

And so, you know, it used to take maybe like ten, 15 minutes from the east side to the hospital.

Now you're coming from, like, you know, Eastlake, Horizon, from far west Canutillo You can take, you know, at least half an hour, right.

And if a family doesn't have, you know, a right to go to come to us or any E.R.

for that, you know for that matter, that could put a barrier.

To the families.

--Absolutely.

The other thing probably just, you know, we screened for a lot of, you know, food insecurity, upfront, you know, child abuse, kind of those, those, those issues that we screened for can sometimes pose, a barrier as well.

And you kind of look at the socioeconomic factors.

The good thing about the E.R.

is that we see everyone, regardless of whether they can pay or not.

Right.

So really I'm not out there asking who has insurance, who doesn't come through my E.R..

I will treat you just like any other, you know, any other patient.

So although that might, you know, some families might think that, you know, the E.R.

bill is going to be really high.

I, I don't think that should be, you know, a barrier for the families.

And you all too are the point of contact for places outside of El Paso too.

And that's I mean we are, we're isolated but we're not.

We've got a lot of communities that are coming in.

You've got Demming, you've got, you know, people and I and I do want to, talk a little bit about the urgent cares that you have.

I understand you're going to have two of them pretty soon And there's one you're talking about Eastlake area, and there's going to be one that's opening up on East Lake.

You're probably opened by the time this this program airs.

And then also one on Zaragoza And either one of you, I'd like for you to to differentiate what the urgent care, pediatric specific urgent care is versus the pediatric hospital.

Who wants to take that on?

And you guys can kind of go back and forth.

Excellent.

Thank you.

Yeah.

And so with you know, I think as a parent, it can be tough sometimes to know Who do I take my sick kid to?

- -Exactly.

That's the biggest question.

Do I go to a pediatrician?

Do I need to go to an urgent care?

Do I need to go to the emergency room?

And because, you know, we - it's not necessarily common knowledge which should go where And we certainly see patients from that should probably more go to one, present in another right?

And the with the urgent cares, being able to take, your child to the pediatric, specific urgent care, I think is extremely helpful because, there you'll get people that are also trained in seeing kids.

And, can be a little bit the same way that, the adult E.R.

is a little bit different from pediatric care, same thing as urgent care When they focus on pediatrics, they're, they're going to be more comfortable dealing with kids in the home.

And that, for when to go to work during the emergency.

We certainly see a lot of patients that, are not as sick to require emergency services.

Right.

And and they do, it does lead to, very packed waiting rooms, because those patients, by virtue of not being sick a lot of times, what does that have to wait a little bit longer?

As a sicker patients, obviously priority to an emergency.

And so it's helpful to be able to filter out knowing where would be appropriate thing, right from the start.

Right.

For, an urgent care, I think things that are that are probably a little more appropriate are things that you would probably go to a pediatrician for, for a sick visit But either they're not open or you'r not able to get visits which happens obviously very often, especially during busy seasons So I'm thinking things like you know, colds, or a stomach virus you know, sore throat.

Some urgent cares have different capabilities, you know, so at the El Paso Children's urgent care there is x ray capabilities of things like an injury to an arm--Great Because I was going to ask somebody falls off the monkey bars at summertime.

Is that urgent care or is that hospital?

And so, anytime that I would say the E.R..

Anytime there is an obvious deformity, summertime is when we see all of our injuries.

Right.

So anytime there's obvious deformities where you look at that, and you're like no "something's not right".

Those, it's not even worth going to urgent That's a straight to the E.R..

Exactly.

It's, making sure that you stop giving them anything to eat or drink, because they may need sedation and they can't have anything in their tummy, and take them to the E.R.

because that's where the definitive care is We're fortunate at El Paso Children's Hospital where we're covered by orthopedics 24 seven in-house, meaning that, 24 hours a day, there's an orthopedic, surgeon who is a who helps us out in the E.R.

with, reduction of fractures that need to be moved or put in place.

And so.

So that's true.

You ask any person, I think I'm 58 years old, It's like, well, have you ever had a broken bone?

Yeah, when I was 12.

I did this when I was eight.

I did that, you know, usually rarely unless you're in sport is or something that's like broken before that.

And that will be one of my next questions too is yes, it's summer, but let's first take overall like what are the most common emergencies that you see in a pediatric E.R.. And then I'd also like to kind of go into summer.

I do want to bring up heatstroke.

I do want to bring up drowning.

I do want to bring up, just in general, some of the protocols that you all have in place, too.

But what do you see the most?

You know, I think probably the fever.

I think the most common thing.

Okay.

We see a lot of abdominal pain, trouble breathing, asthma exacerbations, especially with, you know, El Paso being so windy and dusty and recently, I think those are probably my top three things that I've been seeing most recently.

So on those notes, specifically in your E.R., because you know what the high acuity levels are, you have people you protocols talk a little bit about that to the audience so they can kind of get and see, boom, how people just can come in and help fix things.

And yeah, I think so the the child and family come in and we have, you know, pediatric nurses that are doing the triage and right from triage.

They have their specific protocol, whether it's, you know, if they have a fever, how old are they?

Can we give ibuprofen or can we give acetaminophen They have asthma.

How old are they?

How much do they weigh?

How much albuterol can we give?

Things like, you know, the nurse will recognize a really sick a really sick patient and they look like they're, you know, sepsis, septic shock, anything like that.

Right away, they'll come grab us and they'll put the child in the, in the resuscitation room.

But we have specific pediatric triage guidelines that we use.

So we can kind of tailor the child's care.

Okay.

That makes sense.

When you're looking also at when you said sepsis.

So I think that is a word that it's loaded.

What is sepsis.

How do you get to a point where a person has A little one, a child, you know, pedia-- And do we identify that anyone under 18 do I remember that, right?

I mean, you know, pediatric.

So how how does one get to that point?

Again, this feel free to kind of bounce off of each other.

So, you start since you brought it up?

Yeah I think so.

Yeah.

Anyone can get sepsis from the newborn all the way to the elderly, right.

And, it can recognize differently in the newborn versus like an 18 year old.

That we see in the E.R.

we base it off of how does the child look?

Does a child have a fever?

How high is their heart rate?

How fast or slow are they breathing and what is their blood pressure.

And really the main thing that causes sepsis would be you know bacterial infections.

The viruses can also cause sepsis.

And see?

I feel like I never hear about viruses causing sepsis It's a--I knew about bacteria getting infected.

So yeah let's let's take both of those on.

I mean it's not as common as like bacterial, but, you know, the child can have RSV or, you know, like a, viral stomach bug, and that can cause sepsis, which can then lead to dehydration, which could cause a different type of, like, shock that we see in the E.R.

Okay.

But yeah, bacterial is by far the most common thing and the one we want to avoid and what we can actively treat with antibiotics.

Okay.

And then when you're looking at this too and maybe give me a case study of how long it would have taken for once the treatment starts for the sepsis to start subsiding to where it doesn't appear to be dangerous anymore Is there a case that you can think of that that was that situation?

So with sepsis, the sooner you can get antibiotics into the system and, the better the outcomes.

Okay.

And there's a-- think about a golden hour.

of having, getting antibiotics and within the first hour.

But ideally as soon as you can recognize that, the better, patients that are septic, basically have very severe infections.

And it can very quickly lead to, compromising the organs and that organ function.

So the heart, the lungs Right.

And, it goes fast, that's a point that fascinates me.

And with kids and especially with younger kids, it's tough because they can look ok Look good okay and then they drop off the cliff and it can be in the blink of an eye.

And so part of recognizing sepsis early is appreciating that, it does come to certain vital signs, abnormalities, a certain physical exam findings and those vary, from age to age.

And so, for example, our hospital, we have, sepsis screening protocols where every single patient that comes in gets screened - -Oh, every patient?

- -Every patient.

and majority of kids, you know, they don't they don't pass that screening.

But it's looking, it's basically trying to cast a wide umbrella to, to catch as many of these patients as possible.

Very nice.

Okay.

And depending on having a certain number of criteria, then that triggers the triage nurse to inform The pediatric Attending who will go assess the patient and go you know it.

You know, we actually we have classified like red, yellow, green Like how suspicious are we?

Are they red?

Is this definitely sepsis?

We need to get stuff in within half an hour.

Is it yellow?

Where maybe it is, but you have a little bit more time before having to do antibiotics.

Or is it green where something else Explains their abnormalities and unlikely to be sepsis Okay.

And, a lot of that, you know, it is dependent on, the physician.

Right.

And obviously, the more experience you have seeing very sick kids who are septic, the better you get, being able to identify these.

So.

But these are the kids that we see every day.

And so, we, we these protocols are put in place, to really try and maximize, not only a defined number of, of kids, who have sepsis, but also as quickly as possible to get the appropriate testing and treatment.

Well, I'm going to go to, I feel like this is something that's not new.

It's been around long time.

Measles.

But it went away for a while, and now it's kind of coming back with a vengeance.

I want to address it.

So has it been, what, five, six, seven months now?

Where it really started to be, okay We see a couple more cases here and I have my measles shot.

I have my little scar and everything.

But why is that?

Number one?

Why is the resurgence happening?

And number two, what are we doing with it now?

And where do we see that being a year from now?

I know it's three questions in there.

But again resurgence how and why and how do we treat it right now?

I think the resurgence was the most recent because I think we've had, you know, breakouts here and there over the last years But I think the most recent was probably from that area in West Texas, where we had that one like measles case that then kind of started multiplying, multiplying, multiplying.

And the measles is just so contagious that if you're unvaccinated, whether by choice or because you're too young, maybe, or you have, you know, a compromised immune system, they can the patient can easily, easily contract it.

And I think that area, you know, they're we're all in, like, the whole West Texas area that I think people travel.

And I think it just travels, made its way You know, with the families that have, you know, parents that work in the oil fields, in that area, they come back home, you know, they may not know that they, you know, have, you know, their little fever, ill something that, you know, could have been measles and they gave it to them, you know, to the child of the family.

And how serious can measles get?

I think that sometimes to those families like, well, there's chicken pox, there's measles.

I'm just thinking when we were a kid got all the shots for everything.

Again, I'm 58.

So just remember when we were getting all of our vaccinations.

But, how bad can measles get?

Because it wouldn't be a big deal if people don't really get sick from.

Yeah, I mean, measles can get bad.

Yeah.

High fever is can cause dehydration, which can lead to, a pneumonia in the lungs, which can lead to the kiddo, you know, not being able to breathe, ending up with, you know, needing antibiotics because of a superimposed bacterial infection, ending up intubated, it can even lead to, like, an encephalitis or a swelling of the brain down the line as well, too.

Okay, so we're into June right now 2025.

How are we doing currently?

And do you see this getting better within the next year?

I think this I mean Dr. Maldonado has more of the numbers.

But I feel like it's gone a little bit.

It's gone down I feel like I haven't heard as much for the last month - -the department has a very nice measles dashboard on their website that.

You can kind of track to see the number of active cases and and you can follow the trend for the past few months.

It does look actually like we're on the downswing of it.

Like Dr. Arroyo said, it is super, super contagious.

And it's interesting because, it's really none of us that that have trained, recently have, you know, seen measles in our lifetime because it was we were so well vaccinated and with herd immunity.

It was something that really was seen in people that travel from abroad, or primarily unvaccinated.

And so, when we started seeing cases in El Paso, our infectious, control department, you know, it was kind of like it was very kind of similar to when Covid started, where it was like the alarms blared and all hands on deck and we had to, you know, everyone was on board was recognizing, how contagious it is and how, serious of a potential problem it was.

And very quickly, protocols were placed in terms of screeners and certain questions kind of making, because even even being in a room with somebody for five minutes as far away as you and I are right It's easy to pass.

So, so these were patients that we really needed to avoid.

And just sitting in the waiting room with other patients potentially passing it on from person to person.

So this may be a bit controversial, but let's talk about vaccines for a second because I know that kind of goes back and forth, you know, and I think as the months go, we'll find are these kids the ones that are not vaccinated, etc., etc.

in your because you are a director as well.

So you do get to do some administrative.

So what, what are some things that you're hearing?

Both on a state and national level and in general in health care when it comes to vaccines and certain vaccines.

--Sure.

So for measles specifically, the measles vaccine works very well.

You use a two shot series, the first one you get around around, 12 months of age, that will protect you close to, like, 90 to 93%.

So nice.

Very well.

Okay.

The second one that you get, a little later, gets you up to like 97, 98%.

So when you have a whole lot of people that are 97, 98% you, it's very easy to protect, those people who might fall on those 2% or those people that are too young to receive the vaccines or, you know, compromise like Dr. Arroyo I mentioned.

And so it is a vaccine that works very well, but it only works well enough when there's enough people that have taken it.

You said herd immunity.

So I thought, okay, let's let's do talk about this.

Yeah.

Yeah.

So the more people that you have that are vaccinated against a certain disease, the less likely they are to get it.

And less likely to spread it to other people.

With something as contagious as Measles.

It's very important to keep the herd immunity numbers high, to be able to let that, keep it from falling to the cracks and causing the outbreak like this And so, so once we once measles got here to El Paso, you know, we worked very hard to make sure that we were, screening digitally.

Right.

And which meant sometimes, screening people that they.

Okay, well, they don't look exactly the way the textbook says the measles looks.

But, you know, because of how contageous it is we need to make its not So, so swabbing and testing people, putting them on, quarantine until we have some test results.

And I think that went a long way to, to helping it be, small of an outbreak than it could have been.

Okay.

And, I don't have the exact number of how many we ended up seeing positive here in El Paso.

I know the last positive case was probably about, like, 8 to 10 days ago.

Okay.

So, which which is good because initially, like, we were seeing, like, several cases a day.

Yeah, but you're saying one 8 to 10 weeks ago.

So that's really that curve is really has really gone down, which is great.

I want to talk about this before I get with some of the like I have like these rounds of, okay, let's talk about summer illnesses and things that are coming in.

But I do want to talk about.

So I think you guys did it so beautifully.

Is the mental health that El Paso Children's helps and puts around, not just the kids, but the families and how you involve everyone, because I think that's something that that we don't always think it's like, okay, you came in and your ankles broken and you know, you got a knee sticking out.

We got to fix all that.

But there are other things too.

And when we were talking about some of the, you know, borderland issues, sometimes we can only get one person to take to that child.

And then, you know, everybody else is left at home and or you've got all ten family members coming, you know, I, I'm asking the question of how you all handle, the world of mental health at El Paso Children's.

And again, this is something to kind of go back and forth.

And it starts everything from someone who's got mental health issues, but also helping the families out when somebody's hurt Yeah.

You know, kind of also touching on the, you know, protocols like, you know, whether you're coming into the emergency room for a mental health crisis or not.

Depending on how old the patient is, they get screened for certain questions.

That will then let us know, you know, do they screen high for suicide or depression?

Do is screen low.

And if they screen high what resources can we give them.

So we have starting from when you walk in the door I think is something great about you know.

Our E.R.

But so anybody that comes in.

Yeah.

I love that.

--Yes anyone coming in this, that's old enough to answer the question.

Right.

Yeah.

But yeah, the patients that come in, they get a screening, and if they screened a certain, you know, they screen medium or high it'll let us know the physicians.

And then after that, we kind of huddle with, with the nurse that, you know, brings that up to our attention to determine to determine what, you know, what needs that specific patient has Okay.

But, you know, we do, we've seen a lot of kids coming in specifically for mental health crisis And we do approach that kind of like a whole family centered We have our partners with Emergence Health Network that will come and interview not only the child, but also the parent.

And then from there they come up with some sort of treatment plan.

What's the next step for, you know, whether it's outpatient resources or whether it's going to an inpatient psychiatric facility?

But I think we do a great job at identifying those patients and then providing the resources in conjunction with our partners at Emergence Health.

And that spot on to when you are able to partner with other people.

And I love that.

Again, you were talking about the screening, so I love the protocols that are in place, screenings for almost everything.

And I feel like people just know, you know, in your department, okay, we're going to look for this or to look for that.

And then you kind of go from there.

It sounds so simple, but it's not if it's not in place, you know what I mean?

So I just love talking about this kind of being in place.

All right.

I want to talk about when we're talking about protocols.

I have no idea what W A P A is but I'm curious.

So working with pediatric specialists to develop protocols such as walk busses, as we're talking about protocols, define what that is.

So with, with certain illnesses, there are, sort of, protocols that have been shown to improve outcomes.

So whether that's giving steroids, quickly with an asthmatic with, diabetic comes in with DKA, like certain things you want to follow.

And these are, evidence based protocol, meaning that research has been done and proven that there are things that are helpful, and that, we we did we've developed several different protocol for different of problems, in our E.R.

And really all of them have been in conjunction with the subspecialists that relate to that particular problem.

Okay.

For example, for our, the WAPA is our wheezing algorithm protocol.

Basically for asthmatics in conjunction with the pulmonologist that's in town.

We, came up with, ways of, trying to, expedite identifying these patients right from triage, by measuring what's called, CRS score so basically like a respiratory score.

And then depending on that, automatically having the triage nurse have a set of orders they can start to implement rather than, especially if it's busy having that patient have to wait to see a physician to be evaluated and have the order get put in.

Right.

So, all these protocols are put into place to, A. make things more efficient.

And, also, it gives the nurses some autonomy in being able to, start, patients on certain protocols once they're identified that they're appropriate For those protocols.

So, Doctor Arroyo since you said that, one of the big things, especially when we have our storms asthma, we have an issue with that here.

Prior to, and maybe there's just I can't get a ride for another hour or two hours.

We can't get to the hospital.

We can't do urgent care.

Are there some things that you can, Right now, for example, tell parents.

Okay, I know your child's have difficulty breathing.

Obviously.

Get them out of the the wind, the craziness out there.

But what are some things that they can do on their own before they're able to get to you?

I think using their, you know, their, their inhaler, their albuterol inhaler or their nebulizer treatment as they were instructed to do by their physician or whoever prescribed that.

Okay.

That's one thing you need to do.

And then I guess depending on how quickly they can get to the E.R.

If they notice that their child is struggling to breathe, the next step is calling an ambulance I don't think parents should, you know, should wait for that.

Right.

Wait, you know, 45 minutes to an hour.

Because those tiny little lungs are closing up quickly and.

Right.

the quicker we can get, you know, some steroids in them and some albuterol, the better.

So I, I love that you said that I, I'm a fan of 911 calling to get somebody in there.

I would love for you to describe it physiologically.

You talk about the little lungs.

What is it that's closing the little you know, I can see the pictures.

But what is it that causes a difficulty in breathing?

Like what is what is going on in the lungs?

Yeah.

So we all have little muscles around our, our tiny airways at the base of our lungs.

And kids that have asthma have kind of a hyper reactivity, to those muscles.

And so those little muscles will start to, contract, constrict the airways a little airways, which, you can imagine, blowing into like a little straw, you get that kind of whistling sound that's the wheezing that they hear.

And so it makes it difficult for the child to breathe because like I said, I don't think I could breathe through, through a straw.

And so that hyper reactivity causes the lungs to start closing off, causing them to wheeze and causing them to feel bad really quick too.

So now when you're using a nebulizer physiologically, again, if you don't mind, you've got albuterol going into the system.

And what is that doing like you said it's the steroids just trying to open everything up.

So the albuterol a little different than the steroic that we give the steroid that we give is orally.

Okay.

So that it can, you know, while we're getting the albuterol in, the steroid is working in the body to help reduce inflammation of the lungs.

Okay.

As we're giving the albuterol, the albuterol works in the receptors, in the lungs, in those muscles to kind of relax and open their airway so that the patient and the child can breathe, breathe better.

Now that's a good way of visualizing it.

Okay.

I hadn't seen it in that that way of looking at it before.

Okay.

Summertime drownings I want to talk about prevention.

And we're not just talking about pools.

We're talking about the backyard.

We're talking about, you know, little people who tip themselves over.

So, Dr. Maldonado I'm going to ask you to just give us some again, maybe case studies.

I, I like going to case studies because it gives people a story of, you know, one time four years ago, a child came in with A, B, C, and D. This is how it could have been prevented, etc.. What are what do you see?

I think when people think of drownings, you think of, you know, being at the pool and you know, somebody falls in the deep end.

It's not noticed They don't make a whole lot of noise.

It's splashing in down the bottom.

But it's important to recognize we, we, we do see cases where, even a few inches of water, is enough for a toddler to fall in and and drown from that.

So, even the small little kiddie pools it's like a little kiddie pool they can just get up.

There have been instances where where toddlers or or even infants have come in from drowning from those kind of things.

So I think it's recognizing that, it just needs to be enough water where if they have their face in it and they can't get it up, that can cause them to drown.

So I think the vigilance is a big part of it, you know, and, especially with our El Paso heat everybody you know, getting in the pool feels wonderful, right?

Kids love it.

They can spend all day there.

Right.

So part of it is vigilance, in terms of things such as, pool safety having ensured that there's, fences around the pools that, doors that go out to directly to the pool are locked So that that's kind of preventative, stuff, for things like, say a birthday party or it's going to be a pool party designating somebody, hey, you know, from this hour to this hour, you're gonna be my lifeguard, right?

And you're going to be in charge you're not going to be, you know, grilling or you know, talking to your friends you're just going to be there watching all the kids and making sure that that nothing happens.

Right.

So even to somebody, having that responsibility goes a long way towards preventing accidents.

That can happen.

I like that I'm an old lifeguard.

And to your point, and it doesn't have to be someone who's trained in lifeguarding.

It literally can be someone who can pick the kid up out of the water.

So I'm super happy that you said that.

And I'll repeat that if you have a party, just have one adult even if it's a half an hour, you have a half an hour, you have a half an hour.

But appoint them.

And look 'em straight in the eye and say this is your, this is your job.

Then one other thing that to add also And also, and its important.

is that, swim classes, you know, because, you know, I think sometimes, especially in our community, 672 00:32:22,941 --> 00:32:26,477 your older cousins throwing you in the pool and you kind of sink or swim But, especially in the younger kids, I think at some classes can be super valuable.

And, and, they're, they're offered it, you know, places like the YMCA, they even have some classes here in town where, or even, young, young toddlers.

Yes.

Teach them how to turn onto their back.

Exactly.

You can take and, you know, things like that I think are super helpful for those and for all the preventative stuff that we try to do to prevent these accidents, where they slip through those cracks and, and if this is something that's interesting to you, there is, an organization called the Drowning Prevention Coalition that provides the classes that exactly that you're talking about.

You just take a little one, I mean, months old, and it sounds terrible.

You blow them on their face and they learn to hold their breath, and they just figure out how to flip to their back and it it's freaky to watch as a parent.

I did it with one of my children.

The other one was already too old.

But you just kind of don't want to, but, you know, it's a life saving event.

Just that they can flip on their back because they'll naturally float if they know how to flip on their back.

So I love that you brought that up.

I want to talk about I want to talk about allergic reaction.

I feel like we talked a little bit about wheezing and something that could happen when you have an allergic reaction, but this can go we can throw poisoning into that.

We can we can talk about an allergic reaction from a scorpion biting someone, a bee stinging someone.

Just in general when you don't know yet because kids are so young, we don't know what they're allergic to yet.

And so what are some of the things that you see in El Paso children's hospitals, people coming in with allergic reactions to what?

And then how do you treat them immediately?

And then how do you kind of coach the family from there?

What that reaction is.

Yeah.

So we do see allergic reactions.

We see, you know, hives presenting allergic reactions.

And then we also see, you know, the anaphylaxis, which is can be hives.

Plus, you know, you start wheezing, hives and have trouble breathing.

If the kiddo starts off with hives and suddenly is coughing or hives or swelling, you know, your face, your lips, your tongue, or the sensation of you can't, like, swallow, you can't breathe.

Now, those are major anaphylactic symptoms that need to go to an emergency room as soon as possible.

And we see say to various things, you know, we can see it, bees to ants to food, to anything essentially.

And it's important for the family to kind of recognize that and immediately call 911 You know, if it's going to take too long to get to the E.R.

or immediately just come to the E.R.

because 911 has a capability of giving epinephrine, which is the treatment of anaphylaxis.

Okay.

So the faster you get it in, the better.

And talk about, cause I And I think it's, it's nice because I feel like most children teachers will teach other children if there's someone that has a severe nut allergy, for example, and like, okay, this is the EpiPen, this is where she keeps it, her backpack, you know, I, I love that that is a movement.

At least it was in the school where my children were.

Talk a little bit about that.

When a child is, diagnosed to a point where they would be someone that carries an EpiPen with them.

Yeah.

So I just think it's good for awareness.

For anyone who's who's watching.

Yeah, we see them sometimes when, you know, the very first big major anaphylactic reaction.

When I see those kids, I will print out, you know, the anaphylaxis action plan, which the American in Pediatrics has that.

And I will fill out the medications that they need to do.

And the good thing is with that sheet it has what symptoms to look for it.

And then I prescribe them their epinephrine.

And sometimes I'll even have the families go pick up the medicine to try to discharge them.

Because what we typically do is we watch them for some time in the E.R.

just to make sure that the reactions doesn't come back, and when they bring back the epinephrine pens, they do is I think most of the time come with, teaching one's, they're the fake one Right.

And like, oh, I see I got you and that even and they don't have an actual needle You know, that's just kind of like a simulation one because if you've never used one before, how would you know?

Yeah.

Oh, yeah.

I remember again, learning this as a parent and as I think just like last month, or the month before, I called our pharmacy upstairs and I was like, hey, do you can you guys come down and teach the family how to use it?

And they were more than happy.

The pharmacist came down and they using the family's, the, their fake EpiPen.

They showed them how to use it.

Okay.

And so we had the family all squared away with, you know, what medicines you need to give when you see XY&Z And they had their medications in hand luckily for that family because they went to go pick it up.

So that we they were able to have a safe discharge home.

Okay.

Thank you all for doing that.

I mean it's the day is so different now than it was back.

You know, again when I was young we didn't have any of this stuff in school.

It's summer.

Yes.

Go ahead.

Just one more thing to add on to that I think when, when people think of severe allergic reactions, the first thing we think of is the airway involvement And, I think that's one thing that as, as physicians, we also do is, is, anaphylaxis It's a severe allergic reaction where it starts to affect the organs.

And, we also as physicians tend to think of the respiratory system, but, we probably actually miss, cases or delayed diagnosis in cases where it doesn't necessarily affect the respiratory system.

So that involves things like the GI system.

So, like severe belly pain, vomiting.

Vommiting, that can be a sign, of anaphylaxis or a severe allergic reaction the sensation from the throat.

Sometimes you might just see a little kid like, of.

clear the throat like something's stuck in there.

That can be a sign even just, a subjective feeling.

Like.

I feel like it's tough for me to breathe even if you're not hearing the wheezing.

If they're not using their rib muscles to, to breathe, those cannot be signs of more severe allergic reaction.

The last system to think about the neurological system So, you being a little bit confused, passing out being dizzy, those can all be signs and symptoms of a severe allergic reaction to kind of just have in the back of your mind, knowing that it's not always just the lungs that are affected So we've not joked about it at the beginning of the show.

The hardest thing, again, as a parent or grandparent, when is a child presenting enough To where I need to call 911 and you're describing some symptoms.

We can also talk about, you know we have cardiology show.

It's like it's not you know, children also have heart attacks.

So you know, when are the symptoms bad enough for you to say, okay I have to call 911 And I know it's an open ended question and I know it's a hard question to to ask or answer, but you've got some that you think, okay, it's a hypochondriac mom.

They're going to go no matter what the other ones, like you'll be fine.

I'm asking however you want to answer that question.

Fever.

We're talking about a fever over a certain amount, so that could be one.

Correct.

And then go from there.

Seizures, maybe if you have the seizures.

We haven't talked about seizures at all yet.

Okay.

Let's talk about seizures.

Yeah.

With you know, febrile seizures are common in children.

But if your child is having a seizure and has never had a seizure, you know, and I don't think as a parent, if I had never seen a seizure, I probably wouldn't know what to do So describe a seizure because I know there's different descriptions as well.

So there's different types of seizures.

But the most common thing that we see and that the public probably thinks of when they think of a seizure is your whole body kind of shaky?

But there's other other types where you can just be staring, one part of your body can just be twitching.

It can be like a subtle, a subtle twitch.

But there's a whole kind of, like, spectrum of seizures that we see.

But the most common ones, specifically related to fevers, would be the ones where your whole body is shaking, or maybe part of your body is shaking, or you're just staring off, eyes rolling back - -Okay, again, it's different with everyone.

How long do seizures usually or what is the window of normal seizures?

I can't say normal seizures, but anywhere from 30 seconds to a couple minutes.

How is that usually?

Yeah, I mean I think that can last as long as a seizure wants to last, but we need to intervene within like five minutes, you know?

Okay.

For us to give medicine are the five.

The five minute mark is the crucial point.

So like a minute or so, they come into the E.R.

Okay.

We stabilize their airway.

Their breathing their circulation while we're obtaining some sort of access, whether it's an IV.

We drill a needle in there in their bone.

If, you know, if we can't get an IV or you can even give seizure medicines through the nose, your bottom, or even to the muscles too.

Okay, I'll tell you something.

You just got my attention.

With drilling a Needle to the bone.

We're going to go to that in a second because I never heard that before, but I'm super curious about it.

So you said the first five minutes, now we're going to a child at home having a seizure.

They're not gonna be able to get to the E.R.

in five minutes.

What can that, obviously call 911 Get the ambulance on the way as soon as possible.

In the meantime?

--You can turn them on on their side, okay?

They can start vomiting.

Kind of lift their head up a little to open their airway.

Is that they're seizing more like that.

Their little head is, you know, obstructing their, their, their airway so they can't breathe.

So those two things and then I think also the parent, which, you know, it's kind of hard to do, but keeping this calm as possible.

Sure.

Yeah.

So you say, okay, so you said if you can't get a vein, if you can't get an IV, you go into the bone.

Is that a way to hydrate?

It is the way.

I mean, like I heard this for emergency physicians, okay?

We're specifically trained to know how to place that in a child.

Okay.

So, you know, the child comes in for any reason that they would need emergent access, right?

If we can't get an IV, and they need something emergently then the next step is to do an entrance needle.

Where we throw that needle with probably, like, this big in the child into.

You know, the first thing I tried was into their into their leg.

To try to get medicines in there because, remember inside the bone is a bone marrow, and that can absorb medications and fluids rather quickly.

I love everything about hearing that.

I did not know that was a thing.

And we as a pediatric emergency medicine physicians were specifically trained on, you know, doing that.

I remember my daughter was seven months old and she diarrhea for days, would not eat.

And they put an IV in her, and I'm like, how can you have something small enough to fit into a little worm, you know?

And I thought, okay, what if they couldn't find the vein?

I was always wondering how that worked in those instances.

Those children are, you know, in what we call extremis, right?

You know, probably.

But just finding a way to get it right away.

Yes.

Yeah.

Fantastic.

And as part of the duty of pediatric E.R., in our E.R.

the nurses do the vast majority of our, our, IV's And so they're, they're used to doing that tiny little babies up to do all of things.

The with, in coordination with our pick.

You, we've had more and more nurses be trained in ultrasound, which is super helpful.

There are some kids who are just tough.

You know, you get those little chubby, babies, every time I see I wanna squeeze their cheeks and then hope I never have to put an IV in them because little chubby babies are super tough our, our nurses are getting more and more and more on the, on the ultrasound guided IVs which is, super helpful.

And this is where they just try to keep the little ones still like that in and of itself, too.

I can imagine it's very difficult.

I do want to get I know we're starting the countdown, but I want to talk about, dehydration.

I want to talk about, just being in the sun, heat stroke, etc., etc.. A stroke for a little one, but how important it is for parents to recognize, for example, being read skinned but not wet, which means the sweat is not working.

You know, what are the things there to look for as well?

And I'm going to start with you when I go through you, because I know there's there's heat stroke, but there's also just heat exhaustion and, and but it all goes into one.

Yeah.

I mean, living in El Paso, the desert.

I grew up here I know how hot it is Yeah.

Right.

Right.

But yes, some of the symptoms would be, feeling nauseous and vomiting.

But then when you start kind of getting into, like, the exhaustion type.

But the first one would be, you know, the child is really thirsty.

Like you said, red cheeks.

Not sweating.

But then they start to, you know, feel really ill, dizzy or vomiting.

And that's going into the exhaustion, leading into like the heatstroke wanna catch them obviously before that.

So recommending always keeping hydrated, especially if the kids are out during, you know, peak time.

You know what, ten AM.

Right.

And I think the weather says 'till 4PM, but I really think it's till 8 p.m.. Yeah.

Yeah.

Being out there at the at those times constantly drinking water and also not forgetting your hat and sunscreen.

And that's something too you were talking about assigning an adult to the swimming pool.

But I feel like you should also do that with sun.

I mean just being just hammered by the sun all day long.

It's, it's definitely going to take its toll on you, poisoning.

Because I think that's another reason when people go straight to the E.R., like some of them, I think under the cabinet my child got into something, my toddler, etc., etc.. Give me some stories about poisoning and what your suggestions are.

I know that, you know, we childproof the house, right?

But there's still the Windex that you left out from cleaning the table the night before.

Give us some stories of what you have heard and some ideas of what parents can do to try to prevent that.

So with poisonings, we tend to see two kind of peaks And so you've seen the toddler ages right when they're like little vacuum cleaner they get into every single cabinet And then you see it later to teenage years wants to do that kind of stuff.

SO those are the two kind of peaks that we see, people take, medicines or substances they shouldn't In the younger, kind of peak with the toddlers.

There's a, there are a few medicines where it kind of can One pill can kill even one pill of, of certain kinds of medicines or blood pressure.

Medicines can, can cause devastating consequences In a toddler and so I think, a wonderful resource that everybody should kind of have on their speed dial on their fridge is the poison control center.

The, poison control center.

It's, nationwide.

We have, our own, center right here.

Right next to the hospital The West Texas, regional center.

And they are a wonderful, wonderful source of, information.

They're staffed by toxicologists who are specialists at poisonings, as well as other staff that's trained to do it.

They have access to be able to look up to see, you know, not only.

Okay.

What what medicine was it, an overdose?

Was it able to tell you from home?

Because some things, you know, if you take, you know, 5 or 10 there's really nothing to do and then they can be safely observed at home, you can spare yourself a trip to the doctor, to the E.R..

But they can also let you know when it's, when it's something that's more urgent and you need to be seen when it's something that, you know, you need to call an ambulance to get seen So the poison control center is super, super helpful.

And how nice to have your cell phone these days.

You can literally pop that into the engine and get that phone number, right.

'Cause I called that number before scorpion bites.

Oh, goodness.

Yeah.

You're right.

It's not just that, poisonings in terms of stuff you swallow But things like rattlesnake bites scorpion bites they deal with those kinds of problems.

Okay.

The, to probably the, the case that I've seen kids getting most into danger with, are when they get into, like, their grandparents medicines.

Right.

So, you know, their grandma's house family left her their pills next to her bed, right.

They look like candy and the kid takes a bunch of them.

Right.

So, a is poison proofing, like you're saying, to really trying to make sure you, enforce it whenever you know you're at somebody's house, okay?

Like, you know, can you keep these meds locked or up high where they Can't get that right And in the case of the poisoning does happen, it's super helpful to be able to, to, send them with a list of all the potential medicines that were at home.

Okay, so these are all the list and these are all the dosages, counting those pills being like Okay.

You know, I have 30 for the month, and, you know, I'm ten days in and I'm missing 15 back.

And that can be super helpful in terms of determining, the, potential, exposure.

So if you're at home and you're a parent, you know, this has happened again, it's going to take a little bit.

Is there still is an epattack?

I can't remember that.

Do you ever induce vomiting anymore?

I feel ike years ago.

Okay.

And tell us why.

Because like that again is old school and that still in my head.

Tell us why.

Inducing vomiting.

It's not so I think a long time ago, if it happened, made yourself throw up you know, gagging yourself, going to the hospital getting your stomach pumped.

I remember hearing that all the time.

Yeah.

A lot of times they can actually cause more damage coming back.

It can aspirate go into your airway, so it's not really recommended.

It's important to recognize these things early.

If there's something called activated charcoal, which is just like what it sounds like.

It's like liquid charcoal that, helps deactivate a large amount of medicines.

So they're less dangerous?

That has to be given within the first hour for ingestion.

So time is interesting.

Okay.

So, you know, in cases where where, somebody either has a specific ingestion or a whole, like a very large ingestion of a certain type of medicine.

Those do benefit from that.

So if parents are listening right now, they can find activated charcoal at a drugstore or It's a matter of getting them to the E.R.

very quickly Okay.

Poison control is helpful in Hey, this is something that needs that charcoal in the first hour.

You know, get them there quickly if you can't get there quickly, call an ambulance Okay.

And that's why poison control is helpful being guided.

Okay, once they get to the hospital, you know, sometimes we have no idea what they took Sometimes kids come in and they're just altered, and acting confused.

And, you know, that's something that we're always thinking about in the back of our head is possibly I got into something.

And, you know, there's bloodwork that we do EKGs, different things that certain poisonings will present in certain ways.

So there's, you know, kind of a group called meaning that, you know, it gets certain vitals abnormalities or physical finding abnormalities That we're trained to to recognize, when thinking about, poisonings that help guide us in terms of, like, our treatment and our, you know, testing.

Exactly.

Right.

Wow.

It's always so scary.

I know we're running out of time a little bit, but I do want to talk about.

And this is something that I've learned over the last several years about growth plates in children, because you said that there an orthopedic person on 24 seven for broken bones.

and you're setting bones in your, you know, doing surgeries, etc.?

Could you explain to the audience at home, breaking a wrist of a four year old is very different.

A break in the rest of a 16 year old because of the distant, the fast growth that occurs in little ones and how those are set in, in difference.

And I just I just think it's fascinating about the growth port.

And when I think 16 to 18 is about when your growth plate is going to be done done So it kind of vary.

So the growth plate is the part of the bone that is cartilage.

So it's usually at the end of it and that cartilage it turns to bone.

And so as you grow that cartilage well that's how your home grows.

once it's bone, that's it it's solid Girls, the growth plates you close sooner than, boys.

That's why girls tend to stop growing a little bit younger.

And you know that again, the teenage years are usually when you kind of stop.

Sometimes we get a kid who was like 19 or 20, and they still have a sudden growth spurt.

And so it can happen.

But, you know, it's kind of more or less where, what usually happens, injuries to so with, with, fractures you can have fractures through the growth plate which is cartilage.

They can involve the bone kind of above and below the cartilage.

And those do have kind of different treatments, different outcomes.

So, you know, that's why, it's important to have, you know, pediatric orthopedics Yeah, that's the point.

Yeah.

With, how to manage those injuries.

A lot of times are managed in very similar ways, to, other people or, like you said, when you're younger, your bones are much more malleable.

You'll get fractures that, you know, that you can get about like this, but then you'll be able to restrict, as you get older, you lose that malleability.

And so you do have to be more precise in how they're lined up.

As kids get older and their bones are more mature But it is mainly what I've seen, you know, horrific fractures.

And the little kids you're like My gosh, how's it going But then it heals nice and perfectly straight, it's amazing what the body can do.

--The magic of our bodies.

Okay.

We have a whopping five minutes left.

I want to stop asking my questions and ask you all if there's anything that you really wanted to talk about today before you, when you're driving over here in 108 heat Is there anything that we haven't spoken about yet that you'd like to talk about?

Either one of you?

I always I always think about what's what's coming in the future, which I love.

And again, I, you all are going to have two urgent care, areas it's going to be of El Paso Children's Urgent Care Facilities One on Zaragoza, one on Eastlake.

That's where such of the population is.

In general.

What's what's going on that you want to talk about?

I mean, I think specifically about I think in, you know, in general, when a parent, if in doubt, just come to the ER, right.

You know, I'd rather them come to the E.R.

nothing be wrong than them wait and then something ends up being wrong so I'd rather you know, parents are not doctors, right.

And even those parents that are doctors I'm sure that, you know, ideally you look at your own child differently.

Yeah, you really do.

You really do.

Exactly something wrong and someone else for your own child because you're there all the time.

Dr. Maldonado how about you?

But, I want to say that, if I think about the years that I've been here in practice, the sickest kids that I've seen, are those that have chronic medical problems who get another.

You get a cold, get a pneumonia.

you get something else on top of it.

I think the, the beauty in and what, you know, growing up here, like, I remember it was like, before we had a Children's hospital Right.

And one of the best things that that it's had that that's happened as a result of the children's hospital opening is that we have so many more specialists here than we used to.

And, the, it's, the wonderful thing is that, at a true children's hospital, like El Paso Children's Hospital we have all the specialists that are at our fingertips, we are very well versed with dealing with, patients with multiple medical problems, and get very sick.

So, you know, I think that is, one of the benefits of having ER, which, hopefully you don't ever have to, you know, utilize.

But we're were there when, when you are in need.

Yeah.

Another thing is that's going to be coming soon.

That is going to be wonderful.

We're looking forward to very much in the ERs we are looking to have our ER expanded Currently we have, ten bed unit with like, three bed, that kind of area with, kind of a fast track area, and, rapid assessment zone.

But we're set to actually expand by the extra number of beds are kind of, still up in limbo, but anywhere from 7 to 9 beds, which is going to be huge.

Yeah.

Because, half the, the battle of being able to see, all the patients that come in is we just don't have space.

And, you know, and the patients are wonderful in terms of this.

Sometimes we have to see patients in the hallways sometimes around little curtains, which is never ideal.

Right.

You know, but it's the only way we can get to the patients that are in the emergency room.

And having these extra beds is really going to be wonderful.

It's going to include, full sized resuscitation bays for when we have these critical patients.

It's going to include, dedicated areas for those lower acuity patients.

So we can kind of get through them faster, dedicating, things like nurse practitioners that we have working with us in the E.R.

who are invaluable.

And they're really wonderful seeing these lower acuity patients much faster than the physicians are.

A lot of the time we're tied up with with sicker patients and having dedicated areas for that to be able to be seen And I think there is going to be huge.

I love that about our region, is that there are more and more places to be able to go now, which again, over the last several decades has been phenomenal to do.

Doctor Miguel Arroyo, thank you very much for joining us.

Doctor Alfredo, which I didn't get to say earlier Maldonado, thank you so much again, medical director attending physician.

And if you are just now tuning in to this program, or if you want to watch this program again, or if you want to have it running in the children's E.R., there's three different places you can do that, too.

You can go to pbselpaso.org find the El Paso physician on there.

You can also go to the El Paso County Medical Society website.

And that is EPCMS.COM and a lot of people are able to find these programs on YouTube.

So just in YouTube type in the El Paso Physician you can type in El Paso Children's Hospital, you can type in pediatrics.

And throughout the months, in the years, you will also see different topics there that you might be able to come back and watch as well.

Thank you so much for being here again.

This has been "Pediatric Specialized Emergency Care" specifically here in the borderland region.

I can't thank you guys enough for taking care of our babies.

And then hopefully I'll have grand babies eventually someday.

But I'm Kathrin Berg and this has been the El Paso physician.

The El Paso County Medical Society is a nonprofit organization established in 1898 that unites physicians to elevate the health of the El Paso community.

We have been bringing the El Paso Physician Television program to your home for the last 27 years on PBS El Paso.

If you should have any medical questions relating to this program, you may email us at EPMEDSOC@aol.com.

And we will try to have our experts answer your questions.