By Katie Scarvey
Salisbury Post
CHARLOTTE ó It’s Tuesday afternoon, around 3:30 p.m., and 7-year-old Katelyn Refsnider is lying in a treatment room in the children’s emergency department at Carolinas Medical Center.
A huge photo of a happy little girl looks down from the wall, but Katelyn is immune to sunny feelings just now. Despite the morphine she’s been given, she’s focused on the pain in her shinbone.
A collision in gym class with a classmate at Highland Creek Elementary School left Katelyn with a spiral tibia fracture ó often called a toddler’s fracture.
Here, after being attended to immediately upon arrival, Katelyn has been x-rayed and is being treated by an orthopedic resident, Dr. Norman Waldrop.
As Katelyn’s parents comfort her, Waldrop puts a cast on her leg. Its aggressive pinkness seems to lift her spirits slightly. After it’s in place, Waldrop instructs Katelyn’s parents about how to keep her comfortable at home.
At many emergency departments, Katelyn likely would have been splinted and referred to an orthopedist for further treatment. Here, though, she’ll leave with all the treatment her leg requires.

In years past, many emergency departments were not well-equipped to handle their youngest patients.
Start with waiting areas, which typically represent humanity’s messy spectrum ó including the intoxicated and the belligerent.
You won’t find that at the children’s ED at CMC ó but you can expect kid-friendly art and toys. Jerry Springer won’t be blasting on the TV. Instead, kids can watch educational children’s programs.
“Small things make a big difference in the experience people have,” says Dr. Randolph Cordle, medical director of the Division of Pediatric Emergency Medicine at CMC.
Katelyn’s mom, Jennifer, would agree.
When she was taken from Katelyn’s room to discuss how pain medication would be administered, a nurse arranged for Katelyn to watch a video. That focus on her daughter impressed Jennifer. She also appreciated that the staff was conscious of not upsetting Katelyn.
“Never did they use the term ‘broken bone,'” Jennifer said.
“They always talked about ‘fixing her leg.’ ”

The 24-hour children’s emergency department is the region’s first to be dedicated to children. Open since 2004 and now fully integrated with the new Levine Children’s Hospital, it has its own separate entrance, which is part of the hospital’s goal of keeping to a minimum the time pediatric patients are in adult spaces.
More than 27,000 visits are projected this year, says Vickie Hamann, assistant vice president for outpatient services at Levine Children’s Hospital. Volume is growing, she says, as other hospitals in the area ó including Rowan Regional Medical Center ó transfer patients there.
Child life specialists
One thing that makes this department child-friendly is the staff of child life specialists, whose role is to ensure that the whole child is treated, not simply the sickness or injury.
They make sure children are as comfortable as possible and understand what is happening to them, Cordle says.
If a child needs an IV or an MRI, for example, a child life specialist will ease the stress by explaining the procedure ó with age-appropriate language and dolls or other visuals as necessary.
Cordle has given these specialists the authority to stop procedures if they believe a child is too agitated or not receiving adequate pain medication. They serve as advocates for children in cases where parents may be absent ó or not up to the task.
“It’s a nice role to have in an emergency department,” Cordle says.
Child life specialists must have a four-year degree in a relevant field, such as psychology, and go through a 480-hour internship with a certified child life specialist.
The child life personnel who work in the fast-paced emergency room have the challenge of building rapport quickly with children, says Kristin Brown, a child life specialist who works in the oncology department.
They do such a good job, she says ó whether it’s inflating examining gloves like balloons or blowing bubbles to distract a child who’s having an IV inserted ó that sometimes kids don’t want to leave.
The right equipment
Besides a staff trained to deal with children, the department has the equipment and supplies needed for optimum treatment of young patients.
Cordle knows all too well the frustration of working in an ED not well-equipped to handle kids. He remembers spending 16 hours bagging (manually ventilating) a baby because the emergency department where he was working at the time did not have a ventilator for a baby.
Such a scenario would be highly unlikely at CMC, which is well-stocked with all sizes of basic medical equipment, such as IVs, blood pressure cuffs, chest tubes ó items not always readily available in an array of pediatric sizes in general emergency departments.
They also have other specialized equipment ó like an intubating fiberoptic scope that allows easy access to a child’s airway.
Also available is heliox, a breathing gas composed of helium and oxygen, which might be administered to children who have a partial airway obstruction or a bad case of the croup.
“In most cases, (heliox) gives us time to treat with medication and prevent having to put them on a ventilator,” Cordle says.
Bedside ultrasound is another useful tool. If a child has a red skin bump, for example, the ultrasound will help determine whether it’s an abscess, and if so, it can facilitate a safer, faster drainage procedure.
If a child needs to be catheterized to get a urine sample ó a notably uncomfortable procedure ó the ultrasound equipment allows medical staff to determine the right time to catheterize, which can reduce the number of uncomfortable procedures done on children.
A vein transluminator makes it easier for nurses to find a child’s veins.
End tidal carbon dioxide monitoring is also a fairly new tool in the ED.
It helps doctors to know if there is a breathing problem before the oxygen level changes and allows them time to respond to the problem before any ill effects occur, Cordle says. Although it’s been used by anesthesiologists during surgery for years, Cordle says the technology has only recently begun to be applied to emergency departments.nnn
Cordle acknowledges there are some things his emergency department provides that most general emergency facilities can’t.
But he’s quick to point out that parents should not bypass their local emergency departments, particularly in situations in which a child’s life might be in danger.
The important thing to consider in emergency care, he emphasizes, is whether physicians are board certified in emergency medicine. Although his department hires physicians who are board certified in pediatric emergency medicine, board-certified emergency medicine specialists are also well-qualified to handle children, Cordle says.
“I don’t care what shingle you hang … (regular emergency departments) can incorporate the things that a children’s ED does. Putting the word ‘children’s’ in front doesn’t necessarily make you better.”
Contact Katie Scarvey at 704-797-4270 or kscarvey@salisburypost. com.