Have you ever gone to Instacare/Urgent Care only to be sent to the Emergency Room (ER)? Have you ever spent 8 hours waiting in the ER for an ear infection? One of the challenges of parenthood is knowing where to go when something goes wrong with your child. Generally speaking, as you go from office, to Instacare/Urgent Care, to ER, you increase the cost of the visit and the time spent.

Here’s a quick guide on when to go where:

The office

Nearly all problems should go to the doctor’s office (when available). Almost all infections, sicknesses, rashes, behavioral problems, injuries, and routine guidance should happen in the office. When deciding if something is office appropriate, ask yourself if the problem is so severe that the doctor would need to admit your child to the hospital, get immediate specialist help, require stabilization, or require equipment that isn’t available in the office (e.g., CT scan). If the answer is “yes,” go to the ER. If not, come into the office.

Exceptions

There are exceptions to the general rule of “go to the office first.” Let’s talk injury exceptions.

• Bones: If a broken bone occurs that causes the extremity to be visibly deformed (e.g., the forearm makes a 90 degree angle) or a bone is sticking out, that needs an ER (where a specialist will have to operate or reduce it).
• Head Injury: If a head injury occurs that is severe, causing the child to be knocked out or vomiting uncontrollably, that also needs to go to the ER (you may need a CT scan).
• Acute Issues: If the problem will likely need immediate surgery, such as appendicitis, skip the office and go directly to the ER.
• Infectious Exceptions: If your child is struggling to breathe, you better go to the ER (although, most offices are equipped to handle a pretty sick asthmatic or kid with pneumonia). If your child is seriously struggling to breath or is turning blue, an ER is your choice.
• Psychiatric Exceptions: If your child is actively suicidal, you better go to the ER.

It is worth knowing what services your specific doctor’s office offers and what the limitations are. My office, for example, has x-ray and lab abilities (which helps with diagnosing pneumonias and broken bones). If your office doesn’t offer that, do they have an arrangement with a nearby hospital? Also, what does your doctor do? I am trained to cast simple fractures and suture, where some pediatricians don’t. However, I don’t suture faces (unless in the eyebrow or something), because I think that a plastic surgeon should do it to reduce risk of scarring.

If you are uncertain: Go to the office first and your doctor will help you decide.

Instacare / Urgent Care

Think of the Instacare as an extension of your doctor’s office in terms of abilities. The goal of an Instacare is to quickly treat and send home. If your child is so sick that she will be in the Instacare for several hours, or may need to be admitted to the hospital (e.g., trouble breathing), you will be sent to the ER–which may include an expensive ambulance ride.

Advantages

Instacares are usually open nights and weekends. So if the problem is relatively simple, but you don’t want to wait for your doctor’s office to open, the Instacare is a better option than the ER. For example, your child may have strep throat or an ear infection and it’s Friday night. Waiting until Monday morning is a long time for your kid to suffer, so go to Instacare.

Limitations

The same limitations at your doctor’s office exist for an Instacare.

Disadvantages

One huge disadvantage to an Instacare is followup. Your regular doctor knows your child’s history and can help facilitate referrals to specialists, follow up on lab results, and is less likely to make mistakes. Because your doctor knows your child’s history, he or she will know if this is the 5th ear infection, for example, and knows your child needs an ENT for tubes.

The Emergency Room (ER)

The ER really should be used for emergencies only.

Advantages

The great advantage to the ER is that it’s open 24/7.

When to go to the ER

As I mentioned, go to the ER if:

• the illness, injury, or problem is severe,
• requires immediate attention by a specialist,
• requires more involved treatment or intervention than an office can offer,
• or may require the child to be admitted to the hospital.

As a little side note when choosing your ER, consider carefully the hospital. For example, the community where I practice has a children’s hospital. Consequently, most of the surrounding hospitals don’t admit children. (Kids are all sent to the children’s hospital rather than kept at local area hospitals). If your hospital doesn’t admit children (i.e., there isn’t a children’s unit), then, generally speaking, the hospital won’t be as well equipped to handle childrens’ problems (staff will not have much experience seeing children, little access to a pediatric subspecialist, images [x-rays or scans] may not be read by a pediatric radiologist, etc.).

Pop Quiz

So let’s test your knowledge. Here are some examples of common problems. Imagine it is your kid and decide where you are going to go.

1. Monday, 10 am. Your child has a runny nose, cough, and ear ache. Where do you go? [Answer: Office (Not an emergency, just needs an exam, may have an ear infection).]
2. Thursday, 3 pm. Your child fell off the 4-wheeler. Her leg has a seriously unnatural bend to it. Where do you go? [Answer: ER (A true emergency, will likely need sedation for a reduction by an orthopedic surgeon).]
3. Friday, 8 pm. Your son just took a serious hit at the football game, he is mumbling incoherently and has vomited 8 times. Where do you go? [Answer: ER (A true emergency, will likely need a CT scan to rule out a brain bleed).]
4. Saturday, 2 pm. Your child is complaining of a sore throat, her friend has strep. Where do you go? [Answer: Instacare (If it was during the week, could see your regular doc. Needs a strep test, don’t delay possible need for treatment just to see your own doc).]
5. Sunday, 10 pm. Your baby is having trouble sleeping. No fever, looks well, but is irritable. Where do you go? [Answer: Office (Call in Monday morning for an appointment. It’s probably a behavioral problem, but may want to rule out other causes with a good exam).]
6. Wednesday, 3 pm. Your toddler has been throwing up for 12 hours, can’t keep anything down, and hasn’t had a wet diaper all day. Where do you go? [Answer: Trick question, potentially all 3 (Some offices and Instacares will do IV fluids, but most won’t and you’ll have to go to the ER. Will likely need IV fluids to treat.)]
7. Tuesday, 7 pm. Your baby hasn’t pooped in 4 days and you’re worried. Baby looks well, no fever. Where do you go? [Answer: Office (Call in the morning for an appointment. Constipation is rarely an emergency).]
8. Monday, 2 pm. Your child had a 10 minute, grand mal seizure at school (a first seizure). Where do you go? [Answer: ER (May need a work-up to determine cause of seizure, or an EEG).]
9. Saturday, 11 am. Your toddler has a frequent, concerning cough, but is breathing comfortably and running around. Where do you go? [Answer: Instacare (Probably want to have a doctor listen to your child and make sure the cough isn’t a pneumonia).]
10. Saturday, 11 am. Your toddler has a frequent, concerning cough and is laying limp on the cough, breathing 80 breaths per minute and has retractions (where you can see all the ribs going in and out with each breath). Where do you go? [Answer: ER (Your child is in respiratory distress and may require admission to the hospital).]

How did you do? If you got them all, awesome. You’re set to go. If you struggled a bit, take heart. Just make sure you seek care, the medical professional will help guide you from there.