Of the more than 800 patients tested for RSV last week at Cook Children’s, more than 200 (29%) were positive. Four percent of those tested for COVID-19 were positive. The Emergency Department (ED) at Cook Children’s in Fort Worth is treating more than 500 patients a day. An additional 800 patients a day are seeking treatment at one of Cook Children’s seven Urgent Care Centers (UCCs). The influx is leading to over-crowded waiting rooms and long wait times across the board.

These numbers are expected to climb as we move closer to peak respiratory illness season, typically December through January.

Parents and caregivers can help reduce the stress on the system by knowing when to call your child’s physician and when to seek emergency care. Doctors say following these guidelines can reduce traffic to EDs and UCCs, reduce wait times for patients and reduce your child’s exposure to viruses.

Many viral respiratory illnesses can be treated at home with rest and lots of hydration. If you are concerned, call your pediatrician first if your child is experiencing mild symptoms without difficulty breathing or dehydration, or for illness-related symptoms (ear pain, sore throat, diarrhea or vomiting, rash, cough or other non-urgent health concerns). The pediatrician’s office can help you decide what steps to take.

In many cases, physicians can assess and treat a patient via a virtual health appointment. Not only is this a convenient option that saves time, but it keeps you and your child out of a waiting room where they could pick up another virus on top of the one they already have.

Download the MyCookChildrens app to schedule a virtual health/telemedicine appointment here.

Parents should not go to Urgent Care or the Emergency Department for an RSV, flu or COVID test. Your pediatrician can test for all of these.

When to Seek Immediate Care:

●      Any temperature greater than 100.4 in an infant under two months of age is considered a medical emergency. If your child has a fever for more than three days, contact your pediatrician or visit an urgent care center. 

●      Concerns for dehydration. In dehydrated babies, parents will see fewer wet diapers or a lack of tears. Their flat spot can also appear more sunken.

●      Your child is breathing faster than usual or you can see the skin between the ribs being sucked in.

●      If your child is requiring frequent use of their albuterol rescue inhaler or is having worsening asthma symptoms.

Signs and Symptoms

Symptoms of RSV in infants younger than 6 months may include:

●     Irritability

●     Poor feeding

●     Lethargy

●     Episodes where they stop breathing

●     Fever

Infants and children over 6 months may experience:

●     Runny nose

●     Loss of appetite

●     Cough

●     Sneezing

●     Fever

●     Sometimes wheezing

Flu and COVID-19 share similar symptoms as RSV and may also include sore throat, headaches, body aches, chills and change/loss of taste and smell.

Practice Prevention

When it comes to respiratory illnesses, prevention is always the best medicine, especially as we approach the holidays and the many indoor gatherings they bring. Vaccines can help reduce the spread and severity of illness and prevent hospitalization. It’s not too late to get your child’s flu shot or COVID vaccine. Call your pediatrician to make an appointment.

Remind your children to practice healthy habits such as washing their hands and coughing into a tissue or their elbow. If you or your child feels sick, stay home to prevent spreading illness, take time to rest and stay hydrated with lots of fluids.

On Monday, Nov. 18, our staff saw 567 patients in the emergency room, which is equivalent to a patient checking in every 2.5 minutes for 24 hours straight. That’s nearly double the number of patients we typically see in the ED.

What’s causing the high census rate?

Hospitals across Dallas/Fort Worth and the state are experiencing similar situations right now due to a variety of bugs making their way around the region. Respiratory illnesses like RSV and croup are being seen in high numbers. We’re also seeing the first wave of flu cases, along with a range of gastrointestinal illnesses.

What does this mean for you?

If you’re planning to come to Cook Children’s Emergency Department with non-emergent issues, be prepared to wait.

“If your child is experiencing cough, fever or vomiting, you should contact your primary care physician first to make sure the ED is the right place to take your child,” said Corwin Warmink, M.D., medical director of Cook Children’s Emergency Department. “Wait times are going to be much higher than normal, and patients may have to wait several hours to be seen if they are not suffering from a life-threatening emergency.”

If you are going to the ED, please limit the number of people you bring with you (if possible).

“The waiting room at the emergency department is so full that Cook Children’s staff have brought out folding chairs to accommodate as many people as possible,” said Dr. Warmink. “We are working as quickly as we can to get patients into rooms, while still providing quality medical care to each child. We know it’s frustrating for families to be stuck in the waiting room, but we ask for patience.”

Also, be aware that anyone who comes into the ED is at a high risk of being exposed to and contracting an illness. The following groups of people have the highest risk of infection:

• Pregnant women
• Infants and young children particularly under age 2
• People of any age with certain chronic health conditions (including asthma or lung disease, heart disease, diabetes, kidney disease or some neurological conditions).
• People with severely compromised immune systems.

What other options are there besides the Emergency Department?

Cook Children’s has a variety of options for care including primary care offices, neighborhood clinics and urgent care locations.

“If your child is over 3 months old and has a fever, even a high one, it’s OK to see your pediatrician as long as they are breathing comfortably and drinking well,” said Diane Arnaout, M.D., a pediatrician at Cook Children’s Forest Park. “If your child has mild wheezing, we can give breathing treatments in the primary care offices. If you’re not sure whether your child’s issue is an emergency, our nurses can talk to you over the phone about symptoms and help you decide between the ER, urgent care and a primary care visit.”

Cook Children’s has seven urgent care locations that provide services that are both convenient and comfortable for your child during the evenings and on the weekends, including two brand new locations in west Fort Worth and Prosper. Many of these locations are also experiencing a high number of patients, but not nearly as high as the emergency department.

If you’re not sure whether your child’s issue can be seen at an urgent care, click here to see a quick list of conditions and where to go for each.

What else should parents know?

The best way to keep yourself and your child out of the emergency room with seasonal illnesses is to wash your hands frequently. This means before, during and after preparing food, before eating, after using the restroom, after blowing your nose or sneezing. The Centers for Disease Control and Prevention suggests scrubbing your hands for 20 seconds, or hum the ‘Happy Birthday’ song from beginning to end twice. This will greatly reduce your chance of getting sick and spreading bugs to others.

And if you haven’t already done so, get your flu shot! It’s not too late, in fact, flu season is just beginning to ramp up. An annual seasonal flu vaccine is the best way to protect against the flu and reduce the risk of hospitalizations and deaths.

Learn more:

• State Confirms Rio Grande Valley Site of First Pediatric Flu-Related Death, 74 Cases of Flu Last Week at Cook Children's
• Let's Learn About Fevers
• https://www.checkupnewsroom.com/lets-learn-about-fevers/
• ER or Urgent Care? How to Decide Where to Go When Your Child Needs Immediate Medical Attention

When should you be worried? The biggest issue is context. You can read the other posts to see all about that.

Another reason you should be more concerned with fever is if it is lasting more than 5 days. Of course, if you end up with a diagnosis where fever is known to last more then 5 days, no big deal, but otherwise, most fevers should be gone by then.

This situation is called fever without a source.

There are many different definitions of fever without a source but I use: fever greater than 101 for eight days in a child in whom there is no obvious source of the fever through the patient’s story or physical exam.

Because children can often have back-to-back viral infections, it is important that this fever be present daily or near daily. For instance, it doesn’t count if they had fever for 3 days then were better for 2 days and then had fever again for 3 days.

The different things to think about are all over the place and can range from very serious to the “no-big-deal.”

Infections - The most common diagnosis in this instance is “unknown” but the fever goes away on its own. While often not intellectually satisfying (to either me or the parent who wants to know what is going on), this is probably the best outcome for the patient. Most of those are probably viruses for which we don’t have or don’t think to run specific tests. Bacterial infections can also cause long-standing fever.

Rheumatologic - Less commonly, children with prolonged fever can have rheumatologic causes, an example is juvenile rheumatoid arthritis. Often these children will have exam findings like swollen, painful joints or swollen lymph nodes that will help point towards their diagnosis.

Malignancy - Fortunately, this is a very rare cause of prolonged fever but it does happen so we all need to keep it in the back of our mind. The most common type of cancer in children is leukemia.

The workup for fever without a source involves a few things:

1. Repeat histories and physical exams - Often things are discovered over time.
2. Preliminary screening labs - Check these in just about all kids with it.
3. Specific tailored labs and exams - Check some of these based on a child’s story or exam.

Kawasaki disease

One specific cause of fever over five days deserves specific attention. Because many parents are not aware of it and because the diagnosis can be tricky, I thought it deserved its own specific mentions.

Kawasaki disease (KD) is characterized by the characteristic fever over 5 days along with some of the following findings:

• Swelling or redness of the hands and feet, followed by peeling of the tips of the toes or fingers
• Red rash all over
• Redness and crusting of the lips or redness of the tongue (like a strawberry)
• Severe pink eye
• Swollen lymph nodes of the neck

One of the other things to note with KD is that these children are very, very irritable. Not kinda irritable, but noticeably irritable even to a pediatrician who hears crying babies and children all day long irritable.

The cause of KD is unknown. There is some evidence to suggest that there might be an infection involved. The symptoms and complications associated with it are a result of inflammation of small to medium sized arteries throughout the body.

The most commonly known complications of KD involve the heart and can be inflammation or the lining or muscles of the heart or dilation of the arteries that supply the heart.

If you suspect your child has KD it is important to seek your doctor’s advice quickly, as it is much easier for your physician to connect the dots when symptoms are present. Blood tests can help confirm the diagnosis and treatment can resolve the symptoms and help to prevent complications.

The good news is that children with Kawasaki's disease, like the child in the photos with this blog, usually return to normal and don't suffer complications.

But choosing the best place to go for your child's care  can be a difficult one for some parents. After all, Cook Children's offers several options within its system, ranging from primary care, urgent care, the neighborhood clinics and the emergency department.

So how do you know where to go? To begin with, visit the handy infographic to the right or click here.

"Every patient who comes into our Emergency Department is important to us. However, some patients may be able to receive the care they need from their primary care physician, a neighborhood clinic or an urgent care center," said Corwin Warmink, M.D., medical director of Cook Children's Emergency Department. "The best thing a parent can do is know what constitutes an emergency, so they know where to go when that time comes."

When it comes to choosing where to go, Kara Starnes, D.O. medical director of Urgent Care at Cook Children's, advises parents to think about the severity of the issue.

For instance, your child's Cook Children's pediatrician can see a number of ailments, including allergies, the flu, migraines, pink eye, sprains and vomiting.

During times when your pediatrician's office is not available, the Urgent Care Centers at Cook Children's can handle the same ailments, along with most fractures (broken bones) and cuts. Fractures with severe deformities or open fractures should not come to the Urgent Care but instead should go to the Emergency Department (ED). The ED has more equipment to handle the most severe cases, and the child can be admitted quickly to the medical center for continuing care.

If your child has multiple injuries, neck injuries or head injuries with loss of consciousness and/or vomiting, they should go to the ER. These kids typically need the ER because the UCC is not as equipped in imaging and other sophisticated tests available at the medical center.

"Possible surgery, such as appendicitis, is tough for parents to determine because most of the time, abdominal pain is caused by something simple like constipation," Dr. Starnes said. "But severe abdominal pain, testicular pain or swelling, bleeding when vomiting or severe bleeding with bowel movements are reasons to go to the ER."

You should visit the ED with your child in case of a medical problem that could cause death or permanent injury if not treated right away.

Daniel Guzman, M.D., a Cook Children's Emergency Department physician, adds “when in doubt of the severity, always visit the higher level of care such as the Emergency Department” and if immediate attention is required call 911.

And of course, we are right in the middle of flu season. Last week (Jan. 5 to Jan. 11, 2020), 837 kids were tested for the flu. Of those kids, 141 tested positive for Influenza A, 187 for Influenza B and another 102 for RSV. 

For those kids, Cook Children’s has a variety of options for care including the primary care offices, neighborhood clinics and urgent care locations.

“If your child is over 3 months old and has a fever, even a high one, it’s OK to see your pediatrician as long as they are breathing comfortably and drinking well,” said Diane Arnaout, M.D., a pediatrician at Cook Children’s Forest Park. “If your child has mild wheezing, we can give breathing treatments in the primary care offices. If you’re not sure whether your child’s issue is an emergency, our nurses can talk to you over the phone about symptoms and help you decide between the ER, urgent care and a primary care visit.”

I have had the privilege of working in the Emergency Department at Cook Children’s for 10 years, with three of those years as a nurse. I often have people ask me, “How do you do it every day?” or “What is the hardest part of your job?”

It’s hard to describe to an outsider just what happens inside our walls. One thing is certain, dear patients and families, I want you to know that we see you. Every Christmas I work, I remember my first one here. I walked in to find out we had already had two children die. To those families who lost their children, I want you to know that I see you and I think of you at Christmastime.

There are times when I drive home from work in complete silence and don’t even realize I forgot to turn on the radio. There are days when I have to sit in the driveway a few extra minutes before I go in to see my family, and they wonder when I am coming in.

To the mother who I sat with after she received news that her daughter’s cancer was back and metastatic, I see you and I remember you. I remember you when I walk in the door to see my daughter, who is the same age as yours. I see you when I don’t want to get up early to rush through the crazy morning. I see you when I’m lucky enough to drop my child off at school, knowing you would give anything to trade places with me.

As a nurse, I love nothing more than to send your child out the door feeling better and in good spirits. I will drop anything at a moment’s notice to have a bubble party or dance party. I’m never afraid to look silly in the name of making your child smile. I think most of us keep coming back to pediatrics because the good truly outweighs the bad. To the sweet sparkly princess who colored me a picture, told me thank you, and gave me a hug, you gave me the push to get through the rest of my day on a high note.

As an ER nurse, expectations and demands placed on me are high. I experience difficult situations every day. There are always more patients waiting who need care. I try to take a moment if I can to process what happened.

I am lucky to work with truly the best team of people who understand and who support me when I need it. It’s easy to feel lost and overwhelmed at times in our world. If you find yourself here with your child, I want you to know that each of your children impacts my life. They are the reason I come to work every day.

Megan Cole has worked at Cook Children's for 12 years, 10 of which have been in the Emergency Department. Outside of work, Megan enjoys baking, music and spending time with her family. To learn more about Cook Children's Emergency Services, click here.

You walk through the door of the ER to see no one else signing in. You breathe a sigh of relief. This doesn’t look so bad. You get checked in, and it’s not long before they call you back to a room - triage. Your child gets their vitals taken, the nurse asks you a slew of questions and the doctor sees you. Then you are back in another waiting room...WAITING. You think it’s not going to be long, but 45 minutes turns into a couple of hours and you are still waiting.

The ER is just that - an emergency room. Most people try to avoid it completely, while for others, it’s their go-to for health care. No matter where you land in that mix, there is more going on behind the scenes than what you see in the waiting room. 

This is your first tip from an ED Child Life Specialist and mom. Every time I walk through the waiting room on my shift, I think like a mom for those few seconds. I don’t know about you, but as a mom I avoid waiting with my children for everything. This is why drive-thrus were invented! If I can’t avoid it, I come armed with everything possible to make it more bearable. Usually there is a bribe attached to this option.

As a mom with behind-the-scenes experience, there are a few things I think you should know before you sit and wait or, unfortunately, experience a really scary emergency.

The emergency room is a necessary place, and we know how much you don’t want to be there. Trust me, I’ve debated going at midnight with the screaming baby whose ear infection came on within a matter of hours on a Friday night. Confession: I let my oldest go two days with a broken arm and had no idea. The second time, I had her x-rayed the day of. Being a caregiver comes with so many decisions, and I know that deciding whether or not to go the emergency room is one of the hardest ones. Remember that we are here to help you and your child through these hard moments and illnesses that come with childhood. Our motto is: It’s all about the kids! And we mean it!

About the Author

Ashley Pagenkopf is a Child Life Specialist in the Emergency Department at Cook Children's Medical Center. The Child Life program at Cook Children's offers a variety of services, all designed to make your experience at Cook Children's the best it can be. Our services include educating, preparing and supporting your child through tests and procedures, as well as coping with any life challenges you and your child may face. 

Related articles:

• 6 Ways To Prepare Your Kids For Their Next Doctor's Appointment
• Urgent Care or Emergency Room?
• New ED opens just in time for back-to-school injuries

While the increase in self-injuries may not seem that extreme, Lisa Elliott, Ph.D., a licensed psychologist and clinic manager of Behavioral Health for Cook Children’s in Denton, said the study does not tell the entire story. Sometimes the degree of cutting, for example, may not be severe enough to receive medical attention.

Elliott presents to schools, churches and community organizations on the issue of teens and self-harm injuries. She also treats patients in her practice.

“It can be difficult to determine the prevalence of these types of injuries accurately due to the secretive nature of self-harm prevalence,” Elliott said.

Elliott says that the most accurate numbers show that 20 to 23 percent of teens engage in some type of self-injury. The age of self-harm abuse typically begins between the ages of 12 to 14 years old.

Research shows that gender differences appear only to be associated with method of self-injury. Females are more likely to use cutting. Both genders use burning and self-battery. Caucasians are significantly more likely to engage in self-injury than non-Caucasians.

Methods of self-harm include:

• Cutting (70 percent of self-injuries)
• Carving
• Scratching/biting
• Burning/abrasions/branding
• Hitting themselves
• Picking/pulling skin and hair
• Head banging
• Tattooing
• Excessive body piercing

Injuries are most commonly found on arms, hands, wrists, thighs and stomach.

"This is something we see quite often, mainly in female teenagers, and it has increased dramatically in the last several years once it became a 'thing' that teenagers do and have seen or heard about," said Corwin Warmink, assistant medical director in the Emergency Department at Cook Children's. "It is a response to stress and anxiety and gives the performer a sense of control and eases their anxiety. It is not a suicidal behavior, but some studies have shown people who perform self-injury are more likely to commit suicide than people who do not. It also can be indicative of a more serious mental disorder."

So why do kids harm themselves?

“Kids who repeat self-harm injuries are often trying to ease some type of intense, overwhelming negative emotion such as anger, pain, anxiety or frustration,” Elliott said. “That’s the most common reason, but the second most common reason is self-punishment. They are expressing anger at themselves. This is strongly connected to self-derogation and criticism.”

Other reasons for self-harm include:

• Interpersonal influence – as a means to garner affection/caring from others, to identify/connect with others who have self-injured, to “belong” or fit in with a peer group.
• Stress management.
• To feel a sense of control over their own body, feelings or life situations.
• To provide a distraction from painful emotions through physical pain.

Kids who engage in self-harm behavior are more likely to tell and seek help from a peer their own age than tell a parent. Usually, adults only become involved if that peer tells a grownup and asks for help for his or her friend. Other times, a teacher or coach hears talk among other teens and steps in to help.

Elliott offers these tips to identify if your child is involved in self-harming behavior:

• Dressing in long sleeve shirts/hoodies even in hot weather.
• Wearing concealing outfits.
• Avoiding activities such as sports and swimming.
• Making excuses for having cuts, marks, wounds on body.
• Finding razors, scissors, lighters, knives in unusual places such as under the bed.
• Spending long periods of time locked up in bedroom or bathroom.

For more information

To schedule an appointment or refer a patient to Behavioral Health Services, please call 682-885-3917. To have Lisa Elliott speak more on this topic at your school, church or community organization, click here.

My wife nudges me. It’s 2 a.m.

“Hey babe, did you hear that? Who is coughing? Can you go check on them? Take your stethoscope.”

That’s what an Emergency Room visit looks like in our house in the middle of the night. This time of year, many of you might wish you were married to a pediatrician … but, alas, Mrs. Doc Smitty is one of the few with that privilege.

We at Cook Children’s, and hospitals around the nation, have seen a significant rise in the use of our Emergency Departments and Urgent Care Centers over the past few weeks. Not only are we seeing more kids, many of those kids are more complex and more sick than we have seen in previous years. We are seeing RSV, flu, vomiting/diarrhea and just about every other pediatric illness you can imagine. It’s all going around.

Not only do we find ourselves servicing our local area, we are accepting transfers from most of North Texas in an effort to provide service to very ill patients who need the level of care that Cook Children’s can provide. This responsibility is based on Cook Children’s promise that every child’s life is sacred.

But that important commitment to helping so many children means helping a lot of kids. Here’s what we know that means to you.

We know that wait times are longer than usual right now.

We follow the trends in wait time closely – both at our medical center and in our region. All across Dallas-Fort Worth, hospitals are experiencing this surge in visits and we are hearing about increased wait times at emergency rooms throughout the area.

We are working to address this issue. We are increasing the number of providers ready to work in the ED. These are not our regular ED physicians but physicians who will be available to help out with patient surges after their “day jobs.” We are working to educate our families about other locations where they can receive care. Unfortunately, once a patient is checked in at the ED, we cannot ask that they leave to receive care elsewhere. Asking them to leave would be a violation of a law known as EMTALA.

Another issue we are facing is limited space. Hospital beds are filled with sick children that are not ready for discharge. This requires that children who need admission remain in our ED as they wait for a room in the hospital.

Space in the ED is already limited based on the fact that it was built to accommodate 45,000 visits per year but is currently seeing more than 120,000. Much of this problem will be addressed when our new Emergency Department opens, but, for now, we have to work to maximize the use of the space that we have.

Therefore, increasing providers will not cut your wait time down to zero but we will do our best to shorten it as much as possible.

You can help by utilizing our various other ways to care for your child’s medical issues addressed. Do not hear this as a lecture to not go to the ER; that is not the point of this post. We are working hard to provide other means that might help you by addressing the problem more quickly. Consider calling your Cook Children’s pediatrician. Even if they are not open, you can get advice from our outstanding pediatric nurses who can take your phone calls overnight. If your issue requires a visit but the ER seems like too much, check out one of the four Cook Children’s Urgent Care Centers throughout the Fort Worth area.

We know that waiting is terrible.

Doctors are some of the most impatient people I know. I don’t like to wait for anything. I get antsy and frustrated and become very difficult to deal with. If the radiology report or the lab result takes longer than expected, our anxiety level goes up. When we know our patients are suffering and we need those results to relieve suffering, we become even more frustrated. We hope you don’t sense our frustrations as frustrations with you. We just hate to see kids sick and to see more of them sick than usual makes us all sad.

You can hear the frustration in this brief interview with Corwin Wormink, M.D., Cook Children's Assistant Medical Director of Emergency Services.

We are working to address this issue. We are working to speed up all the processes associated with caring for your children so that our providers can be as efficient as possible. We are working to support providers (doctors, nurses and all other staff) so that they can be energized (physically and emotionally) to continue to provide excellent care for your child.

We know that waiting with a sick child is even worse.

We hate it that you are waiting hours to be seen in our ER. When our providers walk into the room and see that you’ve been waiting, our heart hurts about the time you’ve spent sitting in an uncomfortable chair trying to corral your sick child (often with their siblings). We know that you are worried about your child because he or she is sick. You’ve been scared to go to the bathroom, afraid you might miss your name being called out and that you are hungry and tired.

We are working to address this issue. We are looking to staff volunteers in the waiting rooms to help you get to where you need to be, to provide distractions for your children and to do anything they can to help you while you wait. We also are looking to increase our use of text and other notifications to update you on the status of your wait times, need for vital sign checks and other issues. Even when you are waiting, unable to be seen by a doctor, our triage nurses are checking and re-checking your child’s vital signs to make sure that your child’s medical condition is not changing, requiring them to be moved up in line to be seen sooner.

Your child is important to us.

Despite the fact that the numbers of children in the ED are high, we want to continue to provide the best care for your child. No matter how long your wait, we want you to feel like your concerns and questions have been addressed and that you have received the personal care your child deserves. If at any point, you do not feel like you have received that level of care, feel free to reach out to us at 682-885-6698.

You may not have a pediatrician lying next to you in bed for a quick ER check in the middle of the night but we do want you to know that we are here for your child in many other ways. Start by picking up the phone and calling your pediatrician or nurse triage line. If you decide your child needs to be seen, think about trying one of our Urgent Care Centers or in an emergency, our Emergency Department.

Our providers in each area are ready to provide the best care for your child.

Previous articles, related to this topic:

• Sicker kids means longer wait time in ED
• More flu, longer waits in the ED
• Emergency? 6 signs from an ER doc
• Cook Children's to build new South Tower on main campus
• Is it RSV?
• 8 flu myths I wish would go away

Ailments run the gamut from respiratory and fever issues (RSV and influenza) to gastroenteritis with vomiting, diarrhea and severe dehydration. And while there’s not one illness that stands out, one thing is for sure – children in the ED are sicker than they’ve ever been.

“Our ED is running beyond full capacity and has been since December. But in the last few weeks we’re seeing a larger number of very ill children than even during flu season.” said Corwin Warmink, M.D., assistant medical director of the Emergency Department at Cook Children’s. “The sicker the child, the longer it takes to diagnose, treat and properly care for them.”

In December, 20 to 30 kids were admitted for treatment per day from the Emergency Department, but by February, those numbers jumped to about 40 to 50 children a day.

The Emergency Department is averaging nearly 400 patients per day, and during its busiest times a patient will check in every two minutes.

Overall, children appear to be sicker this year. Compared to this time last year, Cook Children’s has seen a 60 percent increase in the percentage of children who need critical care.

As the number of patients admitted and treated in the ED increases, so does the time physicians spend with each child, which contributes to the much longer waiting times.

Depending on the severity of the illness or injury, it could take 4 to 6 hours to care for a child. But it’s not just one physician treating that child. Nurses and health care providers may be brought in too.

“Many of the children we see are dealing with very serious emergencies and they receive immediate care,” Dr. Warmink said. “We use all necessary resources and manpower to care for those children. Unfortunately, that means longer wait times for the families in the waiting room.

“Families could spend anywhere from 5-10 hours or longer in our waiting room, depending on the day they visit. We are actively bringing in extra doctors, nurses and support staff to try and improve these times.”

Dr. Warmink advises parents that Sundays and Mondays are the busiest days of the week in the ED. Evenings after 5 p.m. seem to be popular too.

Families with sick kids who aren’t experiencing emergencies do have other options. The first line of defense is your child’s pediatrician. Making an appointment with a child’s doctor may help avoid a long wait at the ED. Cook Children’s also has several Urgent Care Clinics for non-emergent needs.

Previous articles on this topic:

• More flu, longer waits in the ED
• Emergency? 6 signs from an ER doc
• Cook Children's to build new South Tower on main campus
• Is it RSV?
• 8 flu myths I wish would go away

I must get this question three to four times a day in the office and it's one of those things that keeps you up all night wondering what you should do. The answer, "There is no fever you should go to the ER for..."

That doesn't mean that children with fever don't sometimes need to go to the ER, but the height of the fever is not an indication that a late night drive and time in the ER wait is the right thing to do.

We always want to take the fever into the context of the following questions:

1) What are the other symptoms that the child is having?

• Runny nose, cough? Probably not.
• Abdominal pain? Depends on severity an location.
• Vomiting? Not if can keep some liquids down and still peeing.

2) What is the child's behavior like? Lethargic or active. Is the child laying around all day, not even really wanting to wake up to drink or do they perk up and act like they feel better at times (especially when their fever is down). If they are lethargic, bring them in.

3) Is the child drinking and peeing?  If so, then we will almost always recommend a call to the office over an ER trip.

Common fever myths:

"The child's brain will be fried if the temperature is over 105." Ummm. No. Temperatures that the body is generating on their own as a response to illness will not cause brain damage or any of the other things that your grandmother/neighbor/best friend said they would. We commonly have children with 105-106 temps walk in and out of our office smiling cause they got their stickers for being a good boy/girl.

"If the fever gets above 103 they will have a febrile seizure." Wrong again. In fact, most febrile seizures occur when the temperature is between 102 and 103. We don't know exactly why this is but it is thought that it is related to the rate that the temperature rises and not the absolute number that the temp gets to.

"The baby felt warm so she had a fever" or "The baby was really hot so the temperature must've been about 104." Sorry to the back of grandma's hand, but judging the temperature especially trying to put a number on it by touching a child's head is incredibly unreliable. I would prefer an axillary or temporal thermometer, or in the babies less than 3 months, I'll commonly ask for a rectal temp.

"He had a low grade temp of 99" or "99 is hot for him because he usually runs 96." “Low grade temp” should really be taken out of our vocabulary. They have done studies where they took children's temperatures several times a day and have found that any temp <100.5 in a child less then 3 months and <101 in an older child should not be considered fever. These are normal temperatures that can occur during the course of the day for any child who is healthy and has no reason to be running fever.

So, what temps should I call for?

• Any temp over 100 in a baby less than 3 months.
• Any temp in a child who is not drinking well and with decreased urine.
• Anything else that has you concerned.

The ultimate point is that we should not be afraid of fever. Fever is just another symptom in a long list of possible symptoms a child can have when they are sick. It means that we need to think about what is going on and watch the child close but resist the urge to panic!

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

moment. So, while you have a calm moment, we thought it would be a good idea to take a look at what’s an emergency and when you should go the ER. Otherwise, you probably should take your child to the urgent care center.

Kimberly Aaron, M.D., medical director of the Cook Children’s Emergency Department, gives us six things to check in helping make this decision.

Here are 6 signs your child may need to go to the emergency room. Is your child having:

1. Difficulty breathing
2. Poor skin color
3. Abnormal or altered behavior  
4. Major trauma
5. Severe pain
6. Persistent bleeding

When in doubt, always call 911. Cook Children’s has four Urgent Care Centers to treat your children, Fort Worth, Mansfield, Southlake and Northeast Hospital.

Related Links:

• Medical emergencies: are you prepared?
• Emergency contact sheet
• "What do I do?!" - First-aid and safety information
• Going to the emergency room
• Teaching your child how to use 911
• Is it a medical emergency?
• Poison first aid
• The well-stocked first-aid kit