A history of paediatric emergency medicine in Canada

The development of paediatric emergency medicine (PEM) in Canada as a subspecialty has occurred over stages. Previous articles (1,2) have outlined the development of PEM in the United States and in North America. The present commentary does not elaborate on all the important pioneers and events; however, it is the first article that highlights the critical national events that have contributed to the evolution of the PEM field in Canada (Table 1). Major events in the history of paediatric emergency medicine (PEM) in Canada CAEP Canadian Association of Emergency Medicine Physicians; CTA Canadian Trauma Association; PALS Pediatric Advanced Life Support Major events in the history of paediatric emergency medicine (PEM) in Canada CAEP Canadian Association of Emergency Medicine Physicians; CTA Canadian Trauma Association; PALS Pediatric Advanced Life Support The real pioneers of PEM included parents, nurses and physicians who learned by trial and error using the see one, do one and teach one approach. A major milestone in organizing paediatric care in Canada was the first meeting of the Canadian Paediatric Society (CPS) in 1922, followed 15 years later by the recognition of paediatrics as a specialty by the Royal College of Physicians and Surgeons of Canada (RCPSC) in 1937. Before 1945, there was little evidence for the existence of ‘paediatric emergency departments (EDs)’ as they function today. During World War II, the 1947 annual report of the Montreal Children's Hospital (Montreal, Quebec), one of the oldest children's hospital in Canada, renamed The Montreal Children's Hospital in 1955, mentioned a ‘night clinic’ with 511 annual patient visits. Triaged and treated by highly skilled nursing staff, patients were seen (if absolutely necessary) by residents who covered the entire hospital. The 1957 annual report listed expanded hours of the ‘night clinic’ from 15:30 to 08:00 on weekdays and from Friday evening to Monday morning on weekends, reflecting the ‘off-hour’ importance of ED services, which continues to the present day. By 1957, five centres had facilities specifically dedicated for paediatric emergency care: Sainte-Justine Hospital and The Montreal Children's Hospital, Montreal, Quebec, The Hospital for Sick Children in Toronto, Ontario, BC Children's Hospital in Vancouver, British Columbia, and The Winnipeg Children's Hospital in Winnipeg, Manitoba. Early ED labels included ‘night clinic’, ‘walk-in clinic’, ‘the pit’, ‘the hole’, ‘the dungeon’, ‘the clinic’, ‘the room’ and ‘the emerg’, perhaps reflecting a lack of prestige for the work performed there or a sense of mystery about these areas. A quote in the 1959 annual report from Dr Elizabeth Hillman, director of outpatient services at The Montreal Children's Hospital, states, “we continue to note the urgent need for more space in the emergency clinic”. The annual census at that time was 15,130 patient visits per year. Space would continue to be a problem for the next 60 years at all paediatric EDs. New paediatric graduates saw the ED as a place to work while deciding what they ‘really wanted to do with the rest of their lives’. It was the mid-1970s before full-time staff were hired as emergency medicine physicians. On January 1, 1975, Dr James ‘Jim’ Fallis was appointed full-time director of emergency services through the department of paediatric surgery at The Hospital for Sick Children. On July 1, 1975, the first team of general paediatricians (Saul Greenberg, Peggy Kirkpatrick, Susan Tallett and Mary Thain) were hired to ‘supervise emergency care’, covering the 08:00 to 02:00 shift, daily. On January 1977, the group was joined by Anna Jarvis, who would remain a leader in PEM over the next 30 years. Almost simultaneously, paediatricians at the Children's Hospital of Eastern Ontario (Ottawa, Ontario) began providing 24 h ED coverage as full-time staff. Two models of ED administration evolved, one headed by the paediatric surgery department and another run by the general paediatrician in charge of paediatric outpatient services. Leaders emerged across Canada: Drs Donald Clogg at the Montreal Children's Hospital, Gregg Powell at the Alberta Children's Hospital (Calgary, Alberta), David Smith at the BC Children's Hospital and Louis Geoffroy at the Sainte-Justine Hospital. Milton Tenenbein from The Winnipeg Children's Hospital completed his paediatric residency on June 30, 1977, and became director of the ED on July 1, 1977. He continues in this position 30 years later. In 1984, 18-year-old Libby Zion died in a New York (USA) hospital after admission through the ED. A grand jury investigation found that her death was caused by inadequate staff supervision of housestaff and an excessive service load in the ED. This landmark ruling had profound implications for EDs across North America in that 24 h staff coverage of the ED was legislated in some states and became the standard of care for accreditation bodies. Following this trial, credentialing of ED physicians was essential and the days of ‘moonlighting’ by untrained physicians soon came to an end. With full-time trained staff, the ED was no longer just a place but a combination of a place and a community of physicians and nurses with careers, missions, goals and recognized standards of care. In 1980, ‘adult’ emergency medicine was recognized as a specialty of the RCPSC with the first certification examination in 1983, an essential step before PEM could achieve its own status as a subspecialty. A key breakthrough for PEM in Canada was the development of the PEM Section of the CPS in 1986, achieved by the efforts of Dr Donald Clogg, director of the PEM department at the Alberta Children's Hospital (Figure 1). Presidents of the CPS – PEM Section are listed in Table 2. This became the group that pulled together individuals across Canada with a common goal of advancing PEM. Dr Donald Clogg – first President of the Canadian Paediatric Society – Paediatric Emergency Medicine Section Presidents of the Canadian Paediatric Society – Paediatric Emergency Medicine Section Presidents of the Canadian Paediatric Society – Paediatric Emergency Medicine Section Dr Marilyn Li from Ottawa, Ontario, conducted the first human resources study of PEM physicians. The study identified 49 paediatricians in Canada who stated that they were practicing full- or part-time. Dr Tenenbein is quoted in the 1987 minutes of the CPS – PEM Section meeting as follows: “With decreasing residency positions, the ED service would have to be assumed by staff attending paediatricians in the years to come…we should work towards the development of a subspecialty of Paediatric Emergency Medicine within the Royal College of Physicians and Surgeons of Canada”. No one could have predicted how long this would take! Two initial CPS – PEM Section position statements created heated controversy, the first in 1990 entitled the ‘Management of children with head trauma’ (3) and the second in 1996 on the ‘Management of the paediatric patient with generalized convulsive status epilepticus in the emergency department’. (4). It was the first time that we spoke as a group on the standard of care for a ‘PEM’ problem. Many thought that it was not appropriate that we had ‘dared’ to give guidelines in areas previously owned by other specialties. However, we knew that we had important messages for the academic community. In 1991, Dr Marilyn Li proved the benefits of networking by bringing together directors of PEM departments across Canada with representatives from paediatric intensive care, family medicine, neonatology, the Canadian Heart and Stroke Foundation, the American Academy of Pediatrics (AAP) and others to the First National Consensus Conference on Pediatric Resuscitation in Toronto. It was determined that the Pediatric Advanced Life Support (PALS) course, developed by the American Heart and Stroke Foundation in 1983, would become the national standard course for resuscitation in Canada. This conference led to an explosion of activity across Canada. An expanded Canadian version, ‘PALS Plus’, was developed between the 1970s and the 1980s in Hamilton, Ontario, by Drs Keith Greenway, Anna Jarvis, Charles Malcolmson and Jose Venturelli. Subsequently, virtually all paediatric emergency programs across Canada used the concepts and materials from these two courses to make a major impact on emergency care for children. Dr Anna Jarvis would become the Canadian liaison with the AAP – Advanced Pediatric Life Support (APLS) joint task force. The APLS course pioneered by Dr Martha Bushore-Fallis in the early 1980s has evolved into an interactive, multimedia modular program: APLS – The Pediatric Emergency Medicine Resource (5). Now in its fourth edition, it is revised and updated approximately every four years. Canadians carefully monitored the American PEM situation when the American Board of Pediatrics acknowledged PEM as a subspecialty of paediatrics. Dr Li was the first Canadian to pass the initial American Board of Pediatrics certification examination in PEM in 1992. Many Canadian paediatric programs had already started ‘unofficial’ PEM fellowship training programs of one to two years duration. Programs were neither standardized nor recognized by the RCPSC or by provincial licensing bodies. Lack of certification as a ‘subspecialty’ was of great concern to potential paediatric emergency fellows considering career options. By 1995, there were 10 paediatric hospitals in Canada providing 24 h in-house paediatric coverage in the ED, most having a core of physicians with specialist training or extensive experience in the field. At that time, the CPS – PEM Section was the fourth largest section in the CPS, with 66 members, compared with that of the AAP – Section on Emergency Medicine with 620 members! On November 15, 1995, a proposal for ‘the accreditation without certification by examination’ of PEM as a RCPSC subspecialty of paediatrics and emergency medicine was submitted to the RCPSC. It was submitted by Drs Anna Jarvis, Cheri Nijssen-Jordan, Terry Klassen, Marilyn Li, David McGillivray and David Warren. Essential support came from the Canadian Association of Emergency Medicine Physicians (CAEP), the Canadian Association of Family Physicians, the CPS, the RCPSC Emergency Medicine Specialty Committee and Paediatric Specialty Committee and 100% of the Canadian paediatric departmental chairs across Canada. We were called to Ottawa in 1999 to defend the proposed subspecialty in front of the RCPSC Committee on Specialties. The defence included the following seven points relating to PEM care: a demonstration of deficits in care; a recognition of increased complexity of care; documented human resource shortages; documented increased educational demands; evidence for unique administrative skills required; the development of a PEM community across Canada; a need for a group to set the standards for training and care in the subspecialty; and the rapidly developing research community. On April 25, 2000, we received a letter from the director of the RCPSC, Dr Nadia Mikhael, stating the following, “I am pleased to report that, at its April 2000 meeting, the RCPSC's Council adopted a resolution recognizing Paediatric Emergency Medicine as a subspecialty without examination”. This solidified the future of PEM in Canada, 13 years after the idea was first proposed. At present, there are 10 centres accredited for training in PEM in Canada, seeing a total of over half a million patients per year (ranging from 25,000 to 70,000 patients per year in each centre). First to be accredited was the program at Sainte-Justine Hospital, University of Montreal, with the latest in 2007 at the IWK Health Centre associated with Dalhousie University in Halifax, Nova Scotia. Over 100 candidates have enrolled in programs across Canada since we achieved subspecialty status. In 2006, PEM succeeded in the final step to becoming a subspecialty with certification with examination. The first meeting of the PEM Examination Committee was held in March 2007. The 2007 cohort of residents will be required to take an examination for final certification. Other areas of development occurred at a rapid pace. In 2001, the Paediatric Canadian Triage Acuity Scale was developed by Drs David Warren, Anna Jarvis and Louise Leblanc (nurse educator). It was endorsed by the National Emergency Nurses Association, the CPS, L'Association des Médecins d'Urgence du Québec and the Rural Physicians Association under the sponsorship of the CAEP. This has become the Canadian national ED triage standard for children. The CAEP and the PEM Section have developed a close partnership with PEM representation on their board of directors. The CAEP created a PEM section, the first chairperson being Dr Cheri Nijssen Jordan from Calgary, Alberta. In 2003, Dr François Belanger from Calgary was elected president of the CAEP, the first PEM physician to occupy this prestigious national position. ‘Kids CAEP-ERs’, a PEM roadshow sponsored by the CAEP, was launched on January 28, 2005. Four PEM physicians delivered this course across Canada and internationally. Other close links with our colleagues have been developed with membership on various committees such as the Heart and Stroke Foundation of Canada, the American Heart Association Pediatric Resuscitation Committee, the American Academy of Pediatric Committees (Toxicology, Education, Executive and Research), the Canadian Trauma Association and the Royal College Emergency Medicine Examination Committee, to name a few. Dr Tenenbein, from Winnipeg, is currently the chairman of the AAP Section on PEM. Canadian PEM physicians over the past several years have taught PALS or provided care throughout the world: Japan, Saudi Arabia, Oman, Vietnam, Singapore, Barbados, Morocco, Australia, Russia, France, Kenya, United States and England. Due to the effort of individuals trained in PEM in Canada, the subspecialty of PEM has been recognized over the past two years by medical specialty organizations in Great Britain and Saudi Arabia through the work of Dr Kathleen Berry (former ED physician at McGill University [Montreal, Quebec]) and Dr Fahaad Al-Orifi (the first physician from Saudia Arabia to complete a PEM fellowship in Canada in 1993 at McGill University). After the effort to achieve recognition as a specialty, the academic mission could be focused on research where individuals often worked independently with inadequate resources. A 1994 quote from the CPS – PEM section minutes states the following, “we currently have no mechanism for assessing (research) proposals on a national basis and it may be more appropriate if centers approach one another for projects”. Dr Terry Klassen, PEM physician and current chairman at the Stollery Children's Hospital in Edmonton, Alberta, is quoted as saying, “while working at CHEO I was perhaps the first PEM physician in Canada to have protected research time at 50%”. A meeting of Drs Terry Klassen, David Johnson and Martin Osmond in 1995 led to the creation of the Pediatric Emergency Medicine Research of Canada (PERC) group (6). Their initial mandate was to carry out a retrospective study to examine the use of computed tomography scans for children with minor head injuries. The first formal meeting for the multicentre study, the Canadian Assessment of Tomography for Childhood Head Injury (CATCH), was held in Ottawa on May 21, 2001, with 20 people in attendance. Start-up funds ($20,000) from the Canadian Institutes of Health Research were used to develop the first large PERC conference at the Post Hotel and Spa in Lake Louise, Alberta, in October 2001, which 30 people attended. Subsequently, a PEM fellow's research day was added to the annual PERC group meeting. In 2007, there were 72 participants. Of major importance to PEM research in Canada was the receipt of a 2006 Canadian Institutes of Health Research team grant in PEM for $4.8 million. This allowed each of the paediatric teaching centres to have a 0.4 of a full-time nursing position for five years to help assist with PERC studies and other projects in their own centres. Dr Donald Clogg, the man who had the foresight to establish the CPS – PEM Section in 1986, died on September 13, 2003. In his eulogy, he was credited with introducing racemic epinephrine to Kenya in the 1970s. Many children there died of laryngotracheitis, with a mortality rate from intubation of 80% and a mortality rate from tracheotomy of 100%. Dr Clogg was a straight talker, clear, logical, actionoriented and a consummate advocate for children all over the world. He is best characterized by this quote he gave in replying to a question on the issue of banning baby walkers. He stated, “in conclusion, there are 3 causes why infants are being maimed and killed falling down stairs while in infant walkers. One is the walker, the second is the stairs, and the third is the infant. If one of these is removed there would be no problem. Which one to get rid of? Hhmm? It is time to take a stand”. This type of logic made him a pioneer for PEM. We need more dedicated and outspoken people like Dr Clogg to plan for the future. PEM has come a long way from the ‘night clinics’ of 1947 with 511 annual patient visits (Table 2). Sixty years later, PEM in Canada has achieved full status as an academic subspecialty, excelling in research, education and clinical care at a level of excellence that is comparable with any of the other subspecialties.

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