Eastern Maine Medical Center (EMMC) and Penobscot Pediatrics re-cently announced the resumption of Pediatric Intensive Care services at EMMC. This comes as part of a new, comprehensive, and long-range plan designed to exceed past and current capabilities for the provision of quality care to children of eastern and northern Maine who become seriously ill.

Pediatric Intensive Care is a subspecialty all it’s own. With the expansion of medical knowledge, it is increasingly difficult for general pediatricians to serve as jacks-of-all-trades in the type of highly charged, intensive care situations that arise at a referral center. In such critical situations, any one of the numerous, rapid-fire, yet complex decisions that must be made within seconds to minutes may change a child’s life forever.

Provision of these services would be impossible without the efforts of trained pediatric nurses, pharmacists, social workers, and child life specialists who have a long history of providing a level of care for children unmatched by smaller hospitals. It is because of these services alone that children are transferred to EMMC from outlying areas every day. For years, both the availability of such personnel, and the willingness of Bangor area pediatricians to take responsibility for children who are either from more distant areas or do not have a pediatrician – in addition to their own patients, have been the core of EMMC’s survival as a pediatric inpatient referral center.

More recently, however, several changes have significantly altered this core:

? Improvements in medical care have increased the survival of children with serious illnesses. Consequently, the severity of illness in individuals requiring admission to the hospital is rapidly increasing.

? The pool of physicians and staff willing and able to provide care to these sickest of children is shrinking.

? With the extension of EMMC’s referral network, there is an increase in expectations surrounding the level of services local personnel are expected to provide.

? Pediatric Critical Care offers little in the way of reimbursement to providers. Families may pay their allotments to insurance companies, HMOs, etc. That doesn’t mean this money gets back to the people who care for their children. Yet, the sleepless hours providing care to critically ill children day-in, day-out, nights, weekends, and holidays are physically and emotionally exhausting. After limited time with their own families, physicians and staff return to the hospital or office to confront issues ranging from: respiratory arrest, seizures, serious infections, heart disease, behavioral issues, and metabolic disorders to: child abuse, cancer, suicide, and yes – colds, ear infections, and well child care. And they do so knowing that some patients and parents understand and forgive the inconveniences resulting from rescheduled appointments, or from their child’s provider being late to or called away from an interaction. Some do not.

Over time, due to these factors and more, the subset of local pediatricians maintaining the commitment and skills to care for critically ill, mechanically ventilated children has diminished to the point that, for some time now, it has included only the physicians from Penobscot Pediatrics. They have done so at great sacrifice to themselves and their families.

Bangor is almost certainly the only community in New England to maintain a Pediatric Intensive Care unit using a model in which local, office-based pediatricians (almost all of whom have another pediatric subspecialty to try to keep up with) care for such children.

Committed to providing the best services possible within the scope of local available resources, Penobscot Pediatrics has tried for years, unsuccessfully, to convey to the hospital/medical community the need to recruit Pediatric Intensive Care specialists to EMMC. In 1998, the group even independently recruited a pediatrician with additional fellowship training in Pediatric Critical Care into it’s own practice in an effort to broaden community resources. But, in the face of the previously described changes, it has not been enough. Provision of pediatric intensive care has become increasingly stressful and time-consuming, severely limiting the time available for the physicians of Penobscot Pediatrics to provide outpatient care to their own patients.

Thus, in the fall of 2001, Penobscot Pediatrics made known to EMMC that it would be unable to continue to provide critical care services to children outside it’s own practice. This occurred only after long hours of soul-searching about what, ultimately, would provide the best of care for the children of northern and eastern Maine. With the well-being of children at stake, the group felt it had no choice but to be proactive.

Painful as it was for all involved, the transfer of critically ill children to other regional hospitals clearly illustrated the need for local Pediatric Critical Care services. With this in mind, the current interim resumption of services by Penobscot Pediatrics to children outside it’s own practice is contingent upon the development by EMMC of a larger, more sustainable plan for the provision of Pediatric Critical Care, including the hiring of Pediatric Intensive Care Specialists.

Children are frequently seen as a burden by hospitals, insurance companies, HMOs and governments alike who view them as a financial drain. With the current partnership in care, Penobscot Pediatrics and Eastern Maine Medical Center have chosen to continue to take responsibility for helping children despite the odds – because they care.

C. Elizabeth Trefts, MD, wrote this commentary on behalf of Penobscot Pediatrics, PA, in Bangor.