Two Specialists, Ninety-Six Beds, and a Demand for 24/7 Coverage

Start from arithmetic, because the ask is not physically possible. Two FTE is roughly 4,000 paid hours a year before PTO, education, and meetings. Forty MRI preps a month at even 45 minutes each is 30 hours a month in a two-hour window; 24/7 ED coverage is 8,760 hours a year. Neither fits. Saying so with numbers is not resistance - it is the only way the conversation becomes about design instead of effort.

Priority criteria I would apply openly

1. Risk of harm if unaddressed: unmanaged procedural distress, restraint, failed procedures, repeat sedation.
2. Evidence of effect: preparation and procedural support for young children having MRI has a plausible, measurable effect on rescheduling and sedation rates.
3. Predictability and schedulability: MRI preps are known in advance - the highest-yield use of limited staff.
4. Substitutability: who else can do this if child life cannot? A trained radiology tech with a prep kit is not equivalent to a specialist, but it is better than 'whoever is free.'
5. Equity: families with limited English, developmental concerns, or prior failed procedures are most at risk and least likely to self-advocate.
6. Obligation and escalation: a complaint is a trigger for review, not automatically a mandate for 24/7 coverage.

What that yields: do not accept 'every MRI.' Target the 4-to-10-year-olds with a first MRI, a prior failed or cancelled study, developmental or sensory concerns, or limited language support - probably a third of the 40. Decline 24/7 as a staffing impossibility and offer an interim ED response model with clear consult triggers.

A three-tier model, because a specialist-only model is what is failing now.

• Tier 1 (universal, built into the system): a prep kit on every MRI unit, a short video and photo story on the intranet, a scripted 5-minute phone call the day before for every scheduled pediatric MRI, and a 60-minute education session for radiology and ED staff on developmental preparation, comfort positioning, and distraction. This is how you cover 40 preps a month with two people.
• Tier 2 (targeted): child life sees the flagged children - first MRI, prior failure, developmental or sensory concerns, limited English, high family anxiety.
• Tier 3 (intensive): child life attends selected procedures for children with trauma history, complex communication needs, or repeated restraint.

ED: not 24/7. Instead - consult triggers written into policy (new diagnosis, invasive procedure, death, suspected abuse, unaccompanied minor, repeat visit), a comfort cart, and a named child life contact during business hours with a clear escalation path after hours.

Measures

• MRI reschedule and cancellation rate (baseline 18%), and sedation rate for 4-to-10-year-olds.
• Minutes from room entry to scan start; number of repeat sequences.
• Restraint use, documented.
• Family-reported coping and satisfaction; staff confidence before and after training.
• Child life hours per case type, to show the manager where the time went.

Method: run a three-month pilot on a defined group, compare with the 18% baseline, report back with a one-page dashboard, and be explicit about what you stopped doing to make room. Anything new must displace something old.

Acknowledge the complaint without conceding capacity you do not have. Open with the family: 'Tell me what happened with that family, because if we hurt them I want to know the details.' Specifics convert a complaint into a problem with a solution.

In the conversation

• Present the arithmetic and the pilot data once - not repeatedly, which reads as defensiveness.
• Offer something concrete and immediate: consult triggers, the comfort cart, after-hours staff training, a child life consult pager during the day.
• Ask what the ED can own. Partnership questions ('who on nights could do a two-minute prep with a kit?') work better than refusals.
• Write down what was agreed and send it, so the plan does not evaporate.

What I escalate upward, in writing

1. The capacity math and the specific gap - 8,760 hours of requested coverage against 4,000 available hours.
2. The pilot results and the reschedule/sedation trends, framed in throughput and cost terms, since leadership responds to those.
3. A formal request: additional FTE, or a commitment to fund a part-time evening role, or a trained non-specialist 'comfort champion' model with child life oversight.
4. A patient-safety framing if the numbers support it: repeated restraint, failed procedures, and cancelled studies are harm, not inconvenience.

Guardrails: do not promise coverage you cannot deliver to end an uncomfortable conversation - that converts a staffing problem into a trust problem. Follow the chain of command, keep the family complaint in view, and document the escalation. If the request conflicts with safe practice, say so plainly and put it in writing; that is advocacy, not insubordination.