Emergency Medical Services for Children

Staff Training and Continuing Education

It is a reasonable expectation that all office staff, including receptionists and medical assistants, be trained in cardiopulmonary resuscitation (CPR) with their certification maintained annually. Nurses and physicians should also have training in a systematic approach to pediatric resuscitation. Core knowledge may be obtained through standardized courses in advanced life support (ALS) offered by national medical associations and professional organizations. Frequent practice and timely recertification is important for knowledge retention and skill maintenance. Examples include the Pediatric Advanced Life Support (PALS) and Pediatric Emergency Assessment, Recognition and Stabilization (PEARS) courses sponsored by the American Heart Association (AHA), the Advanced Pediatric Life Support (APLS) course sponsored by the American Academy of Pediatrics (AAP) and American College of Emergency Physicians (ACEP), and the Emergency Nurses Pediatric Course (ENPC) sponsored by the Emergency Nurses Association (ENA).

Protocols

Standardized protocols for telephone triage of seriously ill or injured children are essential. When a child's clinical status is in question and prehospital care is available, ambulance transport in the care of trained personnel is always preferable to transport by other means (e.g., private vehicle). This obviates the potentially serious medical consequences of relying on unskilled and distraught parents without the ability to provide even basic life support (BLS) measures to an unstable child during transport to an ED. Practitioners can work with their local pediatric emergency care resource center (e.g., children's hospital, academic medical center, trauma center) to develop and maintain written protocols for office-based management of a range of conditions, including anaphylaxis, cardiopulmonary arrest, head trauma, ingestions, shock, status asthmaticus, status epilepticus, and upper airway obstruction. Regular practice using mock code scenarios improves office-based practitioner and office staff confidence and self-efficacy in managing these problems.

Resuscitation Equipment

Availability of necessary equipment is a vital part of an emergency response. Every physician's office should have essential resuscitation equipment and medications packaged in a pediatric resuscitation cart or kit ( Table 79.1 ). This cart or kit should be checked on a regular basis and kept in an accessible location known to all office staff. Outdated medication, a laryngoscope with a failed light source, or an empty oxygen tank represents a potential catastrophe in a resuscitation scenario. Such an incident can be easily avoided if an equipment checklist and regular maintenance schedule are implemented. A pediatric kit that includes posters, laminated cards, or a color-coded length-based resuscitation tape specifying emergency drug doses and equipment size are invaluable in avoiding critical therapeutic errors during resuscitation.

To facilitate emergency response when a child needs rapid intervention in the office, all personnel should have designated roles. Organizing a “code team” within the office ensures that necessary equipment is made available to the physician in charge, that an appropriate medical record detailing all interventions and the child's response is generated, and that the 911 call for EMS response or a transport team is made in a timely fashion.

Transport

Once the child has been stabilized, a decision must be made on how best to transport a child to a facility capable of providing definitive care. If a child has required airway or cardiovascular support, has altered mental state or unstable vital signs, or has significant potential to deteriorate en route, it is not appropriate to send the child via privately owned vehicle, regardless of proximity to a hospital. Even when an ambulance is called, it is the PCP's responsibility to initiate essential life support measures and to attempt to stabilize the child before transport.

In metropolitan centers with numerous public and private ambulance agencies, the PCP must be knowledgeable about the level of service provided by each. The availability of BLS vs ALS services, the configuration of the transport team, and pediatric expertise vary greatly among agencies and across jurisdictions. BLS services provide basic support of airway, breathing, and circulation, whereas ALS units are capable of providing resuscitation drugs and procedural interventions as well. Some communities may have only BLS services available, whereas others may have a 2-tiered system, providing both BLS and ALS. It may be appropriate to consider medical air transport when definitive or specialized care is not available within an immediate community or when ground transport times are prolonged. In that case, initial transport via ground to an appropriate helicopter landing zone or a local hospital for interval stabilization may be undertaken, pending arrival of the air transport team. Independent of whether a child is to be transported by air or ground, copies of the pertinent medical records and any imaging or laboratory studies should be sent with the patient, and a call made to the physicians at the receiving facility to alert them to the referral and any treatments administered. Such notification is not merely a courtesy; direct physician-to-physician communication is essential to ensure adequate transmission of patient care information, to allow mobilization of necessary resources in the ED, and to redirect the transport if the emergency physician believes that the child would be more optimally treated at a facility with specialized services.

Access to the EMS System

Virtually all Americans have access to the 911 telephone service that provides direct access to a dispatcher who coordinates police, fire, and EMS responses. Some communities have an enhanced telephone 911 system, in which the location of the caller is automatically provided to the dispatcher, permitting emergency response even if the caller, such as a young child, cannot give an address. The extent of medical training for these dispatchers varies among communities, as do the protocols by which they assign an emergency response level (BLS vs ALS). In some smaller communities, no coordinated dispatch exists, and emergency medical calls are handled by the local law enforcement agency.

When activating the 911 system, the physician must make clear to the dispatcher the nature of the medical emergency and the condition of the child. In many communities, emergency medical dispatchers are trained to ask a series of questions per protocol that determines the appropriate level of provider to be sent.

Provider Capability

There are many levels of training for prehospital EMS providers, ranging from individuals capable of providing only first aid to those trained and licensed to provide ALS. All EMS personnel, whether basic emergency medical technicians (EMTs) or paramedics, receive some training in pediatric emergencies; however, pediatric cases constitute approximately 10% of all EMS transports.

First responders may be law enforcement officers or firefighters, who are dispatched to provide emergency medical assistance, or bystanders. Public safety personnel have a minimum of 40 hr of training in first aid and CPR. Their role is to provide rapid response and stabilization pending the arrival of more highly trained personnel. In some smaller communities, this may be the only prehospital emergency medical response available.

In the United States the bulk of emergency medical response is provided by EMTs, who may be volunteers or paid professionals. Basic EMTs may staff an ambulance after undergoing a training program of approximately 100 hr. They are licensed to provide BLS services but may receive further training in some jurisdictions to expand their scope of practice to include intravenous catheter placement and fluid administration, management of airway adjuncts, and use of an automated external defibrillator (AED).

Paramedics, or EMT-Ps, represent the highest level of EMT response, with medical training and supervised field experience of approximately 1,000 hr. Paramedic skills include advanced airway management, including endotracheal intubation; placement of peripheral, central, or intraosseous lines; intravenous administration of drugs; administration of nebulized aerosols; needle thoracostomy; and cardioversion and defibrillation. These professionals provide ALS services, functioning out of an ambulance equipped as a mobile intensive care unit (ICU). In the joint policy statement Equipment for Ground Ambulances , the AAP, ACEP, American College of Surgeons Committee on Trauma, EMSC, ENA, National Association of EMS Physicians, and National Association of EMS Officials have published guideline standards for essential ambulance equipment, medications, and supplies necessary to provide BLS and ALS care across the age spectrum. This essential equipment list represents one of the reference standards that the federal EMSC program has adopted as a performance measure for state-level operational readiness to care for children in an EMS system.

Both basic EMTs and paramedics function under the delegated licensing authority of a supervisory EMS medical director. This physician oversight of prehospital practice is broadly characterized under the umbrella term medical control. Direct , or online , medical control refers to medical direction either at the scene or in real time via voice or video transmission. Indirect , or offline , medical control refers to the administering of medical direction before and after the provision of care. Offline activities, such as provider education and training, protocol development, and medical leadership of quality assurance/quality improvement programs, represent areas in need of greater pediatric input. As a measure of the degree to which EMSC permanence is being established in state EMS systems, the federal EMSC program has required demonstration of participation in online and offline medical direction activities for pediatric patients and the presence of an EMSC advisory committee at the state level. These advisory bodies are well positioned to support EMS agencies in their pediatric readiness as well as provide a forum for the active engagement of pediatric care experts at a system level.

Destination Determination

The destination to which a pediatric patient is transported may be defined by parental preference, provider preference, or jurisdictional protocol, which is typically predicated on field assessment of anatomic and physiologic criteria and, in the case of trauma, mechanism of injury. In communities served by an organized trauma or regionalized EMS system that incorporates pediatric designation based on objectively verified hospital capabilities, seriously ill or injured children may be triaged by protocol to the highest-level center reachable within a reasonable amount of time. The mantra is to deliver the child to the right care in the right time , even if it requires bypassing closer hospitals. An exception is the child in full cardiorespiratory arrest, for whom expeditious transport to the nearest facility is always warranted.

Regionalization in the context of EMS is defined as a geographically organized system of services that ensures access to care at a level appropriate to patient needs while maintaining efficient use of available resources. This system concept is especially germane in the care of children, given the relative scarcity of facilities capable of managing the full range and scope of pediatric conditions ( Fig. 79.2 ). Regionalized systems of care coordinated with emergency medical dispatch, field triage, and EMS transport have demonstrated efficacy in improving outcomes for pediatric trauma patients, especially for younger children and for children with isolated head injury. Emerging evidence also suggests a similar benefit conferred to children in shock identified in the field who are preferentially transported to hospital EDs with documented pediatric ALS capability. The existence of statewide or regional standardized systems that formally recognize hospitals able to stabilize and/or manage pediatric medical emergencies is another federal EMSC performance measure against which operational capacity to provide optimal pediatric emergency care in the United States is currently being evaluated.

In communities that do not have a hospital with the equipment and personnel resources to provide definitive pediatric inpatient care, interfacility transport of a child to a regional center should be undertaken after initial stabilization (see Chapter 79.1 ).

Disaster Preparedness

Throughout a catastrophic event, natural or human-made, several unique factors place children at disproportionate, increased risk. During an average workday, an estimated 69 million U.S. children are separated from their families, in schools and childcare centers, where mass casualty events can easily occur. This separation adds the additional challenge of safe and timely reunification of children with family during or after an incident. Furthermore, in the event of a biologic, chemical, or radionuclear attack, unique anatomic, developmental, and physiologic features make children especially vulnerable to absorption, ingestion, or inhalation of toxic agents and related morbidity and mortality.

Similar to day-to-day emergency readiness for ill and injured children, pediatric disaster preparedness requires advance considerations of the unique vulnerabilities and needs of children within planning, and exercises, at local, state, regional and even national levels. Pediatric planning considerations include training of first responders and other care providers, patient triage, decontamination, surge capacity and capability, medical countermeasures (medications, vaccines, equipment, supplies), evacuation, transport, sheltering, and family reunification. Planning for children should occur at all levels of the healthcare system, including the medical home, urgent care centers, EMS, acute care hospitals, pediatric tertiary hospitals, alternate care facilities, and rehabilitation services. While the NPRP noted meaningful progress in day-to-day emergency readiness, no improvement was found in disaster preparations, with less than half of U.S. hospitals having a disaster plan addressing the needs of children. Beyond acute medical treatment needs, pediatric planning must also consider the typically broad mental and behavioral health impact disasters have on children and families. Pediatric plans must also be in place for locations where children congregate, such as schools and childcare.

At the local, state, or regional level, healthcare coalitions have been identified as an optimal forum for disaster planning; core participants should include local or state public health departments, emergency management authorities, EMS agencies, and hospitals. Many other key stakeholder groups should be involved in coalition planning, such as healthcare professional organizations. To ensure that the needs of children are effectively considered, it has been recommended that disaster planning at all levels include pediatric subject matter experts. Pediatricians are an obvious source for this expertise and are also uniquely positioned to educate families about emergency readiness, particularly families with special needs children. The presence of an intact medical home during a public health emergency, and after a disaster has occurred, will contribute enormously toward response, recovery, and community resiliency. Lastly, community practice and healthcare system readiness and resiliency begin with personal readiness planning engaged by healthcare providers and support staff.

The AAP's Children and Disasters website *

* https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/default.aspx .

contains toolkits, checklists and other resources pertinent to pediatric readiness within the community, schools, the medical home, and hospitals; educational materials are also available for families. Reliable information and excellent disaster readiness resources may also located on the websites of the EMSC Innovation and Improvement Center ( https://emscimprovement.center ), U.S. Centers for Disease Control and Prevention ( https://emergency.cdc.gov ), U.S. Department of Health and Human Services ( https://www.phe.gov/preparedness/Pages/default.aspx ), and U.S. Federal Emergency Management Agency ( https://www.fema.gov ).