The Problem: An Adult-Oriented Retrieval System Focused on Rapid Movement

Emergency medical services (EMS) and regional flight teams are focused on the major causes of mortality in the adult population, such as myocardial infarction and trauma, for which rapid transfer to a center that can provide definitive care is an important determinant of outcome.⁵ Adult-oriented ED and EMS services do not provide ideal care for children. Still, multidisciplinary teams transport the majority of critically ill children. Many argue that pediatric specialized transport systems are not necessary, for the reasons given in Box 14-1.

With the support of other interested bodies, the American Academy of Pediatrics recently issued a policy statement detailing the recommended pediatric equipment for ambulances.² It is not known what percentage of ambulances are adequately equipped, but two independent studies reported that as recently as 2003, only 6% of emergency rooms were appropriately equipped to care for children. Items frequently not available included laryngeal mask airways and infant and neonatal equipment.⁶

Limited pediatric training coupled with limited exposure to pediatric patients may hamper the ability of EMS providers to respond appropriately to pediatric emergencies. In 2000, nationally registered paramedics received a median 358 total hours of instruction, less than 5% of which were dedicated to pediatrics. Moreover, most paramedics in this study were not required to take pediatric continuing medical education (CME) training.⁷ Without repeated reinforcement, cognitive and interventional skills deteriorate over time. Fewer than 10% of all EMS runs nationwide are for infants and children, and a small percentage of these involve advanced life support (ALS) or critical care.^8,9 Babl et al.¹⁰ demonstrated that in a program with 50 active ALS providers, each provider is expected to have one pediatric bag-valve-mask (BVM) case every 1.7 years, one pediatric intubation every 3.3 years, and one intraosseus cannulation every 6.7 years. Su et al.¹¹ demonstrated that the knowledge acquired in didactic sessions deteriorates rapidly over a 6-month period. Henderson¹² also demonstrated that the ability of a provider to intubate or provide BVM ventilation for a child deteriorates significantly over the course of 6 months.

Underutilization of an acquired skill can lead to a decrement in skill level and a fear-related aversion to performing the procedure. With any given scenario in the EMS setting, adult patients are more likely to receive an appropriate intervention compared with a child having the same problem.^13,14 Prehospital care providers are reluctant to attempt intubation, even when it is clearly indicated. Aijian et al. examined a population of pediatric patients who had suffered a prehospital cardiopulmonary arrest and determined that endotracheal intubation was attempted only 68% of the time, with a success rate of only 64%.¹⁵ In patients younger than 1 year, endotracheal intubation was attempted only 38% of the time, with a success rate of only 50%.¹⁵ Multiple investigators have documented a decrease in the percent of successful intubations in children compared with adult patients, both in ground EMS systems and air ambulance systems.^16–19

Studies of pediatric trauma victims make it clear that prehospital providers could do a better job with children. Children were twice as likely to die of trauma in the field compared with adults, which was attributed to the lack of pediatric training.^5,8,20 Ramenofsky et al. determined that 53 of 100 deceased pediatric trauma victims in their study could have been salvaged given an optimally functioning emergency medical system and that in 79% of the potentially salvageable cases, mortality was associated with prehospital iatrogenic or secondary insults.⁹

Referring hospitals that lack pediatric expertise may create suboptimal situations prior to transport. Esposito et al. found that frequent errors occur in ED management of pediatric trauma, leading to preventable mortality of approximately 9%.²¹ In addition, they reported a 64% error rate in the management of children, including gross violations of basic trauma care.²¹ Han et al.²² found that resuscitation practice in a community ED was consistent with American College of Critical Care Medicine-Pediatric Advanced Life Support (ACCM-PALS) guidelines in only 30% of children who presented with septic shock. Athey et al.²³ found that nearly 10% of all U.S. hospitals without pediatric intensive care facilities admit critically ill and injured children, and that 7% of these hospitals routinely admit these children to adult intensive care units rather than transferring the children to a more appropriate facility. Of the facilities that keep children, few have protocols for obtaining pediatric consultation for emergencies, and most did not have appropriate-sized equipment to care for children.²³ Those referring hospitals that do transport children to pediatric facilities are often inadequately equipped to care for children or unfamiliar with established guidelines and protocols and, as a result, may be in a rush to send children, sacrificing stabilization and eschewing transport by a more experienced team in the interests of saving time. When facilities and physicians lack insight about their ability to care for children, requests for transfer may come too late, after irreparable organ damage has already occurred.

Rapid Transfer, Goal-Directed Therapy, and the Golden Hour

EMS and regional flight teams focused on adult experience work under the assumption that the time between the moment of injury and arrival at a center capable of delivering definitive care is among the most important determinants of survival. This “golden hour” is the driving force for clinical decision-making and usually translates into providing minimal care and moving quickly (Figure 14-1). The concept of the “golden hour” often is described as having its origin in a surgical commentary by Cowley et al.³³ on the success of implementing a helicopter-based program for trauma, during an era when prehospital care consisted of providing supplemental oxygen and a fast-moving vehicle. “Scoop and run” and the “golden hour” remain the prevailing philosophies in the transport of infants and children, few of whom benefit from the speed of transport alone.

Figure 14–1 Traditional model of emergency care based on the concept of the “golden hour.” ED, Emergency department; EMS, emergency medical services; PICU, pediatric intensive care unit.

There are a few disease processes, such as aneurysms requiring neurosurgical intervention or complete transposition of the great arteries requiring urgent atrial septostomy, in which rapid transport to a center that can provide definitive care is the most pressing issue. These are rarities. Respiratory insufficiency and shock are common reasons for referral of pediatric patients. A recent study identified shock in 37% of children transferred to tertiary centers regardless of the reason for referral.³⁴ It is increasingly recognized that rapid resuscitation is critical to the management of pediatric shock.³² In adults and children, protocolized, aggressive, early therapy of septic shock has proven vastly more effective than any pharmacological intervention.^2,22,34,35 Aggressive fluid resuscitation and initiation of inotropes and antibiotics should be accomplished within the first hour after presentation. In adults with septic shock, a delay in antibiotic therapy is associated with worse survival, with mortality increasing by 7% for every 30 minutes that passes without delivery of appropriate antibiotic therapy.³

The American College of Critical Care Medicine (ACCM) clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock are divided into specific tasks to be accomplished in the first 5 minutes, the first 15 minutes, and the first hour. The recommended treatments are simple interventions that can be initiated in community EDs and continued and refined in transport, provided that the treating physician and transferring team appreciate the urgent need and are sensitive to the subtle signs of shock in children. Han et al. reported that when community physicians aggressively resuscitated and successfully reversed shock before a transport team arrived, patients had a ninefold increase in their odds of survival.²² These studies defy the popular notion that out-of-hospital stabilization “wastes time” and “delays” definitive therapy that should be rendered at the receiving facility. Initiating treatment in the referring facility to the best of the institution’s ability and bringing skilled transport personnel to the child rather than transporting the child with inadequately skilled personnel may markedly decrease the time to effective treatment.