Children account for approximately 10% of the total patients treated by prehospital providers, thus making it difficult for prehospital providers to maintain and reinforce life-saving pediatric assessment and management skills.
Prehospital care consists of either basic or advanced life support. Basic life support (BLS) is provided by emergency medical responders (EMRs) and emergency medical technicians (EMTs), while advanced emergency medical technicians (AEMTs) and paramedics provide advanced life support (ALS) care.
Rural emergency medical service (EMS) providers face many challenges when caring for children. They have longer transport times and care for fewer children in general, limiting pediatric-specific skills retention.
Prehospital protocols are developed and approved by EMS medical directors, are limited by a paucity of prehospital literature, and should be linked to provider education, performance metrics, and quality improvement strategies.
Standardized ambulance equipment checklists addressing the specific needs of children have been derived under a collaborative effort of multiple stakeholder organizations.
Offline, or indirect, medical oversight involves the development, implementation, monitoring, and iterative improvement of medical policies and protocols used by field personnel. Online, or direct, medical oversight is the provision of real-time medical direction to field personnel by a medical director or his/her delegate.
Regionalization is the geographical organization of services, including transport, to ensure access to care at a level appropriate to patient needs while maintaining efficient use of available resources and avoiding redundant emergency department (ED) care. It has improved outcomes for certain conditions (e.g., trauma, burns, stroke, and pediatric critical care).
Emergency care without parental consent can be provided regardless of age. Although minors cannot refuse treatment and transport in an emergency situation, if a legal guardian is present, he/she can make an informed decision to refuse transport; refusal of EMS care for children occurs in about 5% of all EMS runs.
For EMS providers interacting with children with end-of-life issues, signed Do Not Resuscitate (DNR) orders must be present in written form, acknowledged verbally by the family as still active, identified as belonging to the patient, and must occur in a state that includes children in DNR laws.
HISTORY AND PEDIATRIC CONSIDERATIONS IN EMS
The importance of prehospital care became evident after the Korean and Vietnam wars demonstrated that mortality decreased when patients were stabilized in the field and transported expediently to a well-equipped emergency facility.1 EMS systems were formally established in the United States in 1966 when the National Highway Traffic Safety Act mandated that states develop EMS systems. Direct funding for these systems became available when Congress passed the Emergency Medical Services Act in 1973.2 With its origins in the military and its civilian focus on cardiac and trauma care, the nation’s EMS systems were slow to consider the needs of children. In 1984, the federal government recognized this need by approving legislation for the creation of the EMS for Children (EMSC) program in the Health Resources and Services Administration’s Maternal Child Health Bureau of the Department of Health and Human Services.2 The goal of the EMSC program is to reduce child and youth mortality and morbidity sustained as a result of severe illness or trauma and to be fully integrated along the continuum of emergency care in the existing EMS system.3 This continuum emphasizes the importance of the emergency response system prior to prehospital care, interfacility transport to definitive care, the rehabilitation process after injury or illness, and injury prevention initiatives.3
The EMSC Program has developed national performance measures to evaluate the operational capacity of hospitals and EMS agencies to provide pediatric emergency care through the availability of online and offline pediatric medical direction for EMS, essential pediatric equipment and supplies on ambulances, a Pediatric Emergency Care Coordinator (PECC) in every EMS agency, statewide data reporting to the National EMS Information Systems (NEMSIS) database, a method to verify provider competency in using pediatric-specific equipment, a hospital recognition system for pediatric medical and trauma facilities, and written pediatric interfacility transfer guidelines and agreements.4 Additional EMSC performance measures assess pediatric emergency education for the license and certification renewal of prehospital providers, the establishment of a permanent EMSC program in each state, and integration of EMSC priorities into existing state mandates.4
In 1993 the Institute of Medicine (IOM), now known as the National Academies of Science, Engineering and Medicine (NASEM), issued a landmark report on the state of EMS for children in prehospital- and hospital-based settings. It highlighted significant disparities between adult and pediatric emergency care and increased awareness about the unique needs of children during medical emergencies.2 In 2007, the IOM released three reports on the future of emergency care in the United States containing several recommendations with pediatric implications (Table 148-1).5–7
|IOM/NASEM Recommendations with Pediatric Implications5,6|
Pediatric calls account for approximately 10% of the total calls received by prehospital providers.8 As a result, EMS providers receive limited reinforcement of lifesaving pediatric assessment and treatment skills, making refresher training extremely important to maintain competencies.9,10 While most EMS calls are for children who have noncritical illnesses or injuries, wide variations across age groups in anatomy, physiology, cognition, and behavior make assessment and management of children more challenging than adult patients.8,11 For example, equipment size changes as children grow; thus, essential equipment must be available for all ages, ranging from infants to adolescents.12 Prehospital providers must be trained and able to recognize signs of physiologic compromise and must possess the skills to manage the cognitive and behavioral variations across differing pediatric age groups.12 One additional factor adding complexity to pediatric calls is the need to provide family-centered care in the prehospital setting, since a children’s complaints are most frequently relayed and interpreted by the caregiver.12
911 AND MEDICAL DISPATCH
Prior to 1968, when 9-1-1 was established as a universal emergency number, access to emergency services was scattered and uncoordinated.13 It was not until 1972, however, that the Federal Communications Commission (FCC) recommended that 911 technology be implemented nationally.13 Since then, 911 availability has become almost completely universal; nearly 99% of the US population now has access to 911–activated emergency services.1
All 911 calls are routed to Public Safety Answering Points (PSAPs), which are centers from where dispatchers can send the appropriate medical, fire, and/or law enforcement resources to the scene.1 Because of the origins of 911, 90% of dispatch centers are operated by law enforcement, whereas only 8% are operated by EMS agencies and 2% are operated by fire departments.13
In the past, callers had to provide the 911 operator with information on the nature of their emergency, their location, and a call-back number. The development of Enhanced 911 (E911) allows for the caller’s information, including location and telephone number, to be immediately available to the 911 dispatch operator to enhance timely dispatch, while the operator continues to obtain additional information that can be transmitted to the responding service already en route.2 The Wireless Communications and Public Safety Act of 1999, also known as the 911 Act, mandates that wireless providers transmit 911 calls directly to a PSAP regardless of whether the caller subscribes to the provider’s service.14 Phase I Enhanced 911 rules require cellular providers to provide PSAPs with the phone number of the caller and the location of the cell station transmitting the call, while Phase II E911 rules require providers to provide the latitude and longitude of the caller.14
Dispatch is one of the most important aspects of an EMS system, as it is the entry point to the system. Activation of an EMS system begins when the patient, caregiver, or other bystander identifies a need for emergency care.15 After a PSAP receives a call, a trained emergency medical dispatcher (EMD) determines whether BLS or ALS is required, using computerized algorithms or local dispatch protocols (based on the caller’s response to certain questions).15 The EMD confirms the caller’s location and dispatches the nearest EMS units capable of providing the appropriate level of care.16 Finally, the EMD provides pre-arrival instructions to the patient or bystanders, based on protocols approved by the EMS medical director.16 All aspects of dispatching are the ultimate responsibility of the EMS medical director, who oversees training, approval of dispatch protocols, the development of pre-arrival instructions, and quality improvement of EMDs within the EMS system.1
Based on the information provided by the caller, the dispatcher may send only a non-transporting EMR that can perform cardiopulmonary resuscitation (CPR) and use an automated external defibrillator (AED).17 In a tiered dispatch system, EMTs will respond to most calls to ensure a rapid response of a provider to the scene. In a tiered system, AEMTs or paramedics are dispatched only to specific cases in which ALS care is likely to be needed.15 Physician medical directors may be asked to respond to the scene as well.15 Uniform dispatch means the same level of personnel is dispatched to every call, which in some systems may be a combined response of both ALS and BLS units or ALS units only.15 In a combined response, paramedics will provide critical care while EMTs can begin to transport patients from the scene. Tiered dispatch systems decrease the need for more paramedics, which are difficult for some communities to support, especially rural ones.15 Tiered-dispatch systems appear to have no effect on prehospital survival rates compared to a uniform system that dispatches only paramedics.15
In 2013, the nomenclature for prehospital providers was standardized nationally to ensure consistency across states.1,18 The differences in provider types are shown in Table 148-2. There are two levels of response in the prehospital setting: BLS and ALS.18 EMRs, formerly known as first responders, and EMTs, formerly known as EMT-basics, can provide BLS care in the EMS system.18 EMRs receive approximately 40 hours of training, while EMTs typically receive between 120 and 150 hours.18 These providers receive training for scene response and initiation of basic life support such as CPR.18 Unlike EMRs, EMTs have the knowledge and skills to provide medical transportation; they make up the majority of the nation’s prehospital providers.18
|Learning Objectives/Scope of Practice||Training||Examples of Skills|
|Emergency medical responder (EMR)||To learn simple lifesaving interventions for critical patients||~ 40 hours|
Use of an automated external defibrillator (AED)
Cardiopulmonary resuscitation (CPR)
|Emergency medical technician (EMT)||To learn basic skills focused on the acute management and transportation of critical and emergent patients||120–150 hours|
Assist patients in taking their own medications
Administration of over-the-counter medications
|Advanced EMT||To learn basic skills, limited advanced skills, and some pharmacologic interventions focused on the acute management and transportation of critical and emergent patients||200–400 hours|
Peripheral intravenous (IV) access
Administration of nitroglycerin, glucagon, naloxone, 50% dextrose, IV fluids
Tracheobronchial suctioning of an already intubated patient
|Paramedic||Basic and advanced skills focused on the acute management and transportation of critical and emergent patients||>1000 hours|
Administration of numerous IV medications
AEMTs and Paramedics are both capable of providing ALS care, but to varying degrees.18 Approximately 7% of prehospital providers are Advanced EMTs, while 31% are paramedics.19 AEMTs were formerly known as either EMT-Intermediates, EMT-85s, or EMT-99s.18 AEMTs have approximately 120 to 200 hours of additional training beyond the EMT level to provide ALS care both on scene and during transport, including administration of intravenous medications.18 Paramedics, formerly known as EMT-Paramedics, are allied health professionals who have extensive training to enable them to provide ALS care to critically ill patients.18