I've written here before about speaking at the International Emergency Catastrophe Management (IECM) Conference & Exhibition in Dubai, United Arab Emirates("Report from Dubai: EMS in a Developing Nation"). I got to do it again this year, and once again it was a very successful meeting. More and more people not just from the Middle East but also all over the world are coming to this meeting, which shows because the exhibition space is growing exponentially. It's a very large group that combines three conferences on emergency medicine, EMS, and critical care and disaster response into one meeting. At intervals I sat next to EMS personnel, nurses and disaster-relief specialists.
One of the reasons I like attending IECM is also that when Dr. Moin Fikree invites me, he has already decided what he'd like me to discuss. Rather than asking me to pull something out of my box of lectures, he gives me topics he'd like to have presented. This pushes me to dig into the research on topics I may not have done before, or at least not recently.
This year, one of my assigned topics was prehospital pediatric care. Haven't done one on this specifically in a while, so I started digging through the literature. As often is the case, I had some preconceived notions of what I would find and was surprised to learn some things. I'd like to share some of the research I discussed, because I believe they're things that will affect planning and care in our near future.
Pain assessment and management
The first thing I came across were several papers on pain assessment and management of pediatric patients in the field. We know that when asked what scares prehospital providers, many of them will say, "Working on kids." These papers pointed out that we have a way to go in our protocols and practice of caring for children in pain.
The first, "Prehospital pain assessment in pediatric trauma," was a study conducted by Izsak E, Moore JL, Stringfellow K, et al. at the Toledo Hospital; Toledo Children's Hospital in Toledo, Ohio. Published in the April-June 2008 issue of Prehospital Emergency Care, the authors reviewed 696 patient charts and found pain was noted in 64.1% of the patients, "no pain" was noted in 17.2% and pain was undocumented in 18.7% of the patients. Only one chart had a documented validated pain assessment, and there no pain interventions were documented in 86.6% of the patients.
In this study they concluded, "hese results identify a void in the documentation of pain assessment and implementation of pain-control interventions for injured pediatric patients. Education for prehospital providers is recommended, emphasizing the importance of pain assessment and documentation of pain-control care for pediatric trauma patients."
Another study "Prehospital pain management in children suffering traumatic injury" by Swor R, McEachin CM, Seguin D, et al. looked specifically at pediatric pain management in the field. The authors concluded in the January-March 2005 issue of Prehospital Emergency Care that, "few pediatric patients receive prehospital analgesia, although most ultimately received ED analgesia. Few factors were identified that could be associated with EMS oligoanalgesia. No difference was found between children and adults in the rates of EMS analgesia."
In yet another study on this topic -- "Prehospital pain management: a comparison of providers' perceptions and practices" published in the January-March 2005 Prehospital Emergency Care --Hennes H, Kim MK and Pirrallo RG concluded that "Significant disparity exists between EMT-Ps' perceptions of acute pain assessment and the frequency of providing analgesia and their actual practice. Children and adolescents had less documentation of pain assessment and received less analgesic interventions compared with adults. Inability to assess pain may be an important barrier to the provision of analgesia."
At the end of the day, these studies point out that we aren't giving pediatric patients in pain the same level of treatment that we give to our adult patients. Surely a variety of reasons exist for this disparity. Other studies talk about the fact that there may be a link between the number of patients we see and our ability to deliver the skills they need us to have. Perhaps our experience with pediatric patients needs to be augmented with training to ensure a better comfort level in evaluating and managing pain in pediatric patients. Protocol development, evaluation of practice and adherence to protocols along with outcome evaluations of this part of our population may assist us in bringing the level of care of our younger patients up to the level of care provided to our adult patients.
I've got more to say about pediatric patients in mass casualty situations, pediatric patients safety, mechanism of injury and outcomes and paramedic determination of non-transport in pediatric patients. I'll continue to share what I learned about pediatric trauma patients in next months' column.