I'm not really into conspiracy theories. I feel fairly certain it was not a right-wing plot that led Monica Lewinsky into the Oval Office, nor was it a leftist movement that caused the government to raid the Branch Davidians. (I think it was because they shot at a U.S. Marshal). I don't believe the Bush administration is full of conspiracies. A conspiracy means that you try to hide what's actually going on, and the current crew doesn't even make an attempt to conceal its disdain for common sense. But as EMS providers and emergency caregivers, I believe that you and I have bought into one of the most dangerous cabals the world has ever known. Here's the name of this devious plot:
Kids Aren't Little Adults
Huh? This well-known, oft-cited mantra is a conspiracy? A plot to undermine what we do and those we serve? You bet.
Let's step back for a moment. Like a lot of things in EMS, at first glance, the line makes sense. We all want the best for kids. That's why we take them to specialists like pediatricians and why pediatricians stress how unique kids are. And they are unique: You can't talk to them like an adult; they don't understand. They get scared and cry, and your heart goes out to them. And, well they're just so tiny. The idea that kids aren't little adults was intended to remind us of the uniqueness of children and our need to render the best care we can for this most precious resource. But as the saying goes, good intentions pave the road leading to the River Styx. (In case you're stuck in the 80s, this is the original Styx, not the ones speaking Japanese to Mr. Roboto.)
The end result of being told that kids aren't little adults is that it takes us out of our comfort zone and we get scared. We start to believe that we can't take care of kids and that the only ones who can are pediatric physicians, nurses and transport teams. We think of ourselves as pretenders who can never hope to provide adequate care and that prehospital care for children is an all-or-none phenomena. When our pediatric colleagues sense our fear, they redouble their efforts to help. But these well-meaning efforts only reinforce the differences between kids and adults, enhancing the fear within the field provider.
I would argue that in the EMS setting, kids are adults. Children and adults share the same priorities in the field. Children represent just another type of patient, not creatures from an alien world. It's my belief that emphasizing the commonalities of care rather than the differences is our best hope for improving prehospital pediatric care.
Let's start by looking at the priorities of care. The care of the adult patient progresses through assessment and management of the ABCs (airway, breathing and circulation). I've never seen any evidence or advice that this priority is any different for children. In fact, it may be even more true. Given the predominance of respiratory problems in the etiology of critical pediatric illness, one could make the argument that the sequence in children should be AAABBC (airway, airway, airway you get the picture). But we're still in alphabetical order. Nowhere in this sequence of events are those differences that are constantly hammered into our brains. Nowhere do we see anything about equipment size, drug dosing or psychosocial needs.
This is not to say that there are no differences between children and adults. The anatomy of a child's airway varies from that of an adult. The epiglottis is "floppier," there is a subglottic narrowing, the tongue is relatively larger and head positioning differs. But the airway of an obese, short-necked adult is also different from the norm, as is the airway of an elderly, kyphotic, bedridden nursing home patient. The management of the medical airway differs from that of the traumatic airway. Kids simply represent an additional group of considerations with adult parallels.
The same is true if we look at vital signs. Vital signs in children and are age-dependent, but we already know that many adult patients will have "normally" altered vital signs (e.g., the gravid female will be "relatively" hypotensive). Fluid management is slightly different, but there are differences now in fluid management between groups of adult patients (fluid management for a GI bleed differs from that of a patient in congestive heart failure, and we're still learning about fluids in trauma). While there are differences in equipment size and drug dosing, we already have to select appropriate IV catheter, laryngoscope blade and endotracheal tube sizes in adults.
We also currently dose many adult drugs on a mg/kg basis; it's not a stretch to use the same formulas on kids. Children do have less effective thermoregulatory systems, and warmth is a priority, but it also is for burn victims or those with environmental illness. Psychosocial dynamics? It's true that children live in a different mental world and require careful handling, a gentle touch, lots of comfort and love. But so do many of the patients we serve who can't understand why we do what we do for them.
Yes, kids are different, but they are no different than any of the other groups we serve. If we can perform well when recognizing the differences between these adult groups, nothing inherently stops us from applying the same philosophy to children.
What does the literature tell us about how EMS performs with children? Recent studies have noted paramedic performance in pediatric care to be less than optimal.
Paramedics have a general discomfort with pediatric procedures and exhibit a reluctance to perform complete pediatric assessments. (Do you take a blood pressure on every pediatric patient? I didn't think so.) One work noted that nearly 80 percent of potentially salvageable pediatric trauma cases die because of prehospital error. Many of us are familiar with the Los Angeles study of a few years back that questioned the ability of paramedics to intubate children.
But all these reports share the same belief in training as key to resolving these problems. I'd contend that a major reason current training is inadequate is because focusing on the differences between adults and children reinforces the perception of incompetence. The focus of prehospital pediatric education needs to change. Our curriculum cannot be centered around the differences between adults and children, but must hone in on their similarities.
Some years ago, I was at a lecture where it was suggested that what was really needed was a separate EMS system for children. Given the state of the economy and the constant pressure to fund current EMS programs, I'm not holding my breath waiting. But even if such funding and staff magically appear, how does it work logistically? Where do we cut off child from adult? A big 12-year-old, or a small 18? A 16-year-old emancipated minor with a child? Patients with special needs no matter what age? How do we distinguish children from neonates (whose unique physiology, I will grant, truly places them in a different class). The system gets very messy very fast. In a sense, the logistical problems inherent in a distinct pediatric EMS system reinforce the ability of paramedics to care for all types of patients. If a pediatric EMS worker can care for both a 4-year old "child" and a 16-year-old "adult," why can't an "adult" paramedic do the same?
I like to use an automotive analogy to describe the results of this paradigm shift. Pediatricians and pediatric nurses involved in EMS are like a small cadre of BMWs. There's not a lot of them around, and they're usually not there when you need them. The rest of us are Yugos, trying to get up to speed, knowing we're going nowhere fast, frightened by the Beemers as they go speeding by. But if we change our thought process to consider children as little adults, the fear factor goes away. Now we can all be Chevrolets. We'll never be the fanciest car on the road, and we'll always be missing a few bells and whistles. But we'll be good enough to get the job done.
So how do we trade up to this year's model? First, we need the pediatric community to come down (or up, depending on your opinion) to our level. They need to accept that others can provide optimal prehospital pediatric care and that the prehospital environment often necessitates a change in approach. For our part, we need to recognize their cutting-edge expertise as a guide to refining our own practice in the field. We all need to work from the same model of care and to key our training to the similarities children share with adults rather than to the differences. Finally, we need to collectively maintain the viability of pediatric specialty transport teams to serve as a resource for those complex cases that are truly unsafe for transfer by an ALS ambulance crew.I've given a version of this column as a talk at a few meetings. It's a lot of fun when it's done in a "point-counterpoint" fashion with a pediatrician. In the end, the audience applauds politely for us both. That's how it should be. No matter which side you think is right, debate is a good thing when it promotes and enhances care. But on the way out the door, usually one or two folks come up to me and say, "You know, I always thought that I never heard anybody say it before." Just like the Warren Report. I love it when a plan comes together.