Transporting children in ambulances presents unique challenges that EMS providers face every day. Issues like the correct use of safety equipment, performance of life-saving procedures like CPR, and the absence of universal standards can make pediatric care in emergency settings more difficult than necessary.
Dr. Nick Cochran-Caggiano, an emergency physician and researcher, has taken a deep look into these challenges through two pivotal studies that every EMS worker should know about. Both studies were discussed on the latest podcast episode of “EMS Research with Professor Bram.”
The Unsafe Reality of Pediatric Transport in Ambulances
One of Dr. Cochran-Caggiano’s studies, published in Pediatric Emergency Care (2023), examined how children are secured during ambulance transport. The study reviewed over 3,000 cases by observing video footage of ambulances arriving at a pediatric emergency department. The findings reveal a troubling reality:
- Just 53.5% of children were transported using the correct safety device for their weight.
- A staggering 77.1% of transport restraints were not used properly, putting children at significant risk.
- Commercially made pediatric restraints were found to be the best option, yet these were still improperly used half the time.
- For many patients, ambulance cots were the default method of transport, but this was only the correct choice in 18.2% of cases.
Dr. Cochran-Caggiano shared his thoughts on this alarming data during a recent interview, emphasizing that the absence of consistent safety standards puts children at unnecessary risk. “Having some sort of ability to transport children safely is a must,” he said. He also pointed out the pitfalls of the current patchwork approach to pediatric safety in EMS. “There’s no appropriate way to secure [a child’s car seat] to an ambulance stretcher. You can make a good faith effort, but that’s really all it is.”
Why This Matters
Improper restraint practices don’t just violate safety protocols—they create scenarios where otherwise preventable injuries become inevitable. Reflecting on the need for systemic change, Dr. Cochran-Caggiano pushed for a proactive approach, stating, “Let’s make a difference before there’s a tragedy. It’s admirable to take sad stories and turn them into growth and change, but it’s even better if we can do that before the end.”
The study calls for federal safety standards to address these gaps. Currently, pediatric safety is regulated inconsistently at the state level, leading to wide variations in practice. Dr. Cochran-Caggiano noted that states with stricter requirements for pediatric transport generally perform better, but national standards are needed.
The Challenges of Performing CPR on the Move
The second study, published in Pediatric Emergency Care (2024), explored the challenges EMS providers face when performing CPR on pediatric patients during transport. Conducted using simulations in moving ambulances, the study presented stark findings for both children and infants:
- For children, there was no significant difference in CPR quality (rate, depth, or chest compressions) whether they were restrained or not.
- For infants, CPR was found to be inadequate across all scenarios. Ventilations fell below recommended levels, and slight differences in chest compression depth did not change the overall safety outcomes.
Dr. Cochran-Caggiano was candid about the implications of these findings, stating, “In motion, you can’t appropriately perform CPR.” The chaotic environment of a moving ambulance not only impacts the efficacy of critical interventions but also creates safety risks for EMS providers themselves.
One overlooked aspect, he noted, is that providers often put their own safety at risk to deliver care. “None of our providers felt safe doing this,” he said, even though the simulation was conducted at just 10 miles per hour on a closed track.
On-Scene Care Over Rapid Transport
This study underscores an important point for EMS workers to consider in their practice. While the instinct to “load and go” is often strong, transporting a pediatric patient without achieving Return of Spontaneous Circulation (ROSC) on scene is unlikely to improve outcomes.
Dr. Cochran-Caggiano explained this further: “The idea that you are making an aggressive move to the hospital because that is what is going to be the best outcome for the patient—that is just generally speaking, not the case.”
When ROSC is not achieved on scene, the likelihood of successful resuscitation in transit or upon arrival at the hospital is extremely low. Instead, the focus should be on providing effective interventions at the earliest possible moment, even if it means prolonged time on scene.
Moving Forward with Better Tools and Training
Both studies underline a critical need for better-designed restraint systems, improved training, and updated protocols. Dr. Cochran-Caggiano reflected on current options, saying, “Ultimately, I think the answer is something that doesn’t exist on the market yet.”
While devices like the Pedi-Mate or Neo-Mate are widely available and relatively easy to use, they are not sufficient for all pediatric patients and often leave dangerous gaps in age or weight compatibility.
He also emphasized infrastructure improvements that could enhance both safety and performance. “We need to finally get rid of the yoke system of securing stretchers,” he said, urging the adoption of safer mechanisms that keep stretchers locked into place during a crash.
Recommendations for Improvement
Based on the findings and Dr. Cochran-Caggiano’s expertise, these strategies can help paramedics improve pediatric outcomes:
- Adopt National Standards: Push for federal regulations that mandate proper pediatric restraint systems and training across all states and EMS providers.
- Improve Training: Ensure that all EMS workers practice using pediatric transport devices in realistic settings to improve proper usage rates.
- Focus on On-Scene Care: Shift priorities toward delivering comprehensive care on scene rather than relying on hospital transport for lifesaving interventions.
- Develop New Equipment: Advocate for product innovation to fill the gaps in current restraint systems and CPR devices.
For the full interview with Dr. Cochran-Caggiano you can see my interview with him on the latest episode of “EMS Research with Professor Bram” https://youtu.be/eYAbmIPkNwk
References
Cochran-Caggiano, N., Till, S., Holt, C., Lang, N., Ata, A., Cerone, J., & Dailey, M. W. (2023). Children and Restraints Study in Emergency Ambulance Transport: An Observational Study and Analysis of Current Pediatric Ambulance Transport Practices. Pediatric emergency care, 39(10), e66–e71.
Cochran-Caggiano, N., Tse, W., Swinburne, C., Lang, N., Till, S., Donovan, S., Woodson, M.C.C. and Dailey, M.W. (2024). Children and Restraints Study in Emergency Ambulance Transport-Cardiopulmonary Resuscitation (CARSEAT-CPR): An Observational Cohort Study of a Simulated Pediatric Cardiac Arrest. Pediatric Emergency Care, 10-1097.
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