Rethinking Pediatrics

If you met Peter Antevy, MD, at a party and asked him what he did for a living, chances are he would say, “I’m a pediatric emergency room doctor.” This answer is the equivalent of calling the Grand Canyon a “deep crater” or Niagara Falls a “waterfall.”

Board certified in pediatric emergency medicine, and medical director for multiple EMS agencies, two paramedic schools and a private ambulance company, Antevy has spent much of his professional life working for innovation and change in pediatric healthcare. He’s worked as a pediatric emergency physician at the Joe DiMaggio Children’s Hospital in Hollywood, Fla., since 2005, following six years of training at two top children’s hospitals, but still felt unprepared for his first resuscitation as a new attending physician.

“I felt inadequate because what we had been taught about resuscitation in my residency and fellowship didn’t work,” he said. Antevy, and others in the ED, struggled with how to administer the correct dosages of medication for children. The more resuscitations he performed, the more stressed he became. “Every resuscitation that came was worse for me,” he said.

He forged ahead, trying to calculate the correct dosage of epinephrine or dextrose for children in the midst of a medical crisis. One morning, Antevy sat down with eight common drugs in mind and created a spreadsheet. He calculated those doses for children and listed them as volumes.

“I figured out a system that was age-based and easily understandable to my brain,” he said. After he recognized the pattern of those drug calculations and could easily recall them under duress, he felt present and confident at every resuscitation.

For years Antevy used his system, never telling anyone what he was doing, until a pediatric nurse asked him one day after a resuscitation how he did it. How did he know all the drug dosages by heart? 

“I minimized what I was doing because I was embarrassed,” he said. “I thought everyone was supposed to know it.”

A few years later, Antevy gave a presentation on pediatric emergencies to 200 paramedics. In the presentation, he included two slides detailing his trick of calculating pediatric drug dosages.

“The lecture was over and I had 50 people line up,” he said. “They all wanted the last two slides of the presentation on drug dosages. I realized everyone wanted the information that I had been keeping to myself.”

Antevy shared what he knew about the eight drug calculations, but EMS agencies told him they had the same need for dosages of dozens
of drugs.

“The next step was to create customized information that every EMS agency uses,” he said. So, Antevy developed a Web-based software program that allows a user to correctly calculate any drug dosage for a child.

“In about 30 minutes, the user can create a customized pediatric medication book for their agency or hospital,” he said. “It’s a robust version of the same system I taught for years. It’s 100% customized and takes the math away from the paramedic during the resuscitation.”

In addition to the software and website, Antevy also created an educational video and “Badge Buddy,” which can be attached to an ID badge for quick reference. “The badge has all the ages and dosages on it,” he said. He doesn’t sell them; instead he gives them out to those who attend his lectures. So far, more than 15,000 people have one.

Antevy stresses that the system, including the badge, equipment and customized medication book, aren’t just widgets. It’s a program he teaches to entire EMS departments to help them understand there’s no difference in treating pediatric and adult patients. “That goes against what is taught in medical, nursing and paramedic schools.”

In his classes, Antevy taught students to remember the calculations by using their hands to remember ages and weights. Someone coined the memory device “the Handtevy Method,” which stuck.

He’s also integrated resuscitation psychology into the system by teaching a concept known as System 1 and System 2 thinking. System 1 is when the brain automatically comes up with an answer, whereas System 2 is when the brain has to stop and think in order to calculate the answer.

“Adult medicine is almost entirely a System 1 process,” he said. “Pediatric medicine, on the other hand, is predominantly System 2, and we have discovered a way to change it into System 1. What has happened is that paramedics and EMTs now see pediatric and adult patients the same. They don’t get nervous anymore. They stay and resuscitate on scene.”

Over the past two years, Antevy has helped more than 60 EMS agencies move to his system, along with major cruise lines and helicopter agencies. Premier hospital systems, such as the Cleveland Clinic, have also recognized the value the system gives to both its patients and providers.

The effects of Antevy’s innovative system on lives saved have been tremendous. He describes Broward County, Fla., as “the epicenter of drowning in the country” because of its high mortality statistics. He witnessed child after child die in the ED from a drowning, which left a deep impact. He wondered why the kids hadn’t been resuscitated on scene.

“We now mandate throughout Broward County that you’re not allowed to leave the scene unless you have given the child a chance to survive,” he said. “We mandate that EMS professionals stay on scene, provide the child with oxygen, compress the chest, and administer epinephrine, without just scooping and running to the hospital. This has helped us save a lot of lives.”

Antevy highlights a national study that he coauthored, which was presented at the National Association of EMS Physicians conference in January. Over 19 million run reports were queried and the data showed the rate of epinephrine administration in pediatric out-of-hospital cardiac arrest patients hovering around 38%.

“That means six out of 10 children in cardiac arrest did not get the maximal lifesaving treatment, which is astounding,” he said. “Now we give paramedics the tools, so they will stay on scene. They’ll be confident, they’ll know the drug dosage, and they’ll feel comfortable.”

Antevy is most proud of the changes in procedures his process has helped make with paramedics when it comes to pediatric medicine and resuscitation. “I can count many saves where kids have been dead on scene, and they’ve been brought back to life on scene, in front of mom and dad,” he said.

He emphasizes that the crux of this work goes far beyond properly resuscitating a child. The process is, in fact, a new way to train the brain. “It’s about teaching them why their brain wants to run and then giving them the tools to make their brain say, “˜I’ll stay,'” he said. “It’s about rearranging the tools that we provide to let their brain want to do the right thing. It’s a lot deeper than just memorizing a system. It’s a culture and mindset change.”

Antevy says that the importance of this can’t be overemphasized because of the long-term ramifications of a child’s death on the family. “When a child dies, it’s not just the death of the child, which is a major thing, but in many cases, it’s the death of the family. Parents get divorced and siblings develop major psychiatric problems. I’ve seen families completely dissolve over the death of a child.”

Antevy’s innovative resuscitation process has effectively prevented these family tragedies, where a prehospital provider saved a child on scene, instead of panicking and transporting without medical intervention. He uses a recent example of a 2-year-old child who drowned in Miami-Dade County as the kind of success he’s striving for across the country. “The paramedic stayed on scene and got the child back,” he said. “The child walked out of the hospital two weeks later completely neurologically intact.”

For the Broward County doctor, the idea “every child saved is a family saved” is central to his mission. His goal is to provide the tools and education that will empower EMS providers in understanding that pediatric and adult resuscitations are similar and should be approached accordingly.

Antevy, a self-described big kid himself, also sees himself protecting children, who are a vulnerable part of the population that too-often gets pushed aside in medicine. “I think it’s my role in life to give kids a voice in healthcare in whatever way I can,” he said. “It’s the legacy I’d like to leave.”

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