Of all the calls EMS providers respond to, only 10% are for pediatric patients.1 For most responders this is often a relief because pediatric calls are challenging and stressful. That relief, however, is rooted in a lack of knowledge and inability to care for this population of patients.
Most often, EMS providers care for pediatric patients in the setting of trauma–medical calls are far less common. However, when they do occur, these patients typically have a higher acuity of illness than adults with similar presentation. This demonstrates the necessity for the provider to be able to care for pediatric patients safely and in a timely manner.
For most EMS providers, their exposure to pediatric patients is infrequent and, as a result, their skill set for this population is often underdeveloped. All of these factors frequently result in poor care provided to children in the prehospital setting.2
The way to resolve this is through education, beginning with initial training and reinforcement and moving to continuing education for the duration of the provider’s career.
The purpose of this article is to bring awareness to this potential deficiency in prehospital care, and identify ways to improve education and provider knowledge retention. Addressing these potential weaknesses in your system will improve the confidence of your providers and, subsequently, the care rendered to this patient population.
The Problem Begins
There’s currently no minimum required number of hours during initial education that must be presented to EMTs or paramedics specifically on the care of pediatric patients. EMT programs usually range from 110—140 hours of didactic teaching, of which an average of just three hours is spent on pediatric care. Paramedic programs average 8—15 hours devoted to the pediatric population, but there are some programs that don’t devote any time to teaching about the pediatric population.3
In programs that offer pediatric education, providers are expected to learn about pediatric anatomy and the specifics of how pediatrics differ from adult patients. Curriculums also often include the most commonly encountered medical problems with pediatric patients, how to care for pediatric patients in the medical and trauma settings, how to care for pediatric patients with special needs, and advanced skills specific to these patients, which often includes interventions like intubation, obtaining peripheral access and administering medications.4
During this scant amount of training, the provider is also expected to realize the emotional component of caring for a pediatric patient. Providers often find this population more emotionally difficult to care for, and encounters with pediatric patients can have lasting effects on the provider.
Of course, the actual impact of caring for pediatric patients can’t be fully comprehended until the provider is faced with treating one. Therefore, it’s important to address this topic in an effort to make providers aware of this phenomenon.
Issues with Interventions
The most common interventions found to be given inadequately to pediatric patients include obtaining IV and intraosseous (IO) access, intubation and administration of medications. This is partly due to the infrequent nature with which the provider practices these skills, but is also due to inadequate training during their prehospital education.5,6
Practice is required for maintenance of skills, and if the provider isn’t competent to perform the intervention initially, how can they be expected to perform it correctly in the field?
Studies have shown there are consistently more attempts at intubation for pediatric patients than for adult patients.6 This intubation deficiency can be attributed to lack of frequency as well as the provider’s unfamiliarity with the anatomy of a pediatric patient and how intubation differs for this population.
The ability to recognize pain in pediatric patients, particularly the very young who can’t speak or converse well, is a skill that can only be acquired through comprehensive education about pediatric anatomy, physiology, body mechanics, and specifically how these are interrupted by various types of trauma.7
This directly impacts the provider’s management and administration of medications in the field. Amazingly, on average, pediatric patients receive the correct dosage of medications just 50% of the time.7 This is because most pediatric medications are weight-based and providers are frequently not comfortable performing these calculations. It’s also critical to recognize the harmful side effects of patient overdose in these smaller patients.
Another shocking fact is that research has shown the death rate of pediatric patients in the ED who received prehospital care is almost twice that of adults.6,7
This staggering statistic should cause prehospital providers, their clinical supervisors and medical directors to focus on and consider what can be done to better educate their providers to serve this population.
Using simulation allows the opportunity to practice interventions to an exact scale in a safe environment. Photo courtesy Laerdal Medical
Continuing Education
In addition to inadequate education during initial training, there’s no continuing education requirement specific to pediatric patients or interventions.8 This means a provider could potentially work their entire career without having to refresh their knowledge of pediatric patients and interventions.
This fact illuminates the need for advanced preparation of EMTs and paramedics to properly care for this small patient population. There are educational opportunities, separate from initial training, available to EMS providers specifically about prehospital treatment of pediatric patients. Some of the more popular programs include Pediatric Education for Pre-hospital Professionals and Pediatric Advanced Life Support.
These courses are great options for refreshing knowledge and skills; however, it must be again pointed out that the fundamental principles for treating this population should be learned during initial training. Furthermore, these classes often have to be sought out by the provider and usually represent an added expense above initial training costs.
Possible Solutions
Currently, continuing education requirements are set up such that providers must have medical and trauma education. It’s reasonable to suggest that pediatric care be included somewhere in these credits.
Since 10% of all calls are for pediatrics, it may be sufficient that 10% of continuing education credits be specific to this population of patients.
Online education has proven to be one satisfactory method to refresh EMS provider knowledge and awareness of situations involving these patients.9,10 This model of education would benefit providers, in addition to other hands-on practical experience and education about pediatric patients.
Overall, during initial training, more hours of education need to be devoted to prehospital care of the pediatric population. Because this population is so complex and the range of differences in anatomy and physiology between certain age groups can affect interventions universally given to pediatric patients by EMS providers, it’s valuable to highlight different pediatric age groups and adjust the curriculum accordingly. This may include separating topics by age into the following sections:
>> Infant, 0—12 months;
>> Toddler, 1—3 years;
>> Preschool, 3—5 years;
>> Grade school, 5—12 years; and
>> Teen, 12—18 years.
The different disease processes and pathophysiology of these diseases should be incorporated into curriculum as well. A brief list of important diseases for the pediatric population includes: respiratory disease (e.g., pertussis, pneumonia, asthma, cystic fibrosis), common childhood infectious diseases, seizure disorders (including febrile seizures), epiglottitis; foreign body ingestion and choking.
These areas should be addressed in addition to topics about pediatric trauma, the most common mechanism of injury providers see when caring for pediatric patients.
It’s also important to recognize the inability of these patients to provide an adequate patient history. This illustrates the need for providers’ physical exam skills to be specific to the age of their patient and incorporate with scene size-up and mechanism of injury information gathered on arrival at an incident.
Other specific areas where educators should incorporate more hands-on practice through use of different teaching models include the areas where providers are consistently deficient: obtaining peripheral access through IV or IO, pediatric CPR, intubation, pain control and medication calculations.
The Value of Simulation
Another way to improve pediatric skills is through the incorporation of mock and simulated practical situations involving children. One way this can be accomplished is through practical skills days during which children come and afford providers the opportunity to practice full assessments and physical exams on actual pediatric “patients.”
Using mock patients can assist providers in becoming familiar with the varying attributes of pediatric patients, including their physical differences and developmental stages. For instance, practicing interventions and assessments, like vital signs, on a healthy pediatric patient can help the provider recognize what’s normal in this population so that they can apply this to future patients.
Simulation training has also been proven to be a highly effective method for teaching important facts, care principles and procedures essential to properly assess and treat pediatric patients. Increasing the amount of simulation time spent on pediatric scenarios for varying age groups can help sharpen providers’ knowledge and improve their ability to deliver interventions specific to children.
Simulation gives providers the opportunity to practice interventions to an exact scale in a safe environment, with the added benefit of repeating a scenario when mistakes are made without adversely affecting the patient. These situations also allow for team building and practicing the “pit crew” approach for the delivery of critical care, each of which are vital when caring for this population.
The ability of a crew to work together as a team and work in a pre-assigned and practiced manner furthers the care and success of interventions provided to the patient as well as the efficiency of the care.
Another benefit to simulation is post-review assessment of outcomes once the scenario is over. This allows for reflection on the situation, problems, areas of improvement and emotional effect to the provider in an effort to improve during future encounters.
Conclusion
The goal for all EMS providers should be to adequately assess, provide necessary interventions in the prehospital setting and deliver the patient to definitive care regardless of age. This is a more difficult task with a pediatric patient for many reasons, but the lack of education and opportunities to practice interventions are variables that can be altered to allow for increased knowledge and comfort of providers, translating into better care and outcomes for this population of patients.
References
1. Joyce SM, Brown DE, Nelson EA. Epidemiology of pediatric EMS practice: A multistate analysis. Prehosp Disaster Med. 1996;11(3):180—197.
2. Seid T, Ramaiah R, Grabinsky A. Pre-hospital care of pediatric patients with trauma. Int J Crit Illn Inj Sci. 2012;2(3):114—120.
3. Seidel JS. Emergency medical services and the pediatric patient: Are the needs being met? II. Training and equipping emergency medical services providers for pediatric emergencies. Pediatrics. 1986;78(5):808—812.
4. United States Department of Transportation. (1998.) Emergency medical technician-Paramedic national standard curriculum. Retrieved Feb. 17, 2015, from www.ems.gov/EducationStandards.htm.
5. Al-Anazi AF. (2012). Pediatric emergency medical services and their drawbacks. J Emerg Trauma Shock. 2012;5(3):220—227.
6. Paul TR, Marias M, Pons PT, et al. Adult versus pediatric prehospital trauma care: Is there a difference? J Trauma. 1999;47(3):455—459.
7. Greenwald M. Analgesia for the pediatric trauma patient: Primum non nocere? Clin Pediatr Emerg Med. 2010;11(1):28—40.
8. Zaveri PP, Agrawal D. Pediatric education and training of prehospital providers: A critical analysis. Clin Pediatr Emerg Med. 2006;7(2):114—120.
9. Warren L, Sapien R, Fullerton-Gleason L. Is online pediatric continuing education effective in a rural state? Prehosp Emerg Care. 2008;12(4):498—502.
10. Fleischman RJ, Yarris LM, Curry MT, et al. Pediatric educational needs assessment for urban and rural emergency medical technicians. Pediatr Emerg Care. 2011;27(12):1130—1135.
This article is sponsored by Laerdal Medical. For tools and resources to help you effectively assess, plan and implement your simulation training program visit www.laerdal.com/GTF.
