Understanding the psychology of prehospital pediatric emergencies
If possible, EMS providers should approach to a child slowly, and only one person should make the initial contact. Photos courtesy Harald Karutz
No matter what country or EMS system is involved, pediatric emergencies are relatively rare events for EMS providers.1,2 In addition to the difference in their presenting complaints and treatments, pediatric developmental and psychological aspects also differ from adult emergencies.
This article will present an overview of psychological factors that affect children, parents and EMS providers. The focus will be on children less than or equal to 10 years old, because cognition and understanding start to approach those of adults after age 10. The term “younger children” will be used to refer to children less than or equal to 6 years old.
No other differentiation along developmental stages will be presented in this article because this would usually require some form of developmental or psychological testing and may be unreliable in an emergency since regression to an earlier stage might occur.
Child’s Perspective
In contrast to adult patients, the majority of children have limited or no previous experience being injured or involved in an emergency. The situation therefore appears new, alien and unknown, and it’s therefore usually an intense experience.3
Knowledge and cognition: Children frequently lack an understanding of the structure and function of the human body, or have incorrect concepts of the role of organs and structures. This might lead to a misinterpretation of injury severity. For example, internal injuries might be interpreted as benign, while skin grazes/abrasions may be interpreted as life-threatening.4,5
The gap generated by a lack of understanding might be filled with irrational or “mythical” explanations, which can themselves lead to distress.
Younger children tend to take a more egocentric view and relate the situation to their own behavior, even when there’s no objective reason for this. This can lead to feelings of guilt. For example, a child might think that an accident occurred because they behaved badly.
Additionally, a child’s understanding is dominated by immediate awareness and is less focused on future gains; the idea that a painful procedure, such as gaining IV access, might lead to something positive in the future (e.g., analgesia) might be completely alien, particularly to younger children, and these procedures might instead be perceived as punishment.6
Younger children also lack a theory of mind and might not be able to change perspective or understand the intentions of the EMS provider. The latter might therefore be perceived as a stranger or intruder, and this might cause anxiety and distress.
Younger children in particular, still in the phases of language development, might not be able to adequately verbalize pain, negative emotions and worries, and these might be expressed through changes in behavior or facial expressions.
Younger children might also struggle to describe and localize pain as their body awareness is still developing.
Physiology: Due to their unique physiology, children are more sensitive to extreme temperatures and to fluid loss. Therefore, feeling hot, cold or thirsty can quickly contribute to their distress in an emergency.7
Movement: Children have a stronger need or urge to move about than adults. Their proprioception and spatial awareness, on the other hand, is less developed. The distress and arousal in an emergency can increase their urge to move.
Injuries that prevent movement, or the need to restrain a pediatric patient to conduct a diagnostic or therapeutic procedure, might therefore be experienced as particularly distressing. This can be particularly problematic as an increase in distress will lead to a stronger urge to move about, which could mean a greater amount of restraint is necessary.6
Sense of smell: Children often perceive smells as more intense than adults. New, unpleasant or pungent odors (e.g., skin disinfection or burns) can quickly lead to fear, headaches and nausea.
All these factors act together and can cause feelings of insecurity, fear and distress in pediatric emergencies. This creates a risk for long-term psychological harm.
The rate of post-traumatic stress disorder (PTSD) in children varies depending on the type of traumatic event and has been estimated at 15.9%.8 However, there’s considerable variability between studies and rates of up to 75% that have been reported in road accidents.9
EMS providers should know the special emotional needs of children in emergency situations, and they should offer appropriate psychological support.
Parents’ Perspective
Pediatric emergencies often lead to considerable distress not just for the child, but for the parents as well. The following factors can contribute to this.
Emotional bond: Most parents have a strong emotional bond with their children. Many parents’ hopes, dreams and goals in life relate directly to their children.10 This close bond can cause worries and fear in an emergency.
The urgency and extent of injuries might therefore be perceived as greater than they are in reality. Even minor injuries might occasionally be interpreted as life-threatening.
Guilt: Some parents develop feelings of guilt and might question whether they could have done something to prevent an accident or illness (e.g., by being more careful or monitoring their children more closely).10 This can place a considerable burden on parents’ well-being and coping.
Experience of EMS response: Parents often experience a certain ambivalence about the EMS response. On the one hand, parents might focus on the positive aspects of fast and professional medical treatment and procedures, giving them hope. On the other hand, some procedures, especially those perceived as painful, might increase fear and worries.3
Handing over care for their child into someone else’s hands might also be a stressor for some parents. Other factors might play a role as well; parents of a child who are illegal immigrants, for example, might fear being detected or reported to authorities if they call 9-1-1.11
The EMS Perspective
Pediatric emergencies are often considered to be distressing for EMS providers as well.
Parenthood: Parenthood is a contributing factor in how pediatric emergencies are perceived by EMS providers.12 Providers who are also parents might feel that a particular situation reminds them of their own children, especially when a pediatric patient is the same age as the provider’s own children or if they were injured while enjoying similar hobbies.13
In this case, providers might have a strong emotional reaction to the situation and may prefer if colleagues who aren’t parents deal with pediatric emergencies.
Providers who aren’t parents, on the other hand, might feel that they lack the necessary skills to deal with pediatric patients, and might, therefore, prefer that their colleagues who are parents respond to an emergency.
Views about life and death: Pediatric emergencies, especially those that result in death of a child, are a direct contrast to most people’s view of a “normal life,” where the older generation dies first.
Futile resuscitation attempts in the elderly might be cognitively framed as, “they had a good life,” and thus might be easier to accept, whereas a failed pediatric resuscitation might be thought of as, “they still had their entire life ahead of them.”
Therefore, severely ill or injured children might create a cognitive dissonance with EMS providers’ own worldview.6,12
In a similar vein, EMS providers might cope with stressful events by subconsciously assuming a just and moral world. In other words, adopting the mentality of “what goes around comes around.” The injured car driver, for example, is assumed to have caused the accident by driving too fast; or a patient’s chronic lung condition was caused by a lifetime of smoking, etc.
The idea of assigning blame to the patient, however, will seem absurd in pediatric patients, especially in younger children, resulting in pediatric emergencies being perceived as particularly unjust.
Children also appear more vulnerable than adults, and EMS providers might, therefore, feel the need to offer protection and support. The “baby schema” in infant faces might contribute to this enhanced motivation for caretaking.14 EMS providers might, therefore, be inclined to respond faster and “better” than in adult emergencies. Indeed, one study shows response times to pediatric emergencies to be significantly shorter.15
Training: Training deficits might also contribute to the perceived stressfulness of pediatric emergencies.
Pediatric emergencies do require a particular skill set that may be different from adult emergencies.16 Treatment standards and procedures may be different, and even rather simple things such as obtaining a history or taking a set of observations might take considerable effort in pediatric patients. Clinical skills such as intubation or obtaining IV access require fine motor skills and coordination.
Drug calculations can also be difficult under stress and time pressure in pediatric emergencies. In one study, approximately 44% of EMS physicians reported difficulties with drug calculations in pediatric patients.17
An additional factor is that a high number of pediatric conditions seen in EMS are perhaps relatively benign with only a small percentage of emergencies requiring high-risk procedures.1 Training must therefore prepare the EMS provider for both the frequent and the rare, high-risk emergency.
Interaction & Psychological Support
The psychological stressors for the child, parents and EMS provider can, under certain circumstances, increase through interaction. Distress might transfer between parent and child, between parent and EMS provider, and between child and EMS provider.
Because of this, parents and children should be offered psychological support and EMS providers should be aware of appropriate strategies to manage their own stress levels.
Tips for treating Pediatrics
The following tips can help in providing psychological support for pediatric patients.
Making contact: Pediatric patients should be approached slowly by a single provider, if possible. Consider removing turnout gear, high-visibility vests or any other aspect of the uniform that a child might find intimidating.
Look the patient in the eye at eye level (i.e., squat or bend down, being careful not to talk down to the patient). Be aware of your gesture, facial expression and tone of voice- a friendly face, and a deep and calm voice can have calming effects; and
Use a gentle touch on the hands, arms or shoulders of the pediatric patient, stroking the head of younger children. Although this can be helpful, watch the child’s reaction carefully and adjust your approach if you sense they don’t like to be touched.
Communication: Explicitly tell the pediatric patient that you’re there to help. Provide them simple information about injuries, interventions and future actions using concrete time frames (e.g., “10 minutes” vs. “soon”) and appropriate language (e.g., avoid jargon and technical terms, but also refrain from using patronizing “baby speak”).
If the child’s parents aren’t present, tell the patient if their parents have been informed of their illness or injury and give them an idea of when they’ll arrive.
It is also important that you don’t make false promises, particularly around painful procedures. Once trust is lost with a child, it’s very difficult to re-establish.
Self-efficacy: Provide opportunities for the child to gain a sense of control. For example, allow them to make small decisions such as walking to the ambulance instead of being carried (if appropriate).
Allow them to make a seemingly active contribution to solving a problem. You might, for example, have the child hold a roll of tape that will be used to fix a bandage. Although this isn’t a critical function, empowering the child with the subjective impression that they’re doing so can be helpful.
Avoid restraining the child whenever possible. Explanations and talking the child through a procedure are useful alternative, although sometimes restraint is the only option available.
Distraction: Distracting the child is a frequently used strategy to deal with pain and fear and can be very effective.23 It’s important, however, for these distractions to be adequate for the child’s development stage. Older children in particular might otherwise feel as if they’re not being taken seriously.
Soft toys (e.g., teddy bears, stuffed animals) can be helpful in distracting as well as comforting younger children. If possible, the child’s own toy should be used. EMS agencies should consider stocking ambulances with clean, safe, soft toys for use in pediatric emergencies. Pain and distress might persist despite distraction, in which case analgesia and sedation might have to be considered.
Positive reinforcement: Positive behavior, such as “assisting” with a procedure, should be rewarded. This might be done verbally (e.g., saying “well done”) or through the provision of little, inexpensive tockens such as stickers, medals, etc. (This also aids in giving the child the impression that they’re in control.)
EMS providers should transfer simple information about injuries and necessary interventions in an appropriate language.
Support for Parents
As described earlier, pediatric emergencies involve the parents as well as the child. Psychological support should therefore also be available for parents and one team member might be dedicated to providing support for parents.
Parental presence during resuscitation: Although it’s common for parents to support their child during minor procedures in family medicine, the situation is often very different during emergency care. Within the last 30-40 years, efforts have been made to involve parents in resuscitation and to move towards family-centered practice.18
Many guidelines now encourage family presence during resuscitation,19 yet EMS providers might still be reluctant to incorporate this into practice. (Although most guidelines focus on resuscitation, a similar argument can be made for critically ill or injured children.)
Parents causing distraction for EMS providers, parents questioning medical treatment, and potentially impairing care, as well as increased stress for EMS providers, are potential reasons to exclude parents from resuscitation attempts.20,21
Being involved in painful procedures, or in restraining their child, might be uncomfortable for both parents and child. Parents may also, on occasion, blame their child for accidents or injuries exacerbating or increasing their stress or distress.
On the other hand, being separated from their child has been identified as a major stressor for parents, so careful consideration should be given to having parents be present and offer support.22 Parental presence might calm a distressed child, and might also help parents to deal with the situation.
Their presence can often help them in understanding the situation and knowing that “everything possible has been done” for their child.
As noted earlier, physical contact with the child can be particularly helpful. Parents should therefore be offered the opportunity to be present during resuscitation attempts
If parents become disruptive or are clearly upsetting the child, they should be politely asked to leave the room or immediate area. They might still be offered the opportunity to watch (e.g., through a partially open door), and should be provided with frequent updates on their child’s situation. If it’s necessary or best for parents to be away from the treatment area, have a first responder or police office stay with them and comfort them.
Psychosocial support: Pediatric emergencies and resuscitation are very distressing for parents. Psychosocial support should be offered. Different resources exist on local, national or international levels, and might include psychologists, social workers or support groups.
Provider Resiliency
There are a number of psychological strategies available for EMS providers to develop resiliency to deal with pediatric emergencies.
Reflection: If pediatric emergencies are perceived as particularly distressing or worrying by an EMS provider, reflecting about the reasons for this might help in understanding the reaction. Cognitive reframing can then be used to address unhelpful thoughts or expectations. It might also be helpful for EMS providers to reflect on their own strengths and weaknesses.
Social support: Some EMS systems create a formal support structure to help their providers deal with potentially distressing situations. Options include peer supervision/support or Balint groups which offer an opportunity to discuss the medical aspects of a case as well as it psychological effects on the EMS provider. However, informal social support (during or outside of work) and good teamwork can also help in developing resiliency.24
Realism and managing expectations: Being realistic about one’s limitations in dealing with pediatric emergencies can also help in developing resilience: it is not possible for EMS providers to undo an accident or injury.
Similarly, critically ill or injured children might be upset, cry, scream and be difficult to deal with. Providers need to be taught that this isn’t necessarily a reflection of the EMS provider’s skills in dealing with children in general. Their primary goal has to be to provide the best care possible under the given circumstances.
Considering the potential long-term physical and mental consequences of illness and injury in childhood can lead to additional stress for EMS providers. It’s therefore helpful if emergency personnel are trained and encouraged to be realistic about these consequences as well. For example, although a substantial minority of children do develop PTSD after an accident, not every child does.
Relaxation techniques: Learning relaxation techniques is another useful approach for EMS providers who feel particularly anxious or nervous during pediatric emergencies. This includes techniques such as progressive muscle relaxation or simple breathing exercises.
Training: EMS providers often report lacking the knowledge to deal with pediatric emergencies efficiently and feeling unprepared.25,26 Using available training opportunities therefore seems essential. As mentioned, training should cover both frequent conditions and rare high-risk procedures.
Managing Provider Stress
In addition to developing resilience, EMS providers should also be aware of strategies to reduce stress during an actual pediatric emergency.
Cognitive strategies: Protective imagery can help in dealing with distressing and challenging situations. For example, an EMS provider could consider gloves not just as a protection against infection, but also as a barrier against the psychological stresses of a situation. Techniques to stop negative thoughts, such as imagining a stop sign, can also be used if intruding negative thoughts interfere with the ability to provide treatment.
Contingency plans and simple algorithms can provide a fallback in critical situations when workload and stress levels are high. These might be generic (e.g., reciting the ABCs) or more specific (e.g., “if intubation fails, revert to “¦”).
The “10-seconds-for-10-minutes principle” might also help in structuring decision making.27 This principle emerged from more than 10 years of experience trying to enhance patient safety in acute care settings, especially in realistic simulation team training for professional healthcare providers.
The 10-for-10 principle states: “When you see a patient in a critical condition, take your time, don’t make a diagnosis and start treatment within a fraction of a second, but take a deep breath and then a formal team timeout” of 10 seconds.27
Self-monitoring: Cognitive strategies might be particularly helpful when combined with self-monitoring. EMS providers should be aware of signs and symptoms of cognitive overload. (See Table 1). Detecting any of these could then trigger an appropriate stress management technique.
Use available resources: Checklists, pocket guides or guideline apps can help in making the right decision in an emergency, particularly with regards to drug dosage. For example, using a Broselow tape can reduce the rate of adrenaline dosing errors.28
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