EMS Interventions & Pediatric Outcomes

A descriptive study generally reports information without interventions or comparisons; they’re meant to “describe” a group of people or findings.

Case series are reports on a sequence of cases with similar conditions. In the hierarchy of good research, they aren’t as strong as prospective, randomized and blinded studies.

“˜Appropriate’ Use of EMS?
Richards M, Hubble M, Zwehl-Burke S. “˜Inappropriate’ pediatric emergency medical services utilization redefined. Pediatr Emerg Care. 2011;27(6):514—518.

The research this month leads us to question the core of EMS. As always, I hope it sparks some serious debate. But more importantly, I hope budding researchers use good science to prove EMS’ worth.

The authors of this descriptive study used the National Hospital Ambulatory Medical Care Survey to analyze the transportation mode and acuity of more than 250,000 patients–mathematically representative of 914 million emergency department (ED) visits. The authors wanted to understand whether EMS was being over-used for transportation of pediatric patients who don’t need EMS care. They compared adult use of EMS with pediatrics and proportionately compared the acuity of each.

Pediatric cases account for less than 10% of EMS call volumes, and many cases aren’t life-threatening. More than 90% of pediatric patients arrive by private vehicles, and out of these patients, 34% had critical complaints. In fact, critical pediatric cases that might benefit from EMS are transported by private vehicles at a much higher rate than adults. So why isn’t EMS being called for the sickest patients? The authors were careful to say that more research is needed to determine this.

They comment on previous studies that show parents may not recognize that their child is very sick and may not understand the differences in the use of 9-1-1, urgent care clinics and EDs. It’s even more alarming to think perhaps it is best to avoid ambulances in some cases. The authors point out they didn’t have outcome data on these cases and can’t conclude whether the patients transported by ambulance fared better.

On a personal note, I love the fact that a paramedic is the second author on this study–score one for EMS researchers.

Bottom Line
What we know: Previous studies have identified that some physicians and families have low confidence in EMS’ ability to care for sick children.

What this study adds: Scientific evidence showing that EMS is under-used for kids, and the community of healthcare providers and parents may need education about the role of EMS in pediatric emergency care.

Pediatric Traumatic Arrest
Brindis S, Gausche-Hill M, Young KD, et al. Universally poor outcomes of pediatric traumatic arrest: A prospective case series and review of the literature. Pediatr Emerg Care. 2011;27(7):616—621.

We could label this an “encore” study by Gausche-Hill. Some readers may recall the storm of controversy stirred up by the Los Angeles study comparing outcomes of pediatric patients receiving bag-valve mask (BVM) vs. endotracheal intubation (ETI).

Readers familiar with the entire study, not just the headlines and subsequent reactions, may also remember that Gausche-Hill’s landmark study had some serious limitations. Now, more than a decade later, this paper simply takes the same data collected in 1997 and describes the outcomes of pediatric trauma patients who were pulseless on EMS arrival. Can you guess the outcome of a traumatic arrest? Death. Most of the 118 pediatric patients in this case series died. Four patients were discharged with poor neurological outcomes.

The authors note a universal poor outcome for pediatric trauma arrests and an extreme lack of research on this topic, and they question the standard of practice to attempt resuscitation. But before I stop trying to save my pediatric trauma codes, I’d like to see a larger sample than 118 arrested children who had transport times of 5 minutes in a single urban system.

It should be noted that the authors report on the fact that 76% of these children received BVM ventilation, and no difference existed between the ETI group and the BVM group. Although this gives more air time to the airway controversy, I would caution us all to hold researchers accountable to the scientific method and not allow casual associations to become causal associations.

Congratulations to this group for keeping pediatrics in the spotlight. Let’s see if we can find a way to collaborate with EMS systems across the country and confirm or refute the findings. JEMS

Watch Box
Ruston A, Tavabie A. An evaluation of a training placement in general practice for paramedic practitioner students: Improving patient-centered care through greater interprofessional understanding and supporting the development of autonomous practitioners. Qual Prim Care. 2011;19(3):167—173.

For audio commentary, visit www.pcrfpodcast.org

This article originally appeared in October 2011 JEMS as “Pediatric Predicaments: Studies examine outcomes of EMS response & treatment.”

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