EMS Magazine`s Resource Guide: Pediatric Care

Pediatric Reinjury Study: Siblings at Risk

Who is most at risk for sustaining an injury? Someone who has just been injured within the last two weeks. If “accident prone” has been the common misnomer to explain this transient high-risk group, what do you call it when the risk for reinjury reaches past the patient, into the whole family?

Striking new findings in King County, WA, by Brian Johnston, MD, MPH, and his colleagues at the University of Washington Dept. of Pediatrics suggest that the phenomenon of increased risk for a second injury is shared by the entire sibling group when one child has gotten hurt accidentally.

Johnston’s team studied children between infancy and 15 years of age enrolled in various managed-care institutions between 1992 and 1997 who received medical treatment for severe unintentional injuries. Other visits to the ED due to minor injuries, follow-up care and intentional injuries were eliminated from the study.

They found that almost twice as many injured children were siblings of another child who had been treated for injuries recently. Risk for the second injury was greatest during the first 6–10 days, tapering off to normal in about a month; brothers between four and 10 years old had a higher risk for injury than other children.

While the reasons for family injury clusters are unknown, and likely due to a number of factors, researchers’ comments indicate the study might reveal an opportunity for EMS to provide preventive support to a family with children when treating one child for an injury. “Childhood injury prevention may be more effective if targeted toward families that are passing through periods of exceptional injury vulnerability,” says the statement from Harborview Injury Prevention and Research Center (HIPRC). Answering the call for an injured child should alert EMS to a family entering a “period of high injury risk,” which could be offset by “a brief but intensive social support intervention” to decrease that risk.

For more information, visit HIPRC Current Projects at https://depts.washington.edu/hiprc/projects/risk/hrperiods.html or https://articles.findarticles.com/p/articles/mi_m0950/is_3_105/ai_60794256/print.

Role of the Emergency Physician in EMS for Children

Emergency physicians have a duty to advance the care of their pediatric patients. With this principle in mind, in 2003, the American College of Emergency Physicians (ACEP) passed a policy statement outlining the leadership role that emergency physicians play in EMS-related activities, including integrating EMS for children into EMS systems.

In effect, the policy statement says that emergency physicians affect the EMS-EMSC continuum in important ways by providing:

• Leadership in the area of injury and illness prevention.
• Leadership in local, regional and state EMS and EMSC systems by involvement in the provision of medical direction (oversight), education of providers, quality improvement and legislative advocacy.
• Collaboration with other physicians and healthcare professionals, including providing referrals to primary care, specialized care and rehabilitation services.
• Research in the design and function of EMS systems, education of providers, out-of-hospital and emergency care interventions and outcomes of emergency care.
• Expertise for and collaboration with the National EMSC Program (Maternal and Child Health Bureau in collaboration with the National Highway Traffic Safety Administration).

In 2003, an in-depth article supporting the policy statement was published in Annals of Emergency Medicine.1 Its goal, according to the authors, is to educate emergency physicians about the federal EMS for Children Program and the efforts being made to improve out-of-hospital and ED care for children; to provide guidance to emergency physicians on advocacy efforts for children in their communities; and to provide emergency physicians with the information, tools and resources developed by the EMS for Children Program and its advocates.

EMSC began as a national initiative in 1984 for the purpose of reducing childhood disability and death caused by severe illness or injury and to improve emergency care for children.

Reference

1. Gausche-Hill M, et al. The role of the emergency physician in emergency medical services for children. Ann Emerg Med 42(2):206–215, Aug 2003.

Pediatrics: Avoiding the Hospital with Education

“Many pediatric hospitalizations might be avoided if parents and children were better educated about the child’s condition, medications, need for follow-up care, and the importance of avoiding known disease triggers,” says the Agency for Healthcare Research and Quality (AHRQ) regarding a study partially funded by that group. According to the study, “avoidable hospitalizations include conditions whose onset can be prevented (such as through immunization), acute illnesses that could be controlled in ambulatory settings (such as a urinary tract infection), and chronic diseases that can be managed in outpatient settings (such as asthma).”

Glenn Flores, MD, of Boston Medical Center led a research team to survey the parents, primary care physicians (PCPs) and inpatient attending physicians (IAPs) for 554 children under 18 who were admitted with “avoidable hospital conditions” (AHCs). While factors such as poor access to care, poverty, low educational attainment, lack of health insurance and lack of a primary care physician have been blamed for avoidable hospitalizations, until this study, say the researchers, “little [was] known about the perspectives of parents and physicians on how [AHCs] might be avoided.”

What they found showed differences of opinion among the three groups of parents and physicians regarding 1) whether hospitalizations were in fact avoidable and 2) if they were, where the fault lay, each placing more blame on one of the other two groups than on either their own or the traditional factors named above. All agreed, however, that parents and children would benefit by a better understanding of the entire situation.

With that common ground, researchers concluded that many AHCs could be prevented if physicians put more time and effort into 1) better instruction of the proper administration of medications, including dosages, frequency and duration of treatment, and how to obtain refills; 2) better education regarding preventive measures, including avoiding known disease triggers (cigarette smoke, pet allergens, dust, etc.), and the use of condoms for sexually active adolescents; and 3) ensuring a better understanding of the child’s overall medical condition, including the optimal clinical course.

See www.findarticles.com/cf_dls/m0950/5_112/111062737/print.jhtml.

Nash County Emergency Services Offers Explorer Program
By David Joyner

The Nash County Emergency Services in Nashville, NC, and the Boy Scouts of America are proud to offer a program that offers training in EMS, fire, communications and emergency management to young men and women, ages 14–21, and allows these “Explorers” to ride alongside paramedics in the field.

Nash County’s fire division will allow the Explorers to see and participate in fire inspections, investigations and much more as they work side-by-side with our fire marshals.

Our communications division offers program participants a chance to see what happens on the other side of a 9-1-1 call. The Scouts will work with telecommunicators to see what it is like to receive a 9-1-1 call and to dispatch the appropriate emergency service. After completing a 10-step training program, they will have the opportunity to assist telecommunicators in dispatching some calls.

Our emergency management division will provide Explorers with knowledge of operations within the management side of an event. They will be trained in understanding what resources are available from local, state and federal agencies during times of need.

Each division has a unique 10-step training program that will include CPR, first aid, map reading, patient assessment, incident command or 9-1-1 call-taking and dispatching. Once the Scouts have completed the steps, they can ride with the division’s units and become active members on the scene. Explorers will also have the opportunity to take part in the same classes that EMS staff does.

If the Explorers reach a point where they decide that maybe this is something they want to do as a career or volunteer, then we will place them in a class to work toward certification. We want to provide them with every opportunity to help them meet their goals. In a time when it is getting harder and harder to find volunteers and trained personnel to fill much-needed jobs, this program helps us, too.

But it is not all work and no play. We try to take the youth on a camping field trip every three months where they can develop leadership and teamwork skills they will use for the rest of their lives.

This is a youth-driven program and they are the ones who decide everything about their program: They make their budgets, plan their trips, their meetings, their training and much more. Our role as adults is to advise them and lead them in the right direction. As our Exploring motto says, “Our best today for a better tomorrow.” If we don’t take an active role in our youth’s lives, then they will find other things to do.

An important point to make is that no one is turned away for lack of funds. We’ve tried to make the program affordable and donations (not taxes) cover the rest. Everyone is welcome, and the program provides everything they need. No one pays for uniforms, books, training, insurance, badges, shirts or anything else. When we go camping or on other trips, we have fundraisers, so the parents are not burdened themselves, and private donors step in to pay the balance when necessary. Many times parents will not let their youth participate in activities if they feel that every time they turn around they have to pay for something. For a parent who is already just getting by, this is the last thing they need—not to mention embarrassing for both the youth and the parents. We try to eliminate all that.

The best part is that all the adults are volunteers. Even the staff volunteers their time—no one is paid. If the parents want to help, we have places where they can also participate. We always welcome help.

We meet on the first and third Mondays of each month at our emergency services office in Nash County. For more information, contact the author at 252/459-9805, or NCMedicTeach@aol.com.

David Joyner, EMT-P, is a paramedic and EMS instructor for Nash County (NC) EMS, and EMS coordinator for Nash County (NC) Community College.

Medical Emergency Response Plan for Schools

In a survey of elementary and high school teachers in the Midwest, 18% said they have provided some level of emergency care to more than 20 students each school year, and 17% said they have responded to one or more life-threatening student emergencies during their teaching careers.

Although most parents assume that teachers and staff at their children’s schools are trained in CPR and first aid, surveys in New Mexico and the Midwest show that one-third of teachers had no first aid training and 40% had never completed a CPR course.

In January 2004, the American Heart Association published a statement to introduce a public health initiative that would help schools prepare to handle life-threatening medical emergencies like cardiac arrest and severe injuries.

“Medical emergency response plans for children are extremely important,” says Vinay Nadkarni, MD, associate professor of anesthesia and critical care at Children’s Hospital of Philadelphia and immediate past chair of AHA’s Emergency Cardiovascular Care Committee. “As a scientific community, we are recognizing that our young people are spending a considerable amount of time in schools; these schools are the hubs of community activity, not only for children but other individuals attending sports events and other activities. There is a tremendous opportunity to develop responses to emergencies that are appropriate, and children and adolescents can be trained to participate in an emergency response plan.”

Although there are no national statistics about the causes of life-threatening emergencies or deaths in schools, regional statistics show that injuries are the chief complaint listed for two-thirds of EMS dispatches to schools; medical illnesses, such as breathing difficulties and seizures, comprise about one-fourth of school EMS calls.

As part of the AHA’s Medical Emergency Response Plan for Schools, the school nurse and physician, athletic trainer and several faculty members would be trained and equipped to provide first aid and CPR. The statement also recommends that schools train every teacher in first aid and CPR and all students in CPR.

“We know that whenever a child dies from a sudden event, a number of those deaths are preventable, and technology like automated external defibrillators now exist that can assist with that,” says Dr. Nadkarni. “But in order for those tools to be effective and practical, the plan has to include how to access the AED, how to use it, and how to activate the people who can help. Because of that, AHA initiated an evidence-based evaluation to try to identify the interventions that EMS providers and laypersons could do in a school setting to improve outcome. We know that recognizing an emergency is extremely important, so we could teach how to do that; rapid response is critically important; if it’s a cardiac arrest, early CPR needs to be implemented; and, if it’s a cardiac arrest that requires defibrillation, a defibrillator needs to be immediately accessible, whether from EMS or public access. Those are all critical elements to early resuscitation of a child in trouble.”

EMS involvement is critical to the response plan, says Dr. Nadkarni.

“Many schools are just learning about this emergency plan, and they could use a lot of help from their local EMS systems,” he says. “Our local AHA affiliates and their EMS counterparts could make the rounds of schools and help them evaluate how they might facilitate a rapid response. Even something as simple as making available to schools the average EMS response times is important in deciding whether or not to purchase a defibrillator for the facility. If response is more than five minutes, that school might want to target dollars or fundraising toward an AED program; whereas, those with a short response time might spend their money on CPR training. By developing a relationship with the schools, it would not only help the schools understand their barriers to good EMS care, it would help the EMS providers get a before-there’s-an-emergency look at how the school works, what the barriers are and how they would handle an emergency in that setting.”

EMS can also help by tracking where most school emergencies occur and how they are handled.

“That will give us an understanding of exactly when, where, how and why emergencies are happening in schools, so we can develop ever better response programs,” says Dr. Nadkarni.

For complete information on the Medical Emergency Response Plan for Schools, see the Annals of Emergency Medicine, Vol. 43, pp. 83–99, January 2004.

—MN