From Devastation to Determination: The Heavy Burden of Pediatric Care in the Field

Peter Antevy is a featured speaker at EMS World Expo, October 3–7 in New Orleans, LA. Register at EMSWorldExpo.com.

Eight years ago, in a gated South Florida community on a summer afternoon, Jonathan Robbins found himself racing to his first serious pediatric call. He and his crew knew they were responding to an unresponsive 2-year-old drowning victim. This was Robbins’ first month on duty as a paramedic; he'd recently completed paramedic school and the required probationary period at the Coral Springs Fire Department. His adrenaline was surging as he mentally prepared for what was to come.

Eight years later, Jonathan, who is now a Lieutenant, recalls the scene as a blur. “We took the child from the mother’s clutched arms and quickly loaded him in the back of the ambulance.” The engine crew had been on scene to provide extra support and when it was time to go, Robbins, the rookie, was told to drive so the more seasoned providers could tend to the lifeless child.

They want me to drive. I’m not supposed to do that, but this is no time to ask questions, he thought to himself. Back then, getting the child to the hospital was the number one priority and every second mattered.

Robbins started the engine and quickly put the vehicle in drive. As he departed the scene, lights and sirens blaring, the mother and father watched in horror, hoping for the best possible outcome as their son was whisked away. But this would not be the last they would see of the ambulance. To their shock, the sound of the sirens never completely dissipated. Instead, a few minutes later, the sirens became louder, followed by the same ambulance passing their house at a rapid speed.

Robbins was in a state of panic. “I didn’t know how to get out of this gated community,” he painfully recalls. “So I made another turn, and then another, only to reach another dead end. I must have passed the house twice in 5 minutes. The parents were still standing there, and I could see the horror in their eyes.”

The child ultimately arrived at the local community pediatric emergency department, where he was pronounced dead after intensive efforts to revive him. Family members filled the ED and the feelings of grief and loss were palpable. The EMS crews were devastated as well, yet one crew member’s despair was magnitudes higher. Robbins quietly returned to the fire station with a heavy heart.

“I blamed myself for that child’s death,” Robbins recalls as his eyes well up. “But I never told anyone; not a soul. I tried to bury those feelings deep down, but they never went away. It always seemed to creep up on me, especially during pediatric calls, even the ones that were minor.” Robbins recalls hearing that the child was under water for 30 minutes and that any efforts would have been futile. “That didn’t matter, and it didn’t help,” Robbins says.

Confidence from Education

Fast-forward eight years to when Robbins and I met for the first time during a pediatric resuscitation course. There he was, a youthful presence sitting in the front row with his eyes intently focused on every slide. By day’s end I noticed he’d filled a notebook with handwritten notes. I had no idea why this young kid was so engaged but I could sense something special about him. For an instructor, there’s nothing better than an engaged student.

What I didn’t realize at the time was this was Robbins’ chance to crawl out of the deep space he had been living in for so many years. “I thought of this as my chance to finally beat this internal conflict I’d been fighting for so long,” Robbins recalls.

At its core, the course we rolled out that day emphasized on-scene resuscitation for pediatric patients in cardiac arrest. Our mantra was “Let’s treat kids like adults and stay on scene in order to regain a pulse.” This struck a chord with Robbins. “I felt my ACLS skills were very strong and just then realized that the algorithm for pediatrics was no different,” he says. “It was an eye-opener and my confidence level definitely improved. Whether or not I could perform, if the time ever came, was a different story.”

Robbins only had to wait a week to find out if his long-held secret would interfere with his newly found confidence. The tones at Station 80 drove him and his crew into action and they raced a few blocks away to a 2-year-old drowning, the same call he had eight years prior. “My adrenaline surge wasn’t being shy, that’s for sure,” Robbins recalls. He went through the prearrival discussion with his crew. One crew member would start chest compressions, the other was to address the airway with a BVM, and he was prepared to place an IO and administer epinephrine 1:10,000. He knew the dose of 1.2 mL prior to arrival.

Juan Cardona, Coral Springs Fire Department’s EMS division chief, also heard the call and decided to rush to the scene as well. He arrived only minutes after Rescue 80 and remembers the scene vividly. “The crew was at the poolside providing high-quality CPR, the epinephrine had been given and the airway was being upgraded. Lt. Robbins was leading his team and things were amazingly calm; there was no urgency to leave,” Cardona recalls. “That child received great care and ultimately achieved return of spontaneous circulation (ROSC). It was an amazing feeling.”

Fast-forward two weeks and Robbins and his crew were on shift again. This time they were toned out to an unresponsive 1-year-old girl who had choked on a grape. They arrived at the parking lot of a multifamily apartment building to a police officer holding a lifeless child in his arms, waiting to transfer her to their care. Robbins remembers saying to the officer, “Put her down right here.” As his partners started CPR, Robbins suctioned a mouth full of blood secondary to the multiple finger sweeps attempted by the mother. He then inserted his laryngoscope blade, visualized the foreign body and gently removed it with Magill forceps. A sudden rush of air and then a pulse! Another return of spontaneous circulation on scene in a span of two weeks.

This was their time. Robbins and his crew were hailed as heroes by the department, and by the families. “But it wasn’t the attention I longed for,” Robbins says. “What I really wanted was to get rid of those demons in my head. No one knows how heavy a burden that was for me, and I never told anyone the story. I can tell it now because I’m on the other side of it. It hurts me to know how many EMS providers are out there today harboring these same feelings.”

The soft-spoken lieutenant humbly credits the outcomes to his agency’s rollout of a new pediatric system, which he says “systematically trained us to provide rapid, high-quality care on scene, specifically for kids in cardiac arrest.”

A few months ago, at a fundraiser for the fire department, I saw a familiar face. It was that kid who sat in the front row during the pediatric course. “How have you been?” I asked. “Good,” Robbins said. “I have to tell you a story.”

Over the next 20 minutes Jonathan told me the entire story for the first time, from the beginning. As both our eyes welled up, I realized only then how even a seemingly minor event could impact the emotional health of a prehospital provider. The heaviness Robbins felt for so long would be unbearable to most, and unfortunately the field of EMS has lost many of its brothers and sisters to untold stories like these. The news wires are filled with such stories.

One in particular recently had a big impact on the country. Deb Crawford, a 26-year veteran paramedic in Denver, took her own life only hours after responding to a fatal pedestrian vs. train incident and quickly devastated the tightly knit EMS community. The incomprehensible part was Deb was the go-to person at the department for critical incident stress management (CISM). Christopher Colwell, MD, chief of emergency services at Denver Health, recalls the shock and disbelief everyone felt when Deb took her own life. “She was the last person we ever thought would do this. It took us completely by surprise, and we are in great pain,” he said to me in the weeks after it happened.

Culture Adjustment

Mental health intervention for those who provide prehospital care has been in desperate need of new direction and this past year we may finally be turning the corner.

Departmental “culture” remains the biggest roadblock to date. For decades, showing one’s emotional side has been a sign of weakness and could often lead to ridicule by others. Providers notoriously turn to drugs and/or alcohol to numb the pain of emotionally burdensome events. Robbins will tell you how deep his wound was and how long it festered in his head and heart. \

Chief Julie Downey of Davie Fire Rescue feels that “the system is broken and doesn’t allow for providers to open up in order to begin the healing process. EMS agencies need to revisit how they think about mental health.” Currently, most agencies take a reactive rather than a proactive stance. CISM is called after the incident, if at all. Perhaps we should move to a proactive system where the foundational belief is not ‘do you need help?’ but ‘you need help.’

Some feel the highest risk of suicide is toward the end of one’s career in EMS. Prehospital providers who retire at a young age and don’t plan for the emotional turmoil are at high risk. One paramedic was found dead with a self-inflicted bullet wound while dressed in his Class A uniform inside the helicopter he once called home. The event occurred just weeks into his retirement and sent shock waves through the agency. That year, four other prehospital providers committed suicide in that same department.

If we want providers to be at their best and deliver the best care possible, we need to make their emotional health a priority. Departments everywhere are dispatched for heart-wrenching and emotionally charged calls and our first responders are in the thick of these situations with all eyes on them to save lives. The sooner we put standard programs in place that address these concerns, the better emotionally equipped our first responders will be. And that makes a huge difference when the future of so many patients’ lives rests in their hands.

Lt. Jonathan Robbins is considered a hero by many people, including me. By openly talking about what some would consider an inconsequential event, he has allowed us to better understand the emotional burden carried by emergency first responders. Most efforts related to critical incident stress management in EMS are concentrated after a significant event, yet it may be the accumulation of the ‘minor’ unspoken events that carries the heaviest emotional burden. Emergency medical services will need to undergo a much-needed culture change to destigmatize work-related PTSD, depression and anxiety in the coming years. Let us never forget those who sacrificed their lives for the well-being of others, and let’s continue to bring attention to this tremendously important topic.

Available Resources

There is a growing concern that suicides are affecting the emergency services at higher levels than ever before. Fortunately an increasing number of resources offering providers education, assistance and counseling are available.

• The Center for Public Safety Innovation (@CPSITraining) at St. Petersburg College has been grant-funded to develop a suicide prevention training-of-trainers course. The eight-hour course provides an overview of the global suicide issue in the United States, and breaks down the problem at the local level. The suicide prevention course is broken into five modules that include information about suicidal behaviors and communication, prevention efforts, protocol and policy development, issues revolving around stigma and how to care for survivors. The training is designed for fire service trainers, chaplains and EAP representatives who wish to teach suicide prevention and intervention techniques within a fire service setting.
• The Center for Patient Safety (@PtSafetyEMS) in Missouri has recently launched workshops to help identify and support “second victims.” These are healthcare team members involved in an unanticipated patient event, medical error and/or patient-related injury who have become traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second-guessing their clinical skills and knowledge base.
• The Code Green Campaign (@CodeGreenEMS) is another group bringing desperately needed attention to the issues of PTSD, suicide, depression, addiction and other mental health problems in public safety.
• Mental Health Resource Toolkit: Additional mental health resources can be found online at EMSWorld.com/12064878.

Division Chief Juan Cardona can be reached at JCardona@coralsprings.org. Lt. Jonathan Robbins can be reached at JRobbins@coralsprings.org.

Peter Antevy, MD, is an EMS medical director for Coral Springs Fire Department, Davie Fire Rescue, SW Ranches and American Ambulance in Florida. He is the associate EMS medical director for Palm Beach County Fire Rescue and Seminole Tribe Fire Rescue. Antevy serves as medical director at Coral Springs Fire Academy and Broward College’s EMS program and is a pediatric emergency medicine physician at Joe DiMaggio Children’s Hospital. He is founder and chief medical officer of Pediatric Emergency Standards, Inc. Reach him at PAntevy@coralsprings.org.

Rachel Sobel is a published writer and communications professional with more than 15 years’ experience writing for organizations in industries such as healthcare, technology, business, marketing and retail. She’s also a parenting and lifestyle blogger contributing to local magazines and her own blog. She holds both a bachelor’s and master’s degree in public relations and communications.