Industry Insights: A Medical Director’s Journey to Improve Pediatric Outcomes

Editor's note: Industry Insights are sponsored blogs submitted by manufacturers and suppliers serving the EMS industry.

Any EMS provider will admit that a pediatric emergency is scarier than an adult emergency. 

The child may not be able to communicate, the parents are in no shape to help, the assessment is more difficult, and on top of all of that, the dreaded weight-based medication math. In the middle of the night, with panicking parents and a sick kid, a medic is expected to calculate pounds to kilos, then kilograms per milligrams and then milligrams to milliliters.

What happens when this calculation goes wrong, or if the provider makes the wrong diagnosis?

Dr. Kevin McVaney can tell you.

As medical director for the Denver Paramedics, McVaney watched one of his providers experience crippling post-traumatic stress disorder after a distressing pediatric call. On top of the harm experienced by the child, the paramedic’s mental state spiraled downward over a period of years, eventually leading to her termination.

McVaney says the existing training methods are to blame for cases like these. This is apparent during the post-call debriefs. “These medics have just run the worst call of their career,” he says. “No matter what you say to them, they walk away thinking: ‘a child is dead, and it’s partly my fault.”

Treating a child in an emergency is stressful. A provider is required to complete tasks that would be difficult in a controlled environment, much less during a chaotic call such as a pediatric cardiac arrest. It is no surprise, then, that a 2012 study of eight EMS agencies in Michigan demonstrated an astounding 34.7% error rate in medication dosing,¹ and that this error rate for pediatric dosing in the emergency setting has been found to be true in agencies throughout the U.S. 

But it doesn’t have to be this way.

The medication calculations can be done ahead of time, and patients will benefit.

Paramedics can arrive calmly at any pediatric emergency, knowing that the math is done for them, leaving them free to focus on managing the case. 

Paramedics from the Ridgeview Medical Center in Minnesota can attest to that with pre-calculated, age-based doses at their fingertips, so they can administer life-saving medications 70% faster than they could by doing the math on the scene.² Not only do patients receive life-saving medications in a timely manner, but the error rate is drastically reduced.³

McVaney knows that by arming his providers with pre-calculated medication doses and strategically-placed equipment, a revolution will occur in the treatment of pediatric emergencies. The results speak for themselves: after implementing the Handtevy system in Denver, McVaney saw three astounding improvements:⁴

1. Pediatric trauma patients received pain medication 50% more often than they had before;
2. In the littlest patients, those under 5 years old, pain medication was administered more than twice as often as before; and four times more often when given via the intranasal route.
3. Medication dosing errors decreased from 35% to 5%.⁵

McVaney looks back on the way he was trained to approach pediatric emergencies, and frankly, it makes him mad. 

“We have to acknowledge that the way we are taught is fundamentally wrong because it has false expectations for what can be done,” he says. “We set up this training and then when people screw up, we just say, ‘you haven’t trained enough, you’re not smart enough.’”

So, after 15 years of practicing as a medical director, McVaney was fed up. He felt that he was finally in a position to argue that this existing training was just dead wrong.

When Denver Health Paramedics hired a full-time pediatric EMS physician, Dr. Lara Rappaport, she came to McVaney and told him they needed to start focusing on their pediatric medication dosing errors. It was a wake-up call.

“Once I heard that, I knew we had to change,” he says. 

It was the Handtevy system that helped the Denver paramedics turn a pediatric call into something they could be proud of. Prior to its implementation, McVaney found himself debriefing his providers after pediatric calls, but feeling frustrated that his medics seemed to dwell on not doing every single thing right.

Now, things are different. All thanks to a change in training, a change in thinking about pediatric emergencies and the practical hands-on principles taught by Handtevy Course.

Just recently, Denver medics responded to an anaphylaxis call involving a 4-year-old. When they arrived, they found the patient suffering from a severe reaction to ingested peanuts.  What they didn’t know was that they were about to get another patient: the 4-year-old’s brother had also eaten peanuts and was having an anaphylactic reaction of his own. 

The medics, however, didn’t flinch. They knew what medications to give and how much to give. They swiftly administered the correct life-saving doses needed to treat the anaphylaxis, and then loaded both kids into the back of the ambulance.

“The Handtevy system allows Denver Paramedics providers to run a case really, really well and then have a clean conscience when they’re done,” McVaney says. “That’s the difference, because we’ve given them the right tools.”

Giving their providers these tools along with the proper training means that EMS medical directors never have to witness their medics agonize over poor performance on pediatric calls. McVaney knows this all too well. Now, instead, he fills with pride as they walk into the ED and say, “Hey Doc—we just rocked that call."

References

1. Hoyle JD, et al. Medication dosing errors in pediatric patients treated by emergency medical services. PreHosp Emerg Care, 2012. Jan-Mar;16(1):59-66.

2. Madhok M, Krause E, Flood A, Piechota D, Levi J. Assessment of an ideal weight for age based dosing education for EMS using simulated encounter. NAEMSP Poster Presentation, New Orleans, LA, 2017.

3. Ibid.

4. Rappaport L, et al. (2017). Use of Fentanyl in pediatric trauma patients post implementation of the Handtevy field guide. NAEMSP Poster Presentation, New Orleans, LA, 2017.

5. McVaney K. A progressive and pragmatic process for proportioning pediatric dosing: The outcome of rolling out a new system of care for children. Gathering of Eagles, Dallas, TX, 2017.