Chapter 147: Prehospital Care

• Children account for approximately 10% of the total patients treated by prehospital providers, thus, limiting reinforcement of pediatric assessment and life-saving skills.

• There are two levels of response in the prehospital setting: Basic life support is provided by emergency medical responders (EMRs) and emergency medical technicians (EMTs); advanced emergency medical technicians (AEMTs) and paramedics provide advanced life support care.

• Rural EMS providers face many challenges when caring for children as they have longer transport times and care for fewer children in general (limiting pediatric-specific skills retention).

• Prehospital protocols are approved by agency medical directors and are limited in development by a paucity of pertinent prehospital literature. With implementation, they should be linked to provider education, performance metrics, and quality improvement strategies.

• Standardized ambulance equipment checklists addressing the specific needs of children have been derived under a collaborative effort of multiple stakeholder organizations.

• Offline, or indirect, medical oversight involves the development, implementation, monitoring, and iterative improvement of medical policies and protocols used by field personnel. Online, or direct, medical oversight is the concurrent clinical direction provided to field personnel by a medical director or his/her delegate.

• Regionalization is the geographical organization of services to ensure access to care (including transport) at a level appropriate to patient needs while maintaining efficient use of available resources and the avoidance of duplicative ED visits. For certain conditions (e.g., trauma, burns, stroke, pediatric critical care), it has been shown to improve outcomes.

• Emergency care without parental consent can be provided regardless of age. Although minors cannot refuse treatment and transport in an emergency situation, if a legal guardian is present, he/she can make an informed decision to refuse transport; refusal of EMS care for children occurs in about 5% of all EMS runs.

• For EMS providers interacting with children with end-of-life issues, Do Not Resuscitate (DNR) orders must be present in written form, acknowledged verbally by the family as still in effect, link to correct identification of the child as the recipient of the DNR order, and occur in a state that includes children in DNR laws.

Emergency Medical Services for Children

Medical experiences in both the Korean and Vietnam Wars demonstrated that survival rates improved when patients were stabilized in the field and transported immediately to a well-equipped emergency facility.¹ In 1966, the National Highway Traffic Safety Act mandated that states develop Emergency Medical Services (EMS) systems, and Congress passed the Emergency Medical Services Act in 1973 to provide direct funding for regional EMS systems.² With its origins in the military and its civilian focus on cardiac and trauma care, the nation's EMS systems were slow to consider the needs of the pediatric population. In 1984, the federal government approved the EMS for Children (EMSC) program through the Health Resources and Services Administration's Maternal Child Health Bureau of the Department of Health and Human Services.² The goal of the EMSC program is to reduce child and youth mortality and morbidity sustained as a result of severe illness or trauma.³ The intent of the EMSC program is to be fully integrated along the continuum of emergency care in the existing EMS system rather than part of a separate pediatric EMS system.³ This continuum emphasizes the importance of the emergency response system prior to prehospital care, interfacility transport to definitive care, the rehabilitation process after injury or illness, and injury prevention initiatives to mitigate future emergencies.³

The EMSC Program has developed national performance measures to evaluate the operational capacity to provide pediatric emergency care through the availability of online and offline pediatric medical direction, essential pediatric equipment and supplies on ambulances, a hospital recognition system for pediatric medical and trauma facilities, and written pediatric interfacility transfer guidelines and agreements.⁴ Additional EMSC performance measures assess pediatric emergency education for the license and certification renewal of prehospital providers, the establishment of permanence of an EMSC program in each state, and integration of EMSC priorities into existing state mandates.⁴

Institute of Medicine Reports

In 1993, the Institute of Medicine (IOM) issued a landmark report on the state of EMS for children in both the prehospital- and hospital-based settings. It highlighted significant disparities between adult and pediatric emergency care, and it increased awareness about the unique needs of children during a medical emergency.² In 2007, the IOM released three reports on the future of emergency care in the United States.^5–7 Several recommendations from these reports have pediatric implications, including establishment of a national accreditation process for provider education, adoption of national certification for licensure of prehospital providers, recognition of common levels of EMS certification across states, testing of strategies for creating seamless systems of care, workforce strengthening, integration of evidence-based practices, and the inclusion of a pediatric coordinator in all EMS systems to advocate for pediatric needs in the system.^5,6

Pediatric Considerations in EMS

Children account for approximately 10% of the total patients treated by prehospital providers.⁸ As a result, EMS providers get limited reinforcement of pediatric assessment and life-saving skills, making refresher training extremely important to maintain competencies.^9,10 Most EMS calls are for children who have noncritical illness or injury, yet wide variation across age groups in anatomy, physiology, cognition, and behavior, makes pediatric assessment and management challenging relative to adults.^8,11 For example, equipment size changes as children grow; thus, essential items must be available for all ages ranging from infants to adolescents.¹² In addition, a child's physiologic response to a critical illness or injury varies by age; thus, prehospital providers must be able to recognize signs of physiologic compromise across the age spectrum.¹² Furthermore, the cognitive and behavioral variety across pediatric age groups must be considered in a prehospital provider's approach to patient assessment and management.¹² Finally, a child's complaints are often interpreted through the lens of the caregiver, thus, incorporating family-centered care is essential in the prehospital setting.¹²

THE 9-1-1 System

Prior to a universal 9-1-1 number, access to emergency services was scattered and uncoordinated.¹³ In 1968, 911 was established as a universal emergency number, and in 1972 the Federal Communications Commission (FCC) recommended that 911 technology be implemented nationally.¹³ Over the ensuing years, 911 availability grew to become almost completely universal, such that almost 99% of the US population now has access to 911 activated emergency services.¹

Operators at Public Safety Answering Points (PSAP) receive 911 calls, and these centers dispatch the appropriate service, which may be medical, fire, and/or law enforcement.¹ Because of the origins of 911 service, 90% of dispatch centers are operated by law enforcement whereas 8% are operated by EMS, and only 2% are operated by fire departments.¹³

Traditionally, callers provide the 911 operator with information on the nature of their emergency, in addition to their location. Enhanced 911 (E911) allows the caller's information, including location and telephone number, to be immediately available to the 911 dispatch operator to enhance timely dispatch while the operator continues to obtain additional information that can be transmitted to the responding service already en route.² In 1999 the FCC adopted the Basic 911 rule, which mandated that wireless providers transmit 911 calls directly to a PSAP, even if the caller did not subscribe to the service.¹⁴ Additional rules ensure that wireless providers transmit the location of the nearest cell tower or the caller's latitude and longitude within 6 minutes to the PSAP.¹⁴ Recently, service providers have created phones with E911 capability, and providers must make them available to at least 85% of their customers.¹⁴

Medical Dispatch

EMS activation begins when the patient, caregiver, or other bystander detects a need for emergency care.¹⁵ After a PSAP receives a call, a trained Emergency Medical Dispatcher (EMD) determines whether Advanced Life Support (ALS) or Basic Life Support (BLS) is required. This can be done with computerized algorithms or with local protocols, based on the caller's¹ response to certain questions¹⁵ The EMD confirms the caller's location and notifies the closest provider to dispatch EMS services.¹⁶ Finally, the EMD provides prearrival instructions to patients or bystanders based on protocols approved by the EMS medical director.¹⁶ All aspects of emergency medical dispatching are the ultimate responsibility of the EMS medical director, who oversees training, approval of dispatch protocols, the development of prearrival instructions, and quality improvement of EMDs within the EMS system.¹

Based on the information provided by the caller, the dispatcher may send only a nontransporting EMR that can perform cardiopulmonary resuscitation (CPR) and use an automated external defibrillator (AED).¹⁷ In a tiered dispatch system, EMTs will respond to most calls, as they can maintain a rapid response time. In a tiered system, advanced EMTs or paramedics respond only to critical cases, and a physician medical director is present at the scene in only unique circumstances.¹⁵ Uniform dispatch is one in which the dispatcher sends the same level of personnel to every call, which in some systems may be a combined response of both ALS and BLS units, or just ALS units only.¹⁵ In a combined response, paramedics will provide critical care while EMTs can begin to transport patients from the scene. The tiered dispatch system decreases the need for more paramedics, which are difficult for some communities, especially rural ones, to support.¹⁵ This appears to have no effect on prehospital survival rates compared to a one-tier system that dispatches only paramedics.¹⁵

Provider Nomenclature

Recently the nomenclature for prehospital providers was standardized nationwide to ensure consistency from one state to another.^1,18 There are two levels of response in the prehospital setting: BLS and ALS.¹⁸ EMRs, formerly known as First Responders, and emergency medical technicians (EMTs), formerly known as EMT-Basics, provide BLS care in the EMS system.¹⁸ These providers receive training for scene response and initiation of basic life support such as CPR.¹⁸ EMTs have fundamental knowledge to provide patient care and transportation, and they make up the majority of the nation's prehospital providers.¹⁸

Advanced emergency medical technicians (AEMTs) and Paramedics provide ALS care.¹⁸ AEMTs were formerly known as either EMT-Intermediates, EMT-85s, or EMT-99s.¹⁸ AEMTs have additional training to provide ALS care both on scene and during transport including advanced airway management and the administration of medications.¹⁸ Approximately 7% of prehospital providers are Advanced EMTs.¹⁹ Paramedics, formerly known as EMT-Paramedics, are allied health professionals who have undergone extensive training to enable them to provide ALS care to critically ill patients.¹⁸ Approximately 31% of prehospital providers in the nation are paramedics.¹⁹

Scope of Practice

In general, the amount of EMS provider training parallels their scope of practice as outlined in the National EMS Scope of Practice Model, and specific educational requirements for licensure vary from state to state.¹⁸ The scope of practice for EMRs focuses on basic airway maneuvers such as head tilt and chin lift, use of the oropharyngeal airway, bag mask ventilation, and supplemental oxygen therapy.¹⁸ They have training in vital sign assessment, including manual blood pressure measurement, and have training in basic management of medical conditions, including assisting a patient in the use of autoinjectors, manual CPR and AED use.¹⁸ Their trauma training includes manual stabilization of cervical spine and extremity injuries, control of bleeding, and eye irrigation.¹⁸

EMTs have the basic scope of practice of EMRs, and they can also manage ingestions and burns, provide oral glucose, assist patients with home medications such as inhalers and autoinjectors, stabilize injuries, and use noninvasive devices to maintain an open airway and assist breathing.¹⁸ EMT training includes basic anatomy and physiology with instruction in BLS practices, including CPR and AED usage.¹⁸ EMTs can elicit basic histories and perform physical examinations, and they have basic airway training for upper airway obstruction management and bag mask ventilation.¹⁸ They receive education in basic trauma care including spinal immobilization and splint application, and they are also trained to assist with medication administration to awake and alert patients, including oral and autoinjector medications.¹⁸

AEMTs have the EMT scope of practice with the addition of skills in advanced airway management, including the use of supraglottic and tracheal airways.¹⁸ They also have training in intravenous and intraosseous needle placement, as well as administration of parenteral and inhaled medications.¹⁸

Paramedics have the scope of practice of AEMTs with the addition of several more advanced skills.¹⁸ Paramedics undergo a rigorous educational regimen, which includes instruction on advanced airway management with direct laryngoscopy, end-tidal carbon dioxide monitoring, nasogastric and orogastric tube placement, electrocardiogram (ECG) with 12-lead interpretation to determine the need for cardioversion and transcutaneous pacing, needle decompression and chest tube placement, and infusion of blood products.¹⁸ In response to appropriate rhythms they are able to manually defibrillate, perform vagal maneuvers, administer synchronized cardioversion, and conduct transcutaneous pacing.¹⁸ For orthopedic injuries, they can straighten select fractures and reduce dislocations.¹⁸

Education Standards

In 2009, the National Association of EMS Educators (NAEMSE) created the National EMS Education Standards in an effort to define minimal educational competencies for each level of EMS personnel as identified in the National EMS Scope of Practice Model.²⁰ The education standards define the curriculum for teaching EMS students.²⁰ Because there is no national school where EMS providers receive training, there is significant variation in training between states and between localities within states.²⁰

Each state maintains their own educational requirements for initial education and continuing education for providers to be certified in that state.¹⁹ All 50 states require that their EMS providers be licensed, and many require that EMS providers meet certification and recertification requirements delineated by the National Registry of Emergency Medical Technicians (NREMT).¹⁹ In most states, licensure renewal occurs every 2 to 3 years with continuing education often required for renewal.¹⁹ The NREMT has created specific guidelines outlining education requirements and proof of procedural skill competencies. An estimated 84% of the nation's EMTs are currently certified by the NREMT.¹⁹

Rural Challenges

Rural EMS providers face many challenges when caring for children. They have longer transport times and care for fewer children in general, often resulting in challenges with pediatric specific skills retention.¹⁵ It is challenging to obtain training locally; thus, paramedic level providers are limited.^20,21 Rural providers typically do not have standardized protocols available to them for care, and long transports with limited radio contact for online medical control often leaves them without guidance to provide care.²¹ When available, the medical direction for rural EMS providers often comes from local community hospitals where there is a lack of pediatric emergency medicine expertise.²¹ Moreover, there is a high turnover of EMS staff and a significant number of volunteer providers in these setting with little to no support for provision of continuing education.¹⁵ Finally, most programs must rely on grants to fund rural EMS programs as no systematic method exists to fund these programs.¹⁵

Protocols

Prehospital care is protocol-driven, and EMS agency medical directors approve offline protocols to allow EMS providers to initiate care in the field.¹ Since children have unique needs, the development of pediatric-specific protocols is vital to the care of children in the prehospital setting.^5,6 Many EMS agencies either integrate pediatric-specific emergency care within adult-based care protocols or develop separate pediatric prehospital patient care protocols.^5,6 Some EMS agencies routinely develop separate pediatric protocols to highlight the differences in dosing, equipment size, and patient assessment for each pediatric patient.^5,6

In developing prehospital protocols, consideration should be given to provider training, scope of practice, and the best available evidence.²² Unfortunately, most pediatric patient care protocols are not evidence based due to limited existing evidence in prehospital care, but studies in the emergency department setting and adult studies from the prehospital setting can be used to inform practice for children.²³ Also, soliciting the input of other key stakeholders including nurses, prehospital providers, medical directors, and families may highlight unforeseen needs and constraints in the protocol development process.²² Finally, considerations for the feasibility of implementation in the prehospital setting may also affect decisions about protocol development.²² Prior to and after implementation, provider education and performance improvement measures are important to ensure desirable patient outcomes.²² The EMSC program, in partnership with the National Association of EMS Physicians (NAEMSP), developed model pediatric prehospital protocols in 2003.²⁴ Currently EMSC, NHTSA, the Federal Interagency Committee on EMS (FICEMS), and the National EMS Advisory Council (NEMSAC) are collaborating to develop and implement selected evidence-based prehospital protocols for adults and children.²⁵

Equipment

The 2007 IOM report on emergency care for children recognized the unique challenges associated with caring for children, including the need for size-appropriate medical equipment and weight-based medication dosing.⁵ The American College of Surgeons (ACS) Committee on Trauma has created a list of standardized equipment for ambulances, which has been periodically updated in collaboration with the American College of Emergency Physicians (ACEP), NAEMSP, EMSC, the American Academy of Pediatrics (AAP), the Emergency Nurses Association (ENA), and the National Association of State EMS Officials (NASEMSO) among other key stakeholder organizations.²⁶

Though standardizing equipment and medication lists is helpful for delivering high quality care to children in the prehospital setting, it is also imperative to understand the limitations of having a standardized list across all agencies due to funding and training limitations within a local system. Since not all equipment may be essential, but might be useful when caring for a child, lists of optional BLS and ALS equipment are also noted in the published equipment list document.²⁶ Since local resources may vary, the items on the optional lists are intended to be a guide for items to carry if resources allow for their availability and use.²⁶

Transport

Ground transport options include first responder vehicles operated by police and fire services, BLS and ALS ambulances, specialized all-terrain medical transport vehicles, and critical care transport units.²⁷ Recent decades have also seen a proliferation of air medical transport services including both fixed and rotary wing helicopter units.²⁷

In 2003, a policy paper on Guidelines for Air Medical Dispatch summarized important considerations in the complex decision of determining the best mode of patient transport. Helicopter transport is advantageous because it has the potential to decrease response and transport times when greater distances to traverse are required. Avoiding a ground route can make difficult terrain more accessible, but the risk of accidents in the setting of poor weather, limited availability, and high cost are disadvantages that must be considered.²⁸ The general principles espoused by this guideline include providing critical interventions in the most expeditious manner possible, transporting stable patients in a manner that best addresses the needs of the patient and the system, and transporting the critically ill or injured patient by the fastest available modality with the highest level of transport care skill.²⁸

Safety must always remain the primary determinant of transport modality, and the potential benefit of time saved with lights and sirens does not seem to outweigh the risk of fatal injury to pedestrians and nonambulance occupants when ambulance collisions occur.²⁹ In addition, proper restraint of children in ambulances in accordance with the NHTSA Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances is essential.³⁰ These guidelines emphasize the proper use of safety restraint devices for pediatric patients in ambulances, considering delayed transport if safety equipment is not available for the child who is not ill or injured, stopping the ambulance for interventions in the child whose condition requires continuous monitoring or intervention, securing children to a size-appropriate spine board when spinal immobilization is required, and separately transporting children when part of a multiple patient transport, such as a newborn and its mother or sibling victims.³⁰

Role of the Medical Director

In the United States prehospital providers deliver patient care under the direction and guidance of a designated physician or group of physicians.¹ The basic premise of authorizing the provision of medical care and delegating the actual delivery of care to a nonphysician is the clinical cornerstone of every EMS system.¹ The EMS Medical Director defines the situations for which field personnel must obtain authorization from a base station versus contacting him or her directly or functioning based on guidelines or protocols.¹ It is the responsibility of the medical director to ensure that base station personnel have appropriate pediatric knowledge and skills, and that their online advice conforms to the pediatric guidelines and protocols of their EMS agency.³¹ The medical director oversees agency-based continuing education, including opportunities for cognitive, psychomotor, and affective learning.³¹ Medical directors oversee run reviews as part of a systematic quality improvement program, with defined metrics followed over time such as time to intubation, medication errors, and compliance with protocols.³¹ Medical directors also get feedback from emergency department staff on field management and ultimate diagnosis to enhance the value of run reviews.³¹ Medical directors are often public health authorities for their region and transmit timely information to the public in the setting of a disaster or major public health emergency.³¹

Medical Oversight and Base Stations

There are two types of medical oversight, online and offline.¹ Offline, or indirect, medical oversight involves the development of medical policies and protocols used by field personnel, monitoring of clinical care based on measured outcomes and evidence-based practice, implementing quality improvement programs, and educating providers of all levels.¹ Online, or direct, medical oversight is the concurrent clinical direction provided to field personnel by a medical director or his/her delegate.¹ Direct medical oversight is available in most regions of the United States, and is most commonly initiated either in person, on scene or via staff at a designated base station, communication center or hospital.¹ In addition, base station staff connect field personnel with medical oversight via radio, telephone, or live video feed.¹

The role of a base station is to provide online medical direction and continuing education for prehospital providers, as delegated by the EMS medical director.¹ A base station supports and monitors the implementation of and provider compliance with EMS policy and protocols.¹ In addition, the base station connects providers with physicians when needed.¹ Finally, base stations ensure that the line of communication remains open between every facet of the EMS system that involves clinical care.¹

Federal and Statewide System Organization

Several key federal agencies play an important role in providing structure to EMS at a national level. The National Highway Traffic Safety Administration (NHTSA) is the primary agency that has defined EMS scope of practice and education standards.¹⁸ The Federal Emergency Management Agency (FEMA) has played an essential role in coordinating disaster response with EMS.¹² In 2005, the EMS Support Act created the Federal Interagency Committee on EMS (FICEMS), which provides regulatory authority for EMS on a national level.¹ Although governance of the scope, authority and operation of local EMS is a function of state law, FICEMS ensures coordination among the federal agencies involved with state, local, tribal, or regional emergency medical services and 911 systems by recommending new or expanded programs, grant funding, and improved emergency medical services communications technologies, including wireless 911.¹

The state-level EMS systems are highly variable, and each state has a lead EMS agency that is typically a part of the state health department.^19,33 State EMS systems approve statewide changes in EMS policies, oversee local and regional EMS systems and personnel, license and certify EMS personnel and ambulance providers, provide funding for EMS services, establish training requirements, and establish quality improvement and system performance programs.^32,33

Regionalization

Regionalization is the geographical organization of services to ensure access to care at a level appropriate to patient needs while maintaining efficient use of available resources.^2,5,6 Regional boundaries may include or encompass existing single or multiple state, county, or EMS geopolitical borders. Regionalization allows for the transport of patients to receive the most appropriate care for an injury or illness and prevents transport to an initial hospital that cannot provide definitive care; thus, eliminating duplication of ED evaluations and interventions.^2,5,6 For conditions such as trauma, burns, stroke, myocardial infarctions, and pediatric critical care, it has been shown to improve outcomes by decreasing morbidity and mortality.^6,34

Successful implementation of regionalized care requires a defined geographic area, within which coordination of emergency medical services, hospitals, and rehabilitation facilities occurs.^6,35 It is also important that primary triage occur at the level of EMS and that these criteria are established in advance and used consistently throughout the region.⁶ Secondary triage can occur at the facility level to determine if interfacility transport is necessary.⁶

For the pediatric patient, these models exist in many areas. Pediatric Critical Care Centers (PCCC) are comprehensive centers with pediatric intensive care unit and pediatric subspecialty capability.³⁶ Emergency Departments Approved for Pediatrics (EDAP) have staff, policies and procedures, equipment and medications to care for children based on local, state, or national guidelines.^37,38 Finally, pediatric trauma centers exist, and criteria are often adopted from the American College of Surgeons' criteria.³⁹

Consent for and Refusal of Care

Emergency care without parental consent can be provided regardless of age, and EMS providers should initiate reasonable and appropriate care to minors in emergent and urgent settings.⁴⁰ Minors cannot refuse treatment and transport in an emergency situation, but if a legal guardian is present and refuses care for his/her child, the guardian should be informed of the risks of not treating the child and be asked to sign a form releasing the EMS service from responsibility.⁴⁰ Refusal of EMS care for children occurs in about 5% of all EMS runs, commonly in motor vehicle crashes (MVC), minor injuries, and in respiratory problems or choking episodes.⁴¹

Requirements for nontransport of minors vary from one agency to another, but EMS crews should ensure the lack of immediate life or limb threat for the child and seek approval from both a medical control physician and a guardian who agree with the nontransport decision.^42,43 In many agencies, the EMS provider is not allowed to initiate the request for nontransport.^42,43

Termination of Resuscitation and Out-of-Hospital Do Not Resuscitate Orders

It is known that the likelihood of successful resuscitation in children with cardiac arrest is extremely low, yet controversy exists about whether there are reliable predictors to definitively advise providers of the appropriate timing to terminate resuscitative efforts.^44,45 Although family members may be accepting of termination of CPR in adults, families and EMS providers may be reluctant to terminate resuscitation of children in the field.^45,46 Therefore, many agencies continue CPR until arrival to a hospital, except in cases of obvious futility such as decapitation, rigor mortis, and signs of lividity.^45,46

End-of-life directives, including Do Not Resuscitate (DNR) orders and Physician Orders for Life-Sustaining Treatment (POLST) create a difficult situation for EMS providers.⁴⁷ To be able to honor DNR directives, a written DNR order must be present; having it on file at the hospital or with the primary care physician is insufficient.⁴⁷ Also, the family must verbally agree that the DNR order is still in effect, and the child must be correctly identified as the recipient of the DNR order.⁴⁷ Finally, the state must include children in the DNR laws, and some states require the patient to have a terminal medical condition or be permanently unconscious.⁴⁷ A POLST converts a patient's treatment preferences into a medical order that not only can be used in the prehospital setting, but is transferable throughout the healthcare system.⁴⁷ In the absence of a valid written DNR order or POLST, the EMS providers should provide standard resuscitation and transport.

Child Maltreatment

Prehospital providers have an important role in identifying, reporting, and documenting findings in cases of suspected child maltreatment. They frequently lack knowledge about developmental milestones in children, making the comparison of described behaviors of children and their capabilities difficult.⁴⁸ Though prehospital providers have limited education in child maltreatment, the results of a national survey suggest that most prehospital providers have the skills to recognize signs of physical abuse such as patterned burns and bruises.⁴⁸ Not all EMTs are mandated reporters, so knowledge of local laws and education for prehospital providers on the recognition and documentation of suspected child abuse is essential.⁴⁸