Tia Dickson, RN, BSN

Primary Children's Hospital

It's back to school and that seems like a good time to think about our kids and some of the social behaviors that may lead to an EMS transport.

Excerpts from Cathy Davis, MA ED

Suicide Prevention Education Specialist

Utah Board of Education -reprint

In the past decade, there have been many stories in the media about bullying and links to teen suicide. Research has shown that approximately 1 in 2 teens experience some degree of bullying with up to 1 in 6 report dealing with cyberbullying. Bullying includes actions such as making threats, spreading rumors, attacking someone physically or verbally, and excluding someone from a group on purpose.

There is an emphasis that school administrators and teachers should take the lead in prevention but really this is a huge problem and all community leaders like EMS responders and parents should take part. This is a wide spread problem and it’s prevention should involve us all.

The CDC reported on some common research findings in their pamphlet; The Relationship Between Bullying and Suicide: What We Know and What it Means for Schools and Utah has taken a close look as well Utah Bullying Statistics.

• Youth who feel connected to their school are less likely to engage in suicide-related behaviors
• Youth who are able to cope with problems in healthy ways and solve problems peacefully are less likely to engage in suicide and bullying related behaviors.
• Youth with disabilities, learning differences, sexual/gender identity differences or cultural differences are often most vulnerable to being bullied

At StopTheBullying.gov we get great direction on where to start.

Stop It on the Spot

When adults respond quickly and consistently to bullying behavior, they send the message that it is not acceptable. Research shows this can stop bullying behavior over time. There are simple steps adults can take to stop bullying on the spot and keep kids safe.

Do:

• Intervene immediately. It is ok to get another adult to help.
• Separate the kids involved.
• Make sure everyone is safe.
• Meet any immediate medical or mental health needs.
• Stay calm. Reassure the kids involved, including bystanders.
• Model respectful behavior when you intervene.

Avoid these common mistakes:

• Don’t ignore it. Don’t think kids can work it out without adult help.
• Don’t immediately try to sort out the facts.
• Don’t force other kids to say publicly what they saw.
• Don’t question the children involved in front of other kids.
• Don’t talk to the kids involved together, only separately.
• Don’t make the kids involved apologize or patch up relations on the spot.

Get police help or medical attention immediately if:

• A weapon is involved.
• There are threats of serious physical injury.
• There are threats of hate-motivated violence, such as racism or homophobia.
• There is serious bodily harm.
• There is sexual abuse.
• Anyone is accused of an illegal act, such as robbery or extortion—using force to get money, property, or services.

Find Out What Happened

Whether you’ve just stopped bullying on the spot or a child has reached out to you for help, follow the steps below to determine the best way to proceed.

• Get the facts
• Determine if it’s Bullying
• Keep all the involved children separate.
• Get the story from several sources, both adults and kids.
• Listen without blaming.
• Don’t call the act “bullying” while you are trying to understand what happened.
• It may be difficult to get the whole story, especially if multiple students are involved or the bullying involves social bullying or cyberbullying. Collect all available information.

Support the Kids Involved

All kids involved in bullying—whether they are bullied, bully others, or see bullying—can be affected. It is important to support all kids involved to make sure the bullying doesn’t continue and effects can be minimized.

• Support Kids Who are Bullied
• Address Bullying Behavior
• Support Bystanders Who Witness Bullying

Be more than a bystander, be a supportive bystander

Tip 1: Be their friend

Children can help someone who’s been bullied by simply being nice to them at another time. Being friendly can go a long way toward letting them know they are not alone.

Tip 2: Tell a trusted adult

An adult can help stop bullying by intervening while it’s in progress, stopping it from occurring or simply giving the person bullied a shoulder to lean on.

Tip 3: Help them get away

There are a few simple, safe ways children can help the person being bullied get away from a situation. However they do it, make sure the child knows not to put themselves in harm’s way.

• Create a distraction
• Offer the person a way out, e.g., “Mr. Smith needs to see you right now.”
• Intervene only if it feels safe to do so. Never use violence to help the person get away.

Tip 4: Set a good example

If a child knows not to bully others, then other students will follow their example. To help even more, children can actively participate in anti-bullying activities and projects.

Tip 5: Don’t give bullying an audience

If one of your child’s friends or peers begins to bully someone, they shouldn’t encourage the behavior by giving it an audience. Instead of laughing or supporting it, they can let the bully know that such behavior isn’t entertaining.

If you want help in empowering the children in your community and schools contact The Utah Anti-Bullying Coalition http://www.utahantibullying.org/

Cyber-bullying, the use of electronic communication to bully a person, typically by sending messages of an intimidating or threatening nature, is also a problem in Utah schools.

The NetSafe Utah Project includes presentations, workshops and online resources for kids, teens, parents and educators. NetSafe Utah is adapted continually to provide Utah schools and communities the Internet Safety information they need and helps schools meet Children’s Internet Protection Act (CIPA) requirements.

Opportunities to deploy the tips above may arise in your response to fights or violence at school but any interaction with youth (community fairs or teaching events) may also present a good chance.

Bullying is more than a kid problem. It continues through all levels of education and into the workplace. Bullying and harassment has been a contributing factor in first responder suicides. There is no excuse for bullying in the workplace.

What begins as experimentation can turn into addiction. It is normal for teens to try things and test boundaries. According to Nora Volkow, a physician and the director of the National Institute on Drug Abuse, “The adolescent years are a key window for both substance use and the development of substance use disorders.”

The most common substances used by teens include:

• Marijuana. Marijuana is often thought to be somewhat harmless, but it can be addictive. One study showed that nearly 13% of those with a substance abuse disorder began using marijuana by the time they were 14 years old.
• Alcohol. The appeal of alcohol is often the ease of access. Alcohol is also glamorized by the media and thought to be less dangerous since it is legal for adults to purchase and consume. Many teens do not understand the power of alcohol and its impact on decision-making. Drinking can lead to risky behaviors such as driving while intoxicated.
• Prescription drugs. Prescription and over-the-counter (OTC) drugs are, after marijuana and alcohol, the most commonly abused substances by Americans 14 and older. These drugs have a medical purpose, but when taken in large quantities, snorted, or injected into veins, the possibility of overdose and even death is significantly higher.
• Tobacco/Electronic cigarettes or e-cigarettes.
• Painkillers (Oxycodone, Vicodin)
• Synthetic drugs.

Drug poisoning deaths are a preventable public health problem; they are the leading cause of injury death in Utah, outpacing deaths due to firearms, falls, and motor vehicle crashes. Utah is particularly affected by prescription opioids, which are responsible for 41% of the unintentional and undetermined drug poisoning deaths in the state.

While most of these deaths are adults, Utah’s children are impacted both directly and indirectly by this epidemic and by these deaths.

Opioid overdose kills because it causes respiratory depression. This leads to:

• Slow or no breathing- cyanosis from very slow breathing which progresses to apnea when the breathing stops
• Cardiac arrest as the heart stops because it’s not getting oxygen
• Circulatory collapse as circulation of blood to the brain stops

Clinical Presentation: Mental status changes, respiratory depression, hypo/hypertension, seizures and arrhythmias (tachycardia/bradycardia). A large majority (78%) of reported poisonings are managed safely at home but when EMS is called it is extremely important to stabilize and transports according to agency policy. Even the asymptomatic child must be monitored closely for delayed affects.

An opioid overdose is recognizable by the following signs and symptoms:

• Somnolence- can’t arouse them, they don’t respond to painful stimuli
• Respiratory depression- Very slow or gurgling respirations, and ultimately no breathing (apnea)
• Cyanosis- turning blue, noticed first around lips and fingers
• Pinpoint pupils (miosis)
• Cold or clammy skin
• Bradycardia- slow heartbeat (<50)

Opiate overdose is reversible. Timely administration of the drug naloxone (Narcan) and the provision of emergency care can make all the difference. It will reverse the respiratory depression and stop the overdose very effectively.

• Naloxone is only effective against opioid overdoses and not against overdoses of other substances such as alcohol, cocaine, methamphetamine, or benzodiazepines.
• In some cases, more than one dose of naloxone is needed to reverse the effects of an opioid overdose.
• Reversal effects last only 30-90 minutes. This requires that patients be observed after administration because they are at risk of symptoms returning.
• The main side effect of administration is possible agitation and aggression since the patient may be sent immediately into opioid withdrawal. Vomiting is also reported about 10-15% of the time it is administered.

First responders play the biggest role in administering to antidote but today, there are patients and families (laypersons) who legally have naloxone in their possession to give to someone in the event of an overdose. Those laypersons receiving the naloxone rescue kits are trained to recognize an opioid overdose and to:

1. Call 911

2. Provide Rescue Breathing

3. Administer naloxone

4. Place the person on their side in the event of vomiting

5. Administer 2nd dose of naloxone after 3-5 minutes if needed

6. Remain with them until EMS arrives

Death by opioid overdose is a tragedy that can be simply and safely reversed by administration of naloxone.

On Topic:

• No Peers, No Beers: WVU Research Shows Youth Substance Use Declined During the COVID-19 Pandemic | WVU Today
• Black-White Racial Context and U.S. American Youths’ Moral Judgments of and Responses to Social Exclusion Bullying | The Journal of Genetic Psychology
• Heterosexist Bullying Victimization and Perpetration and Substance Use Among Heterosexual Adolescents | International Journal of Behavioral Medicine
• Interpersonal Violence Victimization Experiences of Middle School Youth: An Exploration by Gender and Sexual/Romantic Attraction | Journal of Homosexuality
• The Influence of Descriptive and Injunctive Norms on U.S. Adolescent Marijuana Use: A Systematic Review of the Literature | Journal of Studies on Alcohol and Drugs
  

Seasonal prevention

• Back to School Month | National Safety Council (NSC)

  Child Pedestrian Safety Curriculum | National Highway Traffic Safety Administration (NHTSA)
  

Suicide prevention

• Youth Suicide Attempts Drop in U.S. States with Hate Crime Laws | U.S. News and World Report
• Preventing Suicide in Schools—A Systemwide Approach | Education Development Center (EDC)
  

Utah EMSC is excited to welcome Sarah Becker as our new Medical Director!

Dr. Sarah Becker received her medical degree from Midwestern University, completed her Pediatric residency at the University of Arizona, and her Pediatric Emergency Medicine fellowship at the University of Utah, Primary Children’s Hospital.

She is currently an Assistant Professor of Pediatrics at the University of Utah in the Division of Pediatric Emergency Medicine at Primary Children’s Hospital.

Her interests include pediatric EMS process improvement, specifically ways telemedicine technology can optimize the delivery of care to pediatric patients. She also continues work on airway management, using cognitive aids to streamline the process of pediatric intubation. She is board certified in pediatrics and in pediatric emergency medicine.

Keep this on your radar

In the last few months, have you treated or transported a first time "wheezer"? They are often in the grips of what looks like a full blow asthma attack but there is no history of asthma. They get an asthma treatment protocol of inhalers, steroids and even magnesium and you find out later they tested positive for rhinovirus.

We are seeing many of these situations at Primary Children's and in fact EDs across the country are seeing huge surges of children with upper respiratory infection (URI) and wheezing, many who have never had wheezing before. There is suspicion that kids testing positive for rhinovirus, in fact have another virus known as enterovirus strain D68 (EV-D68) and we are in the midst of an outbreak.

Making news right now are reports of Acute Flaccid Myelitis (AFM) in children and its possible association with EV-D68.

What is Acute Flaccid Myelitis (AFM): https://www.cdc.gov/acute-flaccid-myelitis/about-afm.html.

• An uncommon but serious neurologic condition. It affects the nervous system, specifically the area of the spinal cord called gray matter, which causes the muscles and reflexes in the body to become weak.
• We have had cases of flaccid paralysis in Utah in kids.
• There have been every other year occurrences of AFM (2016, 2018, skipped 2020, seeing it now in 2022). Early research indicates there may be a relationship to an enterovirus strain 68.
  

The CDC has asked physicians and healthcare providers to be on alert for symptoms of AFM.

What are the symptoms of EV-D68 infection?

EV-D68 can cause mild to severe respiratory illness, or no symptoms at all.

• Mild symptoms may include runny nose, sneezing, cough, body aches, and muscle aches.
• Severe symptoms may include wheezing and difficulty breathing.

Anyone with respiratory illness should contact their doctor if they are having difficulty breathing or if their symptoms are getting worse. Seek immediate medical attention if you or your child develops any of these AFM symptoms following a respiratory illness:

• arm or leg weakness
• pain in the neck, back, arms, or legs
• difficulty swallowing or slurred speech
• difficulty moving the eyes or drooping eyelids
• facial droop or weakness

If there is concern for AFM, call or refer the patient to Primary Children's Hospital.

For more info:

https://www.cdc.gov/acute-flaccid-myelitis/cases-in-us.html

https://www.cdc.gov/non-polio-enterovirus/about/ev-d68.html

https://asm.org/Articles/2022/April/Enterovirus-D68-and-Acute-Flaccid-Myelitis

https://www.webmd.com/children/news/20140909/enterovirus-d68-parents

REGISTRATION CLOSES TODAY!

Are you registered for our annual PECC Conference happening this month, this Friday? Registration closed today!

EMS Agency & Hospital PECC's are invited to our 2nd Annual PECC conference!

When: Friday September 16, 2022

Where: Utah Valley Convention Center, 220 West Center Street, Provo, UT 84601 (you can also attend virtually).

Time: 12:00-16:00

This conference is FREE. Presentations will be a hybrid of virtual and in-person presentations and would like to know how you would like to participate. Please register so we can plan accordingly.

Register by clicking on the link https://tinyurl.com/ywcjw854

Questions - JaredWright@Utah.gov

Do you have a question for our EMSC medical director, Sarah Becker, MD, PCH, ER attending physician about this newsletter topic or anything related to pediatrics? Email tdickson@utah.gov.

Pediatric Education for the Prehospital Provider

Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, regardless of where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth