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EMSC Connects
October 2022; Vol.11, Issue 10
Pedi Points
Tia Dickson, RN, BSN
Primary Children's Hospital
- Nearly 20% of U.S. children younger than age 18 have a special health care need.
- One in 5 U.S. families have a child with a special health care need.
More than 80% of EMS agencies nationally see fewer than 8 pediatric patients per month. They are outside our comfort zone. When you add a complex medical history, unfamiliar medical equipment, and involved treatment protocols these calls can become especially frightening. Halloween time is a great time to face our fears and battle our demons (a.k.a. knowledge deficits).
The Doc Spot
Care for Children with Medical Complexity
David Sandweiss, MD, Pediatric Emergency Medicine
University of Utah and Primary Children's Hospital
Excerpts from September 12th PETOS
Children with medical complexity (CMC) are those with significant chronic health problems. They may have multiple organ system involvement or major functional limitations. They may need substantial health services. In the past decade, U.S. hospitalizations for these children have increased by 33%.
"The Golden Tip" of caring for a child with medical complexity: parental wisdom or knowledge is gold. They know their child, their child's baseline, and vitals. Trust them!
Even if you haven't before, you may start caring for these children more often. Nationally this population is increasing.
- Medical advancements are leading to better survival rates
- Medical technology advances allow these children to live more often at home, school, and within the community
- More support services (less insurance coverage) lead to more community based care
Common chronic conditions you may run into:
- Respiratory
- Cardiovascular
- Gastrointestinal
- Neurological/neuromuscular
- Metabolic
- Immunologic/infectious
- Behavioral
Common Technologies you may run into
Trachs
As the child grows they will need progressively larger tubes.
Reasons a child might have a trach
- Anatomic: an issue with the structure or function of the upper airway. Something prevents air from traveling to the lungs. Examples: trauma, congenital issues from birth, cerebral palsy.
- Diseased tissue (airways/lungs): Example: chronic lung disease.
- Respiratory drive issue: A disconnect between the brain or nerves and the movement of breathing.
Mucus plugging • Accidental decannulation
- Mucus plugging: when mucus collects in the trach tube or airway, it can create a plug. This can block air from flowing through the airway. Treat with instillation of sterile saline drops and suctioning. If the tube cannot be cleared, replace the tube with a new one (which the parent should have with them at all times).
Skill Refresher - How to suction a trach
- Accidental decannulation: Accidental decannulation or extubation refers to inadvertent removal of tracheostomy tube out of the stoma. It could prove fatal in an otherwise stable patient. Treatment would be to replace the tube. If unsuccessful, use a bag-valve–mask device to ventilate the child through the upper airway. To maximize oxygenation, ventilate gently to prevent air escaping through the stoma or carefully occlude the stoma with a gloved hand.
Skill Refresher - Routine Trach Change
Vents
- Lung diseases
- Muscular/skeletal > weakness
- Neurologic diseases > poor effort/weakness
- Airway diseases that limit airflow
Decompensating on a mechanical ventilator may prompt a call to EMS (especially at school or away from the parent).
The DOPE mnemonic is the gold standard for trouble shooting a vent.
- Displacement—starting at the patient, check the trach or ET tube position
- Obstruction—look for patency of the tube
- Pneumothorax—pressures from the vent can blow a pneumo; assess for unequal breath sounds or chest rise
- Equipment failure—Check all connections from the patient to the machine to the plug in the wall.
If your assessment doesn't reveal the cause and decompensation continues, it's best to disconnect from the machine and manually bag through the trach.
Skill Refresher: when and how to use manual ventilation
Lines
Central line tips for EMS
- Unless it's life or death, do not use these tubes, establish your own peripheral line.
- If the tube is leaking or broken, do not pull it out. Clamp above the break toward the patient and cover the hole or broken end with a sterile gauze.
Tubes
- Nasogastric tube (NG tube) inserted through the nose to the stomach
- Nasojejunal tube (NJ tube) inserted through the nose to the intestine (done by fluoroscopy)
- Percutaneous endoscopic gastrostomy (PEG) inserted directly into the stomach through the belly
G-tube tips for EMS
You won't often be called to a scene for a primary G-tube problem. If you are, it tends to be because the tube has been pulled or has popped out. Parents are trained to replace a nasogastric tube and usually won't involve EMS. Nasojejunal tubes must be replaced by a radiologist.
Occasionally EMS may be involved when a PEG (or MIC) tube pops out of the belly and the parent can't replace it. The important thing to remember is that stoma (the hole through the abdomen into the stomach) is surrounded by muscle and it can close very quickly. If closed, the child will need surgery to replace it. Our priority is to keep that hole open. Inserting a small, place-holding tube into the stoma is often the EMS providers best option. Using an 8fr suction catheter or similar tube, lube the end and gently insert the tube into the stoma about 1 inch. Tape it in place. This is a clean, not sterile procedure. Do not force it but gentle pressure and a twisting motion can help relax the muscles.
Other Resources
Protocols in Practice - Airway and Tracheostomy Management
News From National
On Topic:
Seasonal prevention
- October 1-31, 2022, National Pedestrian Safety Month | National Highway Traffic Safety Administration
Suicide prevention
Every year 2,817 children and adolescents age 0-19 die by suicide. Suicide was the second leading cause of death among individuals between the ages of 10-14 and the third leading cause of death among individuals between the ages of 15-24 in 2020. Recently the U.S. Surgeon General issued an advisory on protecting youth mental health, a public health crisis. Below are recent CSN resources on suicide prevention:
- Child Safety Data for Adolescent Suicide Deaths (Fact Sheet)
- Suicide Prevention Fact Sheet: Means of Suicide (Fact Sheet)
- Culturally Relevant Approaches to Preventing Suicide Among American Indian and Alaska Native Youth (Webinar)
- Preventing Suicide and Self-Harm Among Black Youth (Webinar)
- Firearm Safety: Preventing Death by Suicide (Infographic)
988: Three Digits and the Nationwide Effort to Help Millions in Crisis | McKinsey Health Institute
News from Utah EMSC
EMSC open office hours
Zoom link
BEMSP is inviting you to a scheduled Zoom meeting.
Join Zoom meeting
https://utah-gov.zoom.us/j/87005645259
Meeting ID: 870 0564 5259
When
Monthly from 9 a.m. to 10 a.m. on the first Tuesday from Tuesday, November 1 to Tuesday, February 7, 2023 (Mountain Time—Denver)
PECC Development
Along with the above monthly open office hours to be used prn, we will implement a quarterly, virtual, PECC meeting. We want to stay in touch, network, and hear from you throughout the year. Our first meeting will be November 15, 2022.
The 2nd Annual PECC Conference was held on September 16, 2022 in Provo. Eighty-three people attended, both online and in person. The agenda was packed with PECC role instruction and resources. If you were unable to attend you can watch the recording here: https://drive.google.com/file/d/1b8p5imH5Flyl6t6l6YDXSfaU-GM5hxG5/view?usp=sharing
Attendance included orientation materials and digital google doc access to trainings and other materials to aid you in your role. If you would like those resources, please contact Jaredwright@utah.gov
Barriers and enablers to recruiting for the PECC role in EMS agencies
More than 80% of EMS agencies see fewer than eight children per month. As a result, many EMS professionals may have limited pediatric-focused education opportunities and infrequent encounters with children. In 2007, the Institute of Medicine recommended EMS agencies designate a pediatric emergency champion, or pediatric emergency care coordinator (PECC), to support the care of children. The PECC oversees pediatric quality improvement initiatives, provide skills-based pediatric training to agency staff, and ensure pediatric medications, equipment, and supplies are available.
To identify best practices to increase the percentage of EMS agencies with PECCs—which is a performance measure for the EMSC Program’s 58 State Partnership grantees—the EMSC Innovation and Improvement Center hosted a 6-month PECC Learning Collaborative (PECCLC). Findings from the PECCLC were published last month in the journal Prehospital Emergency Care.
The PECCLC engaged 9 states (Connecticut, Kentucky, Montana, New Mexico, New York, Ohio, Pennsylvania, Rhode Island, and Wisconsin). State representatives participated in virtual monthly learning sessions with subject matter experts and support staff as well as a 2-day in-person meeting.
PECCLC outcomes
Outcomes of the PECCLC showed that during the 6-month collaborative, state representatives recruited 341 PECCs (92% of predetermined recruitment goals). During the 5 months after the collaborative, 184 more PECCs were recruited for a total of 525 PECCs (142% of goal). State representatives and PECCs reported the biggest barriers to PECC recruitment were:
- competition from other EMS responsibilities,
- budgetary constraints,
- lack of incentive for agencies to create the position, and
- lack of requirement for establishing the role.
On the other hand, the biggest enablers were:
- an EMS agency recognition program that includes the PECC role,
- train-the-trainer programs, and
- inclusion of the PECC role in agency licensure requirements.
Interviews with PECCs identified the most common activity associated with their role was pediatric-specific education and the most important need for PECC success was agency-level support.
“Long-term PECC recruitment and retention may be possible through local and national EMS agency support, and the continued development of and outreach to interested individuals in prehospital pediatric care,” says Hoi See Tsao, MD, MPH, an assistant professor of Pediatric Emergency Medicine at UT Southwestern Medical Center who serves as the Prehospital Domain EMSC Fellow and is the publication’s lead author. “Future work includes investigating other methods and outreach efforts to further increase the number of PECCs in addition to the use of learning collaboratives. This may provide insight into additional effective ways to increase the number of PECCs and best practices, and ultimately improve the prehospital care of children.”
EMSC-funded studies—including Targeted Issues grant projects in North Carolina, Connecticut, Rhode Island, Colorado, and Louisiana—are evaluating the effects of EMS agency PECCs on patient care. The National Prehospital Pediatric Readiness Project is supporting EMS agency pediatric readiness efforts with a publicly available toolkit containing more than 100 resources, including resources developed by the PECC-focused Targeted Issues grant in Connecticut, which is led by Mark X. Cicero, MD.
PEAK resource highlight—Pain
Untreated pain has short- and long-term consequences for children in emergency settings—there's the discomfort of the pain itself; then there's the stress and anxiety for the child and their family—and don't forget the slower healing time and possible reluctance to seek health care in the future.
But it doesn't have to be that way.
The EMSC Innovation and Improvement Center (EIIC) is excited to share its latest Pediatric Emergency and Advocacy Kit (PEAK) on pain.
What makes PEAK resources different? They’re: 1) developed and vetted for accuracy based on the latest scientific evidence by interdisciplinary subject matter experts; 2) free and open access; 3) multimodal, with something for every learning style.
Plus, a new collaborative podcast series featuring:
Covid and Kids
Birth transfers? We need your feedback for QI
Ask Our Doc
Pediatric Education from Utah EMSC
Pediatric Education and Trauma Outreach Series (Petos)
Utah EMS for Children (EMSC), Primary Children's Hospital (PCH), and Utah Telehealth Network (UTN) offer the pediatric emergency and trauma outreach series (PETOS) to EMS providers.
This course provides 1 free CME from the Utah Department of Health and Human Services Office of Emergency Medical Services for EMTs and paramedics. The lectures are presented by physicians and pediatric experts from Primary Children’s Hospital. The format is informal; inviting questions and discussion.
Join us on Zoom each second Monday at 2 p.m. mountain time (U.S. and Canada) Click the pic below!
Archived presentations can be viewed and also qualify for CME. Access at https://intermountainhealthcare.org/primary-childrens/classes-events/petos
To obtain a completion certificate
- For "live" (virtual) participants: To receive a certificate of completion for attendance be sure to include your email address when the host requests it in the chat during the live presentation. Certificates are e-mailed out after verification of attendance and processing.
- For archived viewing: After viewing archived presentations (link above) e-mail utah.petos@gmail.com with the date and title of presentation viewed. You will receive a three question quiz to verify participation. Once the quiz is returned, certificates are e-mailed out.
We try to have certificates out within a week but will occasionally have delays.
Monday, Oct 10, 2022, 02:00 PM
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Looking for a PEPP class?
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.
Other Pediatric Education
Fall Injury Prevention Learning Series
To view previous sessions for all our series visit this link
Hosted by the Trauma Outreach & Injury Prevention Team
Nursing Contact Hours offered @UofUTrauma
Thursday, Oct 13, 2022, 11:30 AM
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2022 UPTN Conference
UPTN holds an annual conference to discuss hot topics and provide pediatric trauma updates.
This year we are scheduled for October 28 at the Blair Education Center in Park City. The conference is free of charge.
Friday, Oct 28, 2022, 08:00 AM
Blair Education Center, Round Valley Drive, Park City, UT, USA
EMS Focused Education
University of Utah's EMS Grand Rounds (Offered every 2nd Wednesday of even months)
Wednesday, Oct 12, 2022, 02:00 PM
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Emergency Medical Services for Children, Utah Bureau of EMS and Preparedness
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