Pediatric emergency medicine trisk 1151

ambulance. EMS agencies transport 89% of the pediatric calls they respond to; although, this varies between
regions.
For pediatric patients transported by EMS, basic life support (BLS) interventions, such as oxygen
administration or spinal motion restriction, occur in nearly 40% to 50%. ALS interventions occur less frequently,
with IV access noted in 14% and airway management occurring in 0.6% to 2.5%. The National Emergency
Medical Services Information System (NEMSIS), developed and maintained by the National Highway Traffic
Safety Administration Office of EMS, is a national database that stores EMS data submitted by states and
territories. While the database does not contain every single EMS activation that occurs in the United States,
analysis of NEMSIS data has shown that as recently as 2011, only 7% of EMS responses involved children, and
that critical procedures were performed in 10 per 1,000 pediatric cases, with an 81% success rate. Specifically
examining airway procedures, the 2012 NEMSIS data demonstrated that 4.5% of pediatric patient care events
involved airway management procedures, with invasive airway management or ventilation procedures taking
place in only 1.5% of patient care events. Endotracheal intubation (ETI) success rate was reported to be 81%;
however, success was not reported in 14% of cases.
According to data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2016, 4.4% of
patients under the age of 15 years visiting an ED arrived via EMS, which is significantly lower than the
percentage of adults arriving to an ED by ambulance. Previous surveys have demonstrated that children
transported by EMS were four times more likely to be admitted to the hospital, with a 16% compared to a 4%
admission rate among non–EMS transported ED patients. Certain patient characteristics were associated with
EMS use, including nonwhite race, urban residence, visit due to injury or poisoning, and lack of insurance.

Governance of EMS Systems
There is no nationally standardized definition of what constitutes an EMS system. In all 50 states, legislation
exists to provide a statutory basis for individual EMS agencies to exist and operate. After the EMS Act of 1973,
all states identified lead agencies that coordinate EMS activities within the state. In most states, the lead agency is
headed by an EMS medical director who reports to the state department of health. Often, state-level advisory
councils exist to direct and assist in the development of protocols and minimum standards of operation.
In addition to control at the state level, local government may regulate the organization and authorization of
services provided by EMS personnel. States are frequently divided into EMS regions, at which level prehospital
care becomes operational, and where local government, hospitals, and ambulance services interact with each
other. Regional advisory councils may exist as well.

While all EMS agencies are regulated at a state and/or regional level, different types of EMS agencies exist,
depending upon the governing structure. Physicians are likely most familiar with municipal agencies, like a city
or county fire department that contains an EMS section, or a free-standing municipal EMS agency that functions
separately from fire services. EMS agencies may also be part of a hospital or healthcare system, with providers
and administrators functioning as employees of the hospital. Other privately owned EMS agencies may contract
with hospitals or municipal fire services to provide interfacility or scene medical transports. Volunteer agencies
(often with limited experience in pediatrics) are prevalent in rural areas of the United States.
This patchwork of governance over EMS systems may make it very difficult to speak with a unified voice
when it comes to patient care, training, and certification, and makes it difficult for EMS professionals to move
between communities. The National Registry of Emergency Medical Technicians (NREMTs) serves as a
centralized credentialing group, but this organization does not authorize an EMT to practice in a state or region,
and there is little consistency around the issue of states granting reciprocity for EMS providers.

Components of Prehospital Care Systems
The prehospital component of EMSC is an architecture that involves a variety of personnel and equipment, only
some of which is standardized and regulated. To understand the extent of the services provided by prehospital
care systems, it is important to understand the training, capabilities, and scope of practice of prehospital personnel
and the equipment available to them.

EMS Providers
The National Highway Traffic and Safety Administration (NHTSA) developed the first National Standard
Curricula for prehospital providers in 1977. Four levels of care provider were clearly outlined: emergency
medical responders (EMRs), emergency medical technicians (EMTs), advanced emergency medical technicians


(AEMTs), and ALS providers (paramedics). Some states and regions use their own notations for the skill levels of
providers, but their personnel typically fit into one of the categories described here. BLS care is provided by
EMRs and EMTs, while ALS care is provided by AEMTs and paramedics. Approximately 57% of U.S. EMS
providers are EMTs and 31% are paramedics. The EMS National Scope of Practice model was most recently
revised in 2019, and retained the four levels of providers.

Training standards and requirements for certification exist for all of these groups, established by the DOT and
NHTSA ( ). The National EMS Core Content published in 2005
describes the full body of EMS knowledge and skills. The National EMS Scope of Practice Model establishes
minimum competencies for each level of provider. The National EMS Education Standards , published in 2009,
define the minimal entry-level educational competencies (knowledge, clinical behavior, and judgment) for each
EMS personnel level ( Table 134.1 ). The DOT provides these guidelines only, but does not conduct training or
issue licenses or certifications to EMTs.
Training for EMS personnel occurs at community colleges, technical schools, and other health profession
universities. Training programs are accredited by the Committee on Accreditation of Educational Programs for
the Emergency Medical Services Professions (CoAEMSP). A general outline of the training and skills
competencies for each level of provider is discussed below. While the National Scope of Practice Model guides
the skills that each level of provider should be capable of, each EMS medical director overseeing the providers
within his or her jurisdiction may credential any level of provider to perform skills that may be traditionally
reserved for a higher level, as long as that provider is given special training and competencies are maintained.
An EMR is a person who is certified in limited but significant lifesaving capabilities. A certified EMR course
includes a 40- to 60-hour curriculum, and providers can be registered by NREMT. The role of the EMR is vital in
rural and wilderness areas where extended response times are common, and skills such as hemorrhage control,
airway positioning, and early defibrillation with an AED can be truly lifesaving. In suburban and urban EMS
areas, this level of provider is prevalent in the police and non-EMS fire services, as well as in some rural areas.
EMTs have skills that exceed those of EMRs. They are trained to recognize and treat pulselessness, apnea,
upper airway obstruction, and extremity deformity, as well as recognize respiratory distress, altered mental status,
shock, mechanisms of injury, and obvious death. EMTs are capable of patient assessment, spinal immobilization,
noninvasive ventilatory assistance, and defibrillation with AEDs. EMT training typically requires 100 or more
hours as well as observation time in an ED. This level is prevalent with volunteer fire department members and
others who provide EMS on a volunteer basis. It is also the standard level of training for private industry EMTs
who perform the interfacility and discharge transport of medically stable patients from a medical facility. The
EMT curriculum typically involves one educational module on infants and children, representing a relatively
small percentage of the total training exposures. They learn basic resuscitation skills and external airway
management as well as some of the nuances of injury that apply to children and infants.
AEMTs possess additional clinical skill beyond that of the EMT, but less than those of a paramedic. This

frequently includes the ability to acquire vascular access (including intraosseous access) and to perform advanced
airway management; however, the midlevel provider’s advanced airway management capabilities typically are
limited to a dual-lumen airway device. In some systems, the AEMT scope of practice also includes administering
medications. AEMT training requires 300 to 400 hours, including clinical preceptorship and internship. The
benefits of performing intermediate level procedures in the field are and have been a topic of much debate. It is
important that AEMTs are expert providers of BLS skills and not overly reliant on rarely performed advanced
interventions, especially in children. It is important to consider that, although this level of training may be ideal
for someone who is paired with an EMT-P, it is rarely an acceptable alternative to paramedic-level services except
when the EMS system would otherwise not be able to operate beyond the BLS level.
Paramedics have 1,000 to 2,000 hours of training, internship, and clinical hospital time, and they are capable
of administering a high level of medical care in the field. Their capabilities include advanced diagnostic skills,
recognition, and treatment of arrhythmias, and advanced airway management, including ETI and in some areas
emergent surgical airways and medication-enhanced intubation using sedatives and paralytics. In addition, they
can administer lifesaving medications and fluids in the field. Their ability to use diagnostic tools and diagnose
suspected cardiac disease, stroke, and trauma in the field can lead to the diversion of eligible patients to medical
centers that can provide the most appropriate care. Paramedics have formal didactic training in the emergency
care of children, which may include the American Academy of Pediatrics (AAP), Pediatric Education for
Prehospital Professionals (PEPP), or American Heart Association (AHA), Pediatric Advanced Life Support


(PALS) courses, but many will still admit to being uncomfortable with younger patients due to the lower volume
of and limited exposure to pediatric patients.

Medical Oversight of EMS
Due to the sophisticated nature of emergency medical care delivered by EMS personnel, EMS systems require
physician oversight. EMS medical directors exist at local, regional, and state levels. Their primary role is “to
promote continuous quality improvement and patient-centered delivery of medical care by the EMS service,” and
their responsibilities are numerous ( Table 134.2 ). In exchange for performing these responsibilities, EMS
systems typically provide the medical director with compensation for services and liability insurance for the
actions performed in this role.

TABLE 134.1
NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION, U.S. DEPARTMENT OF
TRANSPORTATION, NATIONAL EMERGENCY MEDICAL SERVICES EDUCATION
STANDARDS: MINIMUM PSYCHOMOTOR SKILLS

Medical direction of field clinical practice occurs in two forms: indirect, or offline , and direct, or online.
Offline medical direction typically occurs through established protocols, or a set of standing orders for a specific
condition or presenting symptom ( Fig. 134.2 ). Offline protocols guide rescuers’ actions in the field, standardize
patient care, and can facilitate rapid and effective treatment. They can also serve as a gauge to measure adherence
to guidelines, furthering the quality of prehospital care. Medical directors are responsible for every action
outlined in offline protocols, and for every patient outcome resulting from proper adherence to these protocols.
An example of a protocol for allergic reaction/anaphylaxis is provided in Figure 134.2 . Note that there are a