Pediatric emergency medicine trisk 1153

FIGURE 134.2 Sample offline patient care guideline. (From Utah Department of Health, Bureau of EMS.)

9-1-1 calls are answered at a public safety answering point (PSAP). There, Emergency Medical Dispatchers are
specially trained in emergency medical dispatch (EMD) to prioritize calls, determine the appropriate level of
response (EMR, BLS, or ALS), give callers prearrival instructions, and stay on the line with the caller to provide
support. Formal EMD systems exist in guide card and electronic formats. Using structured, protocol-driven caller
interrogation, dispatchers follow scripted medical protocols based upon the chief complaint. The goal of
standardized dispatch is to send “the right resource in the right mode at the right time.”
EMS systems vary in the configuration of personnel into units or teams. Some systems have EMT-only units,
while other systems may have EMTs partnered with paramedics in all units. In a tiered system , there is a set of
criteria that determine whether an ALS or BLS response is indicated and dispatched, based on the scripted caller
interrogation. For example, a call for an isolated minor foot injury would receive a BLS unit, while a call for a
seizure would receive an ALS ambulance. In a nontiered system , the highest level of provider is dispatched to all
calls. Based on local policies, other resources such as police and fire units may be dispatched along with EMS.
It should be a goal in every community to have reliable medical advice available for the 9-1-1 caller while
awaiting EMS response. The importance of EMD has been underscored by increased recognition and research.
For instance, dispatcher-assisted CPR increases rates of bystander CPR, and bystander CPR has been associated


with improved morbidity and mortality outcomes of out-of-hospital cardiac arrest. More information can be
found at .

EQUIPMENT AND MODES OF TRANSPORT
EMS transports occur by ground ambulance and by air ambulance, in both rotor-wing and fixed-wing aircraft.
Both modes of transport are used for scene and interfacility transports. The mode of transportation is determined
by personnel at the scene or at the transferring healthcare facility, by 9-1-1 dispatch personnel, or in mass
casualty events, by the incident commander. Guidelines for use of air versus ground ambulance have been
published, including an evidence-based guideline for the use of air transport for trauma patients. Air transport is
covered more specifically in Chapter 11 Interfacility Transport and Stabilization .
In 1969 and 1973, the National Academy of Science and the DOT published documents that generally defined
the purpose of an ambulance and its contents. A list of both adult and pediatric equipment for ground ambulances

has been published collectively by the AAP, the American College of Emergency Physicians (ACEP), American
College of Surgeons Committee on Trauma (ACS-COT), the EMSC Program, the Emergency Nurses Association
(ENA), the National Association of EMS Physicians (NAEMSP), and the National Association of State EMS
Officials (NASEMSO), and was most recently revised in 2013. This list is commonly used to establish the
minimum standard requirements for EMS programs ( Table 134.3 ). The consensus document is undergoing
revision, with anticipated publication in 2020.
There are typically two classes of ambulance service in the United States—each is primarily dedicated either to
ALS or BLS service. BLS units are equipped to conform to the previously mentioned list ( Table 134.3 ).
Included are ventilation and noninvasive airway equipment, an automated external defibrillator (AED),
immobilization devices, bandages, two-way communication equipment, obstetric kits, a length-based
resuscitation tape or similar guidance material, and other miscellaneous items. In addition to the equipment
contained in the BLS list, ALS units carry intubation and vascular access equipment, a portable
monitor/defibrillator, and a variety of medications.
Because of the limited space on an ambulance, most EMS crews will not have all of the mechanical or
pharmacologic options available in a hospital. Examples are a paramedic crew that carries morphine but not
fentanyl for analgesia, or normal saline and not lactated Ringer solution for fluid resuscitation. An example of a
state-approved list of medications for ALS ambulances is provided in Table 134.4 . More technically
sophisticated equipment and medications can often be added if required, as long as its use is established and
monitored by the medical director for the EMS service.

COMMUNICATION
Equipment
It is imperative for EMS personnel to have a means of communication from the scene and while in transit, in
order to fulfill the requirement for online medical direction. This may require redundant systems, including but
not limited to radio transmission, wireless cellular transmission, satellite telephones, and Wi-Fi or WiMAX mesh
networks. In addition, base station hospitals must ensure redundant incoming communication lines and must have
a plan for communication failure, such as forwarding calls to the next closest base hospital. Many base hospitals
are equipped to receive paper transmissions from EMS vehicles, such as prehospital 12-lead electrocardiograms
(ECGs).

EMS Reports to Hospital Personnel
Once the child is en route to the receiving hospital, either medical control or the EMS unit itself should notify the
receiving hospital of the transport, even if online medical direction is not being requested. Based on the nature of
the child’s illness or injury, the facility then can begin to assemble personnel and equipment for prompt treatment.
This is especially important for hospitals where some resources may not be immediately accessible and, in cases
of trauma or serious illness, when a specific resuscitation team can be assembled to meet the EMS personnel in
the treatment room.
On arrival, essential information concerning the child’s condition and the field treatment is transferred by
verbal report to the accepting care team. ED staff receiving patients from ambulance crews will naturally be
focused on their own initial assessment of the patient, which may distract them from listening carefully to the


ambulance crew’s handover. Any information that was not handed over verbally, not recorded on the patient
report form, or not retained by ED staff may be irretrievable after the ambulance crew leave. There is significant
variation in sign out practice, and current processes have been criticized as being highly variable, unstructured,
and potentially unreliable. Several standardized approaches to sign outs have been defined, including IMISTAMBO:
Identification of the patient
Mechanism of trauma or Medical complaint
Injuries or Information relative to the complaint
Signs (vital signs and GCS)
Treatment and trends/response to treatment
Allergies
Medications
Background history
Other
To aid in family reunification, it is important for the transition of care from EMS providers to include
information about the condition and destination of family members. It is also important for providers to report
pieces of information or visual clues to potential nonaccidental trauma or neglect that may be noted at the scene.
Each encounter between EMS and the hospital should be considered as a potential learning and teaching
experience, and deficits noted as a stepping stone for future improvement. Providing patient follow-up, where

allowable, is another way of including the EMTs in the care continuum.


TABLE 134.3
EQUIPMENT FOR AMBULANCES (2014 CHANGES ARE UNDERLINED)