Pediatric emergency medicine trisk 1157

improved training and education, provision of pediatric-specific equipment, and other aspects of EMS. The
program continues to work to ensure that pediatric issues are better integrated into the EMS system. EMSC
programs include state partnership grants, targeted issues grants, support of the Pediatric Emergency Care
Applied Research Network (PECARN), state pediatric regionalization of care grants, and the EMSC Innovation
and Improvement Center.
The EMSC program addresses the entire continuum of pediatric emergency services, from injury prevention
and EMS access, all the way through to rehabilitation and reintegration back into the community. In addition to
addressing the entire spectrum, the guiding principles of the EMSC program are to promote state-of-the-art care
and to ensure that pediatric services are well integrated into the EMS system as a whole and that resources are
available to make this happen. Additional goals of the program are to enhance the evidence base for the
prehospital care of children and to spread improvements in the quality and outcomes of the emergency care of
children through coordination of quality improvement activities among grantees.

History of EMS for Children
Because early EMS systems were designed to provide rapid intervention for sudden cardiac arrest in adults and
rapid transport for motor vehicle crash victims, the specialized care that children require was often overlooked.
The need to improve the capacity of EMS to manage sick and injured pediatric patients initially came from the
providers themselves as well as the physicians who received those patients. Pediatricians and pediatric surgeons,
identifying poor outcomes among children receiving emergency medical care, became advocates on behalf of
their patients. They sought to obtain for children the same positive results that EMS had achieved for adults.
Shortfalls in provider training, pediatric-specific emergency equipment, established standards of care, and quality
pediatric EMS research severely limited the advancement of the specialty.
In the late 1970s, Calvin Sia, MD, president of the Hawaii Medical Association, urged members of the AAP to
develop multifaceted EMS programs that would decrease illness and death in children. Dr. Sia worked with U.S.
Senator Daniel Inouye (D-HI) and his staff assistant, Patrick DeLeon, PhD, to generate legislation for an initiative
on pediatric EMS. In 1984, Senators Orrin Hatch (R-UT) and Lowell Weicker (R-CT) joined Senator Inouye in
sponsoring the first EMSC legislation. C. Everett Koop, MD, then Surgeon General of the United States, strongly
supported this measure, as did the AAP. The 1984 legislation led to the establishment of the EMSC program. Two
years later, Alabama, California, New York, and Oregon became the first recipients of federal grant money
specifically earmarked to improve pediatric EMS.
Since then, EMSC grants have helped all 50 states, the District of Columbia, and five U.S. territories. Grant

funds have improved the availability of child-appropriate equipment in ambulances and EDs; supported hundreds
of programs to prevent injuries; and provided thousands of hours of training to EMTs, paramedics, and other
emergency medical care providers. The EMSC program’s support also has led to legislation mandating EMSC
initiatives in several states, and to educational materials covering every aspect of pediatric emergency care.
The timeline in Figure 134.3 highlights some of the spotlight projects that EMSC has been involved in:
1984: EMS for Children authorized
1986: first grants were distributed
1987: PALS was introduced
1993: all 50 states and DC received EMS for Children funds
1998: Federal Interagency Committee on EMSC Research was established
2004: the IOM project examining emergency care in the United States was convened, and EMSC was
specifically addressed

ROLE OF THE PEDIATRICIAN/PEDIATRIC EM PROVIDER IN EMS FOR CHILDREN
Pediatric-focused clinicians, including physicians and other advanced healthcare providers, should be encouraged
to become involved in the EMSC system in their community, especially those who work in emergency medicine,
critical care, pediatrics, surgery, and family medicine. On a local, regional, or state level, practitioners can serve
as advocates for the pediatric needs within their systems. A list of grantees by state can be found at
ter/emsc-grantee-contact-list , including contact information for the program
managers. The state Office of EMS or its equivalent can be contacted for a schedule of local community medical
services meetings. This is a good way for an interested physician to learn more about the issues facing his or her


EMS providers. There are standardized educational opportunities for EMS providers that can afford the teacher
more experience with pediatric EMS, such as the PEPP curriculum through the AAP. EMTs may also take the
PALS course to supplement their pediatric training, and physician educators play an important role in the success
of this course.
EMSC is an example of a national initiative designed to reduce child and youth disability and death due to
severe illness and injury. Medical personnel, parents, volunteers, community groups, businesses, national
organizations, and foundations contribute to the effort. Examples include the previously referred to list of

essential pediatric EMS equipment for ambulances and the multiple toolkits that can be accessed through the
EMS for Children Innovation and Improvement Center (ter/resources/toolboxes ).
Many other organizations exist to serve as educational resources and as forums for discussing, teaching, and
implementing policies used to promote the specific needs of pediatric EMS. National organizations and their
websites are listed in Table 134.6 .

FIGURE 134.3 EMS for children timeline. (Courtesy of Elizabeth Edgerton, HRSA.)

IOM REPORTS
In 2006, the IOM was commissioned to analyze and report on the capabilities of both prehospital- and hospitalbased emergency care in the United States. Three volumes were published: Emergency Care for Children:
Growing Pains, Emergency Medical Services: At the Crossroads , and Hospital-based Emergency Care: At the
Breaking Point. While complimentary of the past accomplishments of the EMS system, their findings also
highlighted many of the shortfalls that exist around the care of all patients in all of the components of the EMS
system, and also suggested a system of interventions to address these issues. The overall critique of the
emergency care system is that it was severely fragmented, with an absence of system-wide coordination and
planning, and a lack of accountability. The reports highlighted the following:
Insufficient coordination of 9-1-1 dispatch, EMS systems and hospitals
Disparities in response times to emergency calls
Uncertainties around the quality of EMS care, no agreed-upon measures of EMS
No accountability for the performance of EMS systems
A “divided” professional identity in EMS, serving both medical care and public safety, with EMS often
regarded as secondary to fire, police, nurses, and physicians
A limited evidence base for routine EMS practices, with evidence generalized to the prehospital field from
other practice settings
A general lack of disaster preparedness considering the role that EMS providers may play in a large incident or
terrorist attack, and a specific lack of pediatric consideration in disaster planning


Pediatric training for EMS is underemphasized and may not be required to be part of continuing education
requirements for EMS personnel

Pediatric treatment patterns vary widely between EMS and hospital-based care providers
In order to achieve the IOM vision in which all communities are served by high-quality, well-planned
emergency care services, the report recommended the creation of a federal lead agency for emergency and trauma
care, housed in the Department of Health and Human Services. While FICEMS was established in 2005, it is a
committee supported by NHTSA in cooperation with HRSA and the Department of Homeland Security. The
committee is instrumental in working toward the IOM vision of a 21st century emergency care system, but has
limitations regarding impact including numbers of dedicated staff and authority to allocate funds, establish policy,
or implement federal policy.
To help address system financing, the IOM report recommended that the Centers for Medicare and Medicaid
Services appoint a work group to evaluate the reimbursement of EMS services, which is typically based upon
transport distance rather than intensity of services and does not cover treatment without transport.


TABLE 134.6
EMERGENCY MEDICAL SERVICES–RELATED ORGANIZATIONS AND ONLINE RESOURCES