Pre-Hospital Emergency Care – PediaCast 209

Dr Dan Cohen and Fire Chief Steve Shaner join Dr Mike in the PediaCast Studio to discuss pre-hospital emergency care. Over 30 million kids seek emergency care each year in the United States. If your child has an emergency… Who should you call? Where should you go? If an ambulance comes, will it have first-responders with pediatric training? Will it have the right-sized equipment? Is your EMS system prepared to handle kid-sized emergencies? And what should parents do if it’s not? All this, plus the latest in pre-hospital emergency medicine research!

Topic

  • Pre-Hospital Emergency Care

Guests

Links

Transcription

Announcer 1: This is PediaCast.

(Music)

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!

Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast, a pediatric podcast for moms and dads and not just for moms and dads, we're getting a growing number of clinicians, so pediatricians and family doctors and nurses and nurse practitioners and medical students who are listening to the show. So I'd like to welcome all of you on board as well. It is episode 2-0-9, 209 for May 2nd 2012 and we’re calling this one Prehospital Emergency Care.

And you'd notice I've been kind of talking this show up. The last episode I mentioned that we're going to embark on a two-week journey on emergency care and summer safety, so I'm really excited about these two shows because I think it's one of those things where we can make a difference in some people's lives. So, moms and dads, I'd like to think we do that every week here on PediaCast, but in particular, it's really important for all moms and dads because even though you don't want to think about it, each day in the United States more than 100,000 parents seek emergency medical services for their children

01:38

And the question on most moms and dads' mind before this happens is what would you do if your child has an emergency, do you call your doctor? Do you throw your child on the car and drive to the nearest emergency room even if it's at an adult facility or do you drive a little farther to get to a pediatric hospital? When you should you visit an urgent care facility and what about this nurse practitioner in a box grocery store clinics that seem to be popping up everywhere, should you use those?

When do you call 911? And if you do call 911, how long will it take for someone to arrive? Will the responding team be prepared for pediatric emergencies and what type of treatment can these folks start in the field? Will they have the right equipment? Where will they take your child? And of course the question everybody wants to know and asks is can moms and dads ride along in the ambulance?

Also, what kind of research is being done to improve the prehospital emergency care of children? How do the results of this research end up in the hands of first responders? And how do emergency services personnel use new findings to guide their approach?

02:44

So we have lots of interesting stuff to consider today. And next week we're going to kind of build on that and talk about summer safety and preventing an emergency. Dr. Sarah Denny, MD is going to stop by and talk to us about that next week.

But today, our focus is on what to do when there is an emergency. And to help me out with the discussion we have two fantastic studio guests with us, Dr. Daniel Cohen, MD is a physician with the Section of Emergency Medicine here at Nationwide Children's Hospital and Chief Steve Shaner is the man in charge of Fire and Emergency Services for the City of Grandview Heights here on Ohio.

But before we get to our guest, I'd like to remind you if there's a topic that you would like us to talk about on PediaCast or if you have a question for us, it's easy to get in touch, just go to pediacast.org and click on the Contact link. Actually, we even have pediacast.com now, so if you accidentally do pediacast.com it doesn't take you to go daddy anymore, it actually gets you to our site. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

I also need to remind you that the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you do have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find over at pediacast.org.

04:16

All right. Without further ado let's turn our attention to our studio guests, Dr. Daniel Cohen, MD is an attending physician and director of research for the Section of Emergency Medicine here at Nationwide Children's Hospital. He's also an associate professor of Clinical Pediatrics at the Ohio State University College of Medicine. So welcome to PediaCast, Dr. Cohen.

Dr. Daniel Cohen: Thank you for having me, Dr. Mike.

Dr. Mike Patrick: Absolutely. And we also have Chief Steve Shaner with us in the studio today. Chief Shaner is in charge of Fire and Emergency Medical Services for the beautiful city of Grandview Heights right here in Central Ohio. I'd like to welcome you to the program as well.

Chief Steve Shaner: Thank you for inviting me.

Dr. Mike Patrick: I really appreciate both of you stopping by. And Dr. Cohen and I also go way back, I remember working with you when I was a medical student, all those years ago, so it's great to be back here at Nationwide Children's and working with you again.

Dr. Daniel Cohen: Likewise.

Dr. Mike Patrick: So in Grandview, my wife and I love going to stops and hanging out. It's really a beautiful town.

Chief Steve Shaner: It's a nice little destination and we welcome anyone to visit or perhaps move there.

Dr. Mike Patrick: Yeah. Absolutely. So let's start with you, Dr. Cohen. What should parents do when they're facing a medical emergency? So, I mean, you're kind of in the parents' position and your kid is having an emergency, what would you do?

Dr. Daniel Cohen: So, I have a few of my own stories as a parent and emergencies happen to all of us. I think the essential take home message is that we all need to be prepared, because we need to be prepared before the emergency has happened. So as an example, now I have two teenage daughters and they both took babysitting training and they took CPR and I would suggest that everybody needs to take CPR and help them to be able to provide that.

So I think being prepared before an emergency happens is really critical.

Dr. Mike Patrick: Yup.

Dr. Daniel Cohen: And maybe we can talk a little more about that. The other essential question to address is what is an emergency? So, I think sometimes it's really clear, your child is struggling to breathe, you see your child that fell off of playground equipment and there is a bone sticking out in the wrong direction, that's clearly an emergency…

Dr. Mike Patrick: Yeah. Pretty obvious.

Dr. Daniel Cohen: But sometimes it's a little bit hard to know which kind of gets back to the issue of preparation. So, if you have a plan under different circumstances, then you can be prepared. So an example of having a plan is knowing who to call. One important phone number would be that for the Poison Center and there's one number you probably have covered Poison Center…

 

Dr. Mike Patrick: Yeah. 1-800-222-1222.

[Laughter]

06:50

Dr. Daniel Cohen: There's a little jingle. It's on a magnet on my fridge. Yeah. That's the right set of phone numbers which is really, really important; including your neighbors, your doctors, your local urgent care center, potentially and knowing where you might want to go, that's part of preparation.

Dr. Mike Patrick: Yeah. I always tell parents even if it doesn't end up that it is an emergency if in your mind you think it might be an emergency, you're probably better off treating it as if that's what it is. And then if when all said and done you have to say, oh, I overreacted, but if in your heart you thought this could be an emergency or crossed your mind that it could be, then you're better off being wrong about that rather than being wrong the other way and sort of denying that it's really serious.

Dr. Daniel Cohen: I think it gets back to training again. Knowing some basic first aid is really important. In the emergency department, we see families who have brought their kids in by car that probably should have called 911.

Dr. Mike Patrick: Yeah.

Dr. Daniel Cohen: And then we see people coming in by 911 and Chief Shaner can address this as well as I can, that probably shouldn't have been brought in by 911.

Dr. Mike Patrick: Yeah. Who could have seen their doctor the next day.

[Laughter]

Dr. Daniel Cohen: That is exactly correct. There are a couple of really great websites that really go through the issues of preparation and one of which is the American Red Cross. And what they point out is get a kit, make a plan, be informed. I think those are really essential things for parents to do.

08:16

Dr. Mike Patrick: Yeah. Absolutely. And we'll put a link to their site in the Show Notes too, so folks can find it pretty easily. What about calling their doctor? I mean, should that cross their mind in this whole scheme of things?

Dr. Daniel Cohen: Absolutely. I think that's essential know when to call your doctor but at the doctor's visits when you're getting to know your pediatrician go with through with them, what would be an appropriate phone call for them to handle and when should they call 911. And most pediatricians' offices cover this.

Dr. Mike Patrick: Yeah. Yeah. And they're happy to talk with you about it if you want. We're seeing urgent care centers pop up all over the place and in communities and some of them are pediatric specific, some of them aren't, some run by family practice folks who have some pediatrics experience. Do you recommend parents use urgent care centers and wonder what kind of circumstance should they take them there instead of calling 911 or calling their doctor?

Dr. Daniel Cohen: That's a great question.

[Laughter]

Dr. Mike Patrick: And it doesn't have an easy answer, really, it doesn't.

Dr. Daniel Cohen: I think that certain times and certain, especially injuries would probably be best served in urgent care centers. But it really depends on what resources you have locally.

Dr. Mike Patrick: Yeah.

Dr. Daniel Cohen: And there's a spectrum between very minor injuries and very major injuries, very minor illnesses and major illnesses. And that's sort of where the judgment call comes.

Dr. Mike Patrick: Yeah. Yup.

Dr. Daniel Cohen: So if you have your child and they're having serious difficulty breathing and that is an emergency.

Dr. Mike Patrick: Yeah. That's a call 911 kind of thing. I look at urgent care centers and correct me if I'm wrong about this, it's kind of an extension of your doctor's office, so if there's something going on in the evening and your doctor's office is closed or it's something that your doctor doesn't feel comfortable dealing with like lacerations or the possibility of a fracture, your doctor probably doesn't have X-ray facilities on hand, but it's not a life or death situation, but you do need urgent care now, then that's probably the best.

So it's not a life threatening kind of emergency but it's something that's your doctor's office is closed or it's something that they can't handle because they don't have the right X-rays, that sort of thing.

10:32

Dr. Daniel Cohen: I think it's in a large part, logistic and it's more intended for minor injuries and minor illnesses. And again, it can be addressed when you call in. It's really meant to be there when your pediatrician or your family doctor is not available. Because as a pediatrician first, we support having at home and I think that's the right place to go first.

Dr. Mike Patrick: Absolutely. And you know if you call your end again it's one of those things, I'm not calling 911 but maybe I should call my doctor and get some advice on whether is this something that I can wait to see you tomorrow or do I need to go the urgent care now, those kind of things.

So let's turn our attention to true emergencies. So now you are calling 911, you do have the bones sticking out or your child's not breathing, you've started CPR, you learned that from the Red Cross, or there's an AAD device on hand and you can use that.

Let's say that you do call 911, Chief Shaner, what can a parent expect when they call 911?

Chief Steve Shaner: Well, I'll kind of walk you through a typical call. So if a parent dials 911, technologically, here's what happens, the call goes to what's called a Public Safety Answering Point, some people refer to them as PSAPs, the call's then answered and usually they'll say 911, what's your emergency. If you say I have an injured child, they'll say hold on, we'll transfer you over to the EMS or EMS fire dispatcher and that's usually done seamlessly, electronically.

So they'll switch you over and then someone will come on and ask you about the emergency. One thing that's commonly confused is sometimes people will say, well, they kept me on the line for three or four minutes. The people that are answering those calls are usually EMS trained dispatchers and they will give pre-arrival instructions. They will also give medical care advice such as first aid advice, how to do CPR, they can actually talk you through hands only CPR, they can do a lot of things on the phone while they're simultaneously dispatching the run.

So people could actually be on the way while they're talking to you. So it's a little misconception there that folks think all they did was talk to me when they're actually multitasking. They're sending someone at the same time.

12:54

Dr. Mike Patrick: Yeah. So they don't actually have to talk to someone to send, I mean they can type it out and that gets something dispatched?

Chief Steve Shaner: Yes. They can just type it out, push the button and it automatically goes to the system. Now, every system is different.

Dr. Mike Patrick: Sure.

Chief Steve Shaner: In the United States, primarily, we use the E911 system. In many countries they have better systems, they have worse systems, it's all over the place.

Dr. Mike Patrick: Sure.

Chief Steve Shaner: But in general, when you make a 911 call or a call to an emergency system, it's answered and the care system is activated upon your call.

Dr. Mike Patrick: Now when you say E911, is that the enhanced, so if you have a cell phone it's going to figure out where you are or if you have Internet phone at home it's able to get it…

Chief Steve Shaner: The E911 system is pretty well adapted these days. There's a new system, it's called the NG911, which is Next Generation, which will actually be able to text and you'll be able to do a lot of different modes of electronics to get the desired response that you need.

Dr. Mike Patrick: Yeah. Sure. So a parent calls 911, the dispatcher kind of walks him through what they need to do, dispatches the personnel and then what happens when they arrive?

Chief Steve Shaner: When the EMTs arrive, or at least in the United States and most other developed countries, the EMS arrives, the EMS folks are trained, the EMS responders, there are three different levels, actually four different levels of responders, there's a first responder or what they call the emergency medical responder; there are EMTs, which is a higher level of care than a first responder; intermediate EMTs or advanced EMTs, depending upon where your are what they're called and then the paramedics.

14:42

So everyone has a, there's a different level of response and in some areas that level of response is coordinated with that information that's collected from the EMS dispatcher. So, that's all depended upon who gets there is depended upon how your system works.

Dr. Mike Patrick: Sure.

Chief Steve Shaner: Once the folks arrive, they do pretty much, they're all taught to do the same thing and that's do a scene survey. So they'll get out of their vehicle or they'll stop in their vehicle and make sure everything is safe before they get out, because it doesn't do them any good to get injured while they're trying to go provide care for your child. So they have to make sure that they're safe as well. It advances the time much faster if they don't get hurt themselves.

So, you might see them, you wonder why they're just sitting there for a couple of seconds, they're just making sure everything is safe for them before they get out of the vehicle or before they approach the scene. Once they do that, they'll come in and they'll do what's usually referred to as a primary survey or a life threat survey. And what they're going to make sure that there's no immediate threat to that child's life such as a breathing problem, a bleeding problem or an airway problem and once they get through that or if they can't get through that because there is a problem then they'll usually start talking to the parents a little more and start interacting with them and deciding what's best to do for the child at this point.

16:16

Dr. Mike Patrick: So they could decide that the kid just needs a Band-Aid, they're at the scene, or this is something you could see your doctor tomorrow or we're going to take you to the hospital.

Chief Steve Shaner: That's correct. And once they make that initial assessment, some folks call it a doorway assessment, you can tell when something's wrong just by opening the door and you look at them so, once they make that initial assessment then they'll start talking to the parents and if there's no immediate threat to life, they'll start looking for other things, such as just complaints of pain, discomfort, their inability to ambulate or something like that.

So they'll start to scale it down. So they start with the worst things first and then scale it down from there. And it may very well be that it is just something that requires minor care or emergent care.

Dr. Mike Patrick: Yeah.

Chief Steve Shaner: And they kind of will go from there, they'll just start talking to parents and say, you know, we really think this is something that's serious and we need to transport them to the hospital or in some cases, we think this is not necessarily something that's life threatening, it's something that probably could be handled with your doctor or it could be handled at one of the urgent cares.

Dr. Mike Patrick: Sure.

Chief Steve Shaner: So, they'll kind of form an interactive discussion there about what's going on but for the most part, if it is a true emergency there is a little less dialogue and a little more action.

Dr. Mike Patrick: Yeah.

17:44

Chief Steve Shaner: And they kind of get the ball rolling. Now in Ohio and in most other states, all the EMTs follow are written protocols and those protocols are put together with emergency physicians or advisory boards as to what to do. Occasionally, as with any level of medicine, not everything's always in the book.

Dr. Mike Patrick: Yes!

Chief Steve Shaner: So we do have the luxury here and most places have that ability to actually place a call to one of the physicians or what we call medical control physicians and we can discuss the case and decide what the best thing to do.

Dr. Mike Patrick: When there's really an emergency it's kind of easier because you know what you need to do, you need to get them to the hospital, you need to call medical control if there's something that's outside of your protocol. What about when you really don't think that it's a life threatening or even needs urgent attention and the parents are very adamant that they want their child transported to the hospital? Do you run in to that?

Chief Steve Shaner: Yeah, we do. The system in our area here, we usually have an EMS coordinator that can come and discuss that with that parents but as you talked about earlier on in the discussion, an emergency is many times in the eye of the beholder. So if we are positive that it's not an emergency, we'll take a few extra steps to try to steer the patient the correct way but many times it's that fine line area where they could go to the emergency department, they could go to the hospital where there's an urgent care in the hospital that's just as effective as going to an urgent care in the neighborhood, maybe a little less convenient for the parents, but if that's what they want to do then we'll make some accommodations and see if we can do that.

19:36

Dr. Mike Patrick: Yeah. It's kind of a tight road because on one hand there are some parents who know their kids and know they had this situation before and even though it seems like they look good now, they have in the past deteriorated rapidly so sometimes you have to listen to the parent on that.

But on the other hand, if it's not that kind of situation you want to avoid utilizing your resource because if you're transporting someone to the hospital who doesn't necessarily need it and then there's another person who does need it, then your crew is not available for the person who really did need it so I guess everybody has this sort, you look at each others perspective, so to speak.

Chief Steve Shaner: They do and it's truly a discussion that needs to take place at the time and there are times where things aren't what they appear to be then you look at the child, they look fine and the parent says, but I know my child and they do not look right and that's usually good enough for all of us.

Dr. Mike Patrick: Yes.

Chief Steve Shaner: And as first responders we know that when they say this is just not right, that they…

Dr. Mike Patrick: Yeah. You pay attention to that.

Chief Steve Shaner: No one knows their children better than the parents.

Dr. Mike Patrick: Yeah.

Chief Steve Shaner: Or the caregivers.

Dr. Mike Patrick: Yeah. Absolutely. Let's say you decide that they do need to be transported somewhere and they need more than an urgent care facility, how do you make the decision on whether to go to the nearest emergency room or to a pediatric hospital?

20:57

Chief Steve Shaner: Those are usually pre-made decisions on our written protocols and in our area here we have pretty elaborate system of pre-written protocols as to what to do in certain cases, for cases of trauma or for cases where it need specialized care, we'll certainly go to a pediatric center depending upon what their ages are, we go to a pediatric center by default. And so those are pretty much pre-made.

If someone is an extremist and we're having trouble getting signs of basic life we go do have the options to go to a local emergency department where the child can be resuscitated and then transported inter-hospitally after that.

Dr. Mike Patrick: Can parents ride along?

Chief Steve Shaner: Well that's a great question, as Dan would say.

[Laughter]

Chief Steve Shaner: In our area here and in general, I'll speak generally, parents are not only encouraged but in some cases required to go along with their children. And I don't say parents to be exclusive because this could include caregivers who again know their children very well.

Dr. Mike Patrick: Yeah.

Chief Steve Shaner: Not only do the EMS and first responders depend on knowledge from the parents, so do the physicians and nursing staff at the hospitals depend a lot upon the knowledge of parents so they want them there to get the information from them.

Dr. Mike Patrick: Yeah.

22:29

Chief Steve Shaner: So, in general, we make every accommodation that we can to make sure that they come. Sometimes it's not possible for them to ride along with us, sometimes it is. Sometimes they need to bring their own transportation but in general, it's great if they can accompany them in some fashion. Whether they follow us in or whether they drive by themselves or however, it's usually not only a nice thing but it's almost a necessity.

Dr. Mike Patrick: Yeah. And I think that Nationwide Children's and the Columbus community, in general, has really been trailblazers in the whole parent-centered model. I mean, really, parents are welcomed during resuscitations and then the trauma room, I mean, we really want parents to be there and be involved right from the beginning and that's not the case in all places. I think it's gaining momentum throughout the country but it's not necessarily everywhere.

Is there a charge for parents to utilized emergency services?

23:30

Chief Steve Shaner: Again, I'm speaking in generality, in most cases yes, there is some sort of a charge for that. In some cases though, no, there's not.

Dr. Mike Patrick: Kind of depends on the model in the community?

Chief Steve Shaner: Depends on the model in the community, yes. Some folks use strictly a third service or a private EMS response and in those cases they're almost always be supported, some folks use a mix, which are pre-supported as well as tax base supported and some are strictly tax-based supported and they don't have a fee.

Dr. Mike Patrick: You may not know the answer to this, does insurance usually cover that, if there was a fee to the parent, is that something that insurance would typically cover?

Chief Steve Shaner: Yeah. In most cases they do.

Dr. Mike Patrick: OK. And then let me ask you this, what specific pediatric training do providers typically get?

Chief Steve Shaner: Each level that I spoke about, the four levels, they all get some sort of pediatric training in their basic training depending upon the level, the hours increase as you increase in your medical knowledge. Now, the continuing education once you are certified at that level also requires certain specific amounts of pediatric continuing education.

Dr. Mike Patrick: Sure.

Chief Steve Shaner: And that, if you do the math, it equals out to about 14% of the requirement. So if you're required to do 92 hours worth of continuing education in three years then about 14% of that is pediatric focused. There are several specialty courses that, again, this is speaking in general, because everybody is different in what they require, but in this area most responders are certified in different specialty courses such as Pediatric Advanced Life Support, such as ITLS Pediatric courses and there the APLS courses, different courses that are available. And usually most places have participated in one of those programs, some all of them, depending upon how long they've been in the field.

25:43

Dr. Mike Patrick: Yeah. Dr. Cohen, this is not something that's required, the PALS or Pediatric Advanced Life Support or APLS, I mean is that something, it's voluntary, correct?

Dr. Daniel Cohen: In general, it's voluntary. However, the medical directors that are in charge of the EMS programs can require that their folks that work under their guidance have that knowledge.

Dr. Mike Patrick: So, Dr. Cohen, you think that that's something that pretty much all responders should have?

Dr. Daniel Cohen: Yes. I think that 14% seems very robust. The plentitude of pediatric transports ranges depending on your region from 10-14%, sometimes a little bit lower. And of those runs, the minority really require advance life saving skills. So this is a low frequency but very high stakes situation. So I think applying in the extra training is really critical. We always say that children are not small adults, so their anatomy is different, their physiology is different and when kids get sick they can get sick very quickly after having commutative for a long time.

27:04

Dr. Mike Patrick: So they look good and then boom, they're not good.

Chief Steve Shaner: There's fall off the edge of the cliff. And I think having EMS providers recognized and being able to respond preferably earlier requires a significant training and it's great that people invest that way.

Dr. Mike Patrick: Yeah. And the fact that there once like you said, low frequency, I mean if it's only 15% it's even more, for the adult patients you're getting your experience on the job. I mean, you're seeing adult patients, those 75-80% or more of adult patients, so you're practicing those skills everyday and if you're only seeing 15% children then you certainly want that extra training every year so that you are brushed up on your skills and feel a little more comfortable when it does happen.

Dr. Daniel Cohen: And clearly, the adult life saving that EMS providers do much more frequently can be applied to children as well.

Chief Steve Shaner: Yeah.

Dr. Mike Patrick: Now, in this having people on board who are trained specifically, have some specific pediatric training, obviously you want some pediatric specific equipment onboard as well. Can you talk a little bit about that?

28:14

Chief Steve Shaner: So as we mentioned briefly, kids come at a variety of sizes and shapes and we see children ranging from a couple of pounds to 300 or 400 lbs. and that really can provide a challenge to EMS providers to just in terms of the array of equipment that they need and just keeping things organized.

So there is a length-based system that people use and a color coded system so people know the right equipment and the right dosing to guide them in their resuscitation if they need to.

Dr. Mike Patrick: Yeah. So that's kind of a cool thing. So you're talking about the Broselow and basically it looks like a birthday card folded up and then you unfold it and put it at the top of the kid's head and then down to the bottom of their feet and then whatever color that lands on then you have all your drug doses and your tube sizes and things like that.

Chief Steve Shaner: Exactly.

Dr. Mike Patrick: Yeah. Because in an emergency you don't want to be doing complicated calculations in your mind, how much does the kid weigh and then do a little algebra to figure out what size tube you need, so that is a nice resource. And I'm sure that's something that you guys carry on your squads.

Chief Steve Shaner: Yes. It sounds like a simple thing to just make a list of what you think you'll need but actually I did a little research on this and I know that a friend of ours, colleague of Dr. Cohen's and mine, Dr. Andy Fixerbon, a portion of this panel, but I guess I didn't realize that it had so much involvement by so many organizations but the American College of Surgeons, the American College of Physicians, the National Association of EMS Physicians, the EMSC Group and American Academy of Pediatrics all got together and made up a list of what they think that EMS transport vehicle should carry.

And that's a lot of groups to get together and to come up with something and they did that, so that's quite an accomplishment and that has been adopted by our organization and most of the area squads around here or you mentioned that's do have that equipment available. So that's quite…

[Crosstalk]

30:35

Dr. Mike Patrick: So we're talking different size, masks and IV tubing and the tracheal tubes and the blades and scopes that you have to use to put those breathing tubes down; different size backboards, C-collars, I mean, all of the stuff starts to add up cost wise, also consider that they expire, like the plastic tubes and things, so a lot of those then get thrown out. How does that kind of expense to have all that equipment in different sizes? Who pays for that?

Chief Steve Shaner: If it's a fee-based service, most fee-based companies have to absorb that cost. It's the cost of doing business. So the equipment does expire in some case as you said and fortunately there are better and better equipment being developed all the time. And everyone tries to stay current with the appropriate equipment so it's that extra added cost but it's for the population that has the most to gain from it. So it's a worthy investment on our part.

Dr. Mike Patrick: So when you do charge it's not like a flat rate? It's what equipment did you use, how much time did it take, I mean, it's a…

Chief Steve Shaner: Yeah. Depending upon the level of care provided. If it's something that's advanced life support run there is a little bit higher charge for that, but as far as the basic cost it's about all the same.

Dr. Mike Patrick: Yeah. There's a cool program in Wisconsin called the Pediatric Jump Kit Bag Initiative. Can you talk a little bit about that? It's kind of a cool thing. There was a group of women I believe, right?

32:20

Dr. Daniel Cohen: Yes. It started out as a grassroots movement and they partnered with the federal program that Chief Shaner mentioned briefly, EMSC, to provide jump kits or go kits for the EMS units throughout their state. And if you go to one of their websites you can see a map of how it flourished from just a few counties to all across Wisconsin and they've virtually covered the entire state.

And it's really to help local groups provide the right equipment for their own children in their counties and their communities. It was really quite a partnership.

Dr. Mike Patrick: Yeah. And this was just a group of senior citizen women who saw a need and thought we're going to organize and fund raise and try to make this a reality and then they were able to get that equipment into the hands of providers throughout Wisconsin. I'll put a link in the Show Notes to their site as well because there may be some folks listening right now, they say, in our state I'd like to start something like that and so it'll be some encouragement and kind of a model for them.

33:21

Dr. Daniel Cohen: I would say and Chief Shaner covered this just little bit, one of the things we say is all EMS is local and I think that people in their community should really know what their resources are. That's part of being prepared.

Dr. Mike Patrick: Yes.

Dr. Daniel Cohen: And then getting involved if they can to advocate for their community.

Dr. Mike Patrick: Yup. So when you talk about EMSC, which is Emergency Medical Services for Children, Chief Shaner, what exactly is that?

Chief Steve Shaner: EMSC is a multi-faceted organization. EMSC is a federal program actually. It is funded by the Department of Health and Human Services, the Health Resources and Service Administration or what it is referred to as HRSA in many cases, and they have a couple of main goals. Those main goals are basically to ensure that the state-of-the-art emergency medical care is provided to all ill and injured children regardless of their age.

Their second major goal is to ensure that pediatric services are well integrated into the EMS system and to make sure that the entire spectrum of EMS from prevention all the way through any possible illness or injury or acute care and rehabilitation is provided and make sure that it's seamless network there for children.

EMSCs in pretty much all states and U.S. territories they all usually have a main office and that main office is in charge of that specific area or state and pretty much all the activities of that office are taken care of by that state. They're kind of a go between the federal program and the local level of liaison if you will.

35:10

Dr. Mike Patrick: Yeah. So is that an act of Congress that actually created EMSC as I understand it and so it's actually part of the Maternal and Child Health Bureau with the Health Resources and Service Administration of the U.S. Department of Health and Human Services. So I mean this is an official body and really their goal is to try to improve pediatric emergency care across the country and so they have these standards and guidelines and things that individual emergency services bodies can look to try to be compliant with.

How can a parent find out if their local emergency medical services is compliant with the recommendations of EMSC?

Chief Steve Shaner: Well again as Dr. Cohen stated, the EMS resources are mainly local. So the best thing to do if you have a question of any type is to contact your local EMS system and ask them are you folks all trained up as far as your local or regional, whatever it is, EMSC guidelines and have a conversation with them and ask them have they implemented any plans and they will be better educated about the process.

36:27

Dr. Mike Patrick: Sure. So this is something parents out there can really be active and say hey, I want kids in my community to be safer, I'm going to contact the EMS and say hey, are you compliant with EMSC and if not, why not and what can the community do to help you get there.

Chief Steve Shaner: Absolutely.

Dr. Mike Patrick: Yup. Let's talk a little bit about research and improving prehospital emergency care. And I think that the EMSC is involved with that too, aren't they? They have a research arm?

Dr. Daniel Cohen: Yeah. So, EMSCs, one of their objectives is to provide state-of-the-art care to children across the spectrum for emergencies and part of that is to help fund research and they fund Pediatric Emergency Care Applied Research Network, we call it PECARN and that's one of the major arms of the work of EMSC.

In medicine, in general, there are a lot of acronyms and abbreviations and combine that with the federal program we have tons short terms, short abbreviations like PECARN and EMS.

Dr. Mike Patrick: Yeah. It's like a language of its own.

[Laughter]

Dr. Daniel Cohen: It totally is.

37:33

Dr. Mike Patrick: What are some of the goals of research in pediatric emergency medicine? Like why do you research?

Dr. Daniel Cohen: That is a fundamentally excellent question. Much of what we've done in prehospital care, really in the past, has not been evidence-based. And fortunately, moving forward, we're providing more and more research to provide the evidence to do the right thing. A great example I can give you was hot off the presses, it was a study called the RAMPART, another abbreviation and maybe some people watched television a long time ago that might ring a bell?

[Laughter]

Dr. Mike Patrick: That might have been longer ago than I can remember.

Dr. Daniel Cohen: I think Chief Shaner will like this.

Chief Steve Shaner: I am well versed in RAMPART.

Dr. Daniel Cohen: And the RAMPART study looks at these of two types of medications, valium-like drugs or benzodiazepine drugs, for the treatment of seizures and it's just hot off the presses from the New Internal Medicine. And it showed one being as or potentially more effective for the use of seizures and its medication is given in the muscles.

The reason that this is potentially fantastic, an example of light's important, is that in pediatric EMS seizures for us are the number one run for a serious problem. And if we can find evidence to support the right thing to do for seizures, that's a great example of how funding research really can change practice.

39:11

Dr. Mike Patrick: Right. So if we can prove with evidence that one way of doing something is better than another then we can give recommendations to the emergency services folks and say hey, this is really what you should be doing based on the study and that's the sort of thing that EMSC is funding.

The other issue with research and I think we don't talk about quite as much but I think is also important is cost effectiveness. I mean, when you look at the state of the economy today and the recession, are there ways that we can still have great care but can do it in a more cost effective manner. Is that common to the mind of the researchers when they're doing these things?

Dr. Daniel Cohen: Ahmm…

Dr. Mike Patrick: Not always.

[Laughter]

Dr. Daniel Cohen: Yeah. I can think of another study that we're doing through PECARN that addresses somewhat the cost effectiveness but not just in terms of financial cost but exposure cost — the use of CT scanning in minor head injuries. CAT scanning is frequently done in minor head injuries and there's been a recent publication from PECARN looking at a set of rules to try decide who should get a CAT scan and who not.

Clearly there's a cost of those CAT scans and not just financial cost but the radiation exposure cost, I think your listeners and me as a parent care greatly about.

40:27

Dr. Mike Patrick: Oh, yeah. We talked about that before.

Dr. Daniel Cohen: And one of the studies that we're doing right now through PECARN is trying to embed these decision rules into an electronic medical record in the emergency department to provide feedback to the providers as to whether or not a CAT scan would be indicated based on these rules.

So we're in the middle of this research and yes there could be cost utilization component to it but more fundamentally we're trying to get it doing the right thing and to minimizing risk and maximizing…

Dr. Mike Patrick: Yeah. Yeah. Don't do radiation exposure, I mean do it if you have to do it but if you don't, why expose them to the radiation and the cost. Absolutely. With PECARN itself, so Pediatric Emergency Care Applied Research Network, as I understand it, it's divided into six nodes. So we have children's hospitals actually pooling their resources and working together?

Dr. Daniel Cohen: Yes. So there are six nodes spread around the country from coast to coast and within each node there are three institutions. So there are 18 institutions participating from coast to coast.

Dr. Mike Patrick: So what node are we a part of here at Nationwide Children's?

Dr. Daniel Cohen: Again, these are more acronyms for you, Dr. Mike…

[Laughter]

Ours is GLEMSCARN, which is the Great Lakes node.

Dr. Mike Patrick: OK. So it's Nationwide Children's and what other two hospitals are involved with that?

Dr. Daniel Cohen: Ann Arbor in University of Michigan and Detroit Children's Hospital as well.

42:01

Dr. Mike Patrick: All right. And we are the best node, right?

[Laughter]

I'm just teasing. It's like rah, rah, root for your team kind of thing.

Dr. Daniel Cohen: It is a very collaborative group across the country and that's one of the fun parts about working together and move the feet forward.

Dr. Mike Patrick: Yeah. Absolutely. And sharing knowledge and actually that really kind of nicely goes into the next question. Once these pediatric emergency medicine research studies have evidence-based findings, how do we get those findings into the hands of first responders so they can start to change what they're doing based on the latest evidence?

Dr. Daniel Cohen: Chief Shaner mentioned this earlier, EMS providers function virtually the whole time based on their protocols. I think that effect change on the ground would mean changing their protocols. So working through the medical directors, working through the groups that inform the protocols is the way to get there.

But as fundamentally important, engaging the community in the conversation about research because doing EMS research is really difficult and it needs to be very collaborative. And I think we have a lot of educational moments including Dr. Mike's show right now, but also through the times that we teach our EMS providers and we go to continuing education is a great opportunity to disseminate knowledge.

43:28

Dr. Mike Patrick: Sure. I think when you talk about EMS research being difficult and if you put yourself in the parent's mind too, you can really understand that. I mean, when your kid's having an emergency, your focus is on their care right now and so when someone says, can they be a part of a study it's like, no, I just want you to help my kid. And so it really kind of takes a special person to not only be caring for them but then also looking forward to how can we learn from this and communicating that with the parent to get them onboard with helping out.

And I would just put a plea out there for parents that if you're in the position that your child's having an emergency and someone does approach you about having them be a part of a research study, no one's is going to, I would hope, of course I can't speak for every researcher out there, but I would hope it's not something that's going to put your kid's life in danger, but it could help us, help other kids in the future and parents should consider being a part of that.

Dr. Daniel Cohen: Yes. And I would say that the bar is being set for inform, consent and safety is extremely high and this issues related to inform-consent are much higher than in clinical care as it should be.

Dr. Mike Patrick: And Chief Shaner, in your experience, have you seen these studies change what you do?

Chief Steve Shaner: Absolutely. The good part about the system, at least in our area, is even though we've function primarily from written protocols, the interaction between the EMS physicians and our EMS services is very high. We have a great group of EMS physicians in this area as well as I can say in most of the Great Lakes area, because I've been to a lot of places, but we have a good interaction with EMS physicians and that's what gets the word down to the local provider is we're constantly working on those written protocols.

45:33

We have a lot of interaction between the physicians and the folks in charge of running the protocols and based upon that interaction we're always looking for how to better our system and they always draw from Index Research Journals on what's the current thoughts. And the fortunate part about having a huge research facility here in Columbus, Ohio is that we can contact them pretty much anytime we need to and ask them what's the right thing to do.

Dr. Mike Patrick: You have this relationship because you're here in Central Ohio and Nationwide Children's is really involved in pediatric emergency medicine research. But what about folks in Guernsey County, it's a small department, how do they make sure that they're keeping up to date?

Chief Steve Shaner: That's the other fortunate piece about EMSC and about the State of Ohio, how it's organized in the regional system so that those people have basically the same access as we do, even though we're only a mile or so from Children's Hospital, the folks that are 50-60 miles away have the same access. They can get the same direction that we do.

46:46

Dr. Mike Patrick: Great. And we will put a link in the Show Notes over at pediacast.org to EMSC so that parents can go and look if there are in their area of local EMS is not kind of glued in to what EMSC is doing. They'd be able to find their website and get that information and kind of get plugged into the system so they can get the latest findings into their hands as well.

So Dr. Cohen, let's talk briefly about emergency services here at Nationwide Children's Hospital. We have a brand new hospital that is opening on June 28th and we're really excited about the emergency room.

Dr. Daniel Cohen: Oh! It's really exciting. I was fortunate to be part of the design team. It was a really great experience going on the country and seeing how other pediatric emergency departments and generally emergency departments are organized. And we're really, really very fortunate because we have a lot of community support here for our facility and we have a very diverse population.

I know that may not be the perception across the country about Columbus, Ohio but we have a very diverse population.

Dr. Mike Patrick: Yeah. Absolutely.

Dr. Daniel Cohen: And we're very regionalized as Chief Shaner said. That's one of the benefits of Central Ohio and Ohio in general that it really helps lead to the different tiers of care for children. So it's a pretty exciting time here for us.

48:09

Dr. Mike Patrick: Yeah. Absolutely. And the new emergency department, I'm really excited about it. I've toured in it three times now. It's amazing. Really, it's an amazing space. And for those of you who aren't aware, here at Nationwide Children's we have the largest campus expansion in the history of the country going on right now. And there's this huge beautiful tower that going to be opening and it's just really going to be a great resource for the community here in Columbus.

And, when we talk to specialists here, a lot of folks do travel in the Columbus for second opinions or because there isn't a specialist on a certain thing in their area, even though it's a little self-promotion here and we are a national and global podcast, I still like to kind of put our hospital out there because it's a really cool place.

All right. If you check out the Show Notes, we have lots of links for you in this particular episode, emergency services at Nationwide Children's, the Division of Fire for Grandview Heights, Ohio, the EMSC National Resource Center, PECARN, the Red Cross, the Jump Kit Bag Initiative. I mean, lots of stuff that you can use as a resource. So I encourage you to check out the Show Notes for this particular episode.

49:24

And of course we really appreciate both of you stopping by the studio. Before you leave, there's one other thing that we ask all of our guests, one of my passions if for families to do fun things together. They don't necessarily involve screen time, computers and T.V.

And so one of the things that we like to do in our house is play family games, board games, card games, those kind of things. And so we just ask each of our guest what's your favorite family game?

Dr. Daniel Cohen: Our favorite family game right now is Bananagrams.

Dr. Mike Patrick: Oh yeah. So you have the banana-shaped bag with the letters in it?

Dr. Daniel Cohen: Yes.

50:00

Dr. Mike Patrick: Yeah. Very cool. And what about you, Chief Shaner?

Chief Steve Shaner: Well, I have to say we don't have a lot of time for games in our house. It's usually transportation from one sport or activity to another is our game. So I guess we don't have a favorite.

Dr. Mike Patrick: Are you on Facebook or no?

Dr. Daniel Cohen: Yes.

Dr. Mike Patrick: Have you done the words with friends?

Dr. Daniel Cohen: I have not. I have not.

Dr. Mike Patrick: But you've seen it around?

Dr. Daniel Cohen: But I know it's a nationally popular thing.

Dr. Mike Patrick: I did it for a while and I had to stop. I had just deleted it off my phone because it was just taking up too much time.

Dr. Daniel Cohen: Absolutely.

Dr. Mike Patrick: All right. Well thanks again to Dr. Daniel Cohen and Chief Steve Shaner. I appreciate both of you stopping by.

Dr. Daniel Cohen: Thank you.

Chief Steve Shaner: Thanks for the invitation.

Dr. Mike Patrick: Yeah. Absolutely. And of course I want to thank all of you out there for listening to the program. We really appreciate it. Don't forget our next episode we're going to kind of continue this sort of conversation. Dr. Sarah Denny, MD is going to be stopping by, we're going to talk about summer safety. So we have tips on keeping you kids safe this summer. We're going to talk about bike safety, how to pick out the right helmet and to make sure your helmet fits; safety around swimming pools, playgrounds, trampolines, just how you can avoid needing prehospital emergency care.

51:10

I also want to remind you that iTunes reviews are helpful as our links on your webpages and mentions in your blogs, on Facebook and your tweets and on Google+. And be sure to join our community by liking PediaCast on Facebook, following us on Twitter and tweeting with hashtag #pediacast and also hanging out with us over on Google+.

And be sure to swing by the Show Notes at pediacast.org to add your comments on today's show. Also we appreciate you telling your family, friends and neighbors about the program and don't forget to talk us up with your child's doctor at your next well check-up or sick office visit.

We also have posters you can download and hang up wherever moms and dads hang out and you can find them under the Resources tab at pediacast.org. One more time, to contact us if you have a topic suggestion or a question, just head over to pediacast.org, click Contact or you can email pediacast@gmail.com or call the voice line at 347-404-KIDS.

And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody. [Music]

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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