Becoming a parent often brings a completely different perspective on pediatric patients. In preparing for spring classes this semester, I realized I had 10 years of syllabi for the pediatric course that I teach for the local paramedic program. Ten years ago I was on a crusade to improve pediatric care in the community after experiencing the frustration of a call that involved a technology-dependent child.

When it comes to pediatric care, most EMS programs barely scratch the surface on making adjustments to their training, equipment list and public education. A pediatric patient should be at the top of any EMS chief's risk-management profile. Risk managers will tell you that low-frequency, high-risk operations are where your educational and response activities should be focused because they're most likely to result in a loss. If you take into account how the Centers for Disease Control and Prevention measure morbidity and mortality in pediatric patients, some of the greatest costs to the health-care system in years of potential life lost are generated by critically ill or injured children. When a bad outcome occurs in a child, it generally will result in litigation and substantial cost over the child's remaining life.

The emotional toll experienced by EMS providers on critical pediatric calls can be career-ending. Some of the worst cases of critical incident stress have been among paramedics with children the same age as the injured children. The emotional toll also extends to survivors. Parents experience a high divorce rate after the death of a child. The misplaced feelings of guilt, anger or depression are extremely hard to manage without a solid employee assistance program and top-of-the-line counseling resources that specialize in grief and the loss of a child.

Another disconcerting fact is a recent report that states one in six children experiences medication errors; therefore, it's the health-care system itself that contributes to death. In an Institutes of Medicine book called To Err is Human, one study identified 18 patients, or 64% of the children studied, who suffered iatrogenic cardiac or respiratory arrests were found to have been subjected to medical errors. No studies exist on pediatric medication errors in the field by EMS responders, but it can be extrapolated from hospital data that a similar problem may exist given the more uncontrolled environment and lesser training.

While medication errors are still subject to conjecture, there are some emerging statistics regarding the prehospital care of children who require intubation. As with all skills, pediatric intubation competency would be expected to deteriorate in the absence of practice or refresher training. The American Heart Association recommends that paramedics perform from five to 12 intubations per year to maintain proficiency on adult patients. It's nearly impossible for that standard to be applied to pediatric patients in large fire-based EMS programs. In fact, the National Registry allows for only two hours of the core refresher training to encompass pediatric topics, although some pediatric topics on medical emergencies can be applied to other categories. With these and other factors in mind, a large pediatric intubation study in the Los Angeles EMS system resulted in the skill being removed from the inventory of that system's paramedics.

So how does a fire chief make an investment in pediatric care? The first step is to invest in serious training. There are enough alphabet courses in pediatric care to maintain a 6- to 8-year recertification cycle. Using a different program each recertification cycle keeps the information from becoming outdated or redundant. Current courses include Prehospital Pediatric Care, or PPC; Pediatric Education for Prehospital Providers, or PEPP; Pediatric Advanced Life Support, or PALS; Advanced Pediatric Life Support, or APLS; Pediatric Basic Trauma Life Support; and Neonatal Advanced Life Support, or NALS. Paramedics and EMTs should take one of these courses on a rotating schedule every two years.

More aggressive pediatric EMS recertification programs rotate paramedics back to the pediatric ICU or operating room for refresher training and physician shadowing. This is extremely helpful for paramedics who don't have children because it helps them get used to basic interaction with children.

There are other options as well. With appropriate ethical guidelines and planning, animal labs involving intubation of kittens help to maintain pediatric intubation skills. Similarly, intraosseous practice should be done on turkey or chicken legs to allow the paramedic to feel the hardness of bone and aspirate bone marrow. The more “real” you can make the training, the better it will improve performance and decrease the anxiety or stress of caring for sick children.

You can expect miracles from good training. Baby Michael, for HIPPA's sake, was a 4-year-old child found at the bottom of the family swimming pool after more than 15 minutes. He was pulled from the pool by law enforcement first responders, resuscitated with quick ALS and transported to a pediatric ER with board-certified pediatric ER doctors. When the child arrived at the pediatric center with an epinephrine drip and low pH levels, the chance for recovery was slim. Months later, however, a film arrived from the family showing him celebrating his birthday and running around the house. That film was a tribute to the field crews that called for an epinephrine drip and the physician medical direction that deviated from protocol positively effected the child's recovery.

You also need to invest in the proper pediatric equipment. Many fire-based EMS providers still use a small fishing tackle box for their pediatric supplies. Complete systems with tapes and bags based on weight and color codes are significantly improving the performance of prehospital personnel in critical pediatric situations.

For example, a waveform or end-tidal carbon dioxide detector using slipstream technology can mean the difference between a child who arrives with a profound acidosis or a neurologically intact child. Many children experience gastric distention as their stomachs fill with excess air from over-bagging or an excited bystander pushing adult lung capacity into the child's smaller lungs. The overfilled stomach pushes up on the diaphragm and decreases oxygen exchange, resulting in a buildup of carbon dioxide that makes medication like epinephrine ineffective. Capnometry can alert paramedics to the condition. A simple field intervention with a nasogastric tube could change the outcome. A similar indication for capnometry is warranted for a child with asthma whose pulse oximeter may show 95% or higher but may be on the verge of death due to an inability to get carbon dioxide out of the body. Again, technology on the ambulance can predict this event.

In addition, EMS crews should be responsible for identifying and familiarizing themselves with technology-dependent or special-needs children in their first-due district. It's important to send engine companies to the home to meet with parents; learn about the child's specific medical problem; and understand how the child's technology, such as ventilators, feeding tubes or intravenous access, works. Such a meeting also offers a chance to see the child in his or her normal mental state.

There's a tremendous amount of free material and funding available to EMS agencies for pediatric care. The National EMS for Children program funds training, curriculum support, data collection and public health initiatives for children. Local Safe Kids chapters often have funding or training support. Large university or pediatric hospitals may conduct support classes as part of their outreach programs. Charities and private donors are more likely to fund initiatives that positively affect pediatric populations.

As a chief officer, you can make the pediatric care in your service area second to none. The liaisons and relationships you build with other providers of pediatric services can make an impact in your community. A community often is judged by the services it provides and the health of its children. Our local pediatric hospital best summed it up with the motto on the side of its pediatric critical care transport: “Life is precious.”

Bruce Evans is the fire science program coordinator at the Community College of Southern Nevada as well as an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. A captain at the Henderson (Nev.) Fire Department, he has an associate's degree in fire management and a master's degree in public administration.