Treating Kids Like Little Adults

Hi, there. My name is Dr. Peter Anteve. I'm a pediatric emergency medicine physician and an EMS medical director here in South Florida. Today I want to take you through a presentation titled Treating Kids Like Little, Improving Outcomes by Challenging Dogma. And what do I mean by that? Well, I think that children need to have better outcomes than they've had. I think we have to treat them differently than we've been taught to do. And this presentation goes into detail on exactly just that. So let's get started. Before we start, I do have a disclosure. I created a product called Hen Tevi. I'm the founder of that product. But this presentation will not include any information about Hand Tevy. Okay, so I always like to start with this story about an obstetrician from the 1800s. And you may ask, what does that have to do with pediatrics? Well, his story is very interesting. Dr. Semmelweis was treating pregnant women back in the 1800s. And him and his colleagues would see that after they would examine these women over time, that many of them would get septic and they would die. So he looked at his data over time, and here's what he found. He found that one particular clinic, which was the Monday clinic in pink, women were dying at a higher rate than on Tuesday clinic, which was in blue. And the fact that he got to this point where he had his data set up like this, he now understood that there was a difference between Monday and Tuesday. And what was that difference? Monday clinic doctors were coming from the morgue, and on Tuesday, they were coming right from home. So he put two and two together. He cultured the bacteria from the dead bodies, cultured them from the women who had died from sepsis, found them to be exactly the same. And so what Dr. Semmelweis did here in 1847, he instituted chlorine hand washing. He asked all of the physicians coming into clinic on Monday or Tuesday to wash their hands with chlorine. And look what happened to the death rate. It went down to zero in some months. Now, he wrote it up in the journals. He tried to tell all his other colleagues, but no one listened to him. They all thought he was crazy. And an interesting piece of history is that in 1881, our President, President Garfield, died after being shot in the back. But he didn't die from the bullet wound. He died from sepsis. Because the other doctors came to the White House and tried to dig out that bullet with their bare, ungloved, unwashed hands. And so why is it that we still can't change Practice here we have 35 years later, and we know hand washing didn't come into full practice for probably 100 years later. It just seems that medicine is hard and very slow to want to change its ways. And unfortunately, many people die because of it. There's actually another gentleman that I want to introduce you to. This is a very famous doctor. I'll tell you his name in a minute. And back in the day where people were dying from lung cancer, he came up with a theory that the lung cancer could be due to smoking. Right. What a concept. And so they wrote up a paper and they put here in bold letters, and I'll put it here on the screen, that in our opinion, the increase in smoking with the universal custom of inhaling is probably a responsible factor. Now, interestingly, when they published this, everyone thought they were wrong. They were told by many of their colleagues that they have no idea what they're talking about. And it wasn't until decades later.

Just in our generation where smoking is finally been known to cause cancer. So I think this is something that we see over and over again in medicine, over and over again in history. And I think with pediatrics, the same thing has happened. And that doctor is Dr. Alton Ochner. Many of you know Ochsner Medical center down there in Louisiana. So very prominent individual, a great innovator.

And so if we pose this issue today and we say that on this road in your town, that there's 100 people dying every year on this dark, curved road, what would you do about that if you were the city manager? And more than likely people would say, okay, we'll just put some lights on it and we'll see what happens. But if you don't come back a year later, after you've made that implementation, after you've made the change to see what your data has done, well, you haven't done anything. And it turns out when you come back a year later, after putting lights on, it turns out more people have died. So think about that. You had a problem, you had an intervention, and when you came back and looked at your data from that intervention, it made it worse. So are we doing that in ems? Are we doing things and then evaluating our progress, evaluating our data? We really need to be doing exactly that so we don't make this mistake, which is make a change, and then maybe things get worse.

And so today in this talk, what I want to do is really explain that in pediatrics, it's not much more than what I call a nudge or the terminology that's used as behavioral economics, pediatrics can be made a lot better. Not by teaching you all the new medicine, not by teaching you how to use a different drug, but by just shifting your focus to a little bit to the left or a little bit to the right. And all of a sudden it unlocks your ability to treat children better on scene. Let's go through that.

So I want to start with what I call the easy case. So I'm going to present you now with a 2 year old on SVT. He's in your care and this child is now stable. Blood pressure is normal, but the heart rate is about 210. As you're thinking through this case in your mind, you're probably a little bit.

Nervous or having a little anxiety about treating a two year old. So I'm going to pause right there and say, okay, let's stop. And now let's, let's change it up a little bit. What if I told you now it was a 42 year old a little different, start going through what you would do for this guy. And here we go. So you all know that you would try to vagal, then you would try adenosine, try adenosine again. And then finally, if the man went unstable, you would cardiovert after giving some fentanyl, you would give some normal saline, and then perhaps if he starts throwing up on you, you can give some zofran. So you're looking at this screen and you're saying, well, that's so simple, it's so easy to do. So if I take you back to this case, the two year old, why is it then that the same exact algorithm of adenosine, second dose of adenosine, then giving fentanyl cardioverting, giving a saline bolus and zofran is any different? It turns out the algorithms are exactly the same.

So what I've just pointed out to you is something that is different in kids and adults is how you're thinking about the case. From the very moment you're given the case, your brain either goes to the left and is worried or goes to the right and feels comfortable. How do we make it so that for all cases from 0 to 120 years old, we feel comfortable and confident? And that's really what I want to talk about here next.

And why it's important is because when you look at the survival for pediatric cardiac arrest, the neurologic intact survival, you see here on the screen that that flat blue line is the intact pre hospital neurologic intact survival for children. And you can See that since the 1980s, we have made no difference. It's been exactly the same, and it's around 6%. In hospital, you can see that the numbers have gone up for neuro attack survival. But for us in EMS, how could it be that we've gone for 30, 40 years and have made zero impact on survival? This is just like Dr. Semmelweis data of years and years of pregnant women dying from sepsis and people just thinking, that's just how it goes. We know now that not to be the case.

And so that data I just showed you comes right from here, right from the PALS 2015 guidelines, where infants have a 3% neuro intact survival, children have a 10.5% survival rate, and adolescents, which we should call adults, have 15.8%. And the paragraph there on the left shows you exactly that. They say we don't know why things haven't changed. Well, I think we can look a little deeper and maybe have an answer to why things haven't changed. And so if I take you to the adult world now, let's take you to Palm beach county, where my colleague Dr. Schepke and I became the medical directors in 2015. And we did a few things in that first couple of months. And you could see what happened to our data here in a minute. On the top left. We started to stay on scene for at least 20 minutes. Top middle, high performance CPR became the standard of care. And then we started changing how we ventilated children in the field and adults. Every single provider got a codestat summary, which you could see here at the bottom, in the middle. And that codestat summary that you're looking at shows very clearly that there were many compressions that were being missed. For some reason, either we were trying to intubate or we just weren't paying attention. And so it became very, very clear to us that a small change in care and a small change in practice can make a difference. And we evaluated our data afterwards, and here it is. You can see here that in 2014, that's the year before we got there, 2015 is when we rolled out that new platform. And within the same year, we doubled survival to the ED. And then 2016 got better, and it's gotten better every year after that. So I looked at my team and I said, we've done it for adults. Why can't we do it for children as well? And everyone kind of like looks away and they don't want to really address the fact that they think kids are just different. And kids are scarier. And so once you get over that hump and understand that perhaps kids really aren't different, then things can change. And so the way I'd like to really present this is with this slide here. This is a gentleman here who goes into cardiac arrest and let's follow him along his path towards rosc. The first thing he does, he falls over. His spouse sees that he's not doing so well, calls 911 and hopefully she, along with the telecommunicator, do the right things and get started with CPR. 911 is now en route. And when they're en route, they've prepared, right? This is good preparation. And then when they get to the scene, they're doing everything exactly how it's supposed to be on the scene, staying on scene until rosc. And so this right here is a patient who gets rosc, gets a post ROSC evaluation and then is sent over to the hospital with a pulse. This is the perfect case. But what about children? Children unfortunately get exactly the opposite. They don't get bystander CPR as well. The telephone CPR is much worse as I'll show you later. There's different pre planning in EMS for children. And then on scene care is often just someone throwing the child. We take the child and then we run to the hospital, oftentimes in the back of the vehicle with 60 miles an hour in full arrest, getting to the hospital, transferring care with not everything being done correctly. So if we had to look at really what is the difference between adults and pediatric care, it's sitting right here. There's not really much magic that goes into the differences. And this is what we have to change. This is the nudge that we have to change to make you go into a different direction in order to improve care for pediatrics. Okay, so let's test your brain. Let's start off with an adult male who is now in cardiac arrest. And you have a six to eight minute time until you get to the scene. Think of what you're thinking as you're getting to this gentleman. Most of you are thinking of scene safety, bsi, you're thinking of high performance CPR roles, positions one, two and three. You're thinking of, you know, great BLS care. And then you're also thinking of the dose of EPI or amiodarone or the juuls, all that information, you know, en route to the call. What about this guy? 65 year old, anaphylaxis, same thing. You know how much epi? 1 to 1000 you know how much Benadryl, salumedrol, albuterol, normal saline you're going to give this guy, Right? So my point here is that your brain functions in the adult world, you're allowed to get the dosing and start care prior to arrival on scene as opposed to what we've been taught in kids for many years, which is if you have a kid who's in cardiac arrest, oftentimes we've been told to get to the scene, lay the kid flat, get a measurement, get a weight, and then start the calculations for that child. Or even harder, in my opinion is the kid in anaphylaxis. This kid's awake in extremis, sitting on mom, tripoding forward, juuling.

Having inability to breathe, and then we have to lay that kid down, get a weight, start doing calculations. It's exactly opposite in children how we perform and how our brain starts to think through these cases compared to adults. That is the problem, that is the biggest problem in kids. And there's an easy fix to that, which we'll talk about. And so putting this all together, I want to bring up the concept of the arrest life cycle. This is not the arrest life cycle in the child, this is the arrest life cycle in us, the providers of care on scene or in the emergency department. Right. And so let's go through these very important four quadrants with the most important quadrant at the end, which I'll talk about in more detail. So the first quadrant is enroute for the adult. We talked about it, you're en route, you feel good about it, you want to get there. When you get there, you want everyone to understand that you're here to try and help this guy come back to life. You feel proud, you feel confident.

2 year old arrest is exactly different. It's 180 degrees, right? You get there, you're not confident, you can't look at mom and dad in the eyes. People are throwing you this kid and you say, you know what, maybe I'll just run and I'll take this kid to the back of my ambulance and then rush him to the hospital. That's not the right way to do things and you can see that that just doesn't work. Well, let's move on to on scene. For the 65 year old in arrest, we feel comfortable, people are looking at us and that's okay. Spouses are next to us, that's okay. We're not rushing in the child. The two year old arrest doesn't feel so good. We're rushing we're not making eye contact, we're not communicating. Oftentimes we're not performing good BLS care.

The ALS care oftentimes gets done in the back of the ambulance as we're screaming to the hospital, code three.

It's exactly opposite of what we should be doing. And so those two quadrants that you're seeing right here are the two most important quadrants to get you to the next level. And that next level goes into what we call the debrief. And in the adult world, we oftentimes don't do a debrief. Right. And why don't we do a debrief? Because quadrant one went well, quadrant two went well. And we kind of skip right over to the next quadrant, which is closure. But when you have a debrief in kids, the most common question that people ask is, what could we have done better?

That's really not the true question. It's what could I have done better? When you are asking that question in a debrief, you want to know, what could I have done better for that child so that the next time I could perform better? And who you're comparing yourself to, interestingly, is yourself. So when you treat an adult today and you treat a child tomorrow in cardiac arrest, you're comparing your performance on the adult and your performance in the pediatric case, you're comparing yourself to yourself. That is the big critical issue here, that if you're not performing the same, then you won't feel like you're doing a good job. And therefore the debrief and therefore this question of what could we have done better? Let's get down to the closure part, which is really the most important part. What is closure? Closure is after that 65 year old has a cardiac arrest and you transfer the patient to the doctor at the hospital.

Are you able to tell yourself two things? We did all we could. Right? And oftentimes in the adult world, people say that person lived a long life, it was their time. That's often what I'll hear when I ask the question, how do you get to closure? And so getting to closure hinges on the pre arrival. It hinges on the on scene care so that you're able to tell yourself that you did indeed do everything you could. And that's closure part one. Closure part two is when the spouse comes running around the corner and says, hey, wait a minute, weren't you the one who were on scene treating my husband? And you can say, yes, we were there. And then you can take the spouse through what you did. Moment by moment, we were on scene for 20 minutes. We took control of his airway. We were doing cpr. We were giving him medications to help his heart come back to life. And now we've transferred care to the hospital here, to the doctors and nurses, and they're going to take great care of your husband. Godspeed. I hope he does well. Okay. Giving other people the opportunity to get to closure is perhaps just as important as you getting to closure yourself. So think of that. There's two aspects of getting to closure, and in children, that often doesn't happen. Why? Because quadrant one, prior to arrival, you don't feel right. Quadrant two, on scene, a lot of anxiety, no eye contact, very poor communication, running off the scene. And then we are unable to get closure for ourselves, and surely we're not getting closure for the family member. And now we're left into a situation where you have people who are hurting already and now they hurt even more because you just didn't feel like it went right. Like it went as well as it did yesterday. It's a big thing. So if you want to Google something, Google resuscitations that never end. It was written up in JAMA a few years ago. Why this is important is because it says that if you don't get the closure today on a case, you'll never get the closure. So all of us have examples in our own mind of children who we probably could have done a little bit better for children, that we could have perhaps changed their outcome. And it turns out that there's no debrief, there's no therapy that can get you to the point afterwards where you feel better about that. So it's time to now understand that the time to do right by the child is prior to arrival. It's on scene, and it's in the emergency department when we're then leaving the family there in the hands of the doctors and nurses at the hospital.

So we're talking about getting kids back to life. We're focusing on ems. But let me kind of take a step back and say that it can't just be an EMS thing to get kids back to life. We have to have the lay public involved. They're strongly linked with the telecommunicators, which is telephone cpr. Then we get there. So if these three links are tied together closely and are working.

You can then have the best outcome at the moment, which is having ROSC on scene deliver the child to the hospital, and the hospital can then take over and get that kid neurologically normal over the next coming days to weeks. And so the point of this slide is that even if you have the highest functioning EMS system in the world, unless you understand the layperson and telephone CPR aspects before we get that kid, outcomes will never get better in your community. Let's talk about that first part. And I have a 911 call that's very, very moving and it shows something that it took me years to understand, is that the telecommunicator has a very difficult job when it comes to pediatric arrest. Oftentimes it ends up not being arrest. Right. It happens to be a seizure. And so when you're a telecommunicator, you're hedging your entire time to lean towards not giving cpr. And the problem is, is that when a child does need cpr, they end up getting the short end of the stick. And so here's a case, and I won't have you listen to the audio now, but just look at the emotional aspect of the telecommunicator is on the side of no CPR.

Tries to get towards starting CPR twice, as you can see, but never crosses the threshold. Even though the mom said the words unconscious and not breathing normally in the first 13 seconds, those are the cues to actually start CPR for that child. And the mother goes on to say those words over and over and over again. And she says not breathing normally seven times, unconscious seven times. And we were unable to get her to start CPR.

For some reason. But the reason is now becoming very obvious, is that we just have to have better training and a better understanding that when you get to unconscious and not breathing normally, you should start cpr. And in this child, unfortunately, when we got there at seven minutes, he hadn't received one chest compression. We did high performance CPR right in the bathroom on our first look, he was in V fib. We shocked him out of it. Now he's got nsr, he's got pulses back, and we have a child who is now back to life. Hooray. Except that when we followed up at the hospital, what had happened was he ended up getting transferred to another hospital by helicopter. They investigated the mother because they thought she was lying. And now you've separated the mom and the child, you sent the child to another hospital. The child unfortunately ended up dying 36 hours later because of cerebral edema from the hypoxia.

And so when my crews called me four hours later wanting to know what happened with the little boy, they were very upset to find out that he wasn't doing well. And then when they called me 12 hours later to find out how he was doing. And then 36 hours later, the reason they were calling me was because they wanted to get the closure. They wanted to know that what they did and all the training we've put in mattered. And so, unfortunately, this little boy passed away 36 hours later from cerebral edema. But it wasn't because EMS didn't do a good job. It was. It was because what happened prior to our arrival wasn't up to its highest standard. We should have given this kid at least some chest compressions to perfuse the brain, to oxygenate the brain so the brain wouldn't then become hypoxic to the extent that it had cerebral edema and then ended up dying a couple days later. Those couple of minutes and seconds make a difference. We are responsible for that. We are responsible for enhancing telephone CPR in our communities. That's how outcomes will get better. So how it adds up for that little boy is that he had no layperson cpr. He had very poor telephone cpr. Now, he had great EMS cpr, but that didn't matter because the outcome in the end wasn't good.

So my whole point here is that we really need to change the way we think about care for children in the field leading up to the care in the hospital. So I like to show this video here because this is a video not in America. You can see these police officers have arrived on scene. They're not doing, you know, PALS guidelines type care. They're not doing high performance cpr. My goodness, they're flipping his child upside down. They're trying to empty the water from his lung. He had just drowned in the river before he was pulled out.

You can see here that he's not getting good chest compressions. And in a moment you're gonna see that the police officer is gonna pick this child up and put him on his shoulder, and then he's going to start running around in circles and doing laps.

This is not good quality care. But interestingly enough, it's better than what the child in the last example I gave you was getting. He got nothing. He got no movement. He got none of this kind of cpr, which is not good cpr, but it's better than nothing. And so here we go again. Here's round two of doing another lap. And so you're probably looking at this video thinking, my God, this kid has no chance. But it turns out this kid was given a chance. And it turns out that doing something was better than doing nothing. And so here you can see in a moment that this child's eyes are now blinking. He is now breathing. And so, jokingly, I always say that In America it's 15 compressions in two breaths, and in Bangkok, it's 15 compressions in two laps. But all kidding aside, what was done differently here is that this child got something rather than nothing. And so he did not get any EMS cpr. No telephone cpr. Really bad layperson cpr, but a good outcome. So that's an important story to understand. So the questions I really have are, would you prefer no CPR or any cpr? And again, when you listen to the audio at your agency, you'll understand that many children today get no cpr. I would rather them get any cpr. We have to change the education. We have to change what we tell people to make them just do it.

And then do we need to reconsider the way we train the public to intervene? And the answer is a resounding yes. This is why Seattle has historically much better numbers than the rest of the country. Because they do the cpr, the layperson cpr, much better than anybody else. They start young and it's just ingrained in their culture and who they are.

Now, why does this matter? Here is a study out of Korea from September 2018 that shows three different outcomes. Patients who receive no bystander CPR versus those who received dispatch assisted or telephone CPR. And then those who just received CPR without any assistance, just knowing that they needed to help somebody in need. Look at the outcomes. This is a neuro intact survival, no CPR from a bystander. Then you have telephone CPR goes to 8.6% survival. And then CPR by someone who knew that they needed to give it without having to call a telephone operator. From 911, you could see that it quadrupled outcomes before EMS even gets there. We can quadruple outcomes. And that is a very, very big point. We need to change that. And the question is, well, how do we do that? Well, we have to start by telephone CPR modification. And we've done this here in South Florida. We are very thankful to those from Seattle, from Resuscitation Academy, Dr. Eisenberg, Dr. Tom Ray, Dr. Mike Sayer, and all the rest of the gang there, very thankful for what they provided us was a very simple algorithm on how to do this. Telephone CPR is very simple. It's a couple of questions. First you want to know are they conscious or not? And this is how you do it. Is the patient awake? Can you wake them up if the answer is no, is the patient breathing normally? If the answer is no to that? That is the definition of cardiac arrest right there on your screen. And we start cpr. So that's no, no go, very simple. Now how fast can we get to this no, no go. This is the mark of how well your agency is doing. And so let's take a look. The American Heart association put out this information years ago. And again, folks like Dr. Ben Barbaro and his team helped us understand that arrest recognition has to be done within 60 seconds. That's the. Are they conscious or not? Are they breathing normally? And then getting them down on a hard flat surface and starting cpr, hands on chest, within two minutes. Now you may be saying, well, that should be pretty simple. Indeed, it's not so simple. Our data here in Broward county showed that we were at five and a half minutes before we made a change. And now we're right here at the 2 minute mark. It takes a little bit of work. Now most of us are on cares and CARES is a cardiac arrest registry. And we know that CARES has a dispatcher assisted module. So if you belong to CARES today, have your dispatch leadership open up the CARES module, open up the case, and all they have to do now is add in three different times. Time to recognition, time to first instruction, and time to first compression. They listen to the audio, they type in the data, EMS types in their data, hospital types in their data. And now we have a full robust data set. And for the first time, you and your community can learn how you're really doing for telephone cpr. And this is what you'll get at the end of the quarter. You can look at your dispatcher assisted CPR CARES report. And finally, now you can understand where you are, make an intervention and then continue that cycle of reviewing and refining and making it better. This is a continuous CQI algorithm.

And so no, no go, this is how it should look is you have someone who's an adult. Oftentimes when you listen to the audio, this is what you'll see. You'll see the call taker ask a couple of questions, go right into the no, no and then write into go. This should take only 30 seconds. But oftentimes because of language barrier and other obstructions, things take longer. We need to understand what those barriers are to correct them. And I think that whether you're using Pro QA or APCO or another system that you have in your community, you have to understand the barriers and how to get to A successful no, no go program. A successful telephone CPR program that will allow you to have more people come back to life. Now, I will say before I move off this topic, that you're going to have an over triage of people who are getting CPR who don't need cpr. And that's okay, because we know from data that no one dies from getting CPR when they didn't need it. They may get a couple of broken ribs and they may have to have some pain control for a month or so, but that's okay. So here are the differences. Now, just to review between the pediatric and the adult case in dispatch, listen to your audio. You'll hear the difference in this visual. I want you to see the difference. And then on a case by case basis, work with your dispatchers, work with your telecommunicators. Make sure that they understand what some of the barriers are. And one main one, here is the story of Bodie Miller and his little daughter, who was 19 months old when she drowned in a pool in Southern California. And unfortunately, when they came to call 911, even though they started CPR right away, unfortunately, the dad said, I feel a pulse. As soon as the call taker heard that, he said, okay, stop cpr. And the child ended up having a bad outcome and dying. So we know two things in the telecommunicator world in pediatrics that have to change, and they're very simple. It's just that they don't want to start cpr. And that was the first example I showed you. And then the second example with Bodie Miller's daughter, they want to stop prematurely. These are the two unique things that happen in pediatric telephone CPR that you have to address and you have to continue to monitor and help your team get over.

Okay, so now that we've talked about layperson cpr, we've talked about telephone cpr, let's now move into EMS cpr, right? This is all of us. This is what we do. Pre hospital professionals. We get there and oftentimes it's a scene that's very different each and every time. It could be inside the house, outside the house, at the curbside, it could be raining, it could be on the highway. It's different, right? So we have to practice, we have to prepare for these cases. And oftentimes in the adult world, we're fine with it. How do we get there for pediatrics? How do we make it so that we bring children to the hospital who already have a pulse, rather than depending on the hospital to Obtain one. That's the key question. And there's two key elements. And this may be the most important slide of the day, which is pre arrival planning for children is very different. You have to have a deliberate discussion about dosing and equipment sizing prior to arrival. And so whatever mechanism you use to get dosing and equipment sizing, that's okay. You have to have that information prior to arrival. And the reason is, is because if you want to feel comfortable with what you're doing and look mom and dad in the eyes and have that conversation, you can't be nervous about a dose of epi, you can't be trying to figure out your eye gel size or your king tube size. You can't. You need to know that information prior to getting onto the scene. That's a major, major point. Secondly, when you get to the scene, don't waste any time. It's got to be rapid, high quality on scene care with a BLS focus, right? So it's airway, chest compressions and with the airway it's don't hyperventilate, know how to manage that airway with chest compressions. It's the correct rate, the correct depth, make sure you have the right recoil, very important. And then communicate with the family. And that point of communication with the family doesn't mean to start being a therapist. All it means is to address one major thing that mom and dad want to know, which is why are we still here? So if you want to be able to stay on scene for 20 minutes, you have to explain to the mom and dad, we're going to be staying here because your child has the best chance of survival if we stay here. If you don't say that, the parents will slowly get more anxious about why you're still here. Why are there people watching? Why aren't we leaving yet?

So that communication with the family member, mom or dad, has one basic premise, which is make eye contact, develop some trust, and then explain why you're staying. And then the next part of that is early epinephrine, which we'll talk about in kids here in a little bit.

Okay, so here's an image of high performance cpr. And this is specific to Palm Beach County Fire Rescue where we added a fourth person to help along with the eye gel. And I'll go through each person here individually. But every agency should have the positions and exactly what are their roles and at that agency. And so we even go through gear placement. So here's a video where you can see that as we're walking into the scene, everything is placed down on the floor exactly as it should be. There's no guesswork, there's no question as to who will be positioned where. And that's something that you have to practice well beforehand. There was a study that came out recently talking about equipment placement and how it matters. And I think this is a good reference article for us to look at to understand that how we place the equipment will have an impact in outcomes.

How about position one, the chest compressor? Very simple. That person is checking for a pulse and starting chest compressions. They stop their first bout of chest compressions once the monitor is charged. Okay, so the monitor gets charged, we either shock or dump. And then, then the first two minutes of CPR starts. So it's very, very important to get that child on the floor. Start CPR rapidly. And then position two will place the pads, as you'll see here. And now that medic is now charging the monitor. And as soon as the monitor is charged, then that medic should hover. And then based on the rhythm, will either shock or will dump. And then the first two minute cycle starts. That's how it should go. Very, very simply. And now position two has two minutes to place the IO and that's an important step. The IO goes in and then the first dose of EPI can come on in. And that should all be done within the first five minutes of arrival. If you can get to that point, I'll show you why later. That that's very important for outcomes in the field. What about the airway person? Airway person, how we teach it, we come and give two big breaths with a BVM and then we go right to the eye gel. And the eye gel has some different characteristics as far as being placed in children because they don't have the hooks. And here this video shows how we now have to strap down the eye gel. But be that as it may, it's very quick. It doesn't require any stoppage of cpr. And now we can begin asynchronous ventilations for the pediatric patient with a good seal. And now you're going to be checking for compliance and your end title and all the things you would do for the adult.

So this is how high performance CPR should look on scene. You can see here that here is our crew. They're on scene. It doesn't appear that they're rushing off of the scene. They're being confident, they're being quiet. And the only thing really missing here is an image of the mom and dad and one of the officers talking to them as to why we're not leaving right this moment. We'll need a few more minutes and then we'll package your child up and take him down to the closest appropriate hospital. This is how it should be done. This is how you'll get outcomes that will rival those in the adult world.

And we know the data exists, right? So this is data from resuscitation years ago. This is from 2015. We know that staying on scene for children matters. You have the highest survival to discharge. But it turns out that even though we knew it had to be done, we just never knew how to do it and what the important barriers were. This is again, let's go back to Dr. Semmelweis. We knew there was a problem. Let's get it fixed and let's change what we've been doing for so many years, which is running, load and go, scoop and run, massive anxiety. Kids will not survive with that attitude.

And so the timing of epinephrine is important too. And this is a good study from March in 2018 from circulation showing that for every minute you delay epinephrine and out of hospital cardiac arrest, it's a 9% decrease in the chance of survival. That's a lot. That's almost similar to what we say. For every minute that an adult in V fib doesn't get an AED, they have a 10% reduction in survival. Epinephrine is important, early epinephrine. Okay. And you've probably heard of this study, which is paramedics two study out of England back from New England Journal in 2018 of August where they took 8,000 English adults. 4,000 got EPI, the other 4,000 got what looked like EPI. And you could see that epinephrine, although those tripling in survival to the ED or Roscoe, the neuro intact survival wasn't good. It was the same from both groups. And so most people thought EPI doesn't work. But that's not true because when you look at the data, they gave epinephrine 21 1/2 minutes after the patient experienced their cardiac arrest, or 16 1/2 minutes from the time they arrived on scene. So if you're giving epinephrine to a cardiac arrest victim 16 and a half minutes after you arrive on scene, that patient's certainly not going to do well. That was the problem in this study. That's why I'm trying to encourage you. When you get to the scene, try and get high performance bls and then your ALS care immediately after that. It's very important to get that speed down. Now what happens if you have a child that you get a pulse on 20, 30 minutes later? Don't be happy about that. The data shows that in this series of 191 children admitted to the ICU after getting pulses, a large number of them died in the hospital because those first seven, eight, ten minutes where they got no perfusion to their brain led to hypoxic ischemic injury and death. So 4 further data to explain that we in EMS have the biggest chance of survival for those children by performing high quality care, getting pulses back prior to arrival at the hospital. And so if I had to give you kind of the mantra of restart the heart before you depart, and initially I would say strive for two minutes of good care and then four minutes and then six minutes. But it's very simple. Arrive bad chest compression, put the drill, give epinephrine, wash, rinse and repeat. Very simple. Just keep doing the same thing over again. You'll get pulses back. You'll then transport the kids, you'll do a post ROSC assessment. It's not that hard.

Okay, what about things that are not cardiac arrest? You're probably listening and saying, well, I may not even run a cardiac arrest this year. All right, well what about the data on children who are having seizures like this little boy? Well, it turns out the care is not that good either in the field. And here was a study from Texas where we asked is more education. The answer they gave this EMS department education and they actually gave a small group of them more education than the other group. And they called it the PD Steps program, which is very smart, very good program. But then they followed these particular medics who got that additional care. And they looked at did these medics provide better care for children who are having seizures in the field? It's very interesting what they found after giving an eight hour course pediatric specific to these EMS professionals. And you can see here that they ended up having 250 active seizing children in the back of the ambulance. And so here's the Data. Out of 2,200 children who were actively seizing, the study looked at 250 actively seizing children in the back of an ambulance in Houston.

And you can see here that the data is very interesting in that about over 180 of these children were treated by the no additional training group, 65 were treated by this group who got the eight hours of additional training. And you would expect that the children who got treated by the extra training group got better treatment. But in fact that wasn't the case. If you look at here at the top line of this graphic, you could see here that.

For the non trained paramedics, 56% of them received epinephrine, whereas 63% of those who were trained in PD steps gave a dose of midazolam. There's no difference statistically there. Now more Interestingly is that second highlighted row where in both groups 51% gave the correct dose. So that means that even with additional training, we're still not giving the correct dose to children. So what you see here in this study are two types of errors. Errors of omission, where upwards of 44% of children are not even getting a dose of midazolam. And then when they do get the dose of midazolam, 51% only got the correct dose. There's errors of omission and errors of commission. So it turns out that having a pre plan, understanding what you're going to do before you get there, communicating with the family, why you're staying, why you're treating on scene is greatly important. And again, here were the outcomes that only 58% of those children received midazolam and 49% received the incorrect dose. So there is something else at play here rather than just more training. So now let's put it all together because I think that we can make a difference, you can make a difference in your community. And I want to highlight some of my favorite people in the world. Out here in Bend, Oregon, there's a great community, great EMS community for sure. And I want you to listen to not just a 911 call, but look at the outcome. After EMS provided just amazing care to this 8 year old little girl. And the 8 year old girl had a sudden cardiac arrest. The family called 911. I would like for you to listen to this 911 call and listen to how quickly she gets to. No, no, go and listen to how great. She advises the family to continue CPR until EMS gets there. So take a listen.

91 1. What's the address? The emergency, we need you to come. Our daughter is not breathing. What's the address?

Okay, what's the phone number you're calling from?

Okay, tell me exactly what happened. She's been sick. She was downstairs taking a nap, she threw up and we went down there to check on her and she's not breathing now. Okay, I'm going to tell you how to do cpr. Are you with her now?

And so that was just simply amazing. Right now bend, Fire gets there. And look at the outcomes here. They had hands on chest in 30 seconds from telephone CPR. Ben Fire gets there, stays on scene for 40 minutes until they get Roscoe. Now remember why this is important is because you understand that their mantra is there's no specific time. They want to get this child back to life. Seven counter shocks later, this girl now had a good strong pulse, transported to the local hospital, then flown out to the children's hospital. And you can see here that the father when he wrote on Facebook, let's focus on that middle paragraph. He says to the first responders go my undying thanks for never giving up on my daughter. So he viewed 40 minutes in the living room as never giving up on his daughter. And the beauty of this case is the outcome in that here you have an 8 year old amazing little girl who's now neurologically perfectly normal because of the chain of survival that worked. You had parents who did the right thing. Telephone cpr, the telecommunicator did the right thing. Ben fire did the right thing. Then the hospital took that baton and continued this girl's progression towards a discharge neurologically normal. This is the type of outcome that we're looking for. This is why all of you should understand that you have the biggest impact on pediatric survival prior to arrival at the hospital. That's the important part.

And I always like to give a huge thanks to all those at benfire, including Captain Peter Hossek, who's really put this change on his shoulders and really made it happen. So thank you to all those at benfire, our greatest gratitude.

And now the data that it really changed the landscape which is in Polk County. So Polk county does the pre arrival. Polk county stays on scene until kids get rosc. And this is where we learned about the fast epi. So let me show you the Polk county data and you can see here that in 2012 and 2013 they had 38 children going to cardiac arrest. None of them survived, they just had two ROSC. But those children didn't survive in 2014 and 15 they started staying on scene because they had some pre arrival knowledge, they knew how to communicate with the family. And they got 13 children neurologically normal back. And then in 2016 and 17 it jumped again. And the question is why did it jump? When you look at the data, they had a 16 and a half minute time to epi. That number may ring a bell. Prior in the 2012 and 13 years, in 2014 and 15 it went to 7.3 minutes. In 16 and 17 it went to 5.4 minutes. So high quality care starts before you get there and it continues on scene with high performance BLS care followed by very quick ALS care. In this particular case, epinephrine and all that wrapped around good communication with a family member on scene. This is how we get kids back to life. It's been proven. There's no pediatric experts in Polk county in that EMS department. Just great leadership and great know how and how to do it the right way. They are treating kids like they treat adults. And here's their latest data that they've sent over showing that in green you see the neuro attack survival and blue is the rosc. They keep getting better and better year over year.

And so that article they published their data in resuscitation 2019, you can look that up. And I think really it's a landmark trial that definitely shows that how you pre plan, how you act on scene can make a huge impact in outcomes. So my big debt of gratitude to Dr. Paul Banerjee, Dr. Pepe and all those involved in this research.

Then the very last topic I want to talk about is pediatric bereavement. Remember I started off by saying that only 6% of children actually have a neuro intact outcome. That means 94% of them don't. But we weigh completely to the other side, our training on how to treat arrest, but we don't talk about how to deal with the pediatric death, the 94% of the time outcome. And so I was very honored to write this article on pediatric bereavement in EMS world. And it's really what about the family? How does pediatric bereavement start? I feel it starts on scene and I'm not saying to become their therapist, I'm saying to explain to the family why we're staying, why we talked about that already. That's all you have to do. Make eye contact in the emergency department before you leave. Go speak to that same family member, explain to them what you did on scene. Now is the time for the recap of everything you did. Why is that important? Because mom and dad want to know that their child had every chance of survival. If you could take 30 seconds to say we got there at 12 o', clock, we started chest compressions, we placed an airway, we tried to give your child the best chance we could and now we've transported them here and we've transferred care to the doctor. We wish your child, and you use the name of the child, has a good outcome we wish you Godspeed. Give them a hug, do whatever you feel is right, but don't ignore them. Don't leave the emergency room from a side door so that you miss them. They need to see you, they need to speak to you. And again, it could be an officer, but it doesn't have to be anything about the oh, I'm sorry of what happened. It's, this is who we are. This is what we did. We've transferred care. Because I know that it's difficult to go into the other aspects. I'm not asking you to do that. Be very, very simple, but be respectful, have empathy. After what they've been through, they want to hear from you. And parent after parent will tell you that they want to hear what exactly happened and what was done for their child, especially if their child didn't make it. And so here are my five points that I think.

Would make some people upset to hear. But this is what we have to move towards. Like we said, begin on scene, talk to the parent prior to leaving the emergency department. We just talked about that someone should call the family after a death. In our case, it's me, 24 to 48 hours after the child dies, I will call and I will offer my condolences on behalf of the fire department. Most parents are very thankful for doing that.

Will offer to attend the funeral. We just started doing that recently. And parents are very, very happy when you do that. They're honored that you're there. And then should we be sending a card, a remembrance card sometime within that year, Maybe not on a birthday like it says here, but perhaps during the month of their death? May not be a bad idea. And the experts will tell you that's true. Just like we all like to get the condolence phone call or the condolence letter, it's important for families to know that their EMS department, their fire department, cares about what happened to their child. Very, very important. I know these are very difficult concepts. These are new. But now that we've been doing them here for a while, we know that they have a major positive impact. And I would encourage everyone to at least open the conversation about how to do pediatric bereavement in the field in the ER and not just leave it to the doctors and nurses in the hospital. That's not the right thing to do.

So to end, I would say that go start off by looking at your agency, look at your data. Is this what's happening in your agency today where the pre arrival, the telephone CPR is not that good and then the on scene is a throw the baby and then rush off the scene only to find yourself working the child in cardiac arrest en route to the hospital. If this is your today, well, we have to make this your tomorrow. I'm going to nudge you in that direction to understand it's just a simple nudge. This is not.

Major change that I'm asking you to do.

And so when I say treat kids like little adults, what I mean is treat them with the same confidence and the same caliber of care. Do what you would do for that little kid on scene that you would for the adult because the physiology is the same. The brain needs oxygenated blood, the brain needs to be perfused. You have to get good, high quality BLS care on the scene. I think we can get there. Many agencies have proven this and now the data bears this out. So this is exciting times that we know that there's not much we have to do but we can get there. So here's my contact information up on the screen. Reach out to me personally, find me on Twitter. But I wanted to thank everyone in Indiana, mainly Dr. Elizabeth Weinstein, Margo Neffelkamp, the Indiana office of EMSC. I really wanted to thank all of you for what you're doing to help children get back to life. It's you in ems, the pre hospital professional that will make the difference. And you have my big debt of gratitude to all of you for what you do day in and day out, putting yourselves at risk. But just know that you can not only help yourself, but you could help families who have lost loved ones. And that's a big responsibility but it's really something that we do with pride. So Again, this is Dr. Peter Runtbi saying thank you to all of you in Indiana for having me. Have a great day.