Pediatric Annals

EDITORIAL 

A Pediatrician's View

Robert A Hoekelman, MD

Abstract

We all remember Drs Benjamin Pierce and John Mclntyre and nurse Margaret Houlihan, better known respectively as "Hawkeye," "Trapper John, " and "Hotlips, " the heroes and heroine of MASH, the movie and later television series about a Mobile Army Surgical Hospital operative in the early 1950s during the war in Korea. The exploits of such medical-nursing teams in the stabili' zation, treatment, and disposition of severely wounded soldiers saved countless lives and provided a model for the emergency medical services systems and trauma centers later established for our civilian population.

The system was, and is, quite simple in concept. It requires (1) having skilled nonprofessionals (medics or emergency medical technicians) administer to the patient on the scene; (2) transporting the patient (by helicopter or ambulance) to a nearby emergency treatment center (MASH or hospital emergency room) for stabilization of cardiorespiratory functions and immediate management of the underlying medical or surgical problem; and (3) either admitting the patient to the local hospital for further treatment and recuperation or "triaging" the patient to a regional critical care facility for more highly sophisticated treatments. These principles of acute medical and surgical care govern the emergency medical services (EMS) system that is currently operative in the United States and the other developed countries of the world. The EMS system has worked quite well in most respects.

However, not all of our citizens can expect to reap its benefits. There are many areas of the country, particularly small cities and outlying rural regions, that do not have an EMS system; furthermore, their costs, which are extremely high, preclude the establishment of one. Farther, even in established EMS systems, infants and children are less likely to receive the optimum care that adults receive. This is so because (1) emergency medical technicians (EMTs) who provide on-the-scene care and care during transport to the local hospital emergency room and the physicians and nurses staffing those emergency rooms are not always well versed in providing pediatrie emergency care; and (2) the equipment that those professionals have on hand is not always appropriate for managing pediatrie emergencies.

For the most part, EMS systems are designed to care for critically ill adults; thus, infants and children who account for only 10% of EMS system calls are less well served. Because of this, a few states and regions have established emergency medical services for children (EMSC) systems that have proved to be more successful in managing pediatrie emergencies. The factors that distinguish EMSC systems from EMS systems and provide promise for more successful outcomes are listed in the lead article of the issue of Pediatrie Annals. One would hope that EMSC systems could be established throughout the United States and elsewhere, but this is not likely due to the costs involved.

While it would be ideal for every hospital emergency room to be staffed by pediatricians who are specifically trained in pediatrie emergency care, this is not feasible because there are too many emergency rooms and too few such specialists available. There will never be enough of them, despite the growing number of pediatrie emergency medicine fellowship training programs, which require 2 to 3 years of training beyond residency, and despite the growing numbers of pediatricians who are choosing to work in hospital emergency rooms upon completion of their 3 years of residency training.

What, then, must be done to improve the care that pediatrie patients receive within existing EMS systems? First and foremost, the training that EMTs and hospital emergency room physicians and nurses receive must include much more in the care of critically ill infants and children than it…

We all remember Drs Benjamin Pierce and John Mclntyre and nurse Margaret Houlihan, better known respectively as "Hawkeye," "Trapper John, " and "Hotlips, " the heroes and heroine of MASH, the movie and later television series about a Mobile Army Surgical Hospital operative in the early 1950s during the war in Korea. The exploits of such medical-nursing teams in the stabili' zation, treatment, and disposition of severely wounded soldiers saved countless lives and provided a model for the emergency medical services systems and trauma centers later established for our civilian population.

The system was, and is, quite simple in concept. It requires (1) having skilled nonprofessionals (medics or emergency medical technicians) administer to the patient on the scene; (2) transporting the patient (by helicopter or ambulance) to a nearby emergency treatment center (MASH or hospital emergency room) for stabilization of cardiorespiratory functions and immediate management of the underlying medical or surgical problem; and (3) either admitting the patient to the local hospital for further treatment and recuperation or "triaging" the patient to a regional critical care facility for more highly sophisticated treatments. These principles of acute medical and surgical care govern the emergency medical services (EMS) system that is currently operative in the United States and the other developed countries of the world. The EMS system has worked quite well in most respects.

However, not all of our citizens can expect to reap its benefits. There are many areas of the country, particularly small cities and outlying rural regions, that do not have an EMS system; furthermore, their costs, which are extremely high, preclude the establishment of one. Farther, even in established EMS systems, infants and children are less likely to receive the optimum care that adults receive. This is so because (1) emergency medical technicians (EMTs) who provide on-the-scene care and care during transport to the local hospital emergency room and the physicians and nurses staffing those emergency rooms are not always well versed in providing pediatrie emergency care; and (2) the equipment that those professionals have on hand is not always appropriate for managing pediatrie emergencies.

For the most part, EMS systems are designed to care for critically ill adults; thus, infants and children who account for only 10% of EMS system calls are less well served. Because of this, a few states and regions have established emergency medical services for children (EMSC) systems that have proved to be more successful in managing pediatrie emergencies. The factors that distinguish EMSC systems from EMS systems and provide promise for more successful outcomes are listed in the lead article of the issue of Pediatrie Annals. One would hope that EMSC systems could be established throughout the United States and elsewhere, but this is not likely due to the costs involved.

While it would be ideal for every hospital emergency room to be staffed by pediatricians who are specifically trained in pediatrie emergency care, this is not feasible because there are too many emergency rooms and too few such specialists available. There will never be enough of them, despite the growing number of pediatrie emergency medicine fellowship training programs, which require 2 to 3 years of training beyond residency, and despite the growing numbers of pediatricians who are choosing to work in hospital emergency rooms upon completion of their 3 years of residency training.

What, then, must be done to improve the care that pediatrie patients receive within existing EMS systems? First and foremost, the training that EMTs and hospital emergency room physicians and nurses receive must include much more in the care of critically ill infants and children than it currently does. Second, emergency transport vehicles and hospital emergency rooms must have equipment appropriate for treating those patients. These are the most promising means to assure that all children have a reasonable chance to survive life-threatening accidents, ingestions, and illnesses and to recover completely, or without severe morbidity. Pediatricians, surgeons, and anesthesiologists with expertise in the care of critically ill infants and children must contribute to this educational process and ensure that their EMS system is prepared to deal with pédiatrie as well as adult patients.

10.3928/0090-4481-19901001-05

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