Emergency Pediatrics Case Studies - RealDirectionEMS

RealDirectionEMS is an educational resource for pediatric emergency providers who take field calls from EMS providers. This site contains audio from actual calls between physicians and EMS that have been de-identified to protect patient and staff identities. In addition to the audio, each call has teaching points and commentary to learn from. The concept is simple, but powerful. Create a community of sharing and learning using real life examples that can help emergency medicine physicians gain confidence and expertise when speaking to EMS providers. 

If you would like to submit a case, please follow this link to the submission form. We retain final decision-making authority to content included on this site and will evaluate each case submitted for educational value before posting. If you have questions, please email lara.rappaport@dhha.org

Disclaimer

Use this website as a guide only.  This is not meant to substitute for medical judgment.  The concepts discussed are centered about true patients and calls.  The information discussed may depend on the institution’s practice patterns. Local regulations and protocols must always be considered.  This information is subject to regular revision.   

Case Studies

Agitated Pediatric Patient

Destination Clarity

Gang Violence

High Risk Pediatric Refusal

Medication Clarification

Multiple Pediatric Patients: Bus Crash

Pre-Notification Call

Field Pronouncement

Straightforward Pediatric Refusal

Vague Ages

Agitated Pediatric Patient

Volume 1, Case 8
Contribution:  Denver Health Emergency Department
Authors:  Whitney Barrett, Lara D. Rappaport MD, MPH Karl Marzec MD, Kevin McVaney MD, Elena Garcia MD, MD, Aaron Eberhardt MD 
Listen to call
 
This is a tape of a 17 year old female with an unspecified mood disorder who became agitated with police. The EMS provider is asking if he should give Haldol mixed with orange juice.

Teaching Points:

1. EMS protocols can not encompass all situations.  Medical direction is essential for navigating complex situations.
2. The online medical direction can be a resource (different opinions, other specialists)
3. For the agitated patient, assessing risk to patient and providers of restraint or sedation.
4. Rapid and efficient decisions will provide a safer environment for the patient and EMS provider.
5. It is appropriate to remind the EMS provider to consider other causes of agitation (such as hypoglycemia, metabolic abnormalities and head trauma) and ask for supporting evidence such as a glucose or exam pertinent to trauma findings if feasible.
6. It is helpful to be familiar with the medications available on the ambulance.

Commentary:  In this case, the patient was safely transferred to psychiatric care.   This is an example of patient centered collaborative problem solving.

Destination Clarity

Volume 1, Case 6
Contribution:  Denver Health Emergency Department
Authors:  Lara D. Rappaport MD, MPH Karl Marzec MD, Kevin McVaney MD, , Elena Garcia MD, Whitney Barrett MD, Aaron Eberhardt MD 
Listen to call
 
This call demonstrates a pre-notification call where the destination needs more clarity.

Teaching Points:

1. Obtain the full hospital name for the arrival.
2. It is easy for the EMS provider to speed dial the wrong hospital by accident.
3. Use confirmatory words such as, “The University Hospital on Colfax”, The Children’s Hospital downtown.
4. One hospital may take medical direction calls for the entire area that includes multiple different hospitals.

Commentary:  In this case, the patient was in route to the “University” and the physician on the phone interpreted you as “you”, their base hospital.

Gang Violence

Volume 1, Case 4
Contribution:  Denver Health Emergency Department
Authors: Karl Marzec MD, Kevin McVaney MD, Lara D. Rappaport MD, MPH, Elena Garcia MD, Whitney Barrett MD, Aaron Eberhardt MD 
Listen to call
 
This call demonstrates a gang shooting with multiple people injured. The paramedics and EM providers decide the disposition of multiple gunshot victims based on their injuries and level of care requirements.

Teaching Points:

1. Obtain the number of injured patients and their acuity from the EMS provider
2. Understand community hospital capabilities to help direct transportation
3. Communication with prehospital providers in multiple casualty incidents should be brief and to the point and may include a minimum amount of information.   For example, a full set of vital signs for all of these patients is not necessary.
4. Always consider paramedic scene safety

Commentary:  In this case the shooter was still on scene and the EMS providers were at risk. Physicians can help EMS providers with quick, thoughtful decisions which allow them to get off the streets more quickly. 

High Risk Pediatric Refusal

Volume 1, Case 2

Contribution:  Denver Health Emergency Department
Authors: Aaron Eberhardt MD, Elena Garcia MD, Kevin McVaney MD, Whitney Barrett MD, Karl Marzec MD, Lara D. Rappaport MD, MPH
Listen to call

This is a 17 year old male skateboarding and struck by a car.  He rolled on the hood of the car.  He has a dislocated right shoulder and weaker pulse on that side.   He is tachycardic.    Father would like to drive him by private vehicle to a hospital and refuse transport.

Teaching Points:

1. It is helpful to understand why the parents want a refusal.
2. Assessing the amount of risk associated with a refusal includes:  age, mechanism of injuries, complicating factors and differential diagnosis.
3. Your role is to facilitate the best care to the patient.
4. The best way to understand your scene and resources is to ask your medics specific questions.
   It may be helpful to have some strategies on how to manipulate the scene.  For example, would law enforcement be helpful or can the ambulance follow the family to the hospital?

Commentary:  In instances of high risk refusals, having the physician talk to the family on the phone can be helpful. If you believe that the patient is a minor and is at significant risk in not coming by ambulance to the hospital, you may need to get the police involved.   You have the legal ability to take the patient if you are concerned about non-accidental trauma or life threatening  injury or illness.
 

Medication Clarification

Volume 1, Case 7
Contribution:  Denver Health Emergency Department
Authors:  Whitney Barrett, Lara D. Rappaport MD, MPH Karl Marzec MD, Kevin McVaney MD, Elena Garcia MD, MD, Aaron Eberhardt MD 
Listen to call
 
This is a call about a patient with seizures and repeated seizure activity that is not grand mal in nature.  The patient is being transported from the clinic.  The paramedic is calling for direction about treating these seizures.    The paramedic would like to give Midazolam 4mg IM for seizure activity.

Teaching Points:

1. Consultation calls can be for a variety of reasons: additional doses of protocol medications, different modes of medication delivery, use of a regular medication outside the scope of the protocol.
2. It is not necessary to memorize all the protocols for the prehospital providers; however,   you should be familiar with in your own system:
3. What are the common medications available on the ambulance?
4. What common and approved routes of administration for paramedics in your system?
5. What are the indications for various medications in your system?
6. Understand what your medic is asking for specifically (medication, dose, route).
7. Practice good communication skills.  Repeat back the medication, dose, and route to minimize errors.  (In this case intranasal and intramuscular were confused.)

Commentary:  Consultation calls may be difficult.  You as the provider do not usually know all the protocols and medications for your system.  When in doubt, it is reasonable to ask your provider if they have a particular medication or if they are comfortable, allowed, or capable of

Multiple Pediatric Patients: Bus Crash

Volume 1, Case 3
Contribution:  Denver Health Emergency Department
Authors:  Kevin McVaney MD, Lara D. Rappaport MD, MPH, Elena Garcia MD, Whitney Barrett MD, Karl Marzec MD, Aaron Eberhardt MD 
Listen to call
 
This is bus crash with multiple children who mostly appear to be uninjured.   The paramedic is calling in to discuss disposition and destination for the children.  The bus driver is injured and there is no responsible adult initially with the school children.

Teaching Points:

1. Some calls are time sensitive and some are not.  In some cases, you can take extra time to figure out disposition questions.
2. Some MCIs can overwhelm one particular hospital or system.   You should consider sending some patients to non-traditional destination.  Patients who are not critical can go farther away to outlying centers.
3. Understand which hospitals are in your vicinity and what are their capabilities.
4. The primary role of the paramedic is to assess for injury on each individual patient.
5. It is acceptable to release a low risk child to a responsible adult.   A pediatric patient cannot deem themselves uninjured or refuse care. 
6. The paramedic may not need to contact each individual guardian, but should obtain  identifying information.
7. Familiarize yourself with your local MCI or disaster protocols.

Commentary:  In this case, the police contacted the dean of school.   The school sent a responsible adult to the scene and assumed care of all the children who were uninjured.  They were then transported back to the school gymnasium and the school individually contacted parents.   This was an appropriate action in this situation.

Pre-notification Call

Volume 1, Case 5
Contribution:  Denver Health Emergency Department
Authors: Whitney Barrett MD, Aaron Eberhardt MD, Karl Marzec MD, Kevin McVaney MD, Lara D. Rappaport MD, MPH, Elena Garcia MD
Listen to call
 
This is a 3 yo child being brought to the pediatric emergency department “DECC” emergently (code 10).  The child is the victim of an auto-pedestrian accident with respiratory arrest.  Patient has significant head trauma, airway is being managed.  Broselow color is white.  They will arrive in 5 minutes.  

Teaching Points:

1. A notification call is a call initiated by the paramedics to alert you of a patient that is high acuity, requires special resources, or meets other predetermined criteria.
2. This is your opportunity to gather the brief information you need to prepare for the patient’s arrival.  This information should include:
   1. Brief history and physical
   2. Vitals  (full set is helpful, pertinent for decision making is crucial)
   3. Broselow/Handtevy color or age
   4. Approximate time until arrival
3. It is important to understand some specific things in your system including:
   1. What are the predetermined field criteria that will initiate a call? 
   2. What is the language used for an emergent (lights and sirens) return?  (Code 3, Code 10, emergent)
   3. What are the capabilities of your hospital?  Trauma center level? NAT resources?
   4. Based on your hospital protocols, when do you need to pre-alert any other services?  Trauma team: specific vitals or mechanism?  OB/NICU: all outborns, concern for immanent delivery?

   Commentary:  It is important to remember when your providers are calling about a critical patient it is not the time for a long, detailed conversation.  The purpose of the conversation is to glean the information you need to prepare your department for their arrival.  Some indicator of patient age/size, pertinent vital signs, suspected etiology of condition etc. is adequate.  This is also an opportunity to give medical direction for a critical patient if needed/indicated.  Remember your providers are with a critical patient and are doing a lot in the back of the ambulance.  Gather only the information you need to prepare.

Field Pronouncement

Volume 1, Case 10 Contribution:  Denver Health Emergency Department
Authors:  Whitney Barrett, Lara D. Rappaport MD, MPH Karl Marzec MD, Kevin McVaney MD, Elena Garcia MD, MD, Aaron Eberhardt MD 
Listen to call
 
This is call from about a toddler who was found drowning in a bathtub.  The paramedic is calling for a pronouncement in the field.

Teaching Points:

1. What you need to hear to make a field pronouncement:
   1. Signs of death:  dependent lividity, rigor mortis, decomposition, traumatic injury incompatible with life (ex. hemicorpectomy, decapitation)
   2. Futile medical resuscitation as defined by your local protocols.
   3. An active DNR
2. Remind the paramedic that medical assessment of the patient is always a priority over scene preservation.
3. After the pronouncement is made, it is important to leave everything as it is (do not remove lines or tubes, etc.) and to keep the scene as they found it as much as possible for forensic evidence preservation.
4. In pediatric cases, sometimes a transport is initiated for concern of scene chaos, scene safety, and family centered care.
5. Pediatric pronouncements are difficult for everyone involved (family, first responders, paramedics, medical control).  Familiarize yourself with your counseling services and critical incident stress debriefing resources.


Commentary:  As you can tell from the call, the physician is very uncomfortable, and stumbles through questions that are not actually relevant (ex: “What was the water temperature?”). The cold water emersions do not happen in a house drowning situation.  While there may be a temptation to get as much information as possible to understand the circumstances of the event, the most important elements are injuries incompatible with life, obvious signs of death, and/or duration and effectiveness of resuscitation that would make further treatment futile.

Straightforward Pediatric Refusal

Volume 1, Case 1
Contribution:  Denver Health Emergency Department
Authors:  Lara D. Rappaport MD, MPH, Elena Garcia MD, Kevin McVaney MD, Whitney Barrett MD, Karl Marzec MD, Aaron Eberhardt MD
Listen to call
 
This is an 18 month male with an “ATLE refusal”.   He had a 30 second episode of apnea and LOC event after a temper tantrum.  He had a fall from standing and his grandmother threw water on patient.  Now, he is acting awake and alert.  No significant medical history.   Mother would like to transfer him by private vehicle to a hospital.

Teaching Points:

1. A refusal is a call into base initiated by a guardian in order to refuse transport of the child to the hospital.  This is not a paramedic initiated request.
2. To force the transport of a child when there is a sober, competent, legal guardian and safety is not a concern is considered kidnapping.
3. Since it may It may be your responsibility to approve and document refusals, you will need to understand your local definitions:
   1. Do all pediatric calls need a refusals acceptance?
   2. What are age limitations?
   3. What is your system QA/QI process to routinely review these cases?
4. Documentation of the call should include:
   1. Who is refusing
   2. Chief complaint
   3. Where patient is located and who the patient is with
   4. Is the risk acceptable or not acceptable
   5. Full set of vital signs
   6. Specific return precautions and follow up instructions that have been given

Commentary:  To force the transport of a child when there is a sober, competent, legal guardian, and safety is not a concern is considered kidnapping.  Refusal doesn’t necessarily mean the family is refusing to get care for the patient, it means that they do not want EMS to transfer patient in.

Vague Ages

Volume 1, Case 9
Contribution:  Denver Health Emergency Department
Authors:  Lara D. Rappaport MD, MPH Whitney Barrett, Karl Marzec MD, Kevin McVaney MD, Elena Garcia MD, MD, Aaron Eberhardt MD 
Listen to call
 
These are a series of calls where the age of the patient is not clear.

Teaching Points:

1. The age of patient must be communicated clearly with at least two forms of age identification.  Examples include:
   1. “pediatric patient”
   2. “the weight is 10 kg”
   3. “the color is purple on the length based tape”
   4. “we are arriving to the Children’s Hospital”

Commentary:  If your hospital receives all ages, it is critical to get two independent confirmations of age.