EMSC Connects

October 2022; Vol.11, Issue 10

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Pedi Points

Tia Dickson, RN, BSN

Primary Children's Hospital

  • Nearly 20% of U.S. children younger than age 18 have a special health care need.
  • One in 5 U.S. families have a child with a special health care need.

More than 80% of EMS agencies nationally see fewer than 8 pediatric patients per month. They are outside our comfort zone. When you add a complex medical history, unfamiliar medical equipment, and involved treatment protocols these calls can become especially frightening. Halloween time is a great time to face our fears and battle our demons (a.k.a. knowledge deficits).

The Doc Spot

Care for Children with Medical Complexity

David Sandweiss, MD, Pediatric Emergency Medicine

University of Utah and Primary Children's Hospital

Excerpts from September 12th PETOS

Children with medical complexity (CMC) are those with significant chronic health problems. They may have multiple organ system involvement or major functional limitations. They may need substantial health services. In the past decade, U.S. hospitalizations for these children have increased by 33%.

"The Golden Tip" of caring for a child with medical complexity: parental wisdom or knowledge is gold. They know their child, their child's baseline, and vitals. Trust them!

Even if you haven't before, you may start caring for these children more often. Nationally this population is increasing.

  • Medical advancements are leading to better survival rates
  • Medical technology advances allow these children to live more often at home, school, and within the community
  • More support services (less insurance coverage) lead to more community based care

Common chronic conditions you may run into:

  • Respiratory
  • Cardiovascular
  • Gastrointestinal
  • Neurological/neuromuscular
  • Metabolic
  • Immunologic/infectious
  • Behavioral

Common Technologies you may run into


A pediatric tracheostomy tube (TT) has the same basic components when compared to adults but they are smaller. Due to the smaller size, pediatric TTs are single lumen, so there is no inner cannula, they are not fenestrated, and they can be cuffed or uncuffed.

As the child grows they will need progressively larger tubes.

Reasons a child might have a trach

  • Anatomic: an issue with the structure or function of the upper airway. Something prevents air from traveling to the lungs. Examples: trauma, congenital issues from birth, cerebral palsy.
  • Diseased tissue (airways/lungs): Example: chronic lung disease.
  • Respiratory drive issue: A disconnect between the brain or nerves and the movement of breathing.
Tracheostomy complications that may prompt a call to EMS

Mucus plugging • Accidental decannulation

  • Mucus plugging: when mucus collects in the trach tube or airway, it can create a plug. This can block air from flowing through the airway. Treat with instillation of sterile saline drops and suctioning. If the tube cannot be cleared, replace the tube with a new one (which the parent should have with them at all times).

Skill Refresher - How to suction a trach

How to Suction a Trach | Cincinnati Children's
  • Accidental decannulation: Accidental decannulation or extubation refers to inadvertent removal of tracheostomy tube out of the stoma. It could prove fatal in an otherwise stable patient. Treatment would be to replace the tube. If unsuccessful, use a bag-valve–mask device to ventilate the child through the upper airway. To maximize oxygenation, ventilate gently to prevent air escaping through the stoma or carefully occlude the stoma with a gloved hand.

Skill Refresher - Routine Trach Change



Reasons a CMC may need mechanical ventilation
  • Lung diseases
  • Muscular/skeletal > weakness
  • Neurologic diseases > poor effort/weakness
  • Airway diseases that limit airflow

Decompensating on a mechanical ventilator may prompt a call to EMS (especially at school or away from the parent).

The DOPE mnemonic is the gold standard for trouble shooting a vent.

  • Displacement—starting at the patient, check the trach or ET tube position
  • Obstruction—look for patency of the tube
  • Pneumothorax—pressures from the vent can blow a pneumo; assess for unequal breath sounds or chest rise
  • Equipment failure—Check all connections from the patient to the machine to the plug in the wall.

If your assessment doesn't reveal the cause and decompensation continues, it's best to disconnect from the machine and manually bag through the trach.

Skill Refresher: when and how to use manual ventilation

How and when to use manual ventilation


A central line is a tube that is placed in a vein for long-term drug or nutrition therapy. In these cases, a central line is easier and less painful than putting needles in their veins each time the child needs therapy.

Central line tips for EMS

  • Unless it's life or death, do not use these tubes, establish your own peripheral line.
  • If the tube is leaking or broken, do not pull it out. Clamp above the break toward the patient and cover the hole or broken end with a sterile gauze.


A feeding tube is needed when a person can't eat through their mouth, for whatever reason. Nutrition is delivered using a flexible tube inserted through the nose, or directly into the stomach or small intestine. The types of feeding tube include:

  • Nasogastric tube (NG tube) inserted through the nose to the stomach
  • Nasojejunal tube (NJ tube) inserted through the nose to the intestine (done by fluoroscopy)
  • Percutaneous endoscopic gastrostomy (PEG) inserted directly into the stomach through the belly

G-tube tips for EMS

You won't often be called to a scene for a primary G-tube problem. If you are, it tends to be because the tube has been pulled or has popped out. Parents are trained to replace a nasogastric tube and usually won't involve EMS. Nasojejunal tubes must be replaced by a radiologist.

Occasionally EMS may be involved when a PEG (or MIC) tube pops out of the belly and the parent can't replace it. The important thing to remember is that stoma (the hole through the abdomen into the stomach) is surrounded by muscle and it can close very quickly. If closed, the child will need surgery to replace it. Our priority is to keep that hole open. Inserting a small, place-holding tube into the stoma is often the EMS providers best option. Using an 8fr suction catheter or similar tube, lube the end and gently insert the tube into the stoma about 1 inch. Tape it in place. This is a clean, not sterile procedure. Do not force it but gentle pressure and a twisting motion can help relax the muscles.

Other Resources

Protocols in Practice - Airway and Tracheostomy Management

News From National

News from Utah EMSC

EMSC open office hours

In November, EMSC will be offering monthly, virtual Open Office Hours on the 1st Tuesday of each month from 0900 to 1000. Our team will jump on zoom and go live. Anyone with questions, concerns, ideas, or needs is invited to join and discuss with our team. While this offering is focused on EMS and hospital PECCs, anyone with pediatric concerns or a desire to learn more about EMSC is welcome. These will launch November 1, 2022 at 0900!

Zoom link

BEMSP is inviting you to a scheduled Zoom meeting.

Join Zoom meeting

Meeting ID: 870 0564 5259

Monthly from 9 a.m. to 10 a.m. on the first Tuesday from Tuesday, November 1 to Tuesday, February 7, 2023 (Mountain Time—Denver)

PECC Development

PECC Quarterly MeetingsMark Your Calendar!

Along with the above monthly open office hours to be used prn, we will implement a quarterly, virtual, PECC meeting. We want to stay in touch, network, and hear from you throughout the year. Our first meeting will be November 15, 2022.

2nd Annual PECC Conference report

The 2nd Annual PECC Conference was held on September 16, 2022 in Provo. Eighty-three people attended, both online and in person. The agenda was packed with PECC role instruction and resources. If you were unable to attend you can watch the recording here: https://drive.google.com/file/d/1b8p5imH5Flyl6t6l6YDXSfaU-GM5hxG5/view?usp=sharing

Attendance included orientation materials and digital google doc access to trainings and other materials to aid you in your role. If you would like those resources, please contact Jaredwright@utah.gov

Barriers and enablers to recruiting for the PECC role in EMS agencies

More than 80% of EMS agencies see fewer than eight children per month. As a result, many EMS professionals may have limited pediatric-focused education opportunities and infrequent encounters with children. In 2007, the Institute of Medicine recommended EMS agencies designate a pediatric emergency champion, or pediatric emergency care coordinator (PECC), to support the care of children. The PECC oversees pediatric quality improvement initiatives, provide skills-based pediatric training to agency staff, and ensure pediatric medications, equipment, and supplies are available.

To identify best practices to increase the percentage of EMS agencies with PECCs—which is a performance measure for the EMSC Program’s 58 State Partnership grantees—the EMSC Innovation and Improvement Center hosted a 6-month PECC Learning Collaborative (PECCLC). Findings from the PECCLC were published last month in the journal Prehospital Emergency Care.

The PECCLC engaged 9 states (Connecticut, Kentucky, Montana, New Mexico, New York, Ohio, Pennsylvania, Rhode Island, and Wisconsin). State representatives participated in virtual monthly learning sessions with subject matter experts and support staff as well as a 2-day in-person meeting.

PECCLC outcomes

Outcomes of the PECCLC showed that during the 6-month collaborative, state representatives recruited 341 PECCs (92% of predetermined recruitment goals). During the 5 months after the collaborative, 184 more PECCs were recruited for a total of 525 PECCs (142% of goal). State representatives and PECCs reported the biggest barriers to PECC recruitment were:

  • competition from other EMS responsibilities,
  • budgetary constraints,
  • lack of incentive for agencies to create the position, and
  • lack of requirement for establishing the role.

On the other hand, the biggest enablers were:

  • an EMS agency recognition program that includes the PECC role,
  • train-the-trainer programs, and
  • inclusion of the PECC role in agency licensure requirements.

Interviews with PECCs identified the most common activity associated with their role was pediatric-specific education and the most important need for PECC success was agency-level support.

“Long-term PECC recruitment and retention may be possible through local and national EMS agency support, and the continued development of and outreach to interested individuals in prehospital pediatric care,” says Hoi See Tsao, MD, MPH, an assistant professor of Pediatric Emergency Medicine at UT Southwestern Medical Center who serves as the Prehospital Domain EMSC Fellow and is the publication’s lead author. “Future work includes investigating other methods and outreach efforts to further increase the number of PECCs in addition to the use of learning collaboratives. This may provide insight into additional effective ways to increase the number of PECCs and best practices, and ultimately improve the prehospital care of children.”

EMSC-funded studies—including Targeted Issues grant projects in North Carolina, Connecticut, Rhode Island, Colorado, and Louisiana—are evaluating the effects of EMS agency PECCs on patient care. The National Prehospital Pediatric Readiness Project is supporting EMS agency pediatric readiness efforts with a publicly available toolkit containing more than 100 resources, including resources developed by the PECC-focused Targeted Issues grant in Connecticut, which is led by Mark X. Cicero, MD.

Access prehospital resources

Learn more about targeted issues grants

PEAK resource highlightPain

Untreated pain has short- and long-term consequences for children in emergency settings—there's the discomfort of the pain itself; then there's the stress and anxiety for the child and their family—and don't forget the slower healing time and possible reluctance to seek health care in the future.

But it doesn't have to be that way.

The EMSC Innovation and Improvement Center (EIIC) is excited to share its latest Pediatric Emergency and Advocacy Kit (PEAK) on pain.

What makes PEAK resources different? They’re: 1) developed and vetted for accuracy based on the latest scientific evidence by interdisciplinary subject matter experts; 2) free and open access; 3) multimodal, with something for every learning style.

Explore PEAK: Pain

Plus, a new collaborative podcast series featuring:

Covid and Kids

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Birth transfers? We need your feedback for QI

Ask Our Doc

Do you have a question for our EMSC medical director, Sarah Becker, MD, PCH, ER attending physician about this newsletter topic or anything related to pediatrics? Email tdickson@utah.gov.

Pediatric Education from Utah EMSC

Pediatric Education and Trauma Outreach Series (Petos)

Monday, Oct. 10th, 2-4pm

This is an online event.

Utah EMS for Children (EMSC), Primary Children's Hospital (PCH), and Utah Telehealth Network (UTN) offer the pediatric emergency and trauma outreach series (PETOS) to EMS providers.

This course provides 1 free CME from the Utah Department of Health and Human Services Office of Emergency Medical Services for EMTs and paramedics. The lectures are presented by physicians and pediatric experts from Primary Children’s Hospital. The format is informal; inviting questions and discussion.

Join us on Zoom each second Monday at 2 p.m. mountain time (U.S. and Canada) Click the pic below!

Archived presentations can be viewed and also qualify for CME. Access at https://intermountainhealthcare.org/primary-childrens/classes-events/petos

To obtain a completion certificate

  • For "live" (virtual) participants: To receive a certificate of completion for attendance be sure to include your email address when the host requests it in the chat during the live presentation. Certificates are e-mailed out after verification of attendance and processing.
  • For archived viewing: After viewing archived presentations (link above) e-mail utah.petos@gmail.com with the date and title of presentation viewed. You will receive a three question quiz to verify participation. Once the quiz is returned, certificates are e-mailed out.

We try to have certificates out within a week but will occasionally have delays.

Looking for a PEPP class?

Pediatric Education for the Prehospital Provider

Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

Other Pediatric Education

Fall Injury Prevention Learning Series

Thursday, Oct. 13th, 11:30am-1:30pm

This is an online event.

Register Here

To view previous sessions for all our series visit this link

Hosted by the Trauma Outreach & Injury Prevention Team

Nursing Contact Hours offered @UofUTrauma

2022 UPTN Conference

Friday, Oct. 28th, 8am

900 Round Valley Drive

Park City, UT

UPTN holds an annual conference to discuss hot topics and provide pediatric trauma updates.

This year we are scheduled for October 28 at the Blair Education Center in Park City. The conference is free of charge.

Register Here

EMS Focused Education

University of Utah's EMS Grand Rounds (Offered every 2nd Wednesday of even months)

Wednesday, Oct. 12th, 2pm

This is an online event.

Click here to join

Virtual-Zoom Meeting Meeting

ID: 938 0162 7994 Passcode: 561313

Emergency Medical Services for Children, Utah Bureau of EMS and Preparedness

The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, regardless of where they live, attend school, or travel.