Imagine yourself on a stretcher rolling away from your home, out of your driveway. BUMP onto a ramp, then pushed from the ramp into the back of an ambulance. Hear the sound of the stretcher being locked in place, and all you can see is the white ceiling and bright lights. BANG! The door slams after you. You look around and see machines you do not recognise with no understanding as to what they do. They look scary, some of them BEEP, and you are sick and in pain. For any adult, this is daunting.
Now imagine that you are a 5-year-old child. What would be going through your mind?
The back of an ambulance must be one of the scariest environments a child could encounter. As prehospital practitioners, assessing and treating children in this environment is a huge challenge. Seeing a distressed child, sick and in pain, is daunting. Trying to treat their ailments and instil some calm, even more so. How do we do this? How can we do it well…. or better? What is available to us to make this easier and how can we improvise to improve the patient experience for the ones we want to mind the most?
In Ireland, we have an amazing dedicated paediatric transfer ambulance service, designed inside and out with nothing but kids in mind. The Bumbleance Children’s National Ambulance Service operates vehicles equipped with social media streaming, wi-fi, PlayStation, DVDs, games, books, colouring, sensory lighting, Netflix, iPad Air, Beats headphones, Apple TV and Apple Music…providing endless entertainment for the kids that require transfer and minimising the potential impact of clinical care on their journey. While these phenomenal assets are used for scheduled trips and appointments, these features are not in the frontline Emergency Ambulances.
Without reliable access to fun electronic gadgets and gizmos, Emergency pre-hospital practitioners rely more on the fundamentals of paediatric care to maximise their comfort during the call and transfer – getting down to their level to communicate, utilising effective distraction techniques, optimising pain management and using appropriate positioning (with the help of Mum and Dad) are always good places to start.
How about…
Glove Puppets
Straight from the “International Paramedic Practice of Improvisation”! Some creative practitioners have been known to use ECG dots as eyes. Simple and easy and the kids seem to love them. Plenty of evidence out there to support it too.
Bubbles
“Don’t forget” these! We are excellent at ensuring we have our clinical stock checked for each and every shift, but should we have paediatric play / distraction gear checked too? Some astute crews keep bottles of bubbles in their kit bags for the distressed paediatric patients they encounter. Deescalating an upset child, while gaining trust and instilling a fun memory, can add in no small way to positive case outcomes. Importantly, play stimulates and assesses the patient’s level of interaction – what is their level of alertness and are their reacting normally? Now they want to play – excellent, they are obeying commands and blow bubbles just like you do too!
Smartphones
Many practitioners use their devices to pacify patients during the initial assessment, treatments, and transferring onwards to the ED. Having a spare charger for your shift is a good idea. Be up to speed on the latest hit shows, know some characters by name and description, and expect serious brownie points for being able to mimic the voice of their favourite character!
A Bear called Teddy
Another paediatric kit bag essential? An excellent source of comfort and reward for bravery. Where possible and appropriate, be sure to show them how to check Teddy’s oxygen saturations, auscultate his chest, and check his blood sugar level… desensitisation to the experience of clinical assessment, while reducing anticipatory anxiety, can allow you to examine your paediatric patient more thoroughly and pick up subtle objective signs.
Blood Sugars
It might be an idea that whoever is driving on the day are the one to carry out the fingerprick glucose test. This way the child doesn’t have to be in their company immediately afterwards and so it is usually forgotten about by the time they arrive in the ED. Novelty cartoon or superhero plasters will be the most welcome addition to any paediatric kit bag.
Openness and honesty are key in assessing and managing a child. Communication breakdowns lead to loss of trust and a worsening of pain and distress during the prehospital phase of care. Be clear about what you would like to do and what this will involve. This will make them feel better once it’s over. Expect trust to evaporate if you tell them a painful procedure won’t hurt. Use any teddy or toy props available to demonstrate if you can and demystify the process by involving the patient. Lever off parents as and guide them, when needed, to improve your chances of completing a vital clinical task.
Of course, parental anxiety will increase a child’s anxiety. While having them accompany their child in the ambulance is a legal requirement, treating the parent is just as important as treating the paediatric patient themselves. This might be their first time dialling 999/000, their first sick or injured child, or their first time encountering prehospital services. Be conscious that separation may cause great anxiety, keep them in the eyesight of the patient as much as possible. Encourage the carer to keep talking, telling stories, or singing songs. Providing the best possible care is depends on providing adequate emotional support for an unwell child. These core principles are particularly important to remember in cases involving serious paediatric traumatic injury. Minimising distress can have a huge impact on post-event emotional recovery.
While we are very lucky in Ireland to have an impressive number of medications available to both paramedics and advanced paramedics, non-pharmacological means of providing analgesia to patients should not be underestimated. Managing the prehospital phase of care in a safe, fun, and efficient manner will undoubtedly improve the chances of the journey to the ED, and beyond, going much more smoothly.
Pre-hospital paediatric challenges during COVID-19
Managing unwell or injured children in the prehospital environment was plenty challenging before the COVID-19 pandemic. Adding PPE into the mix has represented a significant challenge to all healthcare providers and prompted reflection on communication and distraction techniques alike. The introduction of a facemask, goggles, gown and gloves as contact precautions, has made many adult patients feel uncomfortable. This new work outfit doesn’t lend itself to creating less distress amongst kids either. PPE greatly restricts our ability to communicate with children, removing our core non-verbal expressions, that friendly smile or silly excited face, that we relied on so much before.
How can we tackle this as prehospital practitioners to ease the anxiety that our PPE may cause? Maybe the following points could help in mitigating this problem:
Say it like you mean it
We need to rely and focus more on how we speak to the child by keeping our voice friendly and using our tone, pitch and intonation more to convey excitement. How your message is heard might be different when wearing goggles vs visor so do test this out on a colleague and get feedback when trying out different PPE.
Smile with your eyes
Again, practice makes perfect! This can be difficult if your eye protection keeps fogging but being aware of it will help you anticipate and adjust your strategy as needed.
Show yourself at your best
Perhaps having a printout of a picture pinned to your PPE might help. At least the child will know what you really look like. A mini collection of silly faces would be ideal of course.
It is still Halloween, right?!
Costume wear is now a year-round thing, apparently. This has gotten a few laughs and a few eyerolls too for good measure. Any form of icebreaker that works is a good one!
Cartoon Visors
Creating memories while providing care. Some paediatric departments have sourced visors with cartoon characters and animals on them. Others have taken to showing off their creative side! It has shown to comfort the children and promoted good interactions whilst the healthcare workers go about their job assessing and treating their patient. Prizes should be encouraged for champion efforts!
Creating magical memories while providing excellent prehospital care is achievable with good preparation and acknowledgement of the unique elements involved in transporting the distressed, sick, or injured child.
The journey really does make the destination!
References
Oulasvirta J, Pirneskoski J, Harve-Rytsala H, Laaperi M, Kuitunen M, Kuisma M, et al. Paediatric prehospital emergencies and restrictions during the Covid-19 pandemic: a population-based study. BMJ Paediatrics Open. 2020;4:1-8.
Cowley A, Durge N. The impact of parental accompaniment in paediatric trauma: a helicopter emergency medical service (HEMS) perspective. Scand J Trauma Resusc Emerg Med. 2014;22:32.
Samuel MD N, Steiner IP, Shavit MD I. Prehospital pain management of injured children: a systemic review of current evidence. American Journal of Emergency Medicine. 2014.
Jones J. Analgesia for Acute Care. Children’s Hospital Ireland; 2019. p. 5.
StatPearls. 2020. https://www.ncbi.nlm.nih.gov/pubmed/32119430
Cartoon visors cheer young patients hse.ie2020 [Available from: https://www.hse.ie/eng/about/our-health-service/making-it-better/cartoon-visors-cheer-young-patients.html.
Bumbleance – The Children’s National Ambulance Service 2020 [Available from: https://www.bumbleance.com/?doing_wp_cron=1611411187.1207330226898193359375.
Fogarty E, Dunning E, Koe S, et al. The ‘Jedward’ versus the ‘Mohawk’: a prospective study on a paediatric distraction technique. Emergency Medicine Journal 2014;31:327-328.
