Jason van der Velde. Paediatric pieces for Prehospital practitioners, Don't Forget the Bubbles, 2021. Available at:
I’m one of those that see little humans as little humans and big humans as big humans and don’t buy into the whole angst that children are different. Some humans require small bits of kits and some require rather large bits of kit….
Now before I get hissed at by a sizable proportion of readers, may I place my views into context? This may go some way into keeping you engaged, and, perhaps, convincing you that an alternative approach to equipment management might indeed be applicable to your practice. I’m a rural Prehospital Emergency Medicine and Critical Care Retrieval Physician. I grew up in the ambulance and rescue services in South Africa and have been engaged in looking after humans of all shapes and sizes since 1992. I currently work in stunningly beautiful West Cork, which despite being on the edge of Europe, can feel like being in the Australian Outback when you’re 3 hours away from a hospital with a post-arrest neonate or an 8-year-old with polytrauma. The Trauma Centre I’m attached to in Cork City is exceptionally busy, with a mixed adult and paediatric caseload. Approximately a third of my personal workload is paediatrics; oh and I have 5 children under the age of 14.
COVID has brutally shone a spotlight on the CRM issues we face every day in acute care specialities; particularly with regards to equipment and consumables management. Overnight we decluttered many of our cubicles, creating isolation spaces. Rooms that are devoid of anything that might possibly become “contaminated”. Rooms are just “rooms” and no longer “clinical environments”. We’ve had to adapt and conscientiously think about what consumables we bring to the bedside. Whatever we don’t use will need to be thrown out and whatever we don’t bring in will result in a potentially adverse delay, whilst a runner goes to fetch it from a distant storeroom. Folks, the latter is nothing new to the high visibility brigade… Welcome to Prehospital Care in the hospital!
I’ve recently gone through a major upheaval, totally rethinking my equipment lists and layout whilst bringing a new 258 brake horsepower 4×4 into service. I manage circa 500 patients every year in the field. Kit logistics is everything, given the distant storeroom is a hospital up to 3 hours away and Gardai (the Irish word for police) don’t like to be used as runners. I must confess that I’m pretty old fashioned with what I use, and I don’t like change. It’s probably because I’m used to carrying what I need on my back and started my career in a system that at the time had very little.
I’ve been motivated by the wealth of novel kit management ideas that have evolved from COVID preparation freely shared by colleagues on Social Media. In my own department, we’ve adopted various “Packs” to bring into “COVID Rooms” to both reduce waste and to re-create our “clinical environment”, albeit one patient at a time.
I was asked to write a prehospital post on “adapting kit for children” and to highlight how I “improvise for children”. Sorry to disappoint, I certainly don’t “adapt kit” for children and I certainly don’t “improvise” either. What I do is innovate, putting hours and hours of iterative design and experience into safe equipment governance regardless of the size, shape or dilemma a human might find themselves in.
How often have you reached for the simple in-hospital ward transfer bag, only to realise you probably should have been making use of that gym membership, let alone the health and safety implications of a ridiculously heavy bag stuffed to the gunnels? When you carry everything on your back as part of your daily routine, you get very used to minimising not only packaging but bulk. We’ve effectively been doing this in prehospital care for years without really thinking about it. Modulising equipment by clinical task reinforces a minimalistic approach and dramatically reduces both waste and weight. My new iteration of equipment bags takes this into account whilst also the addition of tackling the COVID infection control dilemma.
Equipment ergonomics is nothing new to paediatric practice. For example, having everything to hand in a logical order is the hallmark of successful phlebotomy in a squirming toddler. The MOST important thing to start with is to ask yourself what you need a kit bag to achieve? I have evolved the primary platform on a comfortable army Bergen, which is equipped to ONLY provide life and limb threatening care to a human from preterm to centenarian a few hours hike through a mountain trail. To achieve this takes an immense amount of preplanning. For me, this latest iteration has built on a prehospital career of over 25 years, with 12 years of Irish practice to adapt, and there’s still so much more to do. The hallmark of quality prehospital care is not cutting corners and not improvising. I have the exact same standard of equipment, monitoring and drugs that you would expect available in a trauma unit. Innovation comes through layout and the principle of packaging everything into procedure based modules.
Experience has proven that it’s counterproductive to have a little bag full of syringes and needles. You’ll either have too many or not enough. Think about each and every life-saving procedure, for example, a chest drain then break it down into individual component parts. Do you have everything you need? With just one flap open on my bag, I have everything I need to pre-oxygenate an infant. There’s an Ayres T-piece, HME, angle piece, and one of each size 1 to 3 facemask, plus a single 10ml syringe for letting air into or out of the facemask seal. I consider airway adjuncts to be a separate module.
In prehospital care, you do not have the luxury of knowing the size of the next patient. In the picture of my opened airway module, you will note I’ve everything required to manage a human airway. Spot the vacuum sealed hand suction if you can! You may notice a lack of toys. Airway cameras fail in the cold and wet. I’ve not yet met one that’s West Cork proof.
Working repeatedly in “COVID positive” homes really wakes you up to the realities of how poor our infection control practices were. In the new system, each module is vacuum-sealed in a clean room, before going into the main bag. If a module is opened, everything, regardless of if it’s used or not, is either discarded or re-sterilized as appropriate. The outside packaging of an unused module is easily decontaminated with a simple wipe or UV light. The bag itself is washable.
Kit unused in a bag that’s been touched repeatedly by contaminated gloves should never have been a thing in the first place. Think about it! When you’re sucked into the moment of treating a sick child, the last thing you appreciate is infection control. Solutions need to be human proof. We can’t simply just do what we’ve always done. I call it the RNLI test. If your kit and all its contents reliably can survive a winter trip to an Irish offshore island, lying exposed in the hull of an open rescue boat, you’ve achieved infection control packaging! This means EVERYTHING, down to the stethoscope and SpO2 monitor requires vacuum sealing.
Another advantage of having everything vacuum sealed is that when you prepare your kit, you’re not rushed, and everything can be meticulously checked with a colleague, using a challenge-response checklist. When you open your kit in chaos, you can be confident that everything you need is there, laid out exactly the same way on a nice clean piece of plastic – and not a dirty floor. Disposing excess packaging reduces clutter around the patient. Whilst there is a cost associated with setting up such a system, there are savings too. You don’t end up throwing as much away. By using a checklist , you also have the ability to record the expiry date of a piece of kit on the outside of the module. You can either opt for having a store room with all the various modules vacuum sealed on a shelf to simply replace, or like me, you have a number of fully stocked bags always ready to go. I chose the latter, with three identical bergens allowing me the “luxury” of being able to offer one bag per polytrauma patient at a rural Road Traffic Collision.
Monitoring has always been a bulky problem. The solution has come about out of a novel community defibrillation project we initiated in West Cork. We wanted to equip every single off-duty member of the ambulance service with a patient monitor and defibrillator in the back of their private vehicle. With these professionals on a text alert system, we are able to go a long way to achieving a 10min response time in rural life or limb-threatening calls. Even the cheapest patient monitor, that conforms to the standards, costs €20k. By modularising everything into a sturdy waterproof case, ie purchasing SpO2, 12 lead ECG, defibrillator, BP cuff individually, we produced the same monitoring and defibrillation standard, in a far more rugged pack for a quarter of the price.
Moving forward, my single kit bag now includes all the monitoring and drugs required for an RSI or cardiac arrest, including waveform capnography and ECG! These are not new technologies, but smaller, cheaper items such as EMMA Capnography and Bluetooth-to-iOS ECG devices. I no longer have the heavy monitor or hands so full of equipment that I can’t safely climb a flight of stairs, let alone reach a child trapped in a mindboggling place! It helps create that clinical environment in a non-clinical area. If further “next step” critical care retrieval paraphernalia is required, such as a ventilator, blood warmer or syringe driver, this can be brought out from the car.
But why on earth would all this be relevant to a paediatrician or paediatric nurse in an average hospital who may or may not ever have to retrieve or transport a sick child anywhere further than radiology?
“Around the corner, around the world” is a philosophy that defines risk in retrieval medicine. It’s not distance, but the very act of transferring a patient from one place to another that carries the risk. Most people are worried about a cardiac arrest en route. What will you do today if that cardiac arrest was caused by an infusion line, chest drain or endotracheal tube dislodging in transit in that unfamiliar, non-clinical space? The riskiest time is just transferring a patient across the bed to the trolley, radiology table or theatre table. After that, my least favourite place to be is an elevator or crowded corridor. Ask yourself the most basic and simple safety question… Is the equipment bag that accompanies me fit for purpose to provide critical care support to this little patient in an elevator?