Pediatric emergency medicine trisk 4620 4620
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There are few times when a higher-speed drive with lights and siren (L&S) will be of benefit to a sick or
injured child. EMS personnel injury rates are nearly 15 times higher when ambulances are operating with L&S,
and time savings have not been shown to be meaningful. Sixty percent of these accidents are the fault of the
emergency vehicle driver. Intersections are the most common site for accidents involving EMS vehicles operating
L&S. The NAEMSP recommends that EMS services develop a policy on L&S use that should be reviewed by the
medical director, because accidents while running “hot” with L&S are a common cause of litigation. Emergency
vehicle accidents are an area of high, and frequently unnecessary, liability in EMS that is borne more out of a
tradition of L&S use than a medical necessity for the patient.
Every ambulance should have the capacity to secure a child or infant safely. Although specialized products do
exist to secure a child to an ambulance cot, the EMS provider must take great care to ensure that it is properly
attached to the cot, and that the child’s head, torso, and pelvis are appropriately secured to prevent injury in an
accident. Many of these products may not have established crashworthiness, and the degree of protection they
provide is unclear. Additional research, including crash testing of ambulance and child restraint devices, is on the
horizon.
In 2012, NHTSA published the Working Group Best-Practice Recommendations for the Safe Transportation of
Children in Emergency Ground Ambulances. The recommendations outline ideal transport mechanisms for five
situations, defined by the patient’s clinical status and the number of patients being treated
( ).
Ideally, children should be secured to ambulance cots either in a size-appropriate child restraint system or with
three horizontal restraints across the torso and one vertical restraint across each shoulder. The family’s own car
seat secured properly in the ambulance may often be the best alternative, providing it is medically safe and
appropriate for the patient’s condition. This also encourages a safe discharge home from the hospital by already
having the child’s safety seat available in the ED. The report also notes that “A child passenger … must never be
transported on an adult’s lap.” Additional means of making the ambulance interior safe for all occupants include:
seat belt use for all occupants;
securing movable equipment, such as monitors; and
monitoring of driver practices, including through the use of technology.
MEDICAL–LEGAL ISSUES
Prehospital care providers and their medical overseers are legally responsible for their actions or lack thereof.
Good Samaritan laws are variable by state and may not provide any coverage if a provider, from an EMT to a
physician, is being paid to be present at the scene of the emergency. It is vital to understand what type of
professional liability coverage exists for both EMS providers as well as medical control clinicians. Many medical
directors will obtain a separate medical license and Drug Enforcement Agency registration number to help
distinguish their activities performed as a medical director from that used for other clinical duties.
All prehospital providers and medical control personnel should provide care that mirrors the standards of
practice that apply to their profession. Standards of care and medical control are established to protect the EMS
provider professionally as well as serve the patient. Deviation from one’s level of training or from an established
and reviewed protocol with or without the involvement of medical control can expose the EMT to unfortunate
legal scrutiny in the event of a poor patient outcome. When a situation is unclear, prehospital care providers
should consult with the online medical control physician.
Proper documentation of EMS activities is the best defense against potential legal action. Special attention
should be given to accurately documenting the patient’s condition on arrival, including vital signs, position, and
restraint during transport, medication and fluid administration, airway status, and other interventions. Of special
importance is the documentation of a properly placed, secured, and patent airway if intubation is performed by
EMS. Some departments use a separate intubation checklist with multiple redundant confirmations for this
important but inherently risky procedure. All EMS documentation should be completed legibly, with errors noted
by a single line cross out, initial, and date. The provider’s signature must be legible and include a printed name
and credentials. The EMS chart is a medical–legal document as well as a simple record of what transpired in the
field. It should reflect the medical decision-making thought process as well as document any online medical
control orders that were acquired.
Many lawsuits that involve EMS result from the transport of patients to inappropriate facilities, deviation from
standardized protocols, perceived or actual slow response time, or the failure to transport patients when indicated
