Pediatric emergency medicine trisk 4621 4621
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(a “no load”). When in doubt, it is usually safest to transport the patient. Language barriers can be an important
factor in accurately assessing a patient and situation, and it is important to address how to approach language
incompatibilities ahead of time. There are numerous resources for telephone-based interpreters available (at a
cost), but these are difficult to access unless the EMS service already has an existing account with a translation
service (such as Language Line). Using telephone interpreters is cumbersome in the EMS setting due to the need
for privacy and mobility, but at times it is the only option. It may also be useful to have printed medical
translation cards specific to the demographics of the EMS service area.
All healthcare providers must understand their duties to provide care. Questions often arise concerning issues
of consent, especially when children are involved. The doctrine of implied consent permits the treatment of
minors without parental consent when a medical emergency exists. In general, any minor with a condition that
threatens “life and limb” is considered an emergency and should be treated and transported. This is typically true
even in the difficult situation when a parent refuses EMS for a patient who appears to be emergent. Minor
patients cannot refuse treatment and transport in an emergency situation. The same is true when parents are
incapable of understanding the risks of refusing care because of cognitive impairment from intoxication or injury.
The use of online medical command can help evaluate and resolve a situation where there may be disagreement
at the scene regarding the need for transport.
Patient refusals for EMS transport are a large source of patient care liability for EMS providers. If
parents/guardians refuse care for their ill or injured child, and the EMS provider deems the child’s condition to be
serious or feels that the parent is not acting in the child’s best interest, the EMS provider is warranted in
escalating to medical control as well as calling the police when indicated. The parents must be informed of the
risk of not transporting a sick or injured pediatric patient, which typically may include death or permanent
disability. Regardless of religious beliefs or parental desires, a child must be treated and transported if there is a
life-threatening emergency or if providers suspect child abuse, even if parents refuse. Medical control should be
involved early, and law enforcement may be necessary to ensure that the patient receives the necessary
emergency stabilization and transport.
All EMTs, regardless of certification level, have a duty to report suspected child abuse at all times and in all
patients. Even if the ED says that they will report a suspected case later on, it is important to immediately report
to the authorities to protect the EMS provider. In some states, failure to report suspected child abuse is treated as
a felony, and providers and medical directors should know the law in the state where they practice. The EMSC
program in Colorado and pediatric specialists at the University of Colorado offer an online training module to
assist EMS providers recognize signs of child abuse, which can be found at .
Many states have an EMS do not resuscitate (DNR) protocol to limit resuscitative efforts for those who have
made that decision with their physician. These are under the authority of the parent/guardian, not the physician,
and they can be revoked at any time if the parent changes his or her mind, something common in pediatric
medical emergencies. Providers and medical oversight physicians must be familiar with the specific documents
required for an EMS DNR to be in effect, commonly a patient wristband as well as accompanying paperwork.
When in doubt, EMS providers must resuscitate a patient and transport them to the ED.
A challenging situation for EMS providers is when a clinician unknown to the EMS service stops at an
emergency scene and wishes to participate in and/or direct the medical care. This is a precarious situation for both
the provider and clinician, since it is difficult to verify the qualifications of the bystander. Wherever possible, this
situation should be guided by a protocol, and at no time should the clinician be allowed to endanger the patient or
providers. ACEP has produced a policy statement that outlines the issues involved in having a bystander clinician
involved in the care of the EMS patient. Because of the liabilities involved in having an unknown bystander take
a role in an established system of providing prehospital care, this is a circumstance where online medical control
should be contacted to determine the ways in which the bystander may assist. Options may range from providing
an extra set of hands to having the clinician assume control for the patient and accompanying them to the ED. It
is strongly encouraged that EMS systems draft an information card or document to give to on-scene providers to
explain how this will work for a specific service. This should be written in conjunction with the EMS service’s
medical director.
REGIONALIZATION
Based on protocol and/or the online medical control, a decision is made regarding the receiving hospital, or point
of entry (POE). The POE selection is based on various factors: patient condition, the capabilities of the receiving
