OBJECTIVE:Emergency medical services (EMS) professionals infrequently transport children leading to difficulty in recognition and management of pediatric critical illness. Simulation provides an opportunity to train EMS professionals on pediatric emergencies. The objective of this study was to examine the effect of serial simulation training over 6 months on EMS psychomotor and cognitive performance during team-based care.METHODS:This was a longitudinal prospective study of a simulation curriculum enrolling EMS professionals over a 6-month period during which they performed three high-fidelity simulations at 3-month intervals. The simulation scenarios included a 15-month-old seizure (T0), 1-month-old with hypoglycemia (T1), and 4-year-old clonidine ingestion (T2). All scenarios were standardized and required recognition and management of respiratory failure and decompensated shock. Scenarios were videotaped and two investigators scored EMS team interventions during simulations using a standardized scoring tool. Inter-rater reliability was assessed on 30% of videos using kappa analysis. Volumes of administered intravenous fluid (IVF) and medications were measured to assess for errors in administration. The primary outcome was the change in scenario score from T0 to T2.RESULTS:A total of 135 team-based simulations were conducted over the study period (48, 40, and 47 at T0, T1, and T2, respectively). Inter-rater reliability between reviewers was very good (κ = 0.7). Median simulation score improved from T0 to T2 (24 vs 31, p < 0.001, maximum score possible = 42). The proportion of completed tasks increased across multiple categories including improved recognition of respiratory decompensation (19% vs. 56%), management of the pediatric airway (44% vs. 88%), and timeliness of vascular access (10% vs. 38%). Correct IVF administration varied by scenario (25% vs. 52% vs. 30%, p = 0.02).CONCLUSION:Serial simulation improved EMS team-based care in both recognition and management of pediatric emergencies. A standardized pediatric simulation curriculum can be used to train EMS professionals on pediatric emergencies and improve performance.

The recent magnitude 7.0 Mw earthquake in Haiti on January 12, 2010, created one of the most severe humanitarian disasters in modern recorded times. According to the most recent estimates, 222,570 people died during the earthquake, with an additional 600,000 injured, and more than 1 million being internally displaced persons [1]. Some statistical models estimated that 110,000 of the injured were children [2]. These estimates rival the 230,000 who perished during the Asian tsunami of 2004. Although the destruction of the Asian tsunami occurred in more than 14 countries, the deaths and destruction of the January earthquake were centered on the tiny island of Hispaniola in the country of Haiti with the epicenter in Leogane, which is 25 km from the capital of Port-au-Prince.

Background. It is unclear if clinicians evaluate for concurrent bacteremia or UTI in young patients diagnosed with acute otitis media (AOM). Objectives. To describe how often, and under which circumstances, emergency providers investigate for bacteremia or UTI in 2–36 month olds with AOM. Methods. Cases of AOM were analyzed from the 2001–2004 National Hospital Ambulatory Medical Care Survey (NHAMCS)-Emergency Department dataset. Results. AOM was diagnosed in 17% of the 10,847 recorded visits of 2–36 month olds. Of these visits, laboratory testing included: CBC: 7%, Blood culture: 4%, urinalysis or urine culture: 5%, and any of these tests: 9%. Rates of testing for 2–6 month olds with temperature ≥ 38.0 (CBC: 13%, blood culture: 9%, urinalysis or urine culture: 7%, any of the tests: 14%) were not significantly different from testing of patients aged 6–12 months, or 12–36 months (all P>.1). Patients with temperature of ≥39.0 were more likely to have all tests, with the exception of urine investigation, than patients with temperature between 38.0 and 38.9. Conclusions. 17% of 2–36 month old patients seen in the emergency department are diagnosed with AOM. Investigating for bacteremia or UTI in these patients is not routine, even in febrile infants.

Mark Winslow, DO, holds an improvised surgical light for Jennifer Bruny, MD, as she repairs a stab wound. Boyd Loehr, RN, right, manned the suction pump, made from a Purell bottle: .We arrived in Port-au-Prince Jan. 18., and as the week progressed, conditions and coordination between hospitals slowly improved. Our team was located in a field hospital in Port-au-Prince at the Matthew 25 Ministries home. Our team, consisting of a pediatric surgeon, three pediatric emergency physicians, four nurses, one physical therapist, one EMT, and one family practitioner, expanded a field hospital set up in a soccer field to include an acute treatment area on a basketball court. We performed three surgeries on a kitchen table, and many wound debridements and fracture reductions outside in the field hospital. Some observations and lessons learned: Ketamine at 1 mg/kg or 50 mg for adults is a great sedative for the field when you do not have anesthesia. We were able to keep our major surgical patients very still and comfortable during amputations and wound explorations with boluses of 50 mg of ketamine. We also performed many ketamine sedations for fracture reductions and wound debridements in the field. Security was not an issue for us. I felt safer with our host, Sister Mary Finnick, a retired nurse, driving around Port-au-Prince than a platoon of marines. Having a local contact or someone who has been to Haiti before is very helpful. We were lucky to join a group led by Dr. Mark Winslow, who has been going to Haiti for many years, and has many contacts in Haiti. By our third day, our team was split up because of the influx of new patients had slowed to our hospital, and we formed a mobile unit to treat and transport patients from a neighboring tent city to our hospital. The mobile units had no concerns about security. You still have to use the same precautions you would while traveling to any developing country (use the buddy system, wear a passport belt). Improvise. During a surgery for a bad stab wound, we realized we did not have any suction. Someone came up with the idea of using the pump from a Purell bottle. Pretty soon we had a nurse who was pumping all the blood out of the wound with the Purell pump, and we finally had a clear surgical field. Be persistent. We had a teenager with a basilar skull fracture who was turned away by six different hospitals because they did not have a neurosurgeon. It took persistence by our team members to convince the military to land a Blackhawk to transport her to the USNS Comfort. Communication. In Port-au-Prince, the cell towers are still mostly functioning, but voice calls are really difficult to make during the day because of the congestion. We had no problems with data, texting, and emailing on our BlackBerries and iPhones any time of the day. Emails and texting were our main modes of communication between the team when separated and from the United States. Again, texting and emailing were essential for getting our patients to the USNS Comfort through various contacts. Haiti uses the GSM cellular standard (AT&T and T-Mobile will work fine). Verizon has some world phones that have dual-mode GSM and CDMA. Contact your carrier to change to an international data roaming plan prior to leaving the United States. Bringing more walkie-talkies would have been helpful, too. Know your resources. As things began to get more organized, we soon learned about other hospitals that could provide higher levels of care, such as orthopedics. We were able to refer more patients out, especially the more complicated cases. Drs. Tham, Mahar, and Wang are pediatric emergency physicians at The Children's Hospital in Aurora, CO.