Simply hearing ‘3-year-old in cardiac arrest’ stresses out EPs; here's why it shouldn't
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Figure: children, cardiac arrest, pediatricians, pediatrics, ACLS, PALS, epinephrine, algorithms, seizure, hypoglycemia, SVT
FigureIt's a phrase we've been programmed to believe since day one of medical school: “Kids aren't just little adults.” Heaven forbid we ever thought otherwise.
I recall waiting for an intern to fall into the trap, with the PEM attending ready to shout out the golden rule, “They aren't just little adults!” We pediatricians were forced to drink the Kool-Aid and had no reluctance in spreading the gospel.
Nothing would have changed were it not for my serendipitous entry into the world of EMS in 2010 when I became the Davie (FL) Fire Rescue medical director. Overnight I found myself managing big and little people. EMS is a new subspecialty of emergency medicine, scaled to thousands of prehospital professionals using medical protocols. No EMS agency protocol is the same, but most have a separate pediatric section, which I thought was OK—at first.
Yet I detected anxiety that began as soon as the medics heard a call for a child come in. I began making changes, starting with removing the pediatric portion of the protocol, instead combining adults and children. The resistance was hot and heavy. I asked why they didn't like the change, and was met with the proverbial, “That's how we've always done it.”
I began asking more pointed questions, and it became clear that the dogma of “kids are not little adults” had poisoned my personnel's well-being. Even showing them the PALS and ACLS cardiac arrest algorithms side by side didn't lay their speculation to rest even though the diagrams were identical.
Help from a Nobel Prize Winner
The “kids are different” brainwashing led to unintended consequences that persisted and sometimes led medics to leave their jobs because of severe PTSD after a bad call. The mental burden rears its ugly head as soon as the tones go off at the station. Simply hearing the words “3-year-old in cardiac arrest” is enough to initiate the stress sequence. But why?
The answer can be found in the best-selling book by Daniel Kahneman, PhD, Thinking, Fast and Slow. The Nobel Prize-winning psychologist explained this angst elegantly by describing two types of thinking we humans do. Take emergency physicians: We make quick decisions that can be described as automatic and that improve with experience. Dr. Kahneman labeled this System 1 thinking.
Consider a 45-year-old with anaphylaxis. You have no doubt what you will do. You know the doses for epinephrine, diphenhydramine, solumedrol, albuterol, and normal saline. That information was easily served up by your brain's hard drive simply by hearing an age and etiology.
But consider the same scenario with a 2-year-old. Do you see what just happened? The reason you cannot make the same leap in medication dosing and equipment sizing is that the calculations require System 2 thinking. This is slow and requires mental space to arrive at the answer. Dr. Kahneman said people presented with an equation, such as 34x12, will move their eyes up and to the left. Their pupils will dilate, and they will become mentally removed from the situation.
You don't want to be out of touch for even a second in the ED, but System 2 thinking makes this inevitable. System 2 activated at an inopportune time triggers the fight-or-flight response. The physiologic cascade that begins just by hearing the child's age quickly spirals out of control, making you want to flee.
This means paramedics have already decided during the six- to eight-minute ride to the scene to leave mentally before they even arrive. How could they consider staying and playing when their endogenous epinephrine stores are surging, triggered by knowing that System 2 is lurking?
Emergency physicians who hear a pediatric arrest is arriving suddenly find themselves tachycardic and unable to put on gloves because their hands are sweaty. Everything goes downhill fast once the child arrives and nurses start asking for medication doses.
The solution to this dilemma is to prevent System 2 from being activated. Doing this means starting with the child's age instead of length, just like you would for an adult. This provides a tremendous psychological advantage because it allows paramedics to determine drug dosages and airway sizing before arriving on scene, with a similar benefit for the hospital before the child hits the ED.
The trick is to memorize five ages and their corresponding weights in kilograms. This easy step will help you determine the dose of the critical life-saving drugs in a fraction of a second (System 1). The ages are 1-3-5-7-9 (years), which correspond to weights of 10-15-20-25-30 (kg). Practice this using the fingers of one hand, and it will become System 1 in no time.
Once you have the weight of the child in kilograms, simply move the decimal point one place to the left, and you have the cardiac arrest epinephrine dose (0.1 mg/mL). A 1-year-old 10 kg patient, for example, needs 1 mL of epinephrine. That same child can also receive 1 mL of amiodarone if necessary. If he is in anaphylaxis, the dose of epinephrine 1 mg/mL IM is determined by moving the decimal point two places to the left twice from the kg weight. The 10 kg child in anaphylaxis needs 0.1 mL of epinephrine 1 mg/mL IM in the lateral thigh. It's that simple.
Aren't the Protocols Different?
Many are convinced that the algorithms for kids and adults are different, but the only significant difference between the ACLS and PALS algorithms is with symptomatic bradycardia, where PALS calls for cardiac arrest epinephrine (0.01 mg/kg) while ACLS does not. Aside from that, the treatment algorithms for cardiac arrest, seizure, hypoglycemia, and SVT are identical. There are important anatomical differences, but the key is to remain calm and keep the same confidence as when treating an adult. Dr. Kahneman's principles will get you where you need to be so you can set the right tone, keep the room under control, and obtain the best outcome.
EMS systems around the country are using these principles, and the results have been nothing short of spectacular. My EMS system no longer has a dedicated pediatric section, and our personnel have gotten so good at providing care to children that we've stayed to run pediatric codes at the hospital by request of the ED staff.
Pediatric care is a state of mind, and understanding the psychological triggers can drastically improve it, literally overnight. Let's stop pushing the notion that kids are different when in fact they are the same exact species as adults. Heck, we all start and end in diapers, so there must be some truth to it!
Dr. Antevyis a pediatric emergency physician at Joe DiMaggio Children's Hospital in southern Florida. He is also board certified in EMS and serves as the medical director for various EMS agencies in southern Florida, including chief medical officer for Brevard County Fire Rescue. He is also the founder and chief medical officer of Handtevy-Pediatric Emergency Standards, Inc. (https://www.handtevy.com), and the lead pediatric EMS specialist/consultant for the Metropolitan EMS Medical Directors Coalition. Follow him on Twitter@HandtevyMD.
