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Risking Our Children's Health: A Need for Emergency Care In 1988, about 21,000 children under the age of 20 died from injuries; additional deaths occurred as a result of acute illness. Hundreds of thou- sands more children were hospitalized, and millions visited emergency de- partments (EDs). Tragically, the care that has been available to these chil- dren has not always been adequate. Children have unique clinical needs that cannot always be met by care designed for adults. Until recently, however, important differences between children and adults in anatomy, physiology, pathology, and psychology have received relatively limited at- tention from EMS systems (Seidel et al., 1984; Seidel, 1986a). Further- more, limited data make it difficult to determine in sufficient detail how many children need emergency care, the kinds of illnesses and injuries they experience, and the nature and outcome of the care they receive. The data that are available provide at least a partial picture of the emergency care that children need. In the broadest terms, injury presents the greatest threat to children's lives and takes an especially heavy toll among adolescents and young adults. Infants and very young children are more susceptible to serious illness than older children are, and until chil- dren approach adolescence, respiratory diseases lead to more hospitaliza- tions than do injuries. This chapter discusses differences between children and adults and the need for special attention to those differences in emergency care. It also reviews available information on the numbers of children and the kinds of conditions that require emergency care. 38

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RISKING OUR CHILDREN'S HEALTH 39 DEFINITIONS Children Childhood begins at birth, but there is no single, universally recognized age at which childhood ends and adulthood begins. It ~s Moselle for ex- ample, to register to froze at age 18 but not to be able legally to consume or purchase alcoholic beverages until age 21. Adolescents are biologically capable of becoming parents as early as 11 or 12 years old but cannot get a driver's license until they are 16 or 17. Even though markers such as these may draw the boundary between children and adults at different ages, the fact that there is a boundary to define demonstrates a need to distinguish children from adults. The American Academy of Pediatrics (AAP, 1988a) has set an unDer . ^. _ ~1 ~ ~ 7 ~ At age ot z~ to Ketone the patient population that falls under its purview, but various factors play a role in determining the age range used in specific settings. the special demands of chronic illness may, for example, call for continued care beyond the age of 21 by pediatric specialists (AAP, 1988a), and a conference on childhood injury research recommended including indi- viduals up to age 24 (NICHD, 1992~. Hospitals and EMS systems often use younger ages to define the pedi- atric population. A survey of state EMS agencies found that only 12 set a specific age limit: five states used age 14; two, age 16; three, ace 18; and of the remaining two, one used age 19 and the other age 21 (Seidel, 1991~. Some states had no policy and others relied on case-specific factors to make a determination. Studies that the committee drew on throughout this report used a variety of ages to define pediatric populations. In situations where a specific age is set for adult patients, children may be defined by default. The survey of state EMS agencies found that 19 of 27 states that specified a minimum age to define adult patients use age 18 (Seidel, 19911. For its new indicators of the quality of trauma care, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 1991) also defines adults as patients age 18 and older. Because older adolescents are much more similar anatomically and physi- ologically to adults than Younger children are. they can often be treated successfully by health care providers without specialized pediatric training. Hospitals may also find that specific circumstances, such as injuries from assaults or gun shots, make it appropriate to separate care for younger children from that for older adolescents (Barlow, 1989; Hailer, 1989a). Nev- ertheless, adolescents, who are not yet adults and who have characteristic psychosocial needs, may make a better recovery if they can receive care from providers with specific training in pediatric and adolescent medicine. The committee declined to fix a specific age range to define "children," ~_ _^ ~ ~ _ A A ~ _ ~ ^ _ ~ ~ _ ~

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40 EMERGENCY MEDICAL SERVICES FOR CHILDREN preferring instead to emphasize that its concern encompasses the entire span of childhood: infants, toddlers and preschoolers, schoolchildren, and ado- lescents. Its view also covers the emergency care needs of all children regardless of basic health status-those who have been healthy before the onset of an emergency condition and those with chronic illnesses or other special health care needs. The one exclusion deemed appropriate Q~ pur- poses of this report is newborns and the intensive care that they may require immediately after birth. Emergency Medical Services The committee views emergency medical services for children (EMS- C) as specialized care, provided by physicians, nurses, paramedics, emer- gency medical technicians, allied health personnel (e.g., respiratory thera- pists, physical therapists), and others, that covers a wide range of services including prevention, prehospital care, stabilization and definitive care in vari- ous inpatient settings, and rehabilitation. As is stressed throughout this report, EMS-C should operate against a broader background of child health and emergency medical care; links with the primary care environment are critical. The usage of "EMS" in this report should be made clear. "EMS sys- tem" refers to services organized on state, regional, and local levels to meet the emergency care needs of the community. "EMS agency" is used in two ways: (1) as the state government office responsible for regulating or ad- ministering emergency care services, particularly prehospital services; and (2) as the local or regional organization (which may be public, private, or volunteer) that provides prehospital services directly to patients. Where EMS is used alone, its context should indicate whether it refers only to prehospital matters or to the broader EMS system. Although the specific care that children should receive from the EMS system depends on the nature of the emergency and factors such as the training and resources available to emergency care providers, the elements of basic life support (BLS) and advanced life support (ALS) form a com- mon core of emergency care. BLS encompasses first aid and basic cardio- pulmonary resuscitation (CPR) aimed at stabilizing a patient until more advanced care is available. Important skills include patient assessment and care aimed at ensuring an open airway and adequate breathing, controlling bleeding, and immobilizing the spine or other skeletal injuries. ALS in- cludes more extensive stabilization and resuscitative care with additional, often invasive, procedures such as endotracheal intubation to provide an airway and promote breathing, intravenous (or intraosseous) administration of fluids and medications, or use of equipment such as defibrillators. BLS training is available to parents and other members of the public as well as health care professionals.

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RISKING OUR CHILDREN'S HEALTH 41 In addition to "care for emergencies," health care providers and organi- zations are also faced with the need to provide "care in emergency settings" to children who are not seriously ill or injured but have limited access to other care. Chapter 3 discusses the history and structural components of emergency care and EMS systems in this country. WHY CHILDREN NEED SPECIAL ATTENTION Children Differ from Adults Emergency care for children must take into account important differ- ences between adults and children and among children of varying ages. Characteristics of anatomy, physiology, and psychological development dif- fer as do the kinds of injury and illness that they experience. These factors all affect children's risks for and responses to injury and illness as well as their treatment. Anatomy and Physiology Anatomically, children are smaller and proportioned differently than adults. Smaller body size results in greater surface area relative to body volume, which makes children vulnerable to excessive loss of heat and fluids. The child's smaller airway can be blocked easily by swelling or foreign bodies. Successfully performing procedures such as endotracheal intubation and intravenous injections in children requires equipment sized appropriately for smaller airways and blood vessels. Accommodating a child's shorter trachea and higher larynx also requires special care during intubation. In very young children, especially, the head is proportionally larger and heavier than in older children and adults, making it a prominent point of injury. The size of the head also affects the alignment of the airway and spine when a child lies face up. Less rigid bones and skeletal structures lead to fewer fractures or fractures of a different character than those seen in adults. Significant lung injury, for example, can occur in children without the rib fractures that would be a hallmark of such injury in an adult. Normal respiratory rates and heart rates are higher in children than in adults and vary inversely with the age of the child (i.e., highest rates in the youngest children). In contrast, normal blood pressure in children is lower than adult levels. These differences in normal rates must be understood in order to distinguish normal and abnormal states in children. Furthermore, the characteristic changes in these vital signs that signal deterioration in adults may not occur in children. For example, impending shock from loss of blood or dehydration can be hard to detect in children because their

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42 EMERGENCY MEDICAL SERVICES FOR CHILDREN generally healthier cardiovascular systems can maintain normal blood pres- sures far longer than adult systems can. Developmental changes over the course of childhood also must be con- sidered. In infants the major organ systems, including the cardiovascular, renal, pulmonary, and immune systems, continue to mature. Neurologic development dunug childhood leads to marked changes in ch~ldren's lan- guage abilities, motor skills, and coordination. Adult assessment tools need to be modified to reflect age-appropriate responses. Preverbal children, for example, cannot answer questions or respond to instructions. Emotional and Behavioral Development Children progress through recognizable stages in emotional and behav- ioral development that affect their risk of injury and illness and their re- sponses to the people and procedures involved in emergency medical care. During the first year of life, infants develop early motor skills and an awareness of their surroundings. By about six months, they begin to fear separation from their parents. They cannot yet communicate verbally or understand events around them; crying is their only means of expressing physical dis- tress from injury or illness. For toddlers, increasing mobility is not yet matched by an understanding of dangers in their environment. They are developing a sense of autonomy but fear separation from their parents and familiar surroundings. Their language skills allow them to express and understand simple information. . A Preschool children have good basic motor skills and an increasing , A, vo cabulary. They do not yet understand the workings of the body and they fear physical injury. additional risk of iniurv An increasing range of activities exposes them to ~ ~ Motor control and language skills continue to improve in schoolchildren. Pedestrian and bicycle injuries are a particular risk for them, and participation in sports presents new hazards. Through school and other activities, these children develop relationships and experi- ences beyond the family. They are increasingly aware of their bodies and begin to have concerns about death. Adolescents face a special challenge in making the transition from child to adult. Their physical development begins to give them adult capabilities that their emotional and intellectual development may not match. Efforts to separate themselves from the family, combined with a sense of indestructi- bility, lead them to behave in ways that put them at increased risk of injury. Access to motor vehicles, for example, creates substantial hazards for ado- lescents who are (or are with) inexperienced drivers, do not wear seashells, or may be impaired by alcohol or drugs.

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RISKING OUR CHILDREN'S HEALTH Patterns of Morbidity and Mortality 43 Two especially important differences exist between children and adults In their experience of illness and injury. First, differences in the origin of cardiac arrest in adults and in children have a significant impact on sur- vival. In adults, cardiac arrest occurs most often as a direct result of distur loances In heart rhythms In individuals with cardiovascular disease. Rapid initiation of CPR and defibrillation substantially improves survival from arrests with ventricular fibrillation. Among children, however, cardiac ar . rest occurs most often as a final stage in progressive deterioration from respiratory or circulatory insufficiencies that can arise from a variety of conditions (e.g., sudden infant death syndrome tSIDS], near-drowning, air- way obstruction from respiratory disease or foreign bodies, injury, dehydra- tion, or seizures). Once a child reaches this stage, chances for successful resuscitation are small. Because the origins of cardiac arrest are so differ- ent in adults and children, adult-oriented ALS training does not provide adequate guidance for treating children. Second, head injury, which poses serious risk of death or long-term impairment in survivors, is a special concern. Among injured children and adults, children are more likely to have experienced a head injury. In 1985, it accounted for about 30 percent of children's and about 12 percent of adults' hospitalizations for unintentional traumatic injury (MacKenzie et al., 1990a,b). Data from two large trauma registries, the National Pediatric Trauma Registry (NPTR) and the Major Trauma Outcome Study (MTOS), reveal that 44 percent of the children and 33 percent of the adults experi- enced head injury alone or in conjunction with other injuries (Tepas et al., 1990~. In these two groups, survival was better among the children than the adults except among the most severely injured, where rates were compa- rable. Evidence indicates, however, that among children outcomes are worse in those who are less than 2 years old (Luerssen et al., 1988~. Special Concerns in Caring for Children Recognizing Serious Illness and Injury Prompt identification and treatment of serious illness and injury in chit dren can be critical to achieving good outcomes. The primary condition must be treated and steps must be taken to ensure that secondary disorders (e.g., respiratory compromise, shock, cerebral edema) do not occur. Health care providers who lack appropriate pediatric training, experience, and guide- lines may, however, find it difficult to recognize the children who are criti- cally ill and require the most urgent care amongst the many others who have only minor injuries, uncomplicated illnesses, or other non-life-threat

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44 EMERGENCY MEDICAL SERVICES FOR CHILDREN ening conditions (Wiebe and Rosen, 1991) to identify, for example, the youngster with meningitis from among the stream of patients with fever and headache. Evaluation of infants can be particularly difficult, and in some settings it may be appropriate to give all infants less than six months old the highest priority for care. llecogn~zir~g whether a child's condition is l~fe-threaten~ng can be com- pl~cated by the fact that indicators of serious illness or disorder may not appear until the child is near collapse. Infants, for example, may not de- velop a fever to signal infection. Blood pressure levels may not reliably reflect a child's circulating blood volume or level of hydration, and a criti- cal loss of fluids may have occurred before low blood pressure is observed. Risk of cardiopulmonary arrest in children is signaled by respiratory arrest or shock rather than by the cardiac arrhythmias that typically precede arrest in adults. Health care providers also need to be able to recognize those children whose condition may seriously worsen if appropriate care is not provided in a timely manner. Thus, knowledge of the potential complications of chronic diseases such as asthma, cystic fibrosis, sickle-cell anemia, and bronchopulmo- nary dysplasia is important. Providers also must be aware of conditions that are unique to children such as growth-plate fractures and croup syndromes, characteristics of urinary tract infections in infants, and shaken-baby syn- drome (a cause of brain injury in abused infants). Numerous assessment tools have been developed to help prehospital, ED, and hospital personnel evaluate the severity of injury and to guide decisions about where and how to treat an injured patient. (They are dis- cussed further in Chapters 5 and 7.) Efforts to develop similar systems for illness have had limited success, in part because it has been difficult to identify objective criteria that can be applied broadly and consistently. Treating Children Once the need for emergency care has been recognized, successfully treating children requires particular knowledge and skills. Providers in all health care settings prehospital, ED, intensive care unit (ICU), inpatient, and ambulatory care need to know about the anatomic, physiologic, and psychological characteristics of children and how those factors influence what care is needed and how it is delivered. Only in the past 5 to 10 years have emergency care providers outside major pediatric hospitals begun to have access to training courses specifi- cally in emergency care for children. Many of those with training may, however, have little opportunity to use their skills because they encounter few seriously ill or injured children; they may lack confidence in their ability to perform even simple, noninvasive procedures (Gausche et al.,

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RISKING OUR CHILDREN'S HEALTH 45 1990). Limited training and experience help make pediatric care especially stressful for many providers. Moreover, their emotional responses to seri- ously ill or injured children can be strong. Helping Children with Special Health Care Needs Although the vast majority of children in this country are fundamen- tally healthy, an increasing population has serious ongoing health condi- tions. Among these are children with acquired diseases such as malignan- cies; children with unstable medical conditions such as asthma, diabetes, or sickle-cell disease; very-low-birthweight infants with residual problems such as bronchopulmonary dysplasia; and children who depend for their survival on high-technology interventions such as respirators, dialysis, or parenteral nutrition. Added to these are children with fixed necrologic deficits and serious birth defects, as well as survivors of previous trauma or illness who are left with residual disabilities. The Office of Technology Assessment (OTA, 1987) estimates that the technology-dependent population may be as large as 100,000 children, and it continues to expand. Estimates of the numbers of other children with chronic conditions are even larger. These children are of special concern because they tend to use emergency care services recurrently and in some circumstances they have special vulnerabilities that are not shared by the general population. Ordinary illness or injury may place them at risk for additional complications. EMS-C systems need special features to ensure that these children re- ceive safe care. Assessment in the field or in the hospital cannot rely on the usual assumptions about a normal baseline condition before the emergency. Furthermore, emergency care providers should not assume that family members of these children are ill-prepared to deal with emergency situations. On the contrary, these family members have often received extensive instruction in caring for their child. In an emergency, they and other caretakers are likely to know a great deal about a child's immediate needs and can make an important contribution to appropriate emergency care. Emergency care pro- viders should be prepared to work with knowledgeable caretakers, should take into account the special needs that these children have, and should understand that appropriate care may be available only at tertiary care cen- ters. EPIDEMIOLOGY OF CHILDHOOD EMERGENCIES Although no one doubts that too many children experience emergencies from injury or illness, it is difficult to offer any precise account of how

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46 EMERGENCY MEDICAL SERVICES FOR CHILDREN many or what kind of emergencies occur or what happens to the children who experience them. Why is this so? Part of the answer is that there is no single authoritative way to identify an emergency. Some conditions that parents believe require emergency care may prove to be much less serious when assessed by a well-trained, experienced physician who regularly treats serious illness and injury in a well-equ~pped pedia-tr~c ED. At other tames, however, parents and health care providers alike may fail to recognize conditions that, if left untreated, pose a true threat to a child's health. Regardless of how cases are identified, data on traumatic or illness- related emergencies in children are seriously limited. Data on severe inju- ries that lead to death or hospitalization are somewhat better than those on illness. Diagnostic coding based on the International Classification of Dis- eases (the clinical modification of the ninth revision ICD-9-CM is cur- rently in use) can identify specific kinds of injuries (e.g., laceration, frac- ture, burn) and events that produce injuries (e.g., fall, motor vehicle collision, bicycle crash). No similar set of diagnostic categories has been recognized as defining emergency illness, making it difficult to compile consistent data. The data that are available come from a variety of sources. The vital statistics system can provide state and national data on numbers of deaths. Hospital discharge data help identify the many additional cases in which seriously ill or injured children do not die. About 30 states maintain data- bases on hospital discharges (CDC, 1992a). National data on hospital dis- charges are available from a sample survey of hospital records, but the sample is too small to permit state-level estimates (NCHS, 1992a). Data on ED visits and prehospital care are even more limited. The American Hospital Association (1991) reports estimates of total numbers of visits (about 92 million in 1990) but does not identify children separately. The National Health Interview Survey estimates that, in 1989, 14.5 million visits were made by children under age 18 (unpublished data, National Health Interview Survey, National Center for Health Statistics, 1991~. In a survey of this sort, however, underestimates are likely; respondents may forget to report visits or may not know about visits by other members of the household. No national data are available on prehospital care, but 29 states collect at least some data on these services (Emergency Medical Services, 1992~. Much of what has been learned about illness-related emergencies and about children receiving prehospital and ED care comes from studies in specific localities (e.g., a single state or city) or even in individual EMS agencies and hospitals. These valuable studies are usually able to assemble much greater detail than the vital statistics or hospital discharge reports, but because they are not broadly based their results must be seen as one piece of a larger picture that may vary somewhat. Unfortunately, comparisons

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RISKING OUR CHILDREN'S HEALTH 47 among the studies are often difficult because definitions and reporting cat- egories vary. These limitations in the data on emergency medical care for children are a serious impediment to full understanding of the scope and character of the conditions requiring care and the effectiveness of the care that is given. Chapter 7 returns to issues of data and data collection with specific proposals for improvements in the current situation. For purposes of the present discussion, what follows draws -from the varied sources of available data to assemble a description of the numbers and kinds of conditions for which children need emergency care. It high- lights the differences in the distribution of those conditions among various settings of care office practices, prehospital care, and EDs, ICUs, and other inpatient settings in community hospitals and in major referral cen- ters. Injury, as the leading cause of death among children, is the starting point for this discussion. - lnjury injury has been defined by the National Committee for Injury Preven- tion and Control (1989, p. 4) as "unintentional or intentional damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat or oxygen." Injuries sustained from an event such as a motor vehicle crash or a gunshot Lack of oxygen is operating in crowning or asphyxiation. For some purposes, trauma or traumatic injury is distinguished from the broader class of injuries. Drowning, near-drowning, and poisoning may be considered nontraumatic injuries (Weinberg, 1989~. Unintentional injuries are the leading cause of death among children over the age of 1 (Table 2-1), and all injury deaths in children have been estimated to cause the loss of 1.2 million years of potential life before age 65 (CDC, 1990~. In 1988, unintentional injuries led to the deaths of 7,073 children between the ages of 1 and 15, about 43 percent of deaths at those reflect the effect of mechanical energy. ~ . . ~ - ages. Among 15- to 19-year-olds alone, unintentional injury led to 8,498 deaths, 53 percent of all deaths. There also were 936 deaths among infants less than 1 year old. Intentional injury homicide (including child abuse and neglect) and suicide added another 5,575 deaths in 1988 among chil- dren and young people less than 20 years old. About 24 percent of all injury deaths in infants were attributed to homicide compared to 10 percent among children ages 1 to 14 and 16 percent among 15- to 19-year-olds. At every age, more boys than girls die from injuries.2 Injuries associated with motor vehicles account for the largest number of deaths of any given cause. The specific motor vehicle risks vary with age, however. Children 1 to 4 years old die in about equal numbers as pedestrians and as motor vehicle occupants; among the 5- to 9-year-olds,

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48 EMERGENCY MEDICAL SERVICES FOR CHILDREN TABLE 2-1 Deaths from Injurya Among Children and Adolescents Ages O to 19, by Cause, Age, and Sex, 1988 Categories of Injury Age <1 1-4 5-9 10-14 15-19 0-19 Mates Unintentional injuries Motor vehicle1185437358034,7676,966 Other4121,1856076471,4644,315 . . . . ntent~onal injuries Homicide151217981691,7272,362 Suicide0051761,6681,849 Other injuries28261544139252 All injuries7091,9711,4601,8399,76515,744 Females Unintentional injuries Motor vehicle974624414442,0183,462 Other3096683192192491,764 . . . . Intentional Injuries Homicide16416481110392911 Suicide00161391453 Other injuries1429783492 All injuries5841,3238498423,0846,682 TOTAL INJURIES1,2933,2942,3092,68112,84921,133 NOTE: The following ICD-9-CM codes were used to define specific categories of injury: unintentional injuries, E800-E949; motor vehicle injuries, E810-E825; homicide, E960-E969; suicide, E950-E959; and other injuries, E970-E999. aDeaths attributed to injury as the underlying cause of death. SOURCE: Data from NCHS (1992b). pedestrian deaths are more frequent; deaths of older children tend to be as occupants of motor vehicles (Children's Safety Network, 19911. Burns (including fire-related factors such as smoke inhalation) and drowning are the next most frequent causes of death in younger children. Among chil- dren over age 10, however, homicide and suicide are exceeded only by motor vehicle deaths. At all ages, intentional injury deaths are likely to be misreported be- cause they are unrecognized or deliberately misrepresented (Guyer et al., 1989; McClain et al., 1993~. A recent analysis suggests that about 85 percent of child abuse deaths, which occur primarily in children under age 5, are attributed to other causes (McClain et al., 19931. In 1988, there were

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RISKING OUR CHILDREN'S HEALTH 55 serious chronic illnesses, 16 percent were hospitalized (Newacheck and Taylor, 1992~. A shift to home care for technology-dependent children who would previously have been cared for in hospitals and long-term care facilities is contributing to increased demand for emergency care (OTA, 1987~. Other Aspects of Pediatric Emergencies Beyond the broad categories of injury and illness that encompass the largest portion of pediatric emergencies are specific conditions or circum- stances that should be noted. Among adolescent girls, pregnancy-related con- ditions account for a substantial number of hospitalizations-nearly 600,000 for 15- to 19-year-olds in 1989 (HRSA, 1991). Although few deaths are attributable to pregnancy, emergency deliveries, especially of premature in- fants, as well as complications during pregnancy can create a need for emergency care. Children and adolescents experiencing psychiatric or behavioral emer- gencies are a growing concern among public health and clinical experts. Two factors are particularly significant: the increasing rates of major de- pression in that age group (Cross-National Collaborative Group, 1992) and the contribution of preventable behaviors and social-environmental condi- tions to much of the morbidity and mortality among adolescents (Millstein et al., 1992~. Situations that require an emergency response include suicidal behavior, threats to harm others, and psychoses (sometimes induced by drugs). During 1991, 49 percent of the calls to poison control centers regarding children 13 to 17 years of age involved intentional poisoning (Litovitz et al., 1992~. Of prehospital calls for 16- to 20-year-olds on Oahu, Hawaii, 12 percent were attributed to behavioral conditions (Yamamoto et al., 1991a). These children, who may require the same medical and surgical care that other ill or injured children need, also require the care of mental health professionals. Violence, in various forms, poses a serious threat to the health of chil- dren and adolescents. With suicide, young people are turning the violence against themselves, but many suffer at the hands of others through homi- cide, assault, or child abuse and neglect. Children who witness violence may suffer emotional wounds even without physical ones (Groves et al., 1993~. Use of firearms is increasing the toll of violence, particularly in urban areas (Barlow, 1992; Ropp et al., 1992), and is increasingly seen as a public health emergency (AAP, 1992b,c; Koop and Lundberg, 1992; Rosenberg et al., 1992~. Major urban trauma centers have seen a 300 percent rise in gunshot wounds (Tanz, 1989), and in Harlem, gunshot wounds have become the leading cause of hospitalization for injury among adolescents (Barlow, 1992~. In 1988, firearms were involved in 65 percent of suicides and 77 per

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56 EMERGENCY MEDICAL SERVICES FOR CHILDREN cent of homicides among boys 15 to 19 years old (Children's Safety Net- work, 1991~. Ready access to handguns among individuals 15 to 24 years of age in one city in the United States was associated with a higher rate of suicide than in a matching city in Canada (Sloan et al., 1990~; in a different analysis, the availability of any type of gun, not just handguns, appeared to be assoc~at-ed with a higher risk of suicide among adolescents (Brent et ails l99T). Among 15- to 19-year-olds, firearm homicide is second only to motor vehicle crashes as a cause of death and is increasing more rapidly than any other cause of death (Fingerhut et al., 1992a). In core urban areas it is the leading cause of death (Fingerhut et al., 1992a,b), particularly among black males (in a small number of identifiable metropolitan counties). Overall, firearm deaths in this age group have increased by 61 percent since 1979. In Detroit, firearm homicides tripled between 1980 and 1988 among young black men 15 to 18 years old (Ropp et al., 1992~. Although child abuse and neglect can be fatal, they are often much harder to identify than a gunshot wound. Emergency care can require the services of medical, surgical, and mental health professionals who must report suspected abuse to the proper authorities. Determining how many children have experienced abuse is difficult: reports may not be confirmed; some cases may not be recognized (or at least not reported); and definitions and reporting criteria can vary among sources or over time (Courter, 1992~. For 1990, the National Child Abuse and Neglect Data System (1992) shows about 1.7 million reports of child abuse and neglect involving 2.7 million children. About 45 percent of these cases are attributed to neglect, and about 40 percent of all the cases have been substantiated. Furthermore, to the extent that child-abusers are themselves children, the issue poses ex- traordinary challenges in the EMS-C arena. Settings for Emergency Care Emergencies Encountered in the Pediatrician's Office Discussions of emergency care tend to concentrate on the principal providers of such care prehospital services, EDs, and hospital inpatient settings but office-based physicians and nurse practitioners also encounter emergency conditions among the children that they see. Among Chicago- area physicians in one study, 62 percent reported seeing each week at least one child who required hospitalization or urgent treatment (Fuchs et al., 1989~. A national survey of pediatricians found that more than 50 percent had seen in their offices in the past year children with meningitis, severe asthma, and severe dehydration (Schweich et al., 1991~. Other conditions encountered included seizures, head trauma accompanied by a change in

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RISKING OUR CHILDREN'S HEALTH 57 mental status, probable epiglottitis, anaphylaxis, and cardiopulmonary ar- rest. Illness predominates, probably because parents can recognize serious injury more easily and seek emergency care more directly. Office-based physicians and nurse practitioners need to be prepared to diagnose possibly life-threatening medical conditions and to provide the immediate treatment that will stabilize a c~h~ld's condition Brazil additional cue is available Paradoxically, some of the children whose conditions can be treated successfully In the office setting rely on the ED for care. Lack of access to a primary care provider may delay routine care for some conditions, making them more serious when they are treated. For children who have a regular source of care, the ED may be chosen for its convenience. Some primary care providers also send their patients directly to the ED (with or without use of prehospital services) for injuries such as cuts, falls, possible frac- tures, and ingestions and for "after-hours" care of all kinds. Prehospital Care Infants, children, and adolescents make up about 30 percent of the population, but they have generally been found to be about 10 percent of the patients cared for in the prehospital setting (Seidel et al., 1984; Tsai and Kallsen, 1987; Yamamoto et al., 1991a). In Arkansas, however, children under age 15 accounted for only 2 percent of prehospital transports in 1986 (Arkansas EMS-C Project, 1991~. Variations such as these are less likely to reflect differences in the relative frequency of injury and illness among children than in expectations about whether prehospital services should be used for children. Younger children in particular are more "transportable" than adolescents and adults, making it easy for parents to take them by car directly to an ED. For some of these children, however, EMS transport may be more appropriate because of the difficulty of making an accurate assess- ment of the seriousness of a child's condition and the potential for causing additional damage when an injured child is moved. Both ill and injured children receive prehospital care. Seizures and respiratory distress are among the more common illness-related conditions encountered; the two most frequent causes of injury are motor vehicle crashes and falls (Seidel et al., 1984,1991b; Tsai and Kallsen, 1987; Johnston and King, 1988~. The distribution of prehospital cases with injuries or illnesses varies as expected with age; the youngest children experience more illness and the oldest ones, more trauma. Patterns differ some by geography. For children in Los Angeles County, illness accounted for about 55 percent of cases (Seidel et al., 19844. In New York State, however, traumatic injuries and burns among children under age 15 were 65 percent of the pediatric prehospital cases (Cooper et al., 19931. (These children also represented 21 percent of all prehospital trauma care.)

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58 EMERGENCY MEDICAL SERVICES FOR CHILDREN A comparison of rural and urban cases found that 64 percent of rural cases and 56 percent of urban cases were for trauma (Seidel et al., l991b). Stud- ies that include older adolescents have found that injury was responsible for about 55 to 65 percent of the cases (Ramenofsky et al., 1983; Tsai and Kallsen, 1987; Johnston and King, 1988~. Tsai and Kallsen (1987) note, however' that the. severity of the ~llr~ss-related cases in their study was somewhat greater than the severity of the injuries. The distribution of calls for prehospital care for children during the day and over the year appears to be related, at least in part, to the timing of school activities. During the day, for example, calls rise steadily from about 6 a.m. with a peak for injuries in mid-afternoon after the school day typically has ended (Tsai and Kallsen, 1987; Seidel et al., 1991b). Calls for illness show an afternoon and evening plateau rather than a peak (Tsai and Kallsen, 19871. Over the course of a year, calls have been found to be higher in the summer for injuries and in the winter for illness (Johnston and King, 1988). ED Care Experts estimate that about one-third of visits to EDs are for children (ACEP, 1990d). This average spans children's hospitals that see children almost exclusively and general hospitals with proportions of pediatric cases as high as 41 percent (Guterman et al., 1985) and as low as 23 percent (Nelson et al., 1992~. In a pattern consistent with the use of prehospital services, most children arrive at the ED in the late afternoon and evening (Fifield et al., 1984; Mayol and Mora, 1989; Krauss et al., 1991; Nelson et al., 1992~. At those hours, the offices of private practitioners and clinics are less likely to be open, making the ED the most readily available source of care (Guterman et al., 1985~. In addition to patients who come to the ED on their own, large numbers of primary care providers refer patients into the ED. Only a small share of children treated in the ED arrive via ambulance. Reports suggest about 5 to 10 percent (Fifield et al., 1984; Guterman et al., 1985; Pon et al., 1989; Yamamoto et al., l991b), although it may be less than 1 percent in some areas (Arkansas EMS-C Project, 19911. Among more seriously ill or injured children, the proportion is generally believed to be higher, but not necessarily equivalent to that for adults. In many set- tings, a large percentage of critically ill children who need hospitalization are brought directly to the ED by their families. Even among trauma center patients injured as pedestrians, 76 percent of the children were transported by ambulance compared with 90 percent of the adults (Derlet et al., 19891. Injury is typically the single most frequent condition treated in the ED, but illness accounts for the larger share overall (Fifield et al., 1984; Mayol

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RISKING OUR CHILDREN'S HEALTH 59 and Mora, 1989; Krauss et al., 1991; Nelson et al., 1992~. In the Boston area, a comparison between a children's hospital and a general ED found that injury accounted for 24 percent of the cases in the former but as much as 43 percent in the latter (Nelson et al., 1992~. Sprains and lacerations made up 64 percent of the injuries in the general ED; trauma requiring ho.spital~zation was less than 1 percent of cases in both settings. Upper respiratory infections accounted for 20 percent of the cases in the ch~ldren's hospital ED but only 8 percent in the general hospital. Elsewhere, a study conducted during summer months found that upper respiratory infection accounted for just 2 percent of ED cases (Fifield et al., 1984~. Behavioral and psychiatric emergencies place an additional burden on the emergency response system for children, particularly hospital EDs. Al- though experts recognize that these problems are growing in frequency and severity, the overall mental health resources (for all ages) have not kept pace; furthermore, the numbers of practitioners and inpatient facilities available in most locales to respond to these emergencies in children are a fraction of the resources available for adults. Thus, children with acute behavioral emergencies are often kept in EDs and acute care inpatient facilities that may be ill-prepared to care properly for them. General Inpatient Settings Many have found that fewer than 10 percent of the children seen in general EDs require admission to the hospital (Fifield et al., 1984; Mayol and Mora, 1989; Arkansas EMS-C Project, 1991; Nelson et al., 1992), but the proportion of children admitted may be higher in some hospitals. Among children with injuries, fewer than 5 percent require inpatient care (Gallagher et al., 1984; Gofin et al., 1989; Rivara et al., 1989; Yamamoto et al., l991b). Overall, trauma accounts for about 15 percent of admissions from the ED (Weinberg, 1989; Peclet et al., 1990a; Nelson et al., 1992~. Some seriously ill or injured children are admitted directly to inpatient units without any preliminary care in the ED. As noted earlier, motor vehicle crashes, falls, and burns (which include fire and scalding) are among the more common causes of injuries that re- quire hospitalization (Runyan et al., 1985; MacKenzie et al., 1990a; Peclet et al., 1990a). Translated into anatomic and physiologic terms, musculo- skeletal injuries and head injuries account for large numbers of trauma- related hospitalizations (Gallagher et al., 1984; Runyan et al., 1985; MacKenzie et al., 1990a; Cooper et al., 19921. About 60 percent of children treated in one trauma center after injury as pedestrians were admitted (Derlet et al., 19891. Among a group of seriously injured trauma patients (who were admitted, transferred, or died), 70 percent were admitted and 18 percent were transferred (Seidel et al., 1984J.

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60 EMERGENCY MEDICAL SERVICES FOR CHILDREN Admission rates for illness differ somewhat from those for injury. Among the most seriously ill patients seen at one group of general hospitals, 59 percent were admitted and another 5 percent were transferred to another hospital (Fifield et al., 1984~. Admission rates are also high for specific conditions: 45 percent of the children with chronic diseases (e.g., hemo- ph~l~a' s~cl~le-cell dBase cystic fibrosis) (Nelson et al-, 1992) Ed about AS percent of pediatric ED asthma cases (Canny et al., 1989; Krauss et al., 1991~. Community-specific factors other than illness per se can affect hospi- talization rates: variations in the practice patterns of physicians, the avail- ability of primary care, and general socioeconomic characteristics of the localities. A comparison of hospitalization rates for children among Bos- ton, New Haven, and Rochester (New York) found that, in general, children in Boston were hospitalized for illness at least twice as frequently as chil- dren in Rochester and as much as five times more often for conditions such as otitis media and upper respiratory infections, croup, and toxic ingestions (Perrin et al., 1989~. For other conditions that are generally regarded as requiring hospital care bacterial meningitis, fracture of the femur, and appendicitis the three cities had similar discharge rates. Some surgical procedures were, however, more frequent in Rochester than in the other two cities. The authors of the study argue that these differences reflect struc- tural and socioeconomic factors more than real differences in the health of children in these cities (Perrin et al., 1989~. Intensive or Specialized Inpatient Care For most of the children admitted to the hospital on an emergency basis, general inpatient care is adequate. The most critically ill or injured children, however, require the specialized care available in pediatric ICUs (PICUs); they generally represent less than 1 percent of children seen in the ED (Kissoon and Walia, 1989; Weinberg, 1989~. The Pediatric Intensive Care Network of Northern and Central California has found for their service area that about 240 children per 100,000 will require intensive care each year (Pettigrew et al., 1986~. Illness, led by respiratory disorders, predomi- nates in PICU admissions; as with overall admissions from the ED, only 15 to 20 percent of these children suffer from serious trauma (Pollack et al., 1988a; Kissoon and Walia, 1989; Weinberg, 1989~. Pediatric trauma centers (PTCs), with specialized services and skilled surgical teams for care of seriously injured children, have begun to develop as part of regional trauma systems (Hailer and Beaver, 1989~. Recent stud- ies have begun to demonstrate that care in PTCs and PICUs leads to im- proved survival for seriously injured children (Pollack et al., 1991; Nakayama et al., 1992; Cooper et al., 1993~. Distinctions between PTCs and PICUs

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RISKING OUR CHILDREN'S HEALTH 61 should not obscure the need for skilled medical and surgical resources to provide the best care for all seriously ill or injured children (Ramenofsky, 1989b; Weinberg, 1989~. Rehabilitation Services Most children make a good recovery from injury and illness, but as has been noted, some survive with impairments of varying degrees of severity that affect their ability to function physically or mentally. Brain and spinal cord injuries, in particular, can lead to permanent loss of functional capaci- ties. For some children, access to rehabilitation services can reduce long- term morbidity and disability, but such services are not always available and may not be affordable (Bush, 1989; Quint, 1992~. Data from the NPTR show that in only 1.5 percent of the registered cases were children placed in inpatient rehabilitation following their discharge from the hospital (Osberg et al., 1990~. Among children with four or more disabilities, about 31 percent were placed in inpatient rehabilitation on discharge. Children who were not treated in major trauma centers or in centers with a rehabilitation program were significantly less likely to be discharged to such a program (Osberg et al., 1990~. COSTS OF INJURY AND ILLNESS Injury Most assessments of financial costs of emergency care have focused on injury. Estimates for 1985 suggest that injury to children under age 15 generated lifetime costs of $13.8 billion, of which $5.8 billion was for direct costs of medical care and the remaining $8 billion for long-term costs associated with mortality and morbidity (Rice et al., 1989~. For 15- to 24- year-olds, the total cost was substantially higher $39.1 billion, with only $8.9 billion going for direct cost of medical care. Motor vehicle crashes accounted for the largest share: $4.1 billion for children under age 15 and $16.1 billion for the 15- to 24-year-olds (Rice et al., 1989~. The initial cost of ED care for the many injured children who are treated without hospital- ization has been estimated at about $2.5 billion per year (1987 dollars) (Malek et al., 1991~. The greatest costs per injured person are apparently associated with firearm injuries among children under age 5 ($108,386) and with drowning and near-drowning among children and young people age 5 to 24 ($159,021 for ages 5 to 14, and $351,406 for ages 15 to 24) (Rice et al., 1989~. Other

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62 EMERGENCY MEDICAL SERVICES FOR CHILDREN estimates of the cost of only initial hospital care have found burns to be the most costly on a per-person basis (Peclet et al., 1990a; Malek et al., 1991~. In 1985, the trauma component of unintentional injury accounted for 266,248 hospitalizations among children under age 15, about 85 percent of hospitalizations for injury of any kind to children of those apes (Rice et al.. 1989; MacKenzie et al.. 1990a71. The hospital charges for these patients were about $g46 million. About ~ percent of children admitted -~or-trauma were judged to have needed advanced trauma care;8 these children ac- counted for 21 percent of hospital charges for children (MacKenzie et al., 1990b). Overall, children under age 15 comprised 13 percent of trauma hospitalizations and incurred about 8 percent of the charges (MacKenzie et al., 1990b). Illness As implied by the discussion just above, data on the direct and indirect financial costs of emergencies and emergency care for children suffering injuries are neither especially timely nor complete. The situation for cost information about illnesses is even worse. (The present inadequacy of financial information is sufficiently great that the collection and analysis of such data receive high priority in the committee's recommendations for planning, evaluation, and research in Chapter 7.) Asthma is one major illness for which costs have been estimated. An- nual direct and indirect costs for children under age 18, excluding medica- tions, amounted to $1.3 billion in 1985, about 28 percent of the total of $4.5 billion for patients of all ages (Weiss et al., 1992~. The direct-cost compo- nent, which includes hospital and outpatient care plus physicians' fees, was estimated at about $465 million. The cost of ED care for children (about $90 million) was 45 percent of total ED costs, probably reflecting a greater reliance on care in that setting than on inpatient care. Nonmonetary Costs Costs are most easily measured in monetary terms, but substantial nonmonetary costs are also incurred (Harris et al., 1989; Malek et al., 1991~. Children experience pain, discomfort, and distress even for relatively minor injury and illness. The lives of their parents and families are also disrupted with psychological stress, loss of work time, and often new or increased child care requirements. Loss of school time or need for special schooling for the ill or injured child pose yet other challenges for all family members. Even when a child's physical recovery is complete, achieving emotional recovery may require continued care for the child and the family (Walsh, 19931. The more serious the condition, the greater are these physical and

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RISKING OUR CHILDREN'S HEALTH 63 psychological costs. Virtually no quantitative information on these aspects of emergencies in children is available. SUMMARY Injury and illness can pose serious threats to life and health that call for emergency care. In i988, about 21,000 children under the age of -~0 flied from injuries; additional deaths occurred as a result of acute illness. Hun- dreds of thousands more children were hospitalized, and millions visited EDs. Appropriate care should be available to children of all ages infants, toddlers and preschoolers, schoolchildren, and adolescents-and for all emer- gencies. To provide that care, EMS-C includes prevention; prehospital ser- vices; hospital EDs, ICUs, and other inpatient settings; and rehabilitation. Links with and return to the primary care environment are especially impor- tant. Ensuring that children receive the best emergency care possible requires modification of adult-based care to accommodate the unique anatomic and physiologic characteristics of children, their behavioral and emotional de- velopment, and the specific disorders and injuries they suffer. Recognizing and treating severe illness or injury in children can be especially difficult for those emergency care providers who have had little experience with children as patients or limited training in caring for them. Children with chronic illness or other special health care needs may require more and more specialized emergency care than other children. Serious gaps exist in the epidemiologic information about pediatric emer- gencies, but some patterns seem clear. Injury is the leading cause of death among children over the age of 1; infants are at risk as well. At least 20 times more children are hospitalized for injury than die, and even larger numbers of children are successfully treated in the ED on an outpatient basis. Nationally, motor vehicle-related injuries account for the largest number of deaths, but in some states drowning and burns are more deadly, especially among younger children. Homicide and suicide are more fre- quent among adolescents than among younger children, but child abuse is a particular threat to children under 5. Illness is the leading cause of ED department admissions to PICUs, particularly for conditions such as respiratory distress, severe dehydration, or infections affecting the brain. Chronic conditions such as asthma may require repeated episodes of emergency care. Among adolescent girls, pregnancy- related conditions may require emergency care. Psychiatric or behavioral emergencies are a particular concern in view of the increasing rates of major depression in the adolescent age group and the underlying elements of these problems (e.g., preventable behaviors and social-environmental con- ditions).

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64 EMERGENCY MEDICAL SERVICES FOR CHILDREN Violence, in various forms, poses a serious threat to the health of chil- dren and adolescents, particularly with increased use of firearms. Children who witness violence may suffer emotional wounds even without physical ones. Children receive emergency care in many settings. They appear to make up about 10 percent of patients receiving prehospita1 services and between 20 and 40 percent of patients In general EDs. The most ser~ousI~ ill and injured children may require care in pediatric specialty centers and access to rehabilitation services. Office-based practices also encounter children requiring emergency care, but studies suggest that many offices may not be adequately prepared to provide the immediate care that those children need. Lifetime costs associated with injury have been estimated at $13.8 bil- lion for children under age 15 and $39.1 billion for 15- to 24-year-olds. Asthma is one of the few major illness for which costs have been estimated: annual direct and indirect costs for children under age 18, excluding medi- cations' amounted to $1.3 billion in 1985. Beyond the monetary costs of illness and injury are significant costs for children in pain, discomfort, and distress even for relatively minor injury and illness. The distress extends to parents and families. NOTES 1. External cause-of-injury codes (which identify the mechanism of injury) from the ICD-9- CM system include E800-E949 for unintentional injuries, E950-E959 for suicide, and E960- E969 for homicide. 2. The Injury Fact Book (Baker et al., 1992) provides a comprehensive overview of patterns of morbidity and mortality for leading causes of injury by age, sex, race, income, and resi- dence. Detailed data on state-specific injury patterns are available in Childhood Injury: State- by-State Mortality Facts (Baker and Wailer, 1989). 3. In this report, recorded deaths from child abuse and neglect are those identified as having an underlying cause attributed to ICD-9-CM codes E904.0, E968.4, or E967. Although child abuse and neglect are commonly viewed as actions by caretakers, some advocate a broader concept of "maltreatment" that would include any behavior by any person that poses a substan- tial risk of physical or emotional harm to a child (NICHD, 1992). Thus, all homicides and assaults and many unintentional injuries (e.g., due to reckless driving) could be considered child maltreatment. A report to be released in 1993 by a National Research Council panel will address the subject of child abuse and neglect in much greater detail (NRC, forthcoming). 4. Hospitalization data from the National Hospital Discharge Survey are based on reviews of a sample of patient records from hospitals within the survey's sampling units. An alterna- tive estimate of injury hospitalizations, 600,000 in 1985 for children ages 0 to 19, is derived from applying hospitalization rates observed in a Massachusetts injury surveillance program to the national population (Guyer and Ellers, 1990). 5. In studying long-term disability among injured children, Wesson et al. (1989) defined disability as inability to perform age-appropriate physical activities as determined through questions based on instruments developed by the RAND Corporation's Health Insurance Ex- periment (citing Eisen et al., 1980). 6. Sudden infant death syndrome has been defined by tale National Institute of Child Health

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RISKING OUR CHILDREN'S HEALTH 65 and Human Development as the sudden death of an infant under one year of age that remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history (Willinger et al., 1991) 7. Excluded from traumatic injury in one analysis were drowning, suffocation, injuries asso- ciated with foreign bodies (ICD-9-CM 930-939), complications of injury, and late effects of injury (MacKenzie et al., 1990a). 8. In the analysis by MacKenzie et al. (199Ob), the need for trauma center care was deter- mir~d on the bas~s of ~ child's ~e, the r~ature of the ~' and this Morley of the injury measured by the number of body systems injured and the score on the Abbreviated Injury Scale. Advanced trauma care was defined as that available at a Level I or Level II trauma center.