Tia Dickson, RN, BSN

Primary Children's Hospital

The world is full of special children. According to the Maternal and Child Health Bureau, children and youth with special health care needs (CYSHCN) are those who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions and also require health and related services of a type or amount beyond that required by children generally.

• An estimated 20% of U.S. children younger than 18, have special health care needs.
• One in five U.S. families have a CYSHCN.
• They often need services from multiple systems including EMS.

CYSHCN are often technologically assisted meaning they have medical devices and equipment to support bodily function. These can intimidate a responder. The most often devices seen during EMS calls are the following . . .

• Why would a child have this? It bypasses the oropharnyx, allowing for easier clearance of secretions. It maintains an open airway, and makes mechanical ventilation easier.
• In case of emergency: Emergencies often have to do with loss of patency. Your training for these should focus on how to suction, deliver oxygen, and bag through a trach. If completely blocked, you should know how to remove or change a trach and how to bag despite a blocked trach. See the videos below.

• Why would a child have this? A central line is a type of catheter placed in a large vein and allows multiple IV fluids or medications to be given and blood to be drawn. They also provide access for long-term nutritional support.
• In case of emergency: Do not use the line; establish a peripheral IV. If the line has been dislodged cover the site and hold pressure. If broken, do not remove. Clamp above the break and cover the hole/broken end with a sterile gauze.

• Why would a child have this? These catheters provide a route for nutritional support when the child is unable or unwilling to take food by mouth.
• In case of emergency: Emergency care for these may include site bleeding—hold pressure. A broken or leaking tube would be treated in the same way as a central line even though these tubes are not sterile. If pulled out, an NG/NJ needs to be replaced by a trained provider. A g-tube site will close quickly as stomach muscles contract so attempt to replace the tube. If it does not fit, insert a smaller catheter into the site as soon as possible. Tape it in place. This will hold open the site and allow for the MD to re-dilate and replace the tube in the ER. Parents often have a kit for this procedure (see below) but a small suction or foley catheter will do.

Remember that all our assessments start with the PAT and ABCs. Caring for CYSHCNs is no different. The parents of these children are your best resource!

Linda Niewender RN, MSN, CPN, CWOCN - reprint

G-Tube Dislodgement in School Children

Advances in medicine are resulting in larger numbers of children surviving previously fatal conditions. Some of these conditions limit the child’s ability to consume adequate nutrition orally. Increasingly, gastrostomy and/or enteric tubes are being placed to provide nutrition for these children. When a tube is inadvertently removed, the opening may shrink and the tract may close within hours.

Enterally-fed children entering the school systems create a dilemma for parents, teachers, nurses, and emergency personnel: What should be done when the child’s tube is dislodged at school? School nurses are able to replace tubes, but may not be at the child’s school when a tube is dislodged. Teachers however, are not trained in replacement of the tube, nor should they be expected to have this skill.

Children who have a G-tube placed at Primary Children’s Medical Center are provided with an emergency replacement kit, and parents are instructed to keep this with the child at all times. Parents are trained in the care and replacement of G-tubes, and most have provided this care for several years. Thus, they may have a difficult time understanding the apprehension of teachers to replace a tube.

If a tube is displaced at school, the school nurse should be contacted. In the event the nurse is unable to get to the school, the child’s parent should be contacted to come to the school and replace the tube or, if necessary, take the child to a clinic or the emergency department. Ambulance transport of a child to the hospital is not warranted. This is an urgent situation, not an emergency. The parent or school nurse is usually able to replace the tube when they arrive. Should the stoma be too narrow, the patient can then be transported to the clinic or emergency room by the parent, consequently avoiding the added expense of ambulance transfer.

In the event EMS is called to the school for a dislodged G-tube, the existing tube should be washed with soap and water, lubricant applied, and the tube reinserted into the stoma. It should then be secured in place with tape. If the existing tube has been lost or damaged, a catheter (contained in the child’s emergency replacement kit) may be inserted into the stoma and secured with tape. Parents can make any adjustments needed when they are available.

Learn about Children and Youth with Special Health Care Needs (CYSHCN) and resources to help them and their families.

The Utah Medical Home Portal (ut.medicalhomeportal.org) offers a wealth of information about kids with chronic and complex conditions, from asthma to autism, Rett syndrome to traumatic brain injury. The Portal’s 55 “diagnosis modules” provide detailed information aimed at primary care clinicians but useful for anyone caring for kids with these conditions. The For Physicians & Professionals section provides information about providing a Medical Home for kids and families, with detail about broader (and some narrower) issues.

The For Parents & Families section helps users understand the many aspects of raising, educating, and supporting kids with chronic conditions and/or disabilities. These include working with health care providers, educators, and others, finding valuable resources and funding care, using assistive technology, understanding legal rights and responsibilities, and keeping and sharing information about the child and their needs.

The Portal’s Utah Services Directory provides information about more than 4,300 providers of local clinical and human/social services relevant to kids and their families. Please visit the Portal to see what information we offer and consider how it might be useful in your work. We welcome your feedback and ideas on how to improve what the Portal offers. Thanks.

Sarah Becker, DO

Assistant Professor of Pediatrics, University of Utah School of Medicine

The Utah EMS for Children (EMSC) team is working on a grant to improve telehealth access to children and youth with special health care needs (CYSHCN) in rural Utah. This project, in collaboration with the federal EMSC program and the EMSC Innovation and Improvement Center, seeks to perform a thorough needs assessment of CYSHCN in San Juan County and the Utah strip of the Navajo Nation. By getting an accurate picture of the medical landscape for these children, we can target ways to deliver telehealth care to them that is high quality, accessible to all families, and technically sound.

In our first phase we have launched a robust needs assessment to develop a better understanding of regional needs, population demographics, and barriers. We are currently waiting for our respondents.

Our end goal is to use the telehealth structure that already exists in local clinics and/or hospitals to coordinate pediatric specialist consultation, medical management of complex patients, and reinforce relationships already established in medical homes. We want to improve medical access for this special population.

We are happy to announce that the Handtevy App purchase is DONE!

Special thanks to Cydney Greenhalgh, the ED Director and EMSC contract manager from Primary Children's for helping us get through the red tape!

Next Steps: Your agency leadership will be contacted via email by the Handtevy team. Once they respond and customize your app, it will be immediately active. Handtevy is ready! They have been working for months to ensure a smooth roll out in Utah.

Encourage your agency leadership to respond. IT'S FREE! We think this app will change and improve the way we care for pediatric patients. Please give it a hard try! Contact our program manager, Mark MarkHerrera@utah.gov with any questions..

Agencies that would like an in-house Handtevy Instructor should consider our upcoming Handtevy Instructor Courses in May (SLC) and June (Carbon County). See events below for registration.

Want more information?

• Our January 11 PETOS topic was Handtevy. Those in attendance had an opportunity to use the demo and practice with the app.
• In September 2020, Dr. Peter Antevy and EMSC held a virtual demo to introduce the app. Follow this link https://register.gotowebinar.com/recording/4248070236387080459

As healthcare providers, please encourage your community members to be vaccinated. We are in a race between vaccination and variant proliferation.

COVID-19 vaccine for children may be available by fall.

Clinical trials are underway now for COVID-19 vaccines for children, and Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, told lawmakers during a hearing with the House Committee on Energy and Commerce last week, a vaccine will hopefully be available for adolescents by this fall and for younger children by early 2022. Here’s a status update on vaccine clinical trials:

• The Pfizer vaccine is now approved only for those 16 and older in the U.S., but Pfizer hopes to have the vaccine available to adolescents ages 12 to 15 by fall and children ages five and older by early 2022.
• Moderna is still enrolling participants in its vaccine trial for adolescents ages 12 to 18, and hopes to provide data sometime this summer. Moderna has also started trial enrollment for kids ages six months to younger than 12, but the company doesn’t expect clinical data until 2022.
• Johnson & Johnson plans to soon begin testing its vaccine in adolescents ages 12 to 18, and hopes to quickly expand the trial to younger children and pregnant women.
• The University of Oxford and AstraZeneca are testing their vaccine in U.K. children ages six to 17 in a phase II trial that began in February. A larger trial involving thousands of children is expected to follow in the U.S.

“Children need to be protected from the short- and long-term consequences of COVID-19,” says Andrew Pavia, MD, chief of pediatric infectious diseases at the University of Utah and Primary Children’s Hospital. “This is especially true for teenagers. Just because the proportion of children who die is much lower than among adults, they’re still seriously impacted by the virus. The long-term symptoms may end up having the most important impact on many young people.”

The prospect of vaccines for children is exciting, Dr. Pavia says. “Not only will vaccines allow kids to go back to a much more normal life, vaccines will greatly improve our ability to control the pandemic,” he says. “If the virus can spread unchecked in children, it can evolve and spread to more vulnerable people. Without vaccinating children and teenagers, it will be very hard to ultimately end the pandemic.”

Read more

(CNN)The first children have been vaccinated in Moderna's Phase 2/3 pediatric Covid-19 vaccine trial, the company announced Tuesday in a statement. The clinical trial, called the KidCOVE study, will enroll approximately 6,750 children in the US and Canada between the ages of six months and 11 years old.

Covid-19 Trackers

Johns Hopkins Global tracker (desktop)

Johns Hopkins Global tracker (mobile)

Utah Department of Health

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything related to pediatrics? Shoot an email to the following address tdickson@utah.gov.

Contact PCH EMS Liasion Lynsey Cooper at Lynsey.Cooper@imail.org

If you are a pediatric advocate within your agency, we need you. Please contact our program manager, Mark Herrera (markherrera@utah.gov) to find out how you can help.

Pediatric Education for the Prehospital Provider

Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth