As a Nobel Prize winning scientist, Daniel Kahneman gave us a deeper understanding of the human brain and how it makes critical decisions. The fascinating thing is that EMS providers must make decisions that are instantaneous.
Like the gearshift of an automatic engine, the decisions that providers make on every call, every day are smooth and effortless, and they are based on years of experience and pattern recognition. This is what Kahneman calls “System 1” thinking and it accounts for 95 percent of what we do in the pre-hospital setting. So what about the other five percent? That small sliver is much more complicated and uses a completely different part of the brain to arrive at an answer. Not surprisingly it is this rarely used portion of the brain that is required during most pediatric calls.
Take the following case for example and see where your brain takes you as you read through it.
A three-year-old boy has fallen off the monkey bars at daycare and is lying on the ground screaming in pain. You have been called to the scene and find a child in severe pain (10/10 FACES) with an isolated right elbow deformity. Distal pulses are intact and perfusion is unaltered. The child hasn’t been moved due to the pain and obvious deformity. You arrive on scene:
School Nurse: Can you please give him some pain medication!
You perform a complete history and physical exam and then prepare to provide an intranasal dose of fentanyl.
What is the dose for this child (as a volume)?
Human Factors Engineering
Human factors engineering is the discipline that attempts to identify and address issues such as described in the above case. It takes into account human strengths and limitations in the design of interactive systems that involve people, tools and technology, and work environments to ensure safety, effectiveness and ease of use. A human factors engineer focuses on how systems work in actual practice by examining a particular activity in terms of its component tasks, and then assesses the physical demands, skill demands, mental workload, team dynamics, aspects of the work environment — e.g., adequate lighting — limited noise, or other distractions — and device design required to complete the task optimally. The focus is how systems work in practice
In order to optimize safety and minimize medical errors in complex environments, human factors engineering utilizes the following techniques:
- Usability Testing
- Forcing Functions
- Resiliency Efforts
In pre-hospital emergency care, usability testing is critical in mitigating medical errors when also considering the situational elements providers need to address on scene. To be “user friendly” many roles must collide, starting with a designer and reaching the clinical team while still considering workflow. It may look good, but is it easy to use when time is critical and you are not in familiar surroundings?
Forcing functions demands that users complete a task based on a limited set of features or controls with the purpose to produce a certain result. Automated AEDs are great examples of nicely utilized forcing functions; this and standardization of protocols and procedures is imperative to decrease variability of treatment and improve quality of care.
Providers have become very adept at number four on the list: Resiliency efforts. Numerous adaptations have surfaced for pediatric dosing over the last three decades due to the inherent issues that exist but have not been formally addressed. We have been left with a hodgepodge of tools and devices to help providers achieve success. This would be okay for inconsequential things yet we are discussing medication dosing and safety for critically ill children.
There is a significant need for the medical community to join forces with the human factors engineers to continue to innovate for pediatrics specifically. Simple modifications will go a long way but will require that dogma to be challenged.
Let’s go back to the case. It may appear basic to a pre-hospital provider, yet drilling down into the details of what it takes to get the final dose may surprise you.
A three-year-old in severe pain needs a dose of fentanyl. What is the first thing you thought of when faced with this medication request?
Odds are you asked yourself, “What’s the weight of the child?” En route to the scene you still don’t know this answer. Current practice forces you to determine the length of the pediatric patient to determine the weight. Since this cannot be performed until arrival on scene, you have inadvertently set your brain on mission impossible. This is a perfect example of a human factors engineering failure.
What would you immediately think of if this were a 65-year-old who fell and needed fentanyl?
Hint: You’d know the dose as soon as you’re given the patient’s age.
Fentanyl = 100 mcg, or 2 mL IV
The Dichotomy – Adult Care
Adult emergency care, with respect to timing of decision-making and medication dosing, is starkly different than in pediatrics. In the treatment of the adult patient, the field provider initiates treatment decisions immediately, while en route to the scene. Upon arrival they immediately begin clinical care: CPR, Monitor attached/charged, IO placed and Epinephrine administered (10 mL of 0.1 mg/mL concentration – prefilled (1 amp).
The critical concepts that distinguish care for the adult are:
- Decision making begins once the provider knows the age
- Treatment known and well-rehearsed prior to arrival
- Medication dosages known prior to arrival
- No math required
- Confidence upon arrival to the scene
- No hurdles from the time of arrival to the provision of care
The Dichotomy – Pediatric
Let’s circle back to our three-year-old patient who is experiencing severe pain. We’ve already established that the provider is unable to determine dosing prior to arrival. Upon arrival they must lay the child flat to use a length-based tape. This is not always possible and it decreases the confidence factor, both for the paramedic, the parents and onlookers.
Providers who use a length-based tape with pre-listed medications are faced with another set of problems. First, they must determine the dose of medication required, in this case fentanyl. Unlike the adult case, in pediatrics they have two options: recall their protocol-dosing algorithm or use a dosing tool. Using the protocol from memory is tricky since different routes sometimes require different dosages and max amounts. Fentanyl is a perfect example since most protocols use a different intranasal (IN) dose compared to the IV dose. Using the length-based tape must be done with caution since the dose of fentanyl listed is not for pain control; rather it’s the premedication dose for RSI (rapid sequence induction).
15 kg x 1.5 mcg/kg = 22.5 mcg of fentanyl
This now must be converted to a volume by dividing the dose by the concentration of 100 mcg/2 mL.
Volume of fentanyl calculation for intranasal use:
22.5 mcg = 0.45 mL
Using Human Factors Engineering to Challenge Medical Dogma
Dogma-lysis — Challenge #1
Length based resuscitation is ideal for pediatrics.
Note: currently it is the standard of care
There is surely a need for the length-based tape, but with a minor caveat.
Using age-based treatment algorithms, similar to what we do for adults, address several components of the human factors engineering guiding principles.
- Providers can use the same mental pathway for decision making in both adult and pediatric patients and the six to eight minutes to the scene can be used efficiently to prepare mentally
- Medication dosing can be determined prior to arrival
- Confidence can be established prior to encounter with the patient
Dogma-lysis – Challenge #2
Pediatric medication dosing is one-size fits all
When dealing with the pediatric emergency, things move at a fast pace. Decisions are rapid fire and they often set in motion a series of other required steps.
The critical pediatric emergency is an entirely different entity than the less emergent case. The speed of the situation requires a customized medication list with pre-calculated volumes. There is no time for dosing considerations during the actual event.
It’s the American way. We customize everything from car features to pizza toppings — it’s time we customize the pediatric code room and every EMS agency. This human factors engineering step can have a tremendous impact on outcomes.
Dogma-lysis – Challenge #3
The Weight is the most important piece of information in Pediatric dosing
From day one, every pediatric intern is taught this golden rule. But is it true?
If we reverse engineer the pediatric code, the most important piece of information about a particular drug is the volume to be infused. If you could say the drug name, concentration and volume to be infused, life would be so simple. Starting with a weight only leads to a litany of other questions such as “what’s the dose per kg,” “what’s the concentration we have,” and ultimately a math equation is needed to produce the final volume. Starting with a weight is analogous to having one ingredient for a meal, whereas having the volume is akin to having the food ready to eat.
Dogma-lysis – Challenge #4
The physician knows all dosing information and equipment sizes
This is the single biggest myth in Pediatric emergency care.
Read the below exchange as an example of what occurs, even in the most prestigious pediatric hospitals.
Doctor: Start a Norepinephrine drip please.
Nurse: Sure, what dose should we start that at? (Likely next step – Look it up)
Nurse: How do we mix that? (Likely next step – Call pharmacy)
Nurse: What rate should the pump be at (Likely next step – Call pharmacy)
Doctor: Can I have a central line?
Nurse: What size would you like, double or triple lumen?
Doctor: Let’s load this child with Fosphenytoin please.
Nurse: How much does the child weigh?
Nurse: What is the dose per kilogram?
Nurse: Is this IV push? How fast can we give this?
Nurse: Fosphenytoin is packaged as 50 mgPE/mL — can I use this concentration or do I have to dilute it?
Doctor: I think you have to dilute it
Nurse: How do I do that? (Likely result – Call pharmacy).
Dogma-lysis – Challenge #5
Kids are not just little adults
It’s time to challenge this notion for the emergency care of the critically ill child.
The algorithms for adult and pediatric critical care are identical with the exception of symptomatic bradycardia. Pre-hospital providers, if given the medication dose in mLs prior to arrival on scene, can care for a pediatric patient as confidently and effectively as they do adults. It’s time to change the way we think about treating critically ill children in the field.
A Personal Mission and a Way Forward
As a practicing pediatric emergency medicine physician, it took me years to understand that positive clinical outcomes depended on the quality of the system rather than on the individual team members. I remember cases where we successfully resuscitated a child yet the nurses were still unhappy about how they felt everything went. Then, after our debrief I recall everyone saying, “That’s just the way it is — pediatrics is just difficult.”
I refused then, and refuse today to believe this. Over the past six years we have followed the principles of human factors engineering and have challenged each of the dogmatic teachings listed above. It has been our mission to challenge the status quo and reverse engineer the seemingly simple yet deceptively difficult task of administering medications to a critically ill child. Without any intention to start a business, an answer to a calling has led us to work with amazing change makers across this country to drastically improve outcomes for children.
Take for example the transformation that has occurred in Polk County, Florida who implemented the Handtevy System in January 2014. In the two years prior to implementation there were 38 pediatric arrests and no neurologically intact survivors. In the years since implementation they have responded to 83 pediatric arrests, of which 25 have survived neurologically intact. It is this type of data — which will be reported this year — that proves that Human Factors Engineering can have a significant impact on pediatric outcomes.
It is time to challenge the dogma and principles that have been taught for decades and investigate whether those assumptions provide the best foundation for improvement in quality and safety.