1. Sean Rogoff, EMT-P REACH Air Medical Services

2. We will be available and prepared to provide customer-oriented, high-quality patient care, in a safe and efficient manner. In every situation, we will do what is right for the patient.

3. REACH’s goal is to get our pediatric trauma patients to definitive care rapidly and safely.

4.  Active local EMS Agency and local hospital involvement  Committed to building relationships with our primary sending and receiving facilities  OutREACH services and injury prevention activities  Volunteer staffing in non transport positions during sand season  Increased staffing during sand season to meet the needs of the community

5. It is not enough to do your best, you must prepare to be your best.  REACH exceeds EMSC standards for pediatric equipment and training.  Dedicated pediatric clinical educators and pediatric intensivist on staff.  Relationships with pediatric tertiary care facilities to allow for clinical rotations and collaborative CQI.

6.  Focus is on rapid primary assessment to identify life threatening injuries.  Perform only the care that must occur on scene prior to loading in the aircraft.  Most patient care is provided while en-route to the pediatric trauma center.

7. Case Study Pediatric MVC

8.  19:48 - REACH 9 dispatched for a pedestrian struck ◦ EC-135 helicopter staffed with Flight RN and Flight Paramedic  Patient transported directly to REACH 9 base at Imperial County Airport via ALS ambulance  19:57 - Patient contact made  2-year-old ◦ Average-sized female patient  13 kg ◦ Broselow tape utilized

9.  Patient was standing behind family pick-up truck when mother backed vehicle, striking patient with rear bumper at low speed  Witnesses initially reported to EMS that patient was not run over; however, it was discovered later that the patient did in fact go under the rear tire of the truck  Patient sustained closed head injury, presented with bleeding from left ear, positive for CSF, no other injuries noted

10.  Ground paramedic at scene initiated full c-spine precautions and obtained intravenous access x 2 (22 gauge)  Initial contact with flight crew ◦ Patient conscious but disoriented ◦ GCS = 7 ( Eyes = 2, Verbal = 1, Motor = 4) ◦ Revised Trauma Score = 10 ( RR = 30, SBP = 121, GCS = 7) ◦ Pupils equal, round and reactive to light ◦ BP 128/79, HR 132, RR 30, SPO2 99% ◦ Spontaneous respirations

11.  Base hospital contact was initiated with El Centro Regional Medical Center  Flight crew directed to transport patient to Rady Children’s Hospital in San Diego (all critical pediatric trauma patients are directed out of county)  At 20:28 - REACH 9 lifted with approximately 50 min flight time

12.  At 20:55 - approximately 20 minutes out from Rady, patient noted to have unequal pupils and described as “obtunded”  Patient condition: ◦ BP 105/73, RR 24, HR 125, SPO2 99% ◦ GCS = 6 (Eyes = 1, Verbal = 1, Motor = 4) ◦ R pupil = 2 mm, L pupil = 4 mm  Flight crew made decision to intubate patient in flight to protect patient airway due to change in LOC  Patient pre-medicated with lidocaine and atropine intravenously, per REACH medical protocol

13.  21:01 - RSI procedure initiated ◦ Amidate (e tomidate) and succinylcholine chloride administered intravenously ◦ Patient intubated with 4.0 mm cuffed ETT ◦ ETT confirmed (vocal cords visualized during placement, CO 2 detector with positive color change, condensation in tube, and end tidal CO 2 with opening value of 38 mm Hg noted)  Post RSI medication: ◦ Norcuron (vecuronium bromide) and Midazolam (v ersed)

14.  Patient not placed on ventilator due to aircraft on final approach to Rady at time of procedure completion  Patient manually bagged with good compliance ◦ SPO 2 = 99%  21:23 - Patient transferred to Rady trauma team  Transfer of care vital signs: ◦ BP 122/84, RR 28, HR 128, SPO2 99%, EtCO 2 39 mm Hg

15. Critical success factors in managing pediatric trauma:  Community involvement  Focus on preparation  Rapid transport to definitive care  Collaboration with tertiary care facilities  Commitment to continuous quality improvement