Patients filled the treatment areas and stretchers lined the hallways of the fictional County General Hospital as Dr. Peter Benton and Nurse Abby Lockhart responded to a pediatric patient in respiratory distress in the Season 7, Episode 5 of NBC’s medical drama “ER” which aired on Nov. 8, 2000.
| WEBINAR: The command blueprint: Build the system, lead the fireground
The episode, “Fight of Fancy,” left Benton, played by Eriq La Salle, in charge of an overcrowded and understaffed emergency department. Lockhart, a former NICU nurse, was with Benton when an infant was brought to the ED with respiratory distress. The two determined that the infant needed to be intubated. Lockhart’s only experience with pediatric intubation was in the NICU and Benton’s experience was limited to the adult population. He immediately requested the assistance of Dr. Cleo Finch, played by Michael Michele, an emergency resident with a specialty in pediatrics.
As Finch entered the trauma room to a quick report from Benton explaining that he can’t get the infant intubated, Finch fired back, “because you have the wrong sized tube and the wrong sized equipment. That’s what the Broselow Tape is for.” Pulling a colorful tape from her lab coat pocket, she measured from the infant’s head to the toes, and with a calm, but direct voice, immediately began providing instruction to staff on medication dosing and equipment sizing.
This would be the first time I had seen such a device used to treat pediatric patients. My career began in a rural community where at times, ALS resources weren’t available, or they had an extended ETA to the scene.
I was fascinated with an aid that could quickly assist clinicians with medical dosages, equipment sizing and the joules setting for defibrillation. I had only witnessed clinicians calculate each of these individually, taking away valuable time needed to evaluate and begin treatment of a critically ill child.
How the Broselow tape works and its limitations
The Broselow Tape is a color-coded length-based measure that is used across the globe for pediatric emergencies. The tape relates a child’s height as measured by the tape to their weight to provide medical direction, and is designed for children from newborn to 12-years-old with a maximum weight of 36 kg or 79 lbs.
The tape, designed in the mid-1980s by emergency physicians Dr. James Broselow and Dr. Robert Luten, is based on the relationship between weight and length. Each colored zone estimates the 50th percentile weight for length, estimating the ideal body weight. With pediatric obesity becoming more widely identified, the Broselow Tape may not be as accurate in modern times.
“Kids today are bigger than they used to be, and we know the Broselow is not super accurate,” Associate Maryland EMS Pediatric Medical Director, Dr. Jennifer Anders, notes. Anders, an associate professor of pediatrics at Johns Hopkins School of Medicine, added, “some guide to estimate weight is helpful. And using some sort of reference card, app or tape is better than doing math in the heat of a call.”
Amy Motz, a flight nurse at Children’s National Hospital in Washington, D.C., says that some type of reference should be the expectation.
“When I practiced in adult medicine, using a reference was looked upon as a weakness. When I transitioned to pediatrics, it was an expectation,” Motz, a registered nurse for 34 years (20 in pediatric critical care), said. “I am glad that I embraced that. Small variations in treatment can have a large implication with pediatrics.”
Motz says that the Broselow Tape is a great reference for providers that do not work with the pediatric population frequently enough to be proficient with estimating weights, “It is a tool to be utilized to obtain a weight in a high stress situation when obtaining a formal weight would prove to be a barrier. Its accuracy can be assumed but not guaranteed.”
Pediatric reference apps gaining traction
Unlike the 80s and 90s, when everyone carried a beeper or a black and white cellular phone with minimal features, today’s technology puts an array of applications at our fingertips.
A simple search of your phone’s app store returns many medical applications created by physicians, EMS professionals and institutions, like Children’s Hospital of Philadelphia and Children’s National.
“Children’s National Hospital has a reference app based either on weight or age to reference equipment sizes, standard/normal vital signs, medication dosages and situational suggestions that is open for download,” Motz said.
Motz added that her hospital also has an application (restricted from public download) that contains the facility-specific protocols, equipment trouble shooting and other references for Children’s National clinicians.
Handtevy and other modern pediatric tools
Dr. Sid Dante, an associate professor of pediatrics at the University of Maryland School of Medicine and associate medical director for the Division of Critical Care, and I discussed several options including the Handtevy method.
The Handtevy method uses both age and length for pediatric resuscitation decisions and allows clinicians to begin considering treatment decisions prior to patient contact by associating five ages with their corresponding weights in kilograms via a finger counting method on your hand.
Like a Broselow tape, this technique then allows clinicians to immediately pull the most appropriately sized equipment and drug dosing calculations from a color-coordinated bag.
Why consistent use of weight-based aids matters
Pediatric professionals agree: if you have a pediatric aid at your disposal, use it to prevent overdosing or underdosing children.
“In the state of Maryland, EMS for Children has created a weight estimating card that we distribute free to our clinicians in the state,” Anders said. “Lots of places use apps for this. Whatever you have, I recommend using it.”
“The best is an application specific for (your) organization; one that encompasses approved treatments and medication dosages that are within guidelines approved by (your) medical director,” Motz said.
Motz added that if the clinician’s organization does not have such a system in place, she encourages providers to search their phone’s app store, reiterating there are a number of apps on the market.
“The most useful tool will be one the provider is comfortable using and able to effectively maneuver through while obtaining their desired information,” she stressed.
