By Chettie Greer, RN
Pediatric readiness in the prehospital setting is getting more attention these days as the EMS for Children Prehospital Pediatric Readiness Project (PPRP) begins to share the results of the 2024 PPRP Assessment. This assessment had participation from 7,000 EMS and fire rescue agencies nationwide. The results of this assessment will help guide EMS agencies to be more prepared than ever to care for children.
| MORE: From data to action: How EMS leaders are closing the equity gap
The realities of rural EMS
North Dakota has over 200 EMS agencies statewide, including air medical and quick response unit crews who do not transport. But with a population fewer than 800,000 spread across over 70,000 square miles, response and transport times can be long. In North Dakota’s rural communities, EMS practitioners face unique challenges compared to urban service agencies. North Dakota EMS for Children (EMSC) wanted to help agencies better prepare for pediatric responses, which required establishing a baseline of care.
Data-driven discovery
In 2024, North Dakota EMSC, which is housed within the North Dakota Department of Health and Human Services (NDHHS), partnered with ESO to create a statewide assessment of pediatric prehospital readiness that reflected North Dakota’s unique EMS challenges. The resulting study used ambulance run ticket data to evaluate pediatric care across the state and identify the top five reasons EMS is called to respond to a pediatric patient. The top reason was “other symptoms and signs involving emotional state” and the fifth reason was “anxiety disorder, unspecified” [1].
That inspired North Dakota EMSC and ESO to further research to investigate just how many calls were for suicide or self-harm. Antonio R. Fernandez, PhD, and his team at ESO completed a retrospective observation study for the calendar years of 2022-2024 in a research poster titled, “Quantifying and describing pediatric patients who received emergency care from North Dakota EMS for suicide or self-harm” [2]. The results were surprising.
The study period examined 11,245 pediatric 911 emergency responses, of which 4% (n=488) were for suicide or self-harm. Over the study period, researchers observed a 42% increase in pediatric 911 responses for suicide/self-harm, while the total 911 pediatric responses only increased by 14%.
Perhaps the most sobering statistic revealed was that one in 25 pediatric 911 emergency responses were for suicide or self-harm. The majority of those calls were for female patients aged 8 to 17. The study also found that for every year a patient aged, the odds of requiring EMS for suicide or self-harm increased 27%. The toughest thing to realize was that 36 pediatric patients during the study period required resuscitation procedures performed by EMS.
From research to response: Equipping EMS for pediatric care
North Dakota EMSC shared these findings with the NDHHS Behavioral Health Division and, together, created a plan to equip EMS agencies with more tools and resources to care for pediatric patients. Starting in late summer 2025, EMS agencies will be provided with:
- 988 Suicide and Crisis Lifeline cards to leave at the scene
- Mindful activities for patients being transported to higher levels of psychiatric care such as focused breathing, finger tracing cards and grounding exercises that engage the five senses
- Tearable notepads with the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS) that EMS can use to identify someone at risk for suicide, determine the severity and gauge the level of support needed
- Education opportunities about pediatric suicide and self-harm, including scripting and dialogue prompts for talking with pediatric patients and caregivers following a suicide attempt, suicidal thoughts or in the event of a crisis
For pediatric patients whose guardians refuse transport, responders will leave a packet of mental health resources at the scene, which includes a list of local mental health professionals for potential follow-up care along with resources from Parents Lead, a program within NDHHS that equips parents and caregivers with tools to support them in promoting their child’s behavioral health.
Discussions are ongoing to request 911 dispatchers ask questions regarding the last hospital discharge for a mental health issue. North Dakota EMSC is also working with ESO to add a drop-down menu to chart if the patient was hospitalized in the past 48-72 hours, as recent discharge after a mental health issue raises the risk of suicide, and to add a charting option asking if the Columbia protocol was used with the subsequent risk evaluation for the patient.
This study also emphasized the importance of charting. The records analyzed in the study included documentation of either ICD10 codes of suicide or self-harm — either the impression field or in the cause-of-injury field. The research shows the potential for — and impact of — missed or incomplete records that do not include these codes.
For example, if the patient had an intentional injury using a motor vehicle, but the incident at the time was documented as a motor vehicle collision, a self-harm or suicide event code likely wouldn’t have been included.
Beyond the call: Supporting providers in rural communities
The close-knit nature of North Dakota’s rural communities means EMS providers frequently respond to calls involving people they know personally — friends, coworkers, neighbors and community members — creating an additional emotional burden to an already challenging situation.
In addition to the North Dakota Critical Incident Stress Management (CISM) program, North Dakota EMSC, with the help of NDHHS Behavioral Health, developed guided writing journals for emergency professionals who need support after experiencing a traumatic pediatric call. It is a start in the battle against EMS burnout, but it is not enough.
There are more questions than answers regarding pediatric mental health and EMS.
- Are EMS professionals the right people to transport a stable pediatric patient to a higher level of care?
- What role should community paramedics play in pediatric mental health?
- Why did the number of pediatric suicide and self-harm incidents increase in North Dakota?
- What will it take to stop the heartache of losing children to suicide?
With time and access to additional research, we hope to answer those questions to benefit both patients and providers, before we lose any more of either.
Share your experience
Has your agency implemented any changes to how your respond to pediatric mental health calls? Share your strategies and resources. Fill out the form below.
REFERENCES
- Chettie Greer, Christopher T.E. Price, Christine K. Greff, Alison Treichel, Remle P. Crowe, J. Brent Myers, Jennifer K. Wilson, Christopher Montera, Antonio R. Fernandez. A Statewide Evaluation of Pediatric Care in North Dakota. NASEMSO Annual Meeting 2024.
- Chettie Greer, Christopher T.E. Price, Mary Waldo, Alison Treichel, Remle P. Crowe, J. Brent Myers, Jennifer K. Wilson, Christopher Montera, Antonio R. Fernandez. A Statewide Evaluation of Pediatric Care in North Dakota. NASEMSO Annual Meeting 2025.
ABOUT THE AUTHOR
Chettie Greer is a registered nurse with 19 years of experience in emergency medicine. She currently serves as program manager for the North Dakota EMS for Children State Partnership Program, where she works to strengthen emergency systems and training protocols for pediatric care across the state.
Her clinical background includes work in critical access hospitals and level two trauma centers, focusing on acute and trauma care. She is a certified instructor in both the Trauma Nursing Core Course (TNCC) and Pediatric Education for Pre-hospital Professionals (PEPP), training healthcare providers in emergency response.
