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Pediatric critical care physician Kyle Willsey discusses his article, “When every second counts: the evolving challenges of pediatric transport.” He shares the high-stakes realities of transporting critically ill children, from his experience stabilizing a severely injured toddler during fellowship to his current role in building a pediatric transport team from the ground up. Kyle highlights the lack of standardization in pediatric transport medicine, the financial barriers to maintaining specialized teams, and the need for high-fidelity simulation training. He also explores how shrinking pediatric inpatient resources make efficient transport systems more essential than ever. Tune in for a deep dive into the evolving challenges of pediatric transport and what it takes to save lives when every second counts.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Kyle Wilsey. He’s a pediatric critical care physician. Today’s KevinMD article is “When every second counts: the evolving challenges of pediatric transport.” Kyle, welcome to the show.

Kyle Wilsey: Thank you for having me. I appreciate it.

Kevin Pho: All right, so briefly tell us about yourself and then the KevinMD article that you wrote for those who didn’t get a chance to read it yet.

Kyle Wilsey: Sure. Thanks for having me. My name is Kyle Wilsey. I’m one of the pediatric critical care physicians at Cedars-Sinai Medical Center. I’ve been in this role for five years now and am happy to continue to grow our transport program. Our unit is an interesting mix of both pediatric general critical care and cardiac intensive care, so we get a whole smattering of things in our unit.

Kevin Pho: All right, so what got you interested in pediatric transport in particular, and then talk about the article. You know…

Kyle Wilsey: At one point, it kind of just fell into my lap, and then as I delved into the intricacies of bringing an ICU to a patient rather than them coming to us, I was like, this is really interesting. This is really cool. There’s a lot of procedures at that intensity. It’s that unknown that really drew me into the position. And on top of that, I’m a big, passionate person for education and providing that kind of knowledge and bridging the gap between your bedside caretakers and your physicians. So it’s really just naturally fallen into something I’m truly passionate about.

As far as how I came up with this article, the interesting part about my job and my current role is that this is a brand-new team starting from scratch, and that’s a little interesting in the current world of pediatrics and critical care in general. Most transport teams that already exist have been around for at least a decade, if not longer, and we’re talking about major, standalone tertiary or quaternary children’s hospitals. So we’re kind of a diamond in the rough in the middle of several diamonds around us, trying to figure out how to get our footing.

As I developed our team, the biggest challenge was that while I had mentors to look to, I was still building from nothing. When I asked those mentors how they started their teams, I always heard the same thing: “Well, what do you mean how I started it? I got handed this role. I don’t know how it started.” That’s how long these teams have typically been around. So I really had to set the pace for my team and learn as they did it. Not to say I didn’t have mentorship, but that’s what drew me and made me want to share my experience with the world in that article.

Kevin Pho: Sure. So to get everyone on the same page, what exactly are we talking about when we talk about pediatric transport, and what are some of the challenges that make it unique in contrast to adult transport?

Kyle Wilsey: The mantra within pediatrics has always been that these aren’t little adults, and it’s true to a very large extent. It’s not uncommon for us to get a call from an ER that may only see a tenth of the volume as pediatrics, and most of those patients that come into ERs are usually OK to get discharged. But then you have that small subset that needs to be admitted, and then you have that even smaller subset of patients that really need critical care—really need that extra TLC to get them across that gap of being sicker.

So you move that mindset to pediatric critical care transport, and it’s even more specialized. You have to be able to care for that entire age range of zero to eighteen months—and we can even include neonatal transport in here—and all the special diseases that go with it. It’s not just your standard respiratory care; you’re talking about congenital heart patients that you’re transporting, bringing an ICU to them, figuring out how to stabilize them. Our adult colleagues may just not have that same amount of experience with those sorts of things. These are specialized things, and having to fine-tune the medicines that we give—and the physiology, quite honestly, is a little bit different for every age range as you go up the ladder—really takes a specialized team. You’ll find that throughout the country, these are the most highly trained, multi-tooled teams you can send into the field. They are specialists among specialists among specialists, so they can be ready for any situation that comes to them.

Kevin Pho: In your article, you talk about a particular case that really piqued your interest in this whole area. For those who didn’t read your article, tell us about that case that was life changing for you.

Kyle Wilsey: It was in my final year of fellowship, and where I trained, the fellows would go out on those calls where they needed an MD in the field. I can remember arriving at this very, very small ER, and—without getting too far into the weeds—this kid had unfortunately been in a car accident and had pretty severe internal wounds. If you look at trauma data about the mechanism of injury, which he suffered by being ejected from the car, unfortunately, the survivability is usually pretty low.

Anyway, they arrived, and this kid had had multiple invasive, trauma-based procedures just to try to resuscitate him. Lo and behold, they did, but resuscitation in pediatric critical care is only as good as the endpoint, and we’re talking about the long end of the game. Unfortunately, this child ended up succumbing to his injuries. But being there, in the trenches for a literal twelve hours, with that hospital anesthesiologist, their trauma surgeon, their ER doc, on the phone with my medical command officer, trying to get this kid stable enough to get from one point to the next, was really eye-opening, because that’s the highest echelon of critical care that you can really do, other than providing something like ECMO.

Kevin Pho: One of the things you talk about in your article is the lack of national standards when it comes to pediatric transport. Tell us the extent of this issue and why that matters.

Kyle Wilsey: Again, as part of my role matriculating into this, I’m making sure my teams remain competent, following—hopefully—national NHTSA safety standards, and all that. And lo and behold, I found that these don’t really exist. EMS sets very regional-based standards, and then you go up the chain to regional and national-based safety standards, but it really doesn’t set the bar for a pediatric critical care transport team.

So the resources for trying to figure out what my team needs, how to create a training and didactic program, how to set competencies for certain procedures that they can do in the field that RNs and RTs can do, is challenging. The AAP does have a very detailed manual, and it’s a great resource, don’t get me wrong, but even they kind of say, “Hey, there’s no national standards for this; we all just kind of set the tone among each other by communicating,” which is probably the best thing we can do at this point. But the needs of a pediatric critical care transport team all depend on the system in which you serve.

For example, I’m centered in L.A. We have multiple pediatric critical care transport teams here locally, so it’s a bit easier to grab those patients, versus a team that might be located in rural Kentucky, which is going to have a much wider catchment range, a wider breadth of skills, and farther distances to travel. All of those things really boil down to having to train your team to what your hospital is going to be attuned to picking up on. That can be a bit of a moving target, especially as seasons change, respiratory viruses come and go, and that makes training a little bit difficult but all the more rewarding when you kind of get your stride.

Kevin Pho: So take us through the logistics of creating a pediatric transport team from scratch. So each major academic medical center that has a pediatric ICU has to come up with its own transport team to bring pediatric patients to them, these critically ill patients?

Kyle Wilsey: It’s not necessarily required. Typically, in your standalone, freestanding children’s hospitals, that’s going to be something that you want just to be able to go out and get kids. But starting from scratch is interesting. You’ve got to hire the right personnel and go through the hiring process, which means finding, hopefully, experienced, dedicated nurses. These are nurses solely fit to the role of transport. Then from there, looking for respiratory therapists who can also be ready and able to do intubations and take over airways in the field, which is something that as physicians and intensivists we’re much more used to doing—or having fellows do. I really have to get their skills sharpened, get that tool set attuned to almost thinking like a physician in a field where they’re used to having physician-ordered direction. So it’s really having to try to bridge that autonomy gap in providing care for kids like this. I think that’s the biggest challenge.

Kevin Pho: Now, this sounds, of course, like an expensive proposition. How do you balance some of the financial pressures that hospitals are facing with your wanting to create, of course, the best team you can assemble?

Kyle Wilsey: This is a bit of a stickler. It’s hard. Without getting too far into the political mire that we’re in right now, it’s difficult because you have to realize who is paying for this, right? Is it the center that pays for it? Do we accept some of the cost? Inevitably, we all share some of the cost. Do we rely solely on charging the health care plans or insurance companies? It does become a proposition of being expensive. You’ve got to have the overhead cost of hiring an RN and RT twenty-four hours a day, seven days a week. You’ve got to have a fleet of vehicles. Sometimes people use third-party EMTs so they can bring them in and out. If you have air transport, those are expensive costs you have to weigh in.

It’s also one of those things that is a community need. At some point, a hospital has to think, man, I know this is expensive, but if you want to help children, you have to have a team that can go out and grab them. Again, if you don’t have a critical care pediatric transport team, it’s going to be a third-party system that is usually used to adult care, and that can leave kids vulnerable.

Kevin Pho: Now that you’ve had this experience for five, six years, what have you learned in terms of advice you could share for other pediatric critical care physicians who may find themselves in similar positions and may need to either optimize or start a pediatric transport system from scratch?

Kyle Wilsey: One of my mentors, whom I work very closely with, always says it’s about scope and scale—scope and scale. We’re going to help whoever we can; it’s the calling of what we do. But you also have to respect the boundaries, not only of the realities of financial implications in medicine (it’s expensive to start these teams and maintain these teams, and it is a high time burden to educate and keep competencies up), but also, you haven’t touched on the fact that most of the time when you deploy one of these teams, it’s typically an RN and an RT. Seldom do you actually need an MD, but that’s another extra layer of cost, training, and comfort that you have to impose on your team.

So I would say scope and scale: understand your audience, understand your community, understand what their needs are, and go out and shake hands, meet the ERs, and ask them, what do you need? What can I do to help you? How can I help achieve that goal?

Kevin Pho: And in terms of the foreseeable future for your program—it’s relatively young, five years or so—what do you see as the continuing challenges of developing your own program?

Kyle Wilsey: Here locally, it’s competition. It’s a lot of competition. I don’t want to say that medicine should be a competition, but when you’re sandwiched between multiple children’s facilities in a large urban population, you certainly have many opportunities to pick up sick children. These are specialized centers, and even though it’s a highly populated region, it still doesn’t feel like there are enough beds, enough support, enough resources for children. So it’s really going to be a slow-growth process, and that’s what you want. You want that reliability. You want your community to be confident in your teams. You want them to be confident and excited when you come to the door and say, thank heavens they’re here; we can partner together and really help get these kids stabilized and get them to the centers they want. Slow and steady always wins the race.

Kevin Pho: We’re talking to Kyle Wilsey. He’s a pediatric critical care physician. Today’s KevinMD article is “When every second counts: the evolving challenges of pediatric transport.” Kyle, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Kyle Wilsey: I would just say kids remain one of the most vulnerable populations that we have the honor to serve in medicine. It’s become a passion, and if you ever have a passion for this, really look out to your community and see how you can help. That’s really how I became entrenched in figuring out transport medicine and started to become, hopefully, a local leader for myself in developing this further. If you ever have interest in it, go to your mentors and say, this is something we need, and I’m interested in it.

Kevin Pho: Kyle, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Kyle Wilsey: Of course. I appreciate it. Thanks so much for the opportunity.