Caring for Children Before They Arrive at the Hospital

During pediatric residency Manish Shah, MD, MS, found he was most excited about caring for children in the emergency department (ED). After completing a fellowship in pediatric emergency medicine, Shah treated a wide variety of clinical conditions that touched on every body system, and cared for patients representative of a diverse population from all socioeconomic groups with varied language preferences, race/ethnicity backgrounds, and access to insurance or higher level of care.

Shah witnessed how healthcare disparities often hindered the management of injuries and illnesses in pediatric patients. For example, asthma disproportionately affects children of lower socioeconomic status, who suffer from limited access to care and face unhealthy living conditions that may exacerbate their illness.

In addition, children do not receive the same quality of prehospital care as adults. During his pediatric emergency medicine fellowship, Shah had an opportunity to teach paramedics. He learned that 90% of the patients emergency medical services (EMS) professionals encountered were adults. Faced with a pediatric patient experiencing a critical illness, they were less confident in providing care due to infrequent exposure to this patient population.

This realization fueled Shah’s commitment to address disparities in prehospital care from a policy perspective, through focused research, and by improving the evidence base for prehospital pediatric emergency care. Shah was drawn to Stanford’s Department of Emergency Medicine in part because several of the department’s faculty serve as medical directors for EMS agencies in many surrounding communities.

Shah is currently involved in two clinical trials for children in the prehospital setting. As principal investigator on the five-year study, Pediatric Dose Optimization for Seizures in Emergency Medical Services (PediDOSE), funded by the National Institute of Neurological Disorders and Stroke (NINDS), Shah and colleagues are focused on improving how paramedics dose midazolam for the treatment of status epilepticus during EMS care. The team is collaborating with EMS agencies in 20 different cities across the country to utilize a standardized protocol that employs age-based midazolam dosing, eliminating the need for paramedics to engage in error-prone calculations when determining the dose for each patient.

Shah is also a co-investigator and helped design the Pediatric Prehospital Airway Resuscitation Trial (Pedi-PART). Funded by the National Heart, Lung, and Blood Institute (NHLBI) and conducted in 10 metropolitan areas across the country, the study explores which airway management technique (e.g., mask ventilation; supraglottic devices, endotracheal intubation) contributes to the best outcomes for children experiencing respiratory failure from trauma, cardiac arrest, or undifferentiated illness. 

The biggest challenge Shah sees in pediatric emergency medicine is readiness in the ability of EMS systems and EDs to care for children across the entire emergency care continuum.

Shah chaired the American Academy of Pediatrics Section on Emergency Medicine’s subcommittee on EMS and now serves on the Steering Committee for the National Pediatric Prehospital Readiness Project (PPRP). He also co-led the PPRP workgroup that developed the first national assessment of pediatric readiness of EMS systems, scheduled to go live in 2024.