Tia Dickson, RN, BSN

Primary Children's Hospital

Many consider this topic divisive, political, or ethical. However, when you approach this from a medical standpoint, the objective is to educate providers in the health care and management of a child who may identify as transgender, or may be undergoing the treatments explained below. As medical providers, our duty is to treat these children professionally and with respect. We seek to create a safe space for all our patients. There are children who identify as transgender in Utah and they are being treated according to current medical recommendations and within the bounds of Utah law. They are occasionally transported in your ambulances. EMS personnel have raised questions we will address in this issue.

This is not an attempt to challenge your personal views. We will share medical information to enable you to care for your patients with compassion.

Transgender kids

Lucy Hansen MD, Division of Pediatric Emergency Medicine, Primary Children's Hospital &

Nancy Roth RN, BSN

Excerpts from April 10 PETOS

Understanding terms can build trust and help a patient feel validated.

• Anatomic sex: the biologic sex (anatomic male, anatomic female, some are born with intersex genitalia)
• Attraction: who you are attracted to romantically
• Identity: how you see yourself
• Expression: outward appearance that people see (the way you dress, behaviors, etc.)

These terms exist on a spectrum recognized by the medical community.

Assigned male/female at birth: the sex determined by genitalia at birth

Intersex: a medical term for a person born without clearly defined anatomic genitalia

Transgender male/boy: someone assigned female at birth who feels their identity is male

Transgender female/girl: someone assigned male at birth who feels their identity is female

Nonbinary: Someone who does not identify as male or female; they feel their identity falls outside traditional roles

Genderfluid: someone who believes their gender identity is not fixed

Pronouns: words used to describe a person in reference to their identity. She/her, they/them, he/him. Medical providers may ask, "What are your pronouns?"

Preferred or chosen name: how a person wants to be addressed. EMS may ask, "What would you like me to call you?"

Gender congruence: you feel your gender matches how you present yourself to the world

Gender dysphoria: your assigned sex at birth does not match your identity. This does not occur in all transgender youth but in those it does, doctors may suggest medical and psychiatric treatment and support.

Conversion therapy: A pseudoscientific practice of attempting to change an individual's sexual orientation, gender identity, or gender expression to align with heterosexual and cisgender norms. Evidence-based research indicates this practice is harmful, especially to children.

1. Social transitioning is when someone changes their name, their clothing, and their pronouns with the idea that others will treat them as their chosen gender. This is reversible and may be suggested by a treating doctor when a child presents with gender dysphoria at a very young age.
2. Hormone blocking is a treatment that delays puberty to give patients and their families time to make mature, solid choices. This is also reversible.
3. Gender affirming hormone treatment is more irreversible. It is the process of taking testosterone or estrogen to achieve body characteristics in line with the chosen identity.
4. Gender affirming surgeries (breast reduction/enhancement, voice box shaving, genital surgery) is that last step. These are rarely performed on minors.

Transitioning as a youth is very carefully and thoughtfully done in a multidisciplinary setting which includes psychologists, therapists, pediatricians, endocrinologists, and the family. There are usually many stages of approval that need to be obtained. Medical providers follow the World Professional Association for Transgender Health (WPATH) guidelines. People may choose all, some, or none of the options listed above.

• Approximately 82% of transgender people have considered suicide
• More than 30% of transgender youth have attempted suicide
• With a supportive and affirming environment, those rates drop to equal those of non-LGBT youth.

• Senate Bill 16: restricts medical care for transgender youth, including use of hormone blockers. Passed
• Senate Bill 93: prevents Utah youth from changing names or gender on birth certificate. Passed
• House Bill 228: Bring back conversion therapy. Failed

Regardless of your opinion on this legislation, understand this a source of stress for these patients and their families. Right now laws will allow those who already receive treatment to continue. No new patients will be allowed to start treatment. These laws are being challenged.

For transgender kids, a frantic rush for treatment amid bans

• Be understanding and respectful
• Use correct pronouns and preferred name
• Ask about family support
  
• Asking the child what toys or crafts they prefer rather than assuming along the lines of perceived gender
• Wear a pin of support, a sign that you are aware of these terms and issues

"Transgender individuals, particularly those who cannot access treatment for gender dysphoria or who encounter unsupportive social environments, are more likely than the general population to experience health challenges such as depression, anxiety, suicidality, and minority stress. While gender transition can mitigate these challenges, the health and well-being of transgender people can be harmed by stigmatizing and discriminatory treatment." Cornell University Research Lit. Review

As medical care providers, we work to establish trust between ourselves and all our patients. Patients need to feel safe to submit to our care. Studies have shown that using the right pronouns and calling them the correct name will foster trust.

How should you give your report to receiving hospital (say you have a anatomic female who identifies as male who presents with abdominal pain)? You may report something like "I have a 15-year-old transgender male who was assigned female at birth who is complaining of abdominal pain." (Italics are optional.)

What should I do if a youth discloses to me that he/she/them has obtained hormone blockers illegally and is taking them but the parents don't know? You may want to tell them about the dangers of unsafe dosages and unknown substances. Legally you will want to report to the receiving care providers and they will follow their policies on disclosing to parents.

What does the scholarly research say about the effect of gender transition on transgender well-being?

University of Utah Transgender Health Program

Gender Spectrum Website

Registration is open for this year’s EMSC Day webinar, May 24 from 5p.m.-6:30 p.m. CT: “The Pediatric Emergency Care Coordinator (PECC): Where Emergency Care for Kids Begins.”

This 60-minute webinar— which will offer CAPCE credits for those who attend live—will highlight the role of pediatric emergency care coordinators (PECCs), also known as pediatric champions, in EMS agencies. National pediatric EMS experts will present the role PECCs play in prehospital pediatric readiness efforts and highlight how PECCs can work with EMS clinicians and community partners to improve the care of acutely ill and injured children. Attendees will learn about local, regional, and state-level activities that support and sustain the PECC role and hear directly from a PECC about the impact on the care of children in their community. A 30-minute Q&A session will follow the 60-minute presentation.

Registration is free and open to all. For those who attend the session live on May 24, 1.5 Live CAPCE credits will be available through Prodigy EMS.

On Topic

LGBTQ Primary Care Toolkit | Pacific Institute for Research and Evaluation

More Than 50% of Trans and Non-Binary Youth in US Considered Suicide This Year, Survey Says | The Guardian

Seasonal

National Mental Health Month | Youth.gov

May 1-31, 2022

National Water Safety Month | Pool & Hot Tub Alliance

May 1-31, 2022

Drowning and cold water drowning

Hilary Hewes, MD

We are all aware of the flooding and high stream run off we are seeing after this record-breaking snow year. Each spring, we face the risk of a child getting swept away in fast moving rivers and streams, and with the high water levels, we thought a review of some points about drowning and cold water drowning might be helpful.

Although Utah does not see as many pediatric drownings as some of the coastal states, we do lose children every year to drownings in pools, rivers, lakes, and backyard ponds. It is important to remember that small children can drown even in small amounts of water. Children who are pulled from water not breathing warrant immediate action, and in the case of drowning, we go back to A-B-C instead of C-A-B as we are taught for other types of arrest, because we know lack of oxygen is usually the primary problem. Here are some tips for initial resuscitation:

• To provide care for a drowning victim, use a multi-tiered approach that includes management of hypoxia, trauma, and hypothermia
• The main objective of prehospital therapy should be to reverse hypoxia and restore normal oxygenation and circulation as quickly as possible to ensure a good neurological outcome
• Because respiratory arrest is the most common cause of cardiac arrest in drowning victims, use A-B-C approach instead of the C-A-B approach
• Look for signs of trauma, but if you see none, prioritize your ABCs
• If not a cold water drowning (see below), try to warm the child quickly

For those kids who are breathing after a submersion event or who quickly regain consciousness, there are things that can help you predict which of these patients can go on to get worse and decompensate, perhaps needing early transfer to high level of care:

Signs and symptoms of respiratory distress due to evolving pulmonary edema:

• Patient complains of difficulty breathing
• Rales or wet lung sounds (crackles)
• Persistent cough
• Increasing anxiety
• Sitting or standing in tripod position
• Difficulty speaking in full sentences

If you think a child had a true cold water immersion event (they were in very cold water [temp <60 F], snow, or ice where they likely got cold before they had their head under the water and stopped breathing), the child may be a candidate for ECMO rewarming at Primary Children’s.

• Submersion vs. immersion—if you think they quickly were submerged and stopped breathing before their core temp got low, ECMO will not be beneficial
• Goal is to get to Primary Children’s Hospital ASAP to attempt ECMO resuscitation if there was an immersion event (child bobbing in cold water or caught in snow, core temp got cold, and then submerged)—you may need to bypass other EDs
• Initial management: secure airway, start CPR, obtain IO access
• Give epi, but max at 3 doses if no ROSC (no benefit and possible harm afterward)
• Give 20mL/kg NS or LR
• Do NOT actively re-warm the patient in these cases; continue CPR and airway management until arrival at PCH

EMSC PECCs, did you get your April PECC newsletter via email? This is a separate newsletter filled with PECC resources including . . .

• Seasonal safety
• Pediatric disaster readiness resources to help hospitals meet trauma verification
• Pediatric QI opportunities and suggestions

If you did not receive it check that annette.matherly@hsc.utah.edu is in your safe contacts list. If you still cannot find this email please contact our program manager to check your contact information. Jared Wright (jaredwright@utah.gov).

EIIC: Upcoming QI collaboratives

Tackling the challenges of treating pediatric mental health in emergency settings

Over the last decade, youth in America have experienced alarming rates of mental and behavioral health conditions. Read more.

Register now for the Pediatric Readiness QI Collaborative

The collaborative kicks off June 15 and will help ED-based teams address gaps identified by the National Pediatric Readiness Project. Read more.

Pediatric education for the prehospital provider

Register online at www.peppsite.com. Look up classes in Utah and find the 1 that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, regardless of where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth