We found that 6% of EMCC calls in our region involved children under twelve years of age, and 50% of these led to a dispatch of an EMS unit. Given a population of approximately 43,000, there was an annual incidence of dispatches of 17 per 1000 children. Of these, 91% were handled by ambulance alone, 8% were handled by ambulance supported by HEMS, and under 1% were handled by HEMS alone. The most common primary medical problems for children receiving pre-hospital care in our region were respiratory distress, altered consciousness, and trauma. The most common medical interventions provided by HEMS physicians were assisted ventilation, resuscitation, and endotracheal intubation.

The prevalence of pediatric EMS patients in our study aligns well with those reported by Dryana et al. and Richard et al., where the prevalence was 8% and 5%, respectively [2, 14]. Further, we found that 50% of the emergency calls regarding children did not lead to an EMS dispatch. There may be different reasons for this. Firstly, the emergency call may have turned out not to represent an emergency after all. Secondly, medical advice from the EMCC operator could have reassured and facilitated the caller to solve minor medical problems over the phone. Finally, the EMCC operator could have interpreted the patient not to be in need of an EMS response, but rather to be able to present at the appropriate healthcare facility with his/her family. The latter is an essential function of the EMCC operators, as they are the role of a gatekeeper to the limited pre-hospital EMS resources [30]. We are not able to study the emergency calls that did not lead to an EMS dispatch, but further studies should examine the characteristics of these calls to ensure that these children are not under-triaged.

In our study, 35% of the patients were assessed and treated by EMS—but not transported. Several studies from various EMSs have found that this patient group varies extensively from 12 to 44% [1, 2, 31]. There might be different reasons for not transporting a patient. It could be that the medical problem has resolved itself from the time of the emergency call to the arrival of HEMS, e.g., seizures [2]. In some instances, the EMS staff probably recommended the parents or caregivers to bring the child to a healthcare facility themselves (e.g., a general practitioner) for a check-up. It is important to note that the decision not to transport the patient by ambulance only refers to the means of transport, not the need for medical care.

While the EMCC classified all incidents assigned to HEMS as acute, the mean NACA score for these patients where 3, which is classified as severe but not life-threatening [25]. Similar findings were reported by Larsson et. al. and Khorram-Manesh et. al [32, 33]. The moderate NACA score could reflect that the barrier for dispatching HEMS to children is low. An American study by Knofsky et. al. found that pediatric patients transported by HEMS are less severely injured compared to adult patients based on lower Injury Severity Score [34].

Primary medical problems, set by the EMCC operator at the time of emergency call, are mainly used to assign each emergency call a severity grade to help decide with which severity to alert ambulance and HEMS. In this study, we have used these medical problems to describe the pre-hospital pediatric population. However, primary medical problems marked as “Others” account for a substantial number of these problems and make it challenging to describe the pre-hospital pediatric EMS population as a whole. The most common primary medical problems for the children in our study were respiratory distress, altered consciousness, and trauma. Similar findings were reported by Drayna et al. in an American study from 2015, with the top three primary problems being respiratory distress, seizure, and blunt trauma [14, 31]. In our study, medical conditions were more common than trauma and injuries, which differs from the findings of other studies where injuries dominated [31, 35]. A possible explanation for this difference could be that we did not include children older than 11 years, representing the majority age group of the injury category in these studies. Another explanation could be that Norway has separate emergency departments and out-of-hours primary healthcare services, so children with minor injuries may be referred to an out-of-hours primary healthcare service without the involvement of EMS [18].

Our study identified six of the fifteen clinical high-priority topics as defined by PECARN; four primary medical problems (seizure, trauma, respiratory distress and cardiac arrest) and two pre-hospital interventions; (assisted ventilation and intubation) [4]. Understanding how these clinical topics are represented in the pediatric population can provide valuable information for further research. The most common ICD-10 diagnosis among HEMS patients in our study was seizures, accounting for 27% of cases. Similarly, Enomoto et al. identified seizures as the most common non-traumatic incident type. However, only 9% of their population experienced seizures [36]. We found that 2% of the HEMS population experienced cardiac arrest. Similar results were reported in a German study by Mockler et al., which found that 3% of the pediatric population suffered from cardiac arrest [37].

Pre-hospital advanced medical interventions were provided to 131 (42%) of the HEMS patients. This is more common than the findings reported by Nielsen et al., who reported that 20% of all pediatric patients in Danish HEMS received advanced medical interventions [19]. In our study, 3% of patients received endotracheal intubation. This is consistent with findings reported by Selig et al. in an Austrian study that reported that 4% received endotracheal intubation, but less common than that reported in a German study by Eich et al., where 8% of the pediatric patients received endotracheal intubation by a HEMS physician [38, 39]. The added competence of a HEMS physician enables more advanced interventions compared to an ambulance alone.

As mentioned, several studies have shown that ambulance staff report heightened anxiety when working with pediatric patients [5, 10,11,12, 37, 40]. These studies have shown that anxiety increased errors in medication, basic airway management and appropriate administration of oxygen among experienced paramedics [10,11,12]. Considerable experience with pre-hospital medical problems and interventions regarding adults is not directly transferable to pediatric patients [41]. Combining knowledge of the skills reported as challenging by Hansen et al. and the incidence of pre-hospital medical problems and interventions found in our study, may help define which topics to address in education and training. A way to apply these findings in an educational program could be to use simulation to practice the skills listed in Table 2 in the context of common clinical scenarios as listed in Tables 1 and 2. Ensuring regular training and opportunities to maintain necessary clinical skills for pre-hospital care is documented to reduce anxiety [13].

Our findings confirm that deaths in pre-hospital care are low. Of the eight pre-hospital deaths in our study, seven had a non-traumatic cause. Similar findings are seen in a Danish study by Nielsen et al., where nontraumatic illness accounted for 19 of 23 deaths [19]. In our study, five patients were considered dead upon arrival of HEMS and, therefore, given a NACA score of seven. Identifying and describing patients who died during or shortly after the pre-hospital care, may help identify areas of improvement in pre-hospital care.

In this study, we utilized data generated by EMCC and EMS staff during the management of emergency incidents. The data were not originally intended to address our specific research questions. Additionally, we had no access to patient data documented by the ambulance staff. The analysis is limited to patient data documented by EMCC operators and HEMS physicians. The EMCC operator’s documentation is primarily based on secondhand information from the caller and, therefore, will be associated with a lower level of certainty. The role of the EMCC operator is, first and foremost, to identify potentially life-threatening conditions and to prioritize limited EMS resources. Consequently, there is a substantial amount of nonspecific and incomplete data regarding primary medical problems labeled “others”. This makes it challenging to characterize the population fully. The patient documentation by HEMS physicians is first-hand documentation with a higher level of certainty. However, data from the HEMS record system LABAS originates from a few patients, making it difficult to draw any conclusions.

Finally, a significant proportion of pediatric emergency calls did not lead to a dispatch of either ambulance or HEMS. Little is known about these patients, and further research is needed to describe this population.