In My Opinion
How “The Tape” came to be, and what its invention says about emergency medicine
Lincoln County Hospital 1982. A mother bursts into the ED waiting room where I happen to be, sees my white coat and hands me a non-breathing infant. The look on her face stuns me and in less than an instant her panic, fears and raw emotions become my own. All the preparation, planning, memorization and practice in the world cannot fully prepare you for that moment. I am certain that an outside observer would have said that our ER team “did the best we could” under difficult circumstances. The problem was that the circumstances were not “difficult;” they were impossible.
In the early 1980s I closed my family medicine practice in Michigan and we moved to North Carolina. Planning to build an office there I supported my family by moonlighting in the ED. To my surprise, I enjoyed it so much that I became an ER Doc. The transition was rather quick as far as adult emergencies was concerned, but dealing with a critically ill child with the mother in the room made me long for the days of the scheduled H and P in the comfort of my office. It was difficult for me to control my thoughts and emotions when a child’s life was at stake and having the family in the room kept me from retreating into my problem solving mode; their anxiety was contagious. I needed a more objective system to lean on, and so the idea of the Tape was born. Over the years people have asked me about that initial spark that led to the idea that has become so ubiquitous. The simple, honest answer is that it was born out of my own anxiety in learning to care for sick children. I woke up one morning and realized that “The Tape” was what I needed.
The first thing I did after seizing upon the idea was ask Dr. Farley, a surgeon at the time, what he thought about pulling out a carpenter’s tape that had all of the doses on it and keeping it in your pocket. He thought it was a good idea. If he’d rejected the notion, called it stupid, the Tape may have died right there. But he didn’t.
At that time it hit me that I needed to do a “study,” which automatically made me chuckle. You see, I was the exact opposite of an academic. I sat in the back row of every lecture in medical school and hoped they didn’t ask me any questions (we were all paranoid in those days). I am sure I slept through the parts that had to do with control groups and statistics and yet there I was in rural North Carolina, attempting to conduct a research study of my own. I had an old copy of Nelson’s Pediatrics which had a height/weight table in the back. I also had a neighbor who was a CPA who had access to a computer. He agreed to turn the tables into a linear scale that statistically put the weights into even KG zones.
This photo, which appeared in the Charlotte Observer in the mid 1990s, demonstrates a roll-up organizer containing appropriate color coded equipment. The prototype was sewn by hand by Bob Luten’s mother.
By that time I was pretty familiar with the local medical community and so I asked three different pediatric offices if they would be willing to measure their children with the Tape – which only had numbers on each zone – weigh the child, and then give me the raw data. They were glad to help. I had no clue how to crunch the numbers, but in Hickory, NC we had Lenoir Rhyne, a college which taught a course in statistics. I asked the head of the course if he was willing to do the evaluation and he suggested he take it on for a class project. About 6 months later he called me up and informed me that the Tape performed quite well.
So I had my data. About that time I read about a new course being put together called “PALS” being headed up by Leon Chemeides, a pediatric cardiologist from Hartford Connecticut. I called him up and told him about my “study.” He was interested and invited me to present it to his academic group. No more sitting in the back row.
I knew I needed a better prototype, so I reached out to yet another neighbor, one who made saddles for a living. I had him cut me a strip of leather and my wife, Millie, wrote the lines and doses on the leather tape with a pen. (What I wouldn’t give to still have that original leather prototype.) Then I was off to Hartford. What I quickly learned was that it wasn’t just me who was nervous about treating an acutely ill or injured child. It was a universal problem, and the Tape provided a much-needed solution. The Tape began to take off, and the rest is history.
The process of creating that first Broselow Tape opened my eyes to how a bad system can confound even the most dedicated healthcare professionals. The system – estimating the weight, weight-based dosing, mgs per/kg, micrograms per kg, conversions to mLs, dilutions, equipment sizes, ventilator settings, missing critical equipment, fragile patients and stress – was a formula for disaster. Why was it a bad system? Because there was no system! In response to this problem, I teamed up with Bob Luten, one of the early PEDS EM leaders who was part of the original PALS subcommittee. We started working together to build a system. Our first step was to look at airway and other equipment needs and Bob headed up studies in the OR showing that length was the best determinant of correct ET tube size.
As we put more equipment and drugs on the Tape, it started to get crowded – so we got creative. We developed a color coding system to reduce the clutter and help communication, as well as to access the right equipment. About the same time, Allen Hinkle, a pediatric anesthesiologist at Dartmouth was working on color coding rings for little fingers to match color coded airway equipment. (Little finger size, as it turned out, correlates with ET Tubes). He licensed the Tape and extended his color coding to the length concept. He also measured length and leak pressure in the operating room and confirmed that length was the best indicator of correct tube fit in children. Bob and I independently color coded a crash cart and the confluence of ideas led to the Broselow-Hinkle Organizer and Broselow-Luten System, now common in EDs across the country. But it wasn’t just about knowing the right size tube. It was about putting a system in place which allowed you to plan ahead and have one tube of every critical size for the entire spectrum of pediatric needs. Ultimately it wasn’t just about getting the decimal point right, but about having a systematic approach that decreased the stress; it enabled critical thinking time to replace wasted time dedicated to repetitive math calculations and memorization.
Recently people have become concerned that an obese child might get slightly less medicine if not dosed at an actual weight. Length defines ideal body weight dosing which is probably OK for most emergency medications, and bumping a color for any medication that might actually have time to disseminate into the body fat is an effective addition to the process if that is a concern. But again, this highlights the importance of there being a system in place from which to work.
I am proud of the Tape, but not just for me. As a relatively new discipline, emergency medicine has learned much of its craft by copying internists, pediatricians, anesthesiologists, psychiatrists and surgeons. However, from the beginning we knew that the ED environment was a new animal, and thus had new requirements not met by other specialties. The development of the Tape and color coding met those new needs and I believe was one of the early indications that emergency medicine was developing into a mature discipline with its own individual character, perfectly capable of making its own unique contributions to the house of medicine.
James Broselow, MD Creator of the Broselow Tape and Founder of eBroselow, LLC