Feasibility of prehospital telemedicine for paediatric emergencies: a cluster-randomised pilot trial in Karachi, Pakistan

Background: Nearly half of all 4.8 million annual paediatric deaths worldwide are caused by acute illnesses, which are preventable with timely triage, emergency care and prehospital transport. We assessed the feasibility of using telemedicine to connect emergency medical technicians (EMTs) in ambulances with paediatric telemedicine physicians (TMPs) to improve patient care in a low-resource setting. Methods: We conducted a pilot cluster-randomised trial in Karachi, Pakistan, with city’s primary emergency medical transport provider and a paediatric telemedicine facility. Ten ambulances were randomised equally to intervention (real-time audiovisual telemedicine support) and control arms. The intervention was piloted using 25 simulated cases, followed by low-acuity and high-acuity patients as classified by the Medical Priority Dispatch System. Primary outcomes included rates of refusal, call completion, safety (rated by EMTs and TMPs) and completion of the Paediatric Early Warning Score (PEWS) in ambulances and hospitals. Findings: Of 166 parents approached, 151 (91%) consented; 73 patients were assigned to the intervention and 78 to the control. The mean patient age was 2.5 years (SD 43 months; range 1 day–12 years). Ambulance dispatchers categorised 35.7% as low acuity and 64.3% as high acuity. Most cases (68%) were interhospital transfers. Calls were completed in 96% of cases; 87% of calls received favourable audio/video quality scores. All interactions were rated as very safe, safe or neutral; none was deemed unsafe. 91% of EMTs and TMPs rated the system as usable (System Usability Scale). PEWS was completed for 100% of patients in ambulances and 86% in the emergency department. Interpretation: Providing real-time telemedicine support to EMTs in ambulances is feasible and safe in low-resource settings. These findings support further research into the clinical impact and scalability of prehospital telemedicine for paediatric emergencies. Trial registration number: This project is a pilot trial for the Cluster Randomised Trial NCT07027813 titled ‘Feasibility and Efficacy of Ambulance-Based m-Health for Paediatric Emergencies (FEAMER) Trial (FEAMER)’ registered on 19 June 2025. The link to the clinicaltrials.gov is attached here: https://clinicaltrials.gov/study/NCT07027813.