# California Pediatric Intubation



## DesertMedic66 (Oct 12, 2017)

The state just announced that pediatric intubation will be removed from the paramedic's scope no later than July 1st, 2018. Direct visualization will still be authorized for FBAO but no tubes on any patient that fits on the Broslow tape (under 40kg). 

They may still allow flight medics and CCPs to have it in their scope but that is undecided currently.

Link: http://remsa.us/documents/memos/20171012SystemAdvisoryPedsIntubationPhaseOut.pdf


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## NPO (Oct 12, 2017)

I have opinions. But, if we were to lose it, I'd just have to use my Pediatric QuickTrach more often.

https://www.mooremedical.com/index....PG=CTL&CS=HOM&FN=ProductDetail&PID=6454&spx=1


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## VentMonkey (Oct 12, 2017)

This is a long time coming, TBCH. It’s also something I don’t think should be restricted to just “California paramedics”, but most paramedics in general.

If I’m not mistaken, Wilco EMS’ medical director,  Dr. Jarvis doesn’t allow his paramedics to intubate pediatrics as well.

Our medical director was telling me about this about a month, or two ago. We’ll see which side of the spectrum HEMS paramedics wind up on, but either way it’s not a huge deal to me.


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## DesertMedic66 (Oct 12, 2017)

VentMonkey said:


> This is a long time coming, TBCH. It’s also something I don’t think should be restricted to just “California paramedics”, but most paramedics in general.
> 
> If I’m not mistaken, Wilco EMS’ medical director,  Dr. Jarvis doesn’t allow his paramedics to intubate pediatrics as well.


I have the same view. In my county we haven’t been able to intubate pediatrics (anyone under 8 years) for 5+ years. 

I honestly won’t be surprised if adult intubation goes away daily soon either.


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## VentMonkey (Oct 12, 2017)

NPO said:


> I have opinions. But, if we were to lose it, I'd just have to use my Pediatric QuickTrach more often.
> 
> https://www.mooremedical.com/index....PG=CTL&CS=HOM&FN=ProductDetail&PID=6454&spx=1


Heh? Not quite sure that I follow. Why would you have to use this device more? 

You do realize that there are differences in the anatomical structures of even subset age groups of the pediatric population, yeah?


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## NPO (Oct 12, 2017)

VentMonkey said:


> Heh? Not quite sure that I follow. Why would you have to use this device more?
> 
> You do realize that there are differences in the anatomical structures of even subset age groups of the pediatric population, yeah?


Because if I'm intubating a ped, it had better be a crash airway situation where an opa isn't doing the trick. 

My point was kind of double edged. 1 being it's a truly emergent procedure, and 2, I'm doing it because nothing else is working.


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## Qulevrius (Oct 12, 2017)

NPO said:


> Because if I'm intubating a ped, it had better be a crash airway situation where an opa isn't doing the trick.
> 
> My point was kind of double edged. 1 being it's a truly emergent procedure, and 2, I'm doing it because nothing else is working.



That’s a 1:1,000,000 pt with completely swollen shut or destroyed airway and, quite frankly, i fail to see how tubing them would make any difference. Especially given the anatomical peculiarities of peds.


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## NPO (Oct 12, 2017)

Qulevrius said:


> That’s a 1:1,000,000 pt with completely swollen shut or destroyed airway and, quite frankly, i fail to see how tubing them would make any difference. Especially given the anatomical peculiarities of peds.


I agree. It's going to be exceedingly rare. But I'd hate to take a ped with airway burns and a closing airway to my nearest burn hospital an hour and a half away with no airway option. 

Again, I know it's very uncommon, but then again, so are a lot of things we do.


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## Qulevrius (Oct 12, 2017)

NPO said:


> I agree. It's going to be exceedingly rare. But I'd hate to take a ped with airway burns and a closing airway to my nearest burn hospital an hour and a half away with no airway option.
> 
> Again, I know it's very uncommon, but then again, so are a lot of things we do.



That would be the only time it is absolutely necessary. Unless there’s a facial trauma, or the medic in question is a whiz who can drop a tube through a nare.


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## NPO (Oct 12, 2017)

Qulevrius said:


> That would be the only time it is absolutely necessary. Unless there’s a facial trauma, or the medic in question is a whiz who can drop a tube through a nare.


In school we all did clinical rotations to teach us how to do our skills.

Why does that stop when we graduate? Are we intubating weekly? Surely not. 

Before we go removing things because we aren't good at them (because we don't practice them), I say we mandate annual or bi-annual clinicals for low-frequency high-risk interventions, including adult intubations. 

I know nobody wants to do more CEs, but if we ever want to be considered professionals, we need to be good at what we do.


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## VentMonkey (Oct 12, 2017)

Qulevrius said:


> or the medic in question is a whiz who can drop a tube through a nare.


Again, a review the subsets of age groups and their airway differences would be in order. Yet another reason why the average provider has no business fiddling around down there. 

We truly, and simply lack the educational know how.


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## Qulevrius (Oct 12, 2017)

VentMonkey said:


> Again, a review the subsets of age groups and their airway differences would be in order. Yet another reason why the average provider has no business fiddling around down there.
> 
> We truly, and simply lack the educational know how.



My point exactly. Even if a medic in question is a virtuoso and a medical prodigy, that’s exceptional. But in reality, 99% of the medics will butcher a ped’s airway trying to slip in a tube.


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## VentMonkey (Oct 12, 2017)

NPO said:


> Before we go removing things because we aren't good at them (because we don't practice them), I say we mandate annual or bi-annual clinicals for low-frequency high-risk interventions, including adult intubations.


Why? We’ve had plenty of time, years in fact, to remediate with no improvements. How much more time do you need?

Do you honestly feel bi-annual skills is sufficient enough to retain competency? I guarantee you it is not. I wouldn’t want a bi-annual medic anywhere near my own child’s airway, I would want an expert. I choose not to live 300 miles away from civilization for such reasons.

Maybe emphasize re-educating the basics *to a tee* before providing any reason why we should continue to keep a skill we continuously show now consistently positive outcomes with.

If higher level providers are allowed to keep such a skillset then you bet your arse they better be well educated in the ins and outs of airway management. Not intubations—a skill—airway management.


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## VFlutter (Oct 12, 2017)

NPO said:


> Before we go removing things because we aren't good at them (because we don't practice them), I say we mandate annual or bi-annual clinicals for low-frequency high-risk interventions, including adult intubations.



I do not have the numbers off hand but even specialty pediatric teams do not have fantastic prehospital intubation statistics. I do not think there bi-annual clinicals in the solution. Most flight programs are good, but not great at it.


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## NPO (Oct 12, 2017)

What is the proposed solution then? Someone somewhere will have a pediatric that needs an emergent airway? Are we agreeing that it's better to let the child die than attempt (and potentially fail) to manage the airway with ETI?

I suppose most all places allow needle cric, if not surgical cric, but how much safer is that? I've never been forced into that position, but my understanding is that a 10g doesn't ventilate very well.


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## DesertMedic66 (Oct 12, 2017)

NPO said:


> What is the proposed solution then? Someone somewhere will have a pediatric that needs an emergent airway? Are we agreeing that it's better to let the child die than attempt (and potentially fail) to manage the airway with ETI?
> 
> *I suppose most all places allow needle cric, if not surgical cric, but how much safer is that?* I've never been forced into that position, but my understanding is that a 10g doesn't ventilate very well.


Yeah, we don’t allow needle or surgical for medics in my county..

Is saving one pediatric worth killing 10 pediatric because we screwed up on the tube?


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## VFlutter (Oct 12, 2017)

NPO said:


> What is the proposed solution then? Someone somewhere will have a pediatric that needs an emergent airway?* Are we agreeing that it's better to let the child die than attempt (and potentially fail) to manage the airway with ETI?*
> 
> I suppose most all places allow needle cric, if not surgical cric, but how much safer is that? I've never been forced into that position, but my understanding is that a 10g doesn't ventilate very well.



I do not agree with that rationale on it's premise. There are a lot of potentially life saving interventions that should not be done in the field regardless if the person would die otherwise. Yes there will be pediatrics that need emergent airway management but does that mean that every paramedic should be allowed to do it? BLS management until advanced provider is available (Closest facility, CCP in fly car, HEMS)  or needle cric in peri-arrest.


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## NPO (Oct 12, 2017)

DesertMedic66 said:


> Is saving one pediatric worth killing 10 pediatric because we screwed up on the tube?



You bring up a good point. So what are paramedics doing that is causing the harm?

Is it intubating too agressivly on patients who could have had their airway better managed with other techniques? Probably.

Is it intubating and delaying other more critical procedures trying to secure an unnecessary airway? Likely.

Is it unrecognized esophageal intubation? In some cases, absolutely.

I'd be curious to see the numbers, but if I had to take a guess, I'd guess it was a combination of agressivly intubating patients who didn't need it and delaying definitive care.


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## NPO (Oct 12, 2017)

I don't disagree. I just think we need a fail safe. Perhaps they fail safe is HEMS with higher trained and licensed practitioners than your average street medic, or, if in proximity to a hospital, a physician.


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## Qulevrius (Oct 13, 2017)

NPO said:


> I don't disagree. I just think we need a fail safe. Perhaps they fail safe is HEMS with higher trained and licensed practitioners than your average street medic, or, if in proximity to a hospital, a physician.



Or instead, the medics could be rotated with anesthesiologists the same way RTs are.


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## DesertMedic66 (Oct 13, 2017)

Qulevrius said:


> Or instead, the medics could be rotated with anesthesiologists the same way RTs are.


I don’t think that is a very plausible option. In my county alone you are talking about 500 medics who are currently in the field.


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## Carlos Danger (Oct 13, 2017)

I thought this happened quite a while back? Thought I remember hearing maybe 10 years ago that medics in CA were no longer able to tube peds. 

This is surprising to me. I'm as critical of prehospital intubation as anyone, but to be honest, kids are usually the easiest airways because they rarely have the co-morbidities that adults do. 

Do the stats demonstrate worse outcomes when peds (as compared to adults) are intubated prehospital?


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## EpiEMS (Oct 13, 2017)

Remi said:


> Do the stats demonstrate worse outcomes when peds (as compared to adults) are intubated prehospital?



A controlled trial from 2000 demonstrated no survival advantage of introducing ETI to a system where BVM was the only other method (and it looks like BVM might be superior to ETI for a couple of etiologies, besides reducing scene time). In summary..."For ETI in this [prehospital] setting, scene time was prolonged and fatal complications were frequent."

Color me suspicious if ETI is a good idea for peds prehospitally...assuming you don't have the best (i.e. regularly intubating successfully on the first pass) medics. Heck, EMS providers don't really feel comfortable with pediatric airway management.

Here's a nice retrospective study. They note: "Our study shows out-of-hospital ETI, the most commonly used advanced technique, has significantly lower success rates compared to in the hospital and alarmingly low rates of C02-based confirmation of placement. Despite the findings of the Gauche-Hill study 15 years ago that showed no benefit and trend towards harm with pediatric ETI, it continues to be the most commonly practiced advanced airway management technique. It is unclear why the current practice is not consistent with the best available evidence."


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## DesertMedic66 (Oct 13, 2017)

Remi said:


> I thought this happened quite a while back? Thought I remember hearing maybe 10 years ago that medics in CA were no longer able to tube peds.
> 
> This is surprising to me. I'm as critical of prehospital intubation as anyone, but to be honest, kids are usually the easiest airways because they rarely have the co-morbidities that adults do.
> 
> Do the stats demonstrate worse outcomes when peds (as compared to adults) are intubated prehospital?


Some areas remove pediatric intubation but not all areas and it was still listed on the state scope of practice. 

We still have areas in CA where there are no skill tests or training. Once you get hired you only have to have BLS CPR, ACLS, and enough CE hours but that’s it. The only training they actually have is when they went to medic school. I’d imagine that our first time pass rate for adult is also very low. 

Also if I remember correctly we still have a couple of isolated areas without EtCO2 capability.


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## Qulevrius (Oct 13, 2017)

DesertMedic66 said:


> I don’t think that is a very plausible option. In my county alone you are talking about 500 medics who are currently in the field.



CCPs and FPs, not just any clown with a blue card.


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## EpiEMS (Oct 13, 2017)

DesertMedic66 said:


> We still have areas in CA where there are no skill tests or training.



Wait, wait...to recertify you don't need to pass a skills exam?


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## MackTheKnife (Oct 13, 2017)

You modern medics amaze me. You applaud doing away with a skill, that might be rare, but is still lifesaving. This is horse hockey. Peds are difficult, but deserve the best treatment possible regardlessly. ETI is the best treatment for an airway in most circumstances. Butchering an airway? How so? Proper technique will prevent that. My worst intubation was a 6yo female in status eplipecticus and vomiting. I got her tubed without chipping teeth and damaging any soft tissue. She made it. Without the tube, she probably would have aspirated. Where is your collective heads at?


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## EpiEMS (Oct 13, 2017)

MackTheKnife said:


> My worst intubation



Hold on, though. I would say you probably don't consider yourself a poor medic, right? (Or even an average one?) We need to worry about the least common denominator.


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## Carlos Danger (Oct 13, 2017)

MackTheKnife said:


> You modern medics amaze me. You applaud doing away with a skill, that might be rare, but is still lifesaving. This is horse hockey. Peds are difficult, but deserve the best treatment possible regardlessly. ETI is the best treatment for an airway in most circumstances. Butchering an airway? How so? Proper technique will prevent that. My worst intubation was a 6yo female in status eplipecticus and vomiting. I got her tubed without chipping teeth and damaging any soft tissue. She made it. Without the tube, she probably would have aspirated. Where is your collective heads at?


So you reject the research that this decision is based on? On what grounds?


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## MackTheKnife (Oct 13, 2017)

EpiEMS said:


> Hold on, though. I would say you probably don't consider yourself a poor medic, right? (Or even an average one?) We need to worry about the least common denominator.


No, we need to worry about what's best for the patient. The LCD is just that, the Least. If we dumb down the standards because of the few, the patient loses and we lose. My problem with tubing kids is the lack of a cuff on the tube.


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## MackTheKnife (Oct 13, 2017)

Remi said:


> So you reject the research that this decision is based on? On what grounds?


Remi, as I have been pursuing my BSN, I have been focused on evidenced-based practice (EBP). I can find EBP representing both sides of an argument when doing research. I am not swayed by purported studies saying this is good or bad. Our hospital, and many others, require IV sites to be rotated every 96 hours due to EBP. Problem is, there is EBP that states the exact opposite.


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## EpiEMS (Oct 13, 2017)

MackTheKnife said:


> No, we need to worry about what's best for the patient. The LCD is just that, the Least. If we dumb down the standards because of the few, the patient loses and we lose.



You're not worried about iatrogenic events? What about that there is no demonstrable survival advantage to ETI over BVM? If you really want something better than a BVM, why not an LMA? At least the LCD can't mess up an LMA...

I can't see any good evidence that an ETI is better than a BVM in pediatric out of hospital care...of course, I could be wrong, and there isn't a ton of research out there. But what we do have - and it is large - shows that BVM is preferable.


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## VFlutter (Oct 13, 2017)

http://gatheringofeagles.us/2013/Friday/Gausche-Hill-PrehospitalPediIntubation.pdf

Pre-hospital pediatric patients whom received BVM vs ETI had better overall survival and significant better neurological outcomes. But if intubating makes you feel like you are doing something for the patient then by all means....

Would ETI be better for a vomiting status patient? Maybe, maybe not. Assuming you successfully intubate the patient with the correct size ETT without multiple attempts and hypoxic events. Which may have happened in your particular situation but frequently is not the case.


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## DesertMedic66 (Oct 13, 2017)

EpiEMS said:


> Wait, wait...to recertify you don't need to pass a skills exam?


In some areas that is correct. The state does not require it but some counties do. All the state requires are: the CE hours, ACLS, and BLS CPR.


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## MackTheKnife (Oct 13, 2017)

Iatrogenic? Please tell me the incidence rates of these events? Survival advantage? Demonstrably ETI over BVM. BVM does NOT control the integrity of the airway. I've seen the studies of cardiac arrest patients surviving not neurologically intact with ETI, but ETI is not the only factor. Length of arrest, length of apnea/anoxia, comorbidities, etc., all factor in. Yet ETI is disdained these days. I said, IMHO, we are looking for an excuse to dumb down the standards and reduce skill sets.


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## EpiEMS (Oct 13, 2017)

MackTheKnife said:


> Demonstrably ETI over BVM.



I have yet to see anything showing that this is the case. I cited the preeminent study on this topic earlier (on pediatric intubation, specifically). I suggest you review it before stating this. Of course, it is an imperfect study, but is corroborated by the fact that EMS providers say they don't know what they are doing with kids!



MackTheKnife said:


> 've seen the studies of cardiac arrest patients surviving not neurologically intact with ETI, but ETI is not the only factor. Length of arrest, length of apnea/anoxia, comorbidities, etc., all factor in.



ETI is a risk factor for anoxic time upon EMS arrival, no? ETI uses people who should otherwise be doing the two things that matter - CPR & defibrillation...



DesertMedic66 said:


> In some areas that is correct. The state does not require it but some counties do. All the state requires are: the CE hours, ACLS, and BLS CPR.



That's crazy...how can they do that?


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## VFlutter (Oct 13, 2017)

MackTheKnife said:


> Iatrogenic? Please tell me the incidence rates of these events? Survival advantage? Demonstrably ETI over BVM. BVM does NOT control the integrity of the airway. I've seen the studies of cardiac arrest patients surviving not neurologically intact with ETI, but ETI is not the only factor. Length of arrest, length of apnea/anoxia, comorbidities, etc., all factor in. Yet ETI is disdained these days. I said, IMHO, we are looking for an excuse to dumb down the standards and reduce skill sets.




Reference the above PowerPoint. Multiple studies have shown no increase in survival or even worse survival with ETI in pediatrics. This was not exclusively in cardiac arrest patients, the majority were TBI. 3/4 of the time the ETT tube was the wrong size. Most are not cuffed. Not sure you can argue it controls the integrity of the airway in most prehospital intubations. You have zero evidence to support your claim other than it feels like the right thing to do. 

ETI Complications (n=186):
Tube size incorrect 44 (24%)
Main stem intubation 33 (18%)
Recognized dislodgement 15 (8%)
Unrecognized dislodgement 12 (6%)
Esophageal intubation 3 (2%)

Results:
Of 420 ETI patients:
305 attempted intubation (73%)
174 successful (57%) 
3 esophageal intubations

Treatment received:
survival - BVM (33%) vs ETI (14%), OR
0.32, 95% CI [0.20-0.50];
neurologic outcome - BVM (26%) vs. ETI
(8%), OR 0.26, 95% CI[0.15-0.45].


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## MackTheKnife (Oct 13, 2017)

EpiEMS said:


> I have yet to see anything showing that this is the case. I cited the preeminent study on this topic earlier (on pediatric intubation, specifically). I suggest you review it before stating this. Of course, it is an imperfect study, but is corroborated by the fact that EMS providers say they don't know what they are doing with kids!
> 
> 
> 
> ...


This is insane! Don't know what they're doing with kids? The anatomy is smaller and trickier, but it is the same. Patience, preoxygenation, eye-hand coordination gets the job done.


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## DesertMedic66 (Oct 13, 2017)

MackTheKnife said:


> You modern medics amaze me. You applaud doing away with a skill, that might be rare, but is still lifesaving. This is horse hockey. Peds are difficult, but deserve the best treatment possible regardlessly. ETI is the best treatment for an airway in most circumstances. Butchering an airway? How so? Proper technique will prevent that. My worst intubation was a 6yo female in status eplipecticus and vomiting. I got her tubed without chipping teeth and damaging any soft tissue. She made it. Without the tube, she probably would have aspirated. Where is your collective heads at?


We applaud doing away with a skill that is very low frequency and high risk because as a whole we suck at it and since we suck at it we found out we were killing patients. CA pulled information on all the pediatric patients in the state who were tubed or at least it was attempted and compared it to patients who were not and found the latter had better survival rates. 

Yes there will always be that one patient who may die because we are unable to tube but it will save the other 9 kids from dying at our hands because we took too long to get the tube, spent too much time on scene, cause too much airway trauma, didn’t realize improper tube placement, or failed to reassess tube placement. 

If the intial education, clinical rotations, continued skills verifications, mandatory ongoing training was better then we maybe able to keep these skills but once again as a whole we don’t have that. 

I am all for increased survival rates over skills.


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## EpiEMS (Oct 13, 2017)

MackTheKnife said:


> This is insane! Don't know what they're doing with kids?



I don't think they know what they're doing with adults, let alone kids...


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## MackTheKnife (Oct 13, 2017)

DesertMedic66 said:


> We applaud doing away with a skill that is very low frequency and high risk because as a whole we suck at it and since we suck at it we found out we were killing patients. CA pulled information on all the pediatric patients in the state who were tubed or at least it was attempted and compared it to patients who were not and found the latter had better survival rates.
> 
> Yes there will always be that one patient who may die because we are unable to tube but it will save the other 9 kids from dying at our hands because we took too long to get the tube, spent too much time on scene, cause too much airway trauma, didn’t realize improper tube placement, or failed to reassess tube placement.
> 
> ...


Great post! Appreciate your honesty. What I have found with ETI and it's inherent difficulties, is knowing when to quit and move on. Adult "no-neckers", peds that were difficult to tube, multitrauma lying on the road after being ejected from their car with maxillofacial injuries and were gurgling.  They required a nasotrachial intubation without manipulating the C-spine. Difficult? Yes. Impossible? No. Put their head in your crotch, legs over their shoulders, and GENTLY pass the tube through a nare while SLOWLY visualizing the airway (#3 Miller usually). So tired of some of these posts that quote studies so they can give up.


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## MackTheKnife (Oct 13, 2017)

EpiEMS said:


> I don't think they know what they're doing with adults, let alone kids...


LOL! The state of modern affairs.!!!!!!!


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## MackTheKnife (Oct 13, 2017)

Chase said:


> http://gatheringofeagles.us/2013/Friday/Gausche-Hill-PrehospitalPediIntubation.pdf
> 
> Pre-hospital pediatric patients whom received BVM vs ETI had better overall survival and significant better neurological outcomes. But if intubating makes you feel like you are doing something for the patient then by all means....
> 
> Would ETI be better for a vomiting status patient? Maybe, maybe not. Assuming you successfully intubate the patient with the correct size ETT without multiple attempts and hypoxic events. Which may have happened in your particular situation but frequently is not the case.


Bagged her, suctioned. Waited for a pause in seizure activity. Went to initiate intubation, seized again. Bagged, suctioned. Successful intubation on 2nd attempt (while we were enroute Code 1).


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## MackTheKnife (Oct 13, 2017)

Chase said:


> Reference the above PowerPoint. Multiple studies have shown no increase in survival or even worse survival with ETI in pediatrics. This was not exclusively in cardiac arrest patients, the majority were TBI. 3/4 of the time the ETT tube was the wrong size. Most are not cuffed. Not sure you can argue it controls the integrity of the airway in most prehospital intubations. You have zero evidence to support your claim other than it feels like the right thing to do.
> 
> ETI Complications (n=186):
> Tube size incorrect 44 (24%)
> ...


You perhaps noticed I mentioned the lack of a cuff???????


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## DesertMedic66 (Oct 13, 2017)

MackTheKnife said:


> Great post! Appreciate your honesty. What I have found with ETI and it's inherent difficulties, is knowing when to quit and move on. Adult "no-neckers", peds that were difficult to tube, multitrauma lying on the road after being ejected from their car with maxillofacial injuries and were gurgling.  They required a nasotrachial intubation without manipulating the C-spine. Difficult? Yes. Impossible? No. Put their head in your crotch, legs over their shoulders, and GENTLY pass the tube through a nare while SLOWLY visualizing the airway (#3 Miller usually). So tired of some of these posts that quote studies so they can give up.


And that is what we don’t have from my own view points on intubation. We have a vast number of providers who must secure a tube at all costs. They will attempt it 10+ times without changing their technique or equipment. They will stop compressions so they can get the tube. They will have extended on scene times so they can get the tube. They are so focused on ETI they don’t realize the harm they are doing. They view that if they have to use a King then they have failed as a medic.


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## Qulevrius (Oct 13, 2017)

ETI should be the least of anyone’s worries when fire spends 15 min on scene trying (and failing) to start an IV on a ped. Because, apparently, they either can’t get the protocols through their thick skulls or simply left the IO at the fire house.


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## RocketMedic (Oct 13, 2017)

Do they have pediatric supraglottics coming onto the trucks instead?


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## VentMonkey (Oct 13, 2017)

I don't know how much experience you have @MackTheKnife, but sometimes numbers, or "years on", can be overrated. Performing an NTI on someone with massive facial trauma such as the one which you've presented is not something/ someone I would be inclined to explain to the hospital, or my medical director. The likelihood of the patient not only having increased ICP, but also a basilar skull fracture (contraindicated) are too high for me not to find other ways to oxygenate and ventilate this patient.

Most of the NTI's I performed before it was removed from our scope was before there was such a heavy push for CPAP and our ground paramedics don't carry paralytics, and even then I don't/ couldn't see many physician not wanting to re-introduce an orotracheal ET tube sooner rather than later given the greater risk of infection passing an ETI through a patient's nostril.

The prehospital setting is often less than ideal for many of these skills were cut loose with trying on people almost as if they're cadavers before becoming actual cadavers. We all know what defines a "failed airway", and it certainly isn't feeling like a bruised-ego failed medic because they took more tools away from our toolbox. I just don't want to be so caught up in selfish praise that I am doing more harm than any good to these patients.

Time and time again even til this day we're focused on "getting the tube", which @DesertMedic66 eludes to. That is not airway management; that is ego. Ego is bad, very bad. It's also disgustingly prevalent in this industry, so much so that we've come to removal of such procedures. Now, if on the whole paramedics took this stuff as serious as they do about it being taken away, well, I don't think we would be having this discussion.

TLDR- we did it to ourselves as a profession. Will the pediatric community suffer a whole lot more than they already have? I hardly doubt it.


RocketMedic said:


> Do they have pediatric supraglottics coming onto the trucks instead?


In California, pediatric intubation was taken away from a majority, if not all? of the systems south of Kern County; not too sure if, or when ICEMA removed it, but it was still in their scope when I worked there. Everywhere else it's still commonly in the protocols, but seldom utilized to include my county. I don't know, and this is pretty unfortunate, of any county's here carrying pediatric SGA's.


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## DesertMedic66 (Oct 13, 2017)

VentMonkey said:


> I don't know how much experience you have @MackTheKnife, but sometimes numbers, or "years on", can be overrated. Performing an NTI on someone with massive facial trauma such as the one which you've presented is not something/ someone I would be inclined to explain to the hospital, or my medical director. The likelihood of the patient not only having increased ICP, but also a basilar skull fracture (contraindicated) are too high for me not to find other ways to oxygenate and ventilate this patient.
> 
> Most of the NTI's I performed before it was removed from our scope was before there was such a heavy push for CPAP and our ground paramedics don't carry paralytics, and even then I don't/ couldn't see many physician not wanting to re-introduce an orotracheal ET tube sooner rather than later given the greater risk of infection passing an ETI through a patient's nostril.
> 
> ...


When I did my internship in ICEMA in 2015 they still had pedi intubation and carried all of the King airway sizes. For us in riverside we only carry King 3, 4, and 5


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## MackTheKnife (Oct 13, 2017)

DesertMedic66 said:


> And that is what we don’t have from my own view points on intubation. We have a vast number of providers who must secure a tube at all costs. They will attempt it 10+ times without changing their technique or equipment. They will stop compressions so they can get the tube. They will have extended on scene times so they can get the tube. They are so focused on ETI they don’t realize the harm they are doing. They view that if they have to use a King then they have failed as a medic.


Thank you for this info. I was unaware of these UNSAFE practices. Wow! 10 times? Give it up after 2-3!


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## GMCmedic (Oct 13, 2017)

DesertMedic66 said:


> And that is what we don’t have from my own view points on intubation. We have a vast number of providers who must secure a tube at all costs. They will attempt it 10+ times without changing their technique or equipment. They will stop compressions so they can get the tube. They will have extended on scene times so they can get the tube. They are so focused on ETI they don’t realize the harm they are doing. They view that if they have to use a King then they have failed as a medic.


Bougie, medics best friend.


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## DesertMedic66 (Oct 13, 2017)

MackTheKnife said:


> Thank you for this info. I was unaware of these UNSAFE practices. Wow! 10 times? Give it up after 2-3!


Exactly but a lot of our medics, from what I have seen, do not understand this and will not give up. It’s viewed as the “gold standard” and as a fire medic skills instructor once said “being able to intubate is what it means to be a paramedic”. They are too focused on a skill to look at the entire patient picture and since there are way too many medics like that, both on the fire side and transport side, it seems to be the safest option is to remove it at least from pediatrics right now. 



GMCmedic said:


> Bougie, medics best friend.


I have talked with a decent number of medics at my company and none of them have ever mentioned the bougie or could even said if their bag or ambulance had one. Once again, at least in my area, using a bougie makes you viewed as less of a medic. I get strange looks and questions when ever I use a bougie. The medic who works my opposite shift always takes the bougie out of the bag so every week I am having to toss a new one in.


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## Qulevrius (Oct 13, 2017)

DesertMedic66 said:


> Exactly but a lot of our medics, from what I have seen, do not understand this and will not give up. It’s viewed as the “gold standard” and as a fire medic skills instructor once said “being able to intubate is what it means to be a paramedic”. They are too focused on a skill to look at the entire patient picture and since there are way too many medics like that, both on the fire side and transport side, it seems to be the safest option is to remove it at least from pediatrics right now.
> 
> 
> I have talked with a decent number of medics at my company and none of them have ever mentioned the bougie or could even said if their bag or ambulance had one. Once again, at least in my area, using a bougie makes you viewed as less of a medic. I get strange looks and questions when ever I use a bougie. The medic who works my opposite shift always takes the bougie out of the bag so every week I am having to toss a new one in.



OCEMSA removed all sedatives but midazolam and all paralytics from the ALS protocols a few years ago, with the medical director saying that the county has a hospital on every corner and the transport times are too short to warrant RSI. But, we all can read between the lines, yeah ?


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## RocketMedic (Oct 14, 2017)

So here's my take on this (please keep in mind I'm coming from a Texan perspective, with rural, suburban and urban experience, and transport times that can approach 40 minutes even going only a few miles). It's got some years, some fancy book learning and a few cases behind it too. And I'm tired, so I might ramble a bit. 

Pediatric intubation is often not strictly necessary in a prehospital environment. Intubation, as a whole, is often not necessary in a prehospital environment. NIPPV, supraglottic airways, and good basic airway management go a long way towards making ETI a rarity. Even concepts such as spinal clearance (resulting in fewer patients boarded and aspirating on their own secretions and vomit) and non-medical changes like safer cars (autostop, lane-departure, etc) are making opportunities for intubation, particularly on traumatic airways, rarer. With that being said, intubation is still a necessity at times, _particularly_ for patients for whom there is no common, readily-available alternative. Pediatric intubation strikes me as _necessary_ from the perspective of saving marginal patients.

With the incidence of intubations declining, I think that CA EMSA's decision is wrong-headed and short-sighted. For one, it is based on a view of outcomes that focuses on how things are currently being done, not best practices. Judging prehospital and in-hospital intubation success rates on pediatric patients, in sub-optimal conditions, and acting surprised that more children who were gorked up enough to need prehospital intubation died than those that didn't strikes me as a deeply flawed analysis. They're pulling the data from places and people who are not necessarily up to the modern state of the science, and although that's real, it's also the root of bad policy- it would be better for those marginal patients to train our paramedics and supply them appropriately (I know, dreaming...) Second, and in a related vein- how many of these cases were performed in deeply sub-optimal conditions as opposed to 'proper' setup, positioning, preparation, etc? I strongly doubt that some of the most effective tools and techniques for intubation in general are a part of the conversation regarding intubation. Third, although it is defensible from a systemic standpoint to point to a high-acuity, low-frequency intervention and screech about its hazards, it is also a massive disservice to the person who will one day need that intervention. Sure, most of us don't intubate kids frequently....but what about that kid that we need to intubate to save? I keep thinking back to a tale my dad told me, of a lad who ate a salt-water taffy and nearly died when he wrong-piped it. Dad used a tube to force the obstruction into the right lung when he couldn't get it out the conventional way, ventilated and saved the kid's life. Somewhere, that person is alive and probably has a family of their own because a paramedic in the mid-90s thought outside the box and intubated them. That's the patient that sticks with you, and watching them die for the sake of a rule would suck. At some point, dead is dead, and it's not a mystery as to where the call is going. For these cases, I think intubation is a reasonable measure.

Fourth, and finally, I think that a lot of the calls to remove intubation from the paramedic scope of practice either in part or totally is because we are seeing the negative effects of half-right or poorly-performed intubations on people. I don't think these are entirely personal issues either. They're systemic issues. When the expectation is to intubate with an old-school direct laryngyscope as the only option (because videos are expensive, nontraditional and tools of the weak) without a bougie (newb stick) and without considerations of rescue devices (wuss tools!), it's not really a surprise that we'll see negative outcomes. Those failures are permitted, facilitated and perpetuated by the systems that send people out into the field, and if we want to keep intubation to save lives, we need to change this. In my opinion, those of us who are intubating need to be well-trained and well-equipped, with the authorization and trust vested in us to do what should be done for optimal patient outcome- be that an airway maintained by positioning, a tracheal intubation, a crike or even a supraglottic placed with or without paralysis and sedation.


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## DesertMedic66 (Oct 14, 2017)

What I would like CA EMS to do is to pull these skills, both adult and pediatric ETI, from the scope and then reintroduce them with proper training, education, and annual or quarterly continuing education and training to paramedics and systems who can prove competency.


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## MackTheKnife (Oct 14, 2017)

RocketMedic said:


> So here's my take on this (please keep in mind I'm coming from a Texan perspective, with rural, suburban and urban experience, and transport times that can approach 40 minutes even going only a few miles). It's got some years, some fancy book learning and a few cases behind it too. And I'm tired, so I might ramble a bit.
> 
> Pediatric intubation is often not strictly necessary in a prehospital environment. Intubation, as a whole, is often not necessary in a prehospital environment. NIPPV, supraglottic airways, and good basic airway management go a long way towards making ETI a rarity. Even concepts such as spinal clearance (resulting in fewer patients boarded and aspirating on their own secretions and vomit) and non-medical changes like safer cars (autostop, lane-departure, etc) are making opportunities for intubation, particularly on traumatic airways, rarer. With that being said, intubation is still a necessity at times, _particularly_ for patients for whom there is no common, readily-available alternative. Pediatric intubation strikes me as _necessary_ from the perspective of saving marginal patients.
> 
> ...


Bravo! Couldn't have said it better!


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## RocketMedic (Oct 14, 2017)

DesertMedic66 said:


> What I would like CA EMS to do is to pull these skills, both adult and pediatric ETI, from the scope and then reintroduce them with proper training, education, and annual or quarterly continuing education and training to paramedics and systems who can prove competency.



We both know it wouldn't come back for most of the state.


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## CLCustom1911 (Oct 14, 2017)

After reading this whole thread, its very interesting and I'll thrown in my 2 cents.  

I'm a cop here in Southern California (been one for almost 9 years). I equate high-risk, high-liability, low-frequency events like intubation as a whole with me getting into an officer involved shooting at work. Usually at minimum, most departments require quarterly range training and qualifications. We are required to know department policy, case law on lethal force, and we watch videos, etc.   All things to either maintain/improve marksmanship, understanding of police, and stay up to date with techniques, tactics, and procedures. Also, mental visualization and mental preparation of using the skill is important.  Like when I am about to pull someone over for a broken tail light, my mind goes  "ok, the nearest tree for cover is right over there. How many are in the car? If they jump out and run, what's the best course of action? If driver jumps out shooting, what's the best course of action....." Etc etc etc.  This thought process happens on ever traffic stop, every time a contact a suspect on the street, every time I go into a 7-11 at 3am. Mental preparation is a HUGE thing.

Police, like EMS, have their dinosaurs that say "its always been done like this, so if you can't do it this way, you're less of a cop" (i.e. calling a bougie a "noob stick" .... Hey, the patient is oxygenated via the "gold standard" airway... who cares that the little stick looks weird with a funny name.).

I concurr with the voices on here saying there is a problem, but solving the problem shouldn't be the knee-jerk "take the skill away" reaction. I'm surprised its not required to practice regularly on a mannequin, with and without a bougie, and do some clinical rotations once a year or so with a surgical unit, Watch videos on new techniques, etc etc on these high-risk, high-liability, low-frequency items.  

As I say (which I've never heard anyone else say)...

Practice makes proficiency.


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## Carlos Danger (Oct 14, 2017)

@MackTheKnife and @RocketMedic, you guys both do a good job presenting anecdotes and “what if” scenarios that support the idea of pediatric intubation. You both provide good service to the hypothesis that pediatric intubation is a beneficial intervention.

However, at the end of the day, your arguments all rest solidly on the premise that prehospital pediatric intubation actually works as intended. But the reality is.......it doesn’t. Many studies - not one, not two, but many - tell us pretty much the same thing.

I know it seems as though it should help, and in a perfect world where paramedics had more training and practice with the skill, it probably would. But we have to deal with the way things _are_, not the way we wish them to be. Like so many other things in medicine, interventions that seem as though they _must_ be a good thing, like they _must_ benefit patients, often are found not to once studied objectively. We can think of many examples. Spinal immobilization seemed like such an obviously good thing that no one even questioned it for decades. Same with intracardiac epi. Same with normalizing BP in trauma patients. Bicarb in arrest. Epi in arrest. Early intubation in arrest. Fluid loading in sepsis. Antibiotics for uncomplicated strep. Nitro in chest pain. The list goes on.

We can talk all day about how “if the skill is broken, fix it instead of taking it away” and that’s probably the best approach, IF you actually have a good way to fix it. I’ve been a paramedic almost 20 years and we were having the same exact debates back when I started.


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## DesertMedic66 (Oct 14, 2017)

CLCustom1911 said:


> After reading this whole thread, its very interesting and I'll thrown in my 2 cents.
> 
> I'm a cop here in Southern California (been one for almost 9 years). I equate high-risk, high-liability, low-frequency events like intubation as a whole with me getting into an officer involved shooting at work. Usually at minimum, most departments require quarterly range training and qualifications. We are required to know department policy, case law on lethal force, and we watch videos, etc.   All things to either maintain/improve marksmanship, understanding of police, and stay up to date with techniques, tactics, and procedures. Also, mental visualization and mental preparation of using the skill is important.  Like when I am about to pull someone over for a broken tail light, my mind goes  "ok, the nearest tree for cover is right over there. How many are in the car? If they jump out and run, what's the best course of action? If driver jumps out shooting, what's the best course of action....." Etc etc etc.  This thought process happens on ever traffic stop, every time a contact a suspect on the street, every time I go into a 7-11 at 3am. Mental preparation is a HUGE thing.
> 
> ...


I wouldn’t call this move a knee-jerk reaction. We (medics in CA) have seen this coming for a long time. The state has been recording data on it and getting many opinions for and against it for a long time as well. They have been comparing systems who can ETI peds and systems that can’t and finding out who has the best survival rates.  

As of right now there is no good way to get everyone to be proficient. The state can’t really just say “all paramedics must have 24 additional hours of pediatric ETI education with 10 live intubations by May 1, 2018 (they could but that will be a logistical nightmare for systems and companies). They aren’t saying that this skill will be gone forever. It may just be taken away until the state can figure out a way to prove proficiency in it and has established guidelines for LEMSAs and individual companies.


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## CALEMT (Oct 14, 2017)

VentMonkey said:


> not too sure if, or when ICEMA removed it



Just before I started medic school I believe. They also took away procainamide and verapamil.


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## VentMonkey (Oct 14, 2017)

CLCustom1911 said:


> I'm surprised its not required to practice regularly on a mannequin, with and without a bougie, and do some clinical rotations once a year or so with a surgical unit, Watch videos on new techniques, etc etc on these high-risk, high-liability, low-frequency items.


I think you’ve inadvertently nailed the crux of the problem right here. Again, many paramedics cry, whine, or have a “knee-jerked” reaction to skills being taken away, but when was the last time you could put 20 medics in a room who honestly, and wholeheartedly took time of their own to review such things?

I’ve sat through enough refreshers with other paramedics, have listened to their replies, jocularity, and demeanor- none of which leads me to believe most would be so self-motivated. Just because the majority of the people in this thread (and others on this forum) might, it still leaves a proverbial “needle in a haystack” of paramedics nationwide.

My county’s (admittedly temporary) solution was to have all of its paramedics provide a yearly optional skills check off with our re-accreditation. Guess what was on the list? Yep, pediatric intubation...once every six months...on a mannequin...in a classroom setting...with adequate rest, ideal conditions, and nothing like its counterpart: reality.

I don’t know when other paramedics will wake up and stop defining themselves by a skillset, but instead by using their proficiency in deferring such things to specialists in such matters, all while being able to maintain this age groups vitality regardless of the tools given to us. 

Doesn’t that sound more progressive, and professional than arguing over a dead-horse argument in which we are not exactly in a negotiable position with?


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## RocketMedic (Oct 14, 2017)

Losing pediatric intubation itself isn't a terrible concern. Losing the ability to secure a pediatric airway concerns me. I think that an appropriately-diverse selection of supraglottic airways is an appropriate substitute. With that being said, if we're going to have that discussion, I think it's also appropriate to discuss who is being intubated or SGA'd and to what extent are they being prepared and managed?


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## MackTheKnife (Oct 14, 2017)

To improve proficiency, establish an ongoing training program. Say, use dummies, then small animals (baby pigs- used in TCCC), then perhaps a rotation with a CRNA, etc. Don't throw the baby out with the bathwater because some can't hack it. No pun intended.


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## TXmed (Oct 14, 2017)

While i am all in favor for prehospital intubation, pedi ET less than 8yrs old is a rarely performed skill. And even if youre highly proficient the complications of tube extubation, right mainstem, and lung injury from high tidal volumes in the prehospital setting remain a high possibility. I believe some of the studies being put out with pedi LMA's are showing good results.


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## RocketMedic (Oct 15, 2017)

^this. I'm not opposed to not performing it if there are better options out there, but I am opposed to wholesale slashing of potentially lifesaving interventions from the realm of the possible. Why not simply keep it as a reserve intervention?


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## Qulevrius (Oct 15, 2017)

RocketMedic said:


> Why not simply keep it as a reserve intervention?



Because the **** swinging is already out of control.


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## DesertMedic66 (Oct 15, 2017)

RocketMedic said:


> ^this. I'm not opposed to not performing it if there are better options out there, but I am opposed to wholesale slashing of potentially lifesaving interventions from the realm of the possible. Why not simply keep it as a reserve intervention?


Why would we keep it as a reserve intervention if we are unable to properly preform the skill and/or are unable to correctly know when to utilize the skill?


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## VFlutter (Oct 15, 2017)

Wouldn’t it be great if every police officer was SWAT or every soldier was in Special Forces? High quality training is a limited resource and is not feasible for everyone. And once you are trained, you still need frequent exposure to maintain proficiency. And some people are just more competent than others. 

Just because it is a necessary or lifesaving skill does not mean that every paramedic should be able to perform it. Limit it to a small group of providers who are able to maintain that competency. It’s a hard enough task just getting a pediatric OR spots for speciality teams.


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## RocketMedic (Oct 15, 2017)

Why does it need to be specialty "live pediatric intubation" training? Make it a last line, med- control intervention or give y'all definitive alternatives like a real crike


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## TXmed (Oct 15, 2017)

RocketMedic said:


> Why does it need to be specialty "live pediatric intubation" training? Make it a last line, med- control intervention or give y'all definitive alternatives like a real crike



Because its a low exposure and high risk skill that when done correctly has plenty of benefits, but there are also plenty of lower risk work arounds or temporizing measures. 

I also dont think every ER doctor should be able to RSI a pediatric unlesd they have annual to bi-annual training for it. So my opinion isnt just related to paramedics only.


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## VentMonkey (Oct 15, 2017)

Isn’t the pediatric age cut off for emergency cric right around 11 anyhow, given their underdeveloped anatomy? 

That said, LMA’s are supposed to be one of the more proficient of the SGA’s, and come in pediatric sizes IIRC. I also think surgical cric truly is the only way to go when given a choice between that, or a 10 gauge needle; a no brainer really.


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## TXmed (Oct 16, 2017)

@VentMonkey ive seen protocols say 12yrs and ive seen 10yrs. I recently listened to a smacc podcasts where a pedi ENT doc said he would go much younger for the cric as you can just cut through the cartilidge to make the whole bigger. And i beleive the little information that is availavle for needle cric is not very positive.


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## jwk (Oct 16, 2017)

Remi said:


> @MackTheKnife and @RocketMedic, you guys both do a good job presenting anecdotes and “what if” scenarios that support the idea of pediatric intubation. You both provide good service to the hypothesis that pediatric intubation is a beneficial intervention.
> 
> However, at the end of the day, your arguments all rest solidly on the premise that prehospital pediatric intubation actually works as intended. But the reality is.......it doesn’t. Many studies - not one, not two, but many - tell us pretty much the same thing.
> 
> ...


Common sense.  Love it!


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## RocketMedic (Oct 16, 2017)

Chase, you're right in that we are not all SF commando Delta operators. However, what CA EMSA is doing is essentially banning the door kick for anyone who isn't, based on potential risk. I don't think we ought to be doing unfacilitated intubation on many kids, particularly with the mindset and tools of the average CA medic. I also don't think a state level ban is the right answer either.

CA folks, what alternatives are y'all fielding?


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## DesertMedic66 (Oct 16, 2017)

RocketMedic said:


> Chase, you're right in that we are not all SF commando Delta operators. However, what CA EMSA is doing is essentially banning the door kick for anyone who isn't, based on potential risk. I don't think we ought to be doing unfacilitated intubation on many kids, particularly with the mindset and tools of the average CA medic. I also don't think a state level ban is the right answer either.
> 
> CA folks, what alternatives are y'all fielding?


We are banning the door kick for officers who have proven that when they door kick the door open they get shot or fail to actually be able to kick the door in. We have proven time and time again that as a whole we are not able to correctly tube pediatrics. 

Most areas are using Kings or some other form of SGA.


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## EpiEMS (Oct 16, 2017)

DesertMedic66 said:


> We have proven time and time again that as a whole we are not able to correctly tube pediatrics.


Not to mention...ETI doesn't demonstrate any patient survival advantage over BVM.


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## VentMonkey (Oct 16, 2017)

RocketMedic said:


> CA folks, what alternatives are y'all fielding?


Dunno about the other counties, but we haven’t gotten that far in mine yet. I don’t even know that the official state memo has come down the pipeline to our county EMS department. I can certainly ask our medical director next time I see him.

On a related note, is anyone out there effectively using pediatric BVM’s to ventilate adults? I know there’s a push in some circles given the lower Vt’s. 

Admittedly, I sometimes still catch myself having to imagine tying one arm behind my back when ventilating an adult with an adult BVM.


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## RocketMedic (Oct 16, 2017)

I just don't squeeze the bag fully...


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## EpiEMS (Oct 16, 2017)

VentMonkey said:


> On a related note, is anyone out there effectively using pediatric BVM’s to ventilate adults? I know there’s a push in some circles given the lower Vt’s.



Certainly seems to work in a simulation setting (and also among Aussie medic students, and German physicians).

(RogueMedic was talking about this back in 2008...woah)


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## vc85 (Oct 16, 2017)

Aren't most SGA's contraindicated in people under 16? 

Also, what are you going to tell a parent when there is no flight medic or pre hospital RN available and the trauma center is >1 hour away in the rare cases where intubation is truly required?  "Sorry you're kid is going to die and there is nothing I'm allowed to do about it"  Talk about a scene safety issue developing


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## StCEMT (Oct 16, 2017)

VentMonkey said:


> On a related note, is anyone out there effectively using pediatric BVM’s to ventilate adults? I know there’s a push in some circles given the lower Vt’s.
> 
> Admittedly, I sometimes still catch myself having to imagine tying one arm behind my back when ventilating an adult with an adult BVM.


I've debated bringing that into practice considering the regularity I am running arrests, it would give me one less thing to have to keep track of. I haven't personally tried it yet though.


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## Qulevrius (Oct 16, 2017)

vc85 said:


> Aren't most SGA's contraindicated in people under 16?
> 
> Also, what are you going to tell a parent when there is no flight medic or pre hospital RN available and the trauma center is >1 hour away in the rare cases where intubation is truly required?  "Sorry you're kid is going to die and there is nothing I'm allowed to do about it"  Talk about a scene safety issue developing



This is the 1st time that I hear about LMAs being contraindicated based on age subset. Just for the record, there are 16 y.o. (and younger) patients who are bigger than adults, and in their case the contraindication is morbid obesity, not their age. And even that can be accommodated with a sheet/towel roll between shoulder blades.

If I’ll ever have to work for a rural system with <1hr transport times and no HEMS div, I might as well carry a pepper spray. Or a tazer.


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## RocketMedic (Oct 17, 2017)

There are SGAs available for pediatric patients. They're just not commonly issued to us in the field because pediatric intubation is exceedingly rare.


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## E tank (Oct 17, 2017)

StCEMT said:


> I've debated bringing that into practice considering the regularity I am running arrests, it would give me one less thing to have to keep track of. I haven't personally tried it yet though.



Interesting point. Adult BVM's are just manufactured too large, IMO. You could almost ventilate horses with them.  That is something that manufacturers should re-examine. Smaller tidal volumes for lung protection aside, just the effect of big breaths on cardiac output should be enough for some introspection on the subject by all of us.


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## StCEMT (Oct 17, 2017)

E tank said:


> Interesting point. Adult BVM's are just manufactured too large, IMO. You could almost ventilate horses with them.  That is something that manufacturers should re-examine. Smaller tidal volumes for lung protection aside, just the effect of big breaths on cardiac output should be enough for some introspection on the subject by all of us.


I listened to Eric Bauer's podcast on this and that is what got me contemplating it. 1. for the cardiac output and 2. for lung protection. In hindsight, I've had some arrests in places that were not ideal and in the whole juggling act I've found little things I could have definitely done better. Being able to remove one variable (mostly) would be nice. I definitely think it is one part of how we manage airways that deserves more thought and attention, I've seen some pretty weird stuff with BVM's.


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## E tank (Oct 17, 2017)

StCEMT said:


> I listened to Eric Bauer's podcast on this and that is what got me contemplating it. 1. for the cardiac output and 2. for lung protection. In hindsight, I've had some arrests in places that were not ideal and in the whole juggling act I've found little things I could have definitely done better. Being able to remove one variable (mostly) would be nice. I definitely think it is one part of how we manage airways that deserves more thought and attention, I've seen some pretty weird stuff with BVM's.


Well all things being equal, I'm less concerned about us and the way we hand ventilate than I am about folks that don't manage airways as a part of their job, whether that is a fireman, non CC RN or whomever. The bag is a liter and a half so that must mean I give liter and a half breaths...so goes the assumption...


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## Carlos Danger (Oct 17, 2017)

vc85 said:


> Also, what are you going to tell a parent when there is no flight medic or pre hospital RN available and the trauma center is >1 hour away in the rare cases where intubation is truly required?  *"Sorry you're kid is going to die and there is nothing I'm allowed to do about it" * Talk about a scene safety issue developing



Or, if you really had to go there at all - which of course you don't - you could at least be ethical and intellectually honest and tell the whole story, rather than just the part that paints the picture you'd like people to believe. "Sorry, your kid is going to die and there's nothing I'm allowed to do about it *because the intervention that I have in mind has not been shown to improve outcomes and might cause even more serious harm to your kid"*.

Seriously though, why all the drama? Most of us will go our whole career without ever encountering a scenario where an ET tube is the difference between the life and death of a child. Why do we think it is makes sense to focus on the very rare (the times when intubation is really needed) and completely ignore the much more common (the times that pediatric ETI results in complications, or at least does not help)?


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## vc85 (Oct 17, 2017)

That brings up a pretty interesting ethical debate not just in this situation 

If a patient is in extremis or already clinically dead; is it better to not do an intervention that has a risk of harm or no benefit  or is it better to do the intervention on the .0001percent chance it would work. 

Obviously is it out of protocol the decision is made, but what if the intervention was still in protocol?


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## VFlutter (Oct 17, 2017)

Clinically dead? Why are you worried about intubation at that point anyway. There is a reason intubation keeps moving down the list in ACLS

We could go around and around with this. Should we resuscitate every traumatic arrest because it may save .001%? Field thoracatomy? I mean they are dead and it may help...

Sorry but that type of thinking is based off emotion and not evidence. At some point we have to play the numbers game and make decisions that don’t feel good but are the most logical. Even if it could have potentially saved a little kid that could grow up to cure cancer.


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## EpiEMS (Oct 18, 2017)

vc85 said:


> If a patient is in extremis or already clinically dead; is it better to not do an intervention that has a risk of harm or no benefit or is it better to do the intervention on the .0001percent chance it would work.



Here's another variable. What if the intervention is very expensive (or very cheap)? How does that change your willingness to do it?


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## Carlos Danger (Oct 18, 2017)

EpiEMS said:


> Here's another variable. What if the intervention is very expensive (or very cheap)? How does that change your willingness to do it?



My guess is that cost is a very minor factor - if a factor at all - in the minds of most EMS providers.


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## EpiEMS (Oct 18, 2017)

Remi said:


> My guess is that cost is a very minor factor - if a factor at all - in the minds of most EMS providers.



Absolutely, if unfortunately, true.


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## StCEMT (Oct 18, 2017)

Remi said:


> My guess is that cost is a very minor factor - if a factor at all - in the minds of most EMS providers.


It is a reason I dislike the "transport everyone, cuz liabilities." mindset. I get some people don't care since they really aren't going to pay anything. However I try to help the regular folks at least be aware of their options and a general idea of what they include.


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## E tank (Oct 18, 2017)

EpiEMS said:


> Here's another variable. What if the intervention is very expensive (or very cheap)? How does that change your willingness to do it?



Sooner or later, training and experience needs to inform reasonable treatment decisions. It's a professional thing.  Also, it begs the question as to the motivation of the person attempting futile effort.


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## EpiEMS (Oct 18, 2017)

E tank said:


> Sooner or later, training and experience needs to inform reasonable treatment decisions. It's a professional thing.



One would think, but healthcare workers perform all kinds of futile (or actively harmful) care, no?


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## E tank (Oct 18, 2017)

EpiEMS said:


> One would think, but healthcare workers perform all kinds of futile (or actively harmful) care, no?



And their professional reputation suffers for it too...


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## aquabear (Oct 19, 2017)

EpiEMS said:


> Not to mention...ETI doesn't demonstrate any patient survival advantage over BVM.


Congrats on reading the abstract.

Gausche wanted to limit prehospital intubation and designed this study to fail, and how did she do it? By conducting it in one of the poorest clinically run EMS systems in the country. Yes, you guessed it, Los Angeles County. The same county had had adult intubation for less than 10 years prior to this study and has provider agencies who routinely “draft” people for paramedic school.

In her study she writes, “Paramedics were trained to mastery of all skills.” Do you know how long according to Dr. Gausche it takes to master pediatric ETI?

6 hours.

The icing on the cake, the instruction was led by RN’s. Not CRNAs, or Anesthesiologists, or Pediatricians, or ER MDs, but RNs.

*end rant*


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## RocketMedic (Oct 19, 2017)

aquabear said:


> Congrats on reading the abstract. Gausche wanted to limit prehospital intubation and designed this study to fail, and how did she do it? By conducting it in one of the poorest clinically run EMS system in the country. Yes, you guessed it, Los Angeles County. The same county had had adult intubation for less than 10 years prior to this study and has provider agencies who routinely “draft” people for paramedic school.
> 
> In her study she writes, “Paramedics were trained to mastery of all skills.” Do you know how long according to Dr. Gausche it takes to master pediatric ETI?
> 
> ...


 
^this. The study was never intended to be successful.


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## aquabear (Oct 19, 2017)

RocketMedic said:


> ^this. The study was never intended to be successful.


Unfortunately this is the only major study on pediatric ETI and EVERYONE cites it as to why they don’t want prehospital pediatric ETI. 

Ideally, it should be redone in a system with more experienced intubators, who have access to DSI/RSI, and modern equipment (VL, capnography, etc).

But I’m just a paramedic. What do I know???


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## DesertMedic66 (Oct 19, 2017)

aquabear said:


> Congrats on reading the abstract.
> 
> Gausche wanted to limit prehospital intubation and designed this study to fail, and how did she do it? By conducting it in one of the poorest clinically run EMS systems in the country. Yes, you guessed it, Los Angeles County. The same county had had adult intubation for less than 10 years prior to this study and has provider agencies who routinely “draft” people for paramedic school.
> 
> ...


To be fair that is about the majority of ETI training for CA. Ours was taught by street medics with no degrees and no advanced training aside from ACLS and maybe PALS.


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## Carlos Danger (Oct 19, 2017)

aquabear said:


> Congrats on reading the abstract.
> 
> Gausche wanted to limit prehospital intubation and designed this study to fail, and how did she do it? By conducting it in one of the poorest clinically run EMS systems in the country. Yes, you guessed it, Los Angeles County. The same county had had adult intubation for less than 10 years prior to this study and has provider agencies who routinely “draft” people for paramedic school.
> 
> ...





RocketMedic said:


> ^this. The study was never intended to be successful.





aquabear said:


> Unfortunately this is the only major study on pediatric ETI and EVERYONE cites it as to why they don’t want prehospital pediatric ETI.
> 
> Ideally, it should be redone in a system with more experienced intubators, who have access to DSI/RSI, and modern equipment (VL, capnography, etc).
> 
> But I’m just a paramedic. What do I know???



I have a few thoughts on all this. I'll bullet point my comments to try to keep them concise:

First, @RocketMedic, the "success" of a study shouldn't be based on whether or not it ends up indicating what you want it to. Conversely, just because you don't like the outcome of an investigation doesn't mean that the project was "unsuccessful". 

@aquabear, while I can't comment either way on Gausche's motivations because I don't know the first thing about her, I don't think there is a case to be made based on the merits of the study itself that she had nefarious intentions, because the study itself was well done. A simple, straightforward RCT with pretty unambiguous findings, and it showed what it showed. It is exactly what we need a lot more of in EMS.

It isn't really an argument that the study is somehow invalid just because it was done in SoCal and SoCal EMS sucks. Whether it is true or not that SoCal EMS sucks, this was a fairly large, well-done study done in the second-largest metro area in the US, arguably the birthplace of American ALS, using fully trained and certified EMT-Paramedics. 

It also isn't an argument that the study is invalid just because it included "only" six hours of training. Again, these were fully trained and certified paramedics to begin with, right? It isn't like they took laypeople off the street, gave them a six hour crash course in airway management, and then drew conclusions about paramedic airway management based on how the laypeople performed. As for the RN thing: that alone also means nothing. Were they PICU RN's who do pediatric airway management daily? Were they flight nurses who do pediatric transports? If they were just run-of-the-mill-RN's with no pediatric airway experience themselves, then I'd agree it's weak training. But if that type of training is customary in that EMS system, then it might be an appropriate thing to do.   

Lastly, this is far from the only study to come to this conclusion. It is the only prospective trial that I'm aware of, but there have been plenty of other retrospective studies that essentially back this one up. The study that was published in Resuscitation in 2015 looked at data from the 2012 NEMSIS database that included over 42,000 pediatric airway encounters across 40 states and was pretty damning in it's findings. Another one just came out in Resuscitation and used data from the CARES registry and showed better outcomes when pediatric cardiac arrests got BVM instead of either ETI or SGA.


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## StCEMT (Oct 19, 2017)

I'll defer to @Remi when it comes to airway studies since that is his lane. 

I get your point about using a not so reputable EMS agency as a source. However, I think we all realize that sometimes protocols have to cater to the weakest links in our career field. Might not reflect the majority here since I don't think there is one regular on this site who doesn't value furthering our knowledge. Not everyone is like that and unfortunately that means the tenured members here can't be the baseline of our scope. I may wish that I had a little more in my intubation protocol if I am going to have it, but since I don't, I am comfortable enough with my knowledge that I can and have managed airways with just a BVM, an OPA/NPA, and a second set of hands on more than one occasion.


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## Tigger (Oct 20, 2017)

I'm always going back and forth on the one size fits all approach. We're a pretty small service (13 paramedics). There is a lot of peer accountability when it comes to education and competencies. For better (and sometimes worse) airway management is at the top of the list when it comes to intra-agency policing. We have the equipment needed for frequent (monthly at least) practice with a variety of airway management. We have some highly experienced paramedics with significant educational backgrounds. We bring docs in for continuing education whenever possible. We are not a typical service, and I understand that. If this skill were to be beneficial (and there are times that it might be), I am reasonably confident that all of our paramedics could properly manage a pediatric airway. I can't prove my position. But I really do believe that our people will do the right thing, just as they have consistently done the right when it comes to managing adult airways. We have not had a failed airway in years. We have patients who were not intubated despite attempts, but they were properly managed and alternative strategy was implemented. We carry peds iGels and can do surgical crics down to 8yo. People here know what their options are. Do they need to lose one of them? If the pediatric intubation is not helpful, then yes, but to me showing that it doesn't improve outcomes is what matters.


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## EpiEMS (Oct 20, 2017)

aquabear said:


> The same county had had adult intubation for less than 10 years prior to this study



This is (well, more or less - she claims >10) acknowledged in the language of the study:


> Adult ETI has been within the paramedic scope of practice in both counties for more than 10 years and BVM for almost 30 years.



It certainly seems like a relevant consideration, but these are folks trained as paramedics...not to mention they received another (albeit brief) set of sessions....

We all know LA & LACo's problems. This is still the best study we've got on the subject, and the findings are corroborated by countless others.


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## Bullets (Oct 20, 2017)

aquabear said:


> Congrats on reading the abstract.
> 
> Gausche wanted to limit prehospital intubation and designed this study to fail, and how did she do it? By conducting it in one of the poorest clinically run EMS systems in the country. Yes, you guessed it, Los Angeles County. The same county had had adult intubation for less than 10 years prior to this study and has provider agencies who routinely “draft” people for paramedic school.
> 
> ...


Also, isnt this study A.) Kinda a small sampling? and B.) Old?

When i was doing my graduate thesis we were not allowed to use any study that was 10+years old. The department felt that science has advanced far enough in 10 years that if you were to attempt to recreate that study now the methodology would have changed to provide different results.


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## VentMonkey (Oct 20, 2017)

EpiEMS said:


> This is (well, more or less - she claims >10) acknowledged in the language of the study:
> 
> 
> It certainly seems like a relevant consideration, but these are folks trained as paramedics...not to mention they received another (albeit brief) set of sessions....
> ...


But do we, really? Even those who have never set foot in California, or that county, but judge it freely from the outside?

I think I’ve made my position on this subject pretty clear, but with that said, yes it’s really hard to know exactly how _intentionally_ one-sided (or not) this rather dated study really is. I do know it’s a fairly notorious one anytime anything airway related comes up in SoCal circles with regard to “why LA County medics can’t intubate”. I’ve even heard, and seen people attempt to cite San Diego’s RSI trial as a reason as to why things turned out so lopsided here.

Having spent entirely too much time around the paramedic firefighters in Los Angeles County the fact of the matter is that they don’t practice paramedicine in any way, shape, or form. I have seen guys literally hop in the back of ambulances while gam-gam is CTD, but followed in as routine with maybe an IV? you can forget airway attempts. This is an adult patient mind you.

If their efforts are so endlessly inept, how couldn’t they be proven anything but in a study? Someone else mentioned there are more studies out there, which I’m sure there are.

Oh, and yes in, Los Angeles all medics are trained by nurses, or former nurses. Many of whom are or were in EM. The schools churning these guys out barely skim by the minimum amount of hours and seem to do all but a “refer to the MICN/ base hospital” for just about all things, so yeah, not so good at such a specialty.


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## EpiEMS (Oct 20, 2017)

@VentMonkey, I'm a little confused - do you mean to say that the (low) quality of most LA medics is a problem for the study's validity? Or perhaps I'm missing the thrust of your comment?


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## Qulevrius (Oct 20, 2017)

VentMonkey said:


> Having spent entirely too much time around the paramedic firefighters in Los Angeles County the fact of the matter is that they don’t practice paramedicine in any way, shape, or form. I have seen guys literally hop in the back of ambulances while gam-gam is CTD, but followed in as routine with maybe an IV? you can forget airway attempts. This is an adult patient mind you.



Case in point - this just in (or rather, a night ago): a 67 y.o. with rr of 34 & audible wheezing, literally turning blue in front of us. These clowns check her blood glucose - ‘just in case because, ya know, there’s no hx of DM’ (with a bottle of Metformin sitting on gurney) and then send her BLS with a chief of N/V.


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## VentMonkey (Oct 20, 2017)

EpiEMS said:


> @VentMonkey, I'm a little confused - do you mean to say that the (low) quality of most LA medics is a problem for the study's validity?


What I’m saying is that this study has been quite the repetitively cited argument for, and against any intubations in general in the SoCal areas, along with (as mentioned) the SD RSI trial.

I don’t know much about the specifics of the SD trial, I do know enough to undoubtedly say that utilizing this (Los Angeles’) county’s paramedics as an example for a study is going to produce a very lopsided outcome. I am speaking from firsthand experience with their paramedics.

Edit: exactly what @Qulevrius said. Nothing has changed, even 10 years later.


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## RocketMedic (Oct 20, 2017)

Qulevrius said:


> Case in point - this just in (or rather, a night ago): a 67 y.o. with rr of 34 & audible wheezing, literally turning blue in front of us. These clowns check her blood glucose - ‘just in case because, ya know, there’s no hx of DM’ (with a bottle of Metformin sitting on gurney) and then send her BLS with a chief of N/V.



Wow. That is _terrible_ care, and it's setting your BLS element up for failure, and your patient up for _death_.


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## Qulevrius (Oct 20, 2017)

RocketMedic said:


> Wow. That is _terrible_ care, and it's setting your BLS element up for failure, and your patient up for _death_.



NRB @ 15LPM on her as soon as the doors closed, 5 min transport to ER, BPAP within 2 min of hitting the ER. The RNs know exactly who they deal with and the engine’s got written up. They tried to play the language barrier card since the pt was Hindu only but ffs, if I was able to communicate with her via hand signs, they have zero excuses.


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## EpiEMS (Oct 20, 2017)

VentMonkey said:


> I don’t know much about the specifics of the SD trial, I do know enough to undoubtedly say that utilizing this (Los Angeles’) county’s paramedics as an example for a study is going to produce a very lopsided outcome. I am speaking from firsthand experience with their paramedics.



That's absolutely a fair criticism. Of course, considering that EMS providers aren't doing much in the pediatric airway management realm (low number of cases) and have fairly low success rates when they do (this is partly due to low frequency, I imagine), I'd be very suspicious of whether you'd get different results outside of LA...

(While there isn't a ton of pediatric specific evidence on ETI...there is a lot for adults. Not sure if it's worth bringing that into this discussion.)


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## VentMonkey (Oct 20, 2017)

@EpiEMS I think the discussion I have seen in this thread is more of we as whole (regardless of state lines) do not need to fiddle around with advanced pediatric airway management-vs.-we should take the time to properly train paramedics for this particular skill.

I personally can’t imagine any paramedic program, or EMS service aside from one who is doing specifically high-risk pediatric call volumes, being where they need to be in terms of both competence, and confidence with the kiddos. 

Again, if advanced airway placement in the pediatric population is repeatedly showing to be a detriment in the prehospital setting, what on God’s green earth are we trying to accomplish with the one patient population that deserves probably the best we can give them?

Waiver- completely not implying every patient doesn’t deserve this kind of care.


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## EpiEMS (Oct 20, 2017)

@VentMonkey I think you're spot on here.


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## VentMonkey (Jan 2, 2018)

Pediatric ETI was officially removed from our protocols today. All peds ETI equipment is being pulled from our ambulances.


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## DesertMedic66 (Jan 2, 2018)

VentMonkey said:


> Pediatric ETI was officially removed from our protocols today. All peds ETI equipment is being pulled from our ambulances.


So now the only people, prehospital wise, who can intubate a pediatric patient are flight nurses


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## CALEMT (Jan 2, 2018)

DesertMedic66 said:


> So now the only people, prehospital wise, who can intubate a pediatric patient are flight nurses



I could probably look this up myself but I’m feeling lazy at the moment. Does this mean our protocol will change from greater than 8 yrs of age?


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## DesertMedic66 (Jan 2, 2018)

CALEMT said:


> I could probably look this up myself but I’m feeling lazy at the moment. Does this mean our protocol will change from greater than 8 yrs of age?


I haven’t heard anything about that changing.


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## RocketMedic (Jan 2, 2018)

I'm guessing pediatric supraglottics are not replacing the tubes...


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## CALEMT (Jan 2, 2018)

DesertMedic66 said:


> I haven’t heard anything about that changing.



Not until April when the new revisions come out.


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## VentMonkey (Jan 2, 2018)

RocketMedic said:


> I'm guessing pediatric supraglottics are not replacing the tubes...


I should clarify and expand a bit. The adjuncts required for FBAO removal will all remain in our airway itinerary. Our cut off for ETI by protocol definition is 14 years old, and yes, assuming we have a pediatric patient who can successfully “accept” an SGA, that is sufficient.

Specifically, I have only heard speculation of our county medical director pushing for pediatric friendly SGA’s such as LMA’s and i-gel’s. I will ask him directly next time I see him, I can’t imagine he is opposed. He’s fairly open-minded, approachable, and certainly EMS-friendly.


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## DesertMedic66 (Jan 2, 2018)

CALEMT said:


> Not until April when the new revisions come out.


I still don’t think that is going to change. I don’t see the county holding out until then to remove or change that from the protocols. 

In April they will probably announce the Ketamine trial study we are supposed to be entering, an update on the TXA trial, I wouldn’t be surprised if there was an update to the APOD policy, and the normal ImageTrends information, and probably an EVOC update.


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## CALEMT (Jan 2, 2018)

DesertMedic66 said:


> I still don’t think that is going to change.



Same here, but at the same time you wonder. I am excited for the Ketamine trial study.


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## Carlos Danger (Jan 2, 2018)

RocketMedic said:


> I'm guessing pediatric supraglottics are not replacing the tubes...


That would be shame. I can't think of any reason not to.


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## RocketMedic (Jan 3, 2018)

What are y'all doing with ketamine?


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## DesertMedic66 (Jan 3, 2018)

RocketMedic said:


> What are y'all doing with ketamine?


Hasn’t been fully announced yet as to what the study is geared towards and/or who will be excluded (patient wise) from the trial study. All we have been told is “hey guys, we might/are supposed to start a trial study”. They do a horrible job at giving us a heads up and instead will have us sit in a meeting and say “hey guys, we now have Ketamine. We can only use it for these selected items. Here is a test that the majority of our medics can’t pass because they can’t process new information”.


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## RocketMedic (Jan 3, 2018)

Ketamine for pain is awesome. Same for ED


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## DesertMedic66 (Jan 3, 2018)

RocketMedic said:


> Ketamine for pain is awesome. Same for ED


It could be used for both and I really hope so but I highly doubt it. We have morphine and Fentanyl for pain and Versed for ED, however we are having a lot of issues with that protocol as of right now.


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## Tigger (Jan 3, 2018)

DesertMedic66 said:


> It could be used for both and I really hope so but I highly doubt it. We have morphine and Fentanyl for pain and Versed for ED, however we are having a lot of issues with that protocol as of right now.


Versed is not particularly suitable for true excited delirium.


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## DesertMedic66 (Jan 3, 2018)

Tigger said:


> Versed is not particularly suitable for true excited delirium.


It has actually worked pretty well in my experience. What makes it not suitable? The main issue we have is that our medics like to call everything ED even if the patient meets none of the classic signs of it. For that reason there is talk about removing it from our standing orders.


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## E tank (Jan 3, 2018)

DesertMedic66 said:


> It has actually worked pretty well in my experience. What makes it not suitable? The main issue we have is that our medics like to call everything ED even if the patient meets none of the classic signs of it. For that reason there is talk about removing it from our standing orders.



There can be some disinhibition in the elderly with versed, which can make things a little worse. But with regard to ketamine...a very useful drug but there will be those folks that will experience the intense dysphoria. I'd hope that something like versed or even valium would be given with it. 

It fell out of favor and actually earned a notorious reputation and early in my career, very few people would touch it. Once folks realized smaller doses with an anxiolytic with it were very effective, the reputation faded from institutional memory. 

The last thing we'd want is to rekindle that bad reputation because it wasn't used with something else to dull the edge. 

My opinion.


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## Tigger (Jan 3, 2018)

DesertMedic66 said:


> It has actually worked pretty well in my experience. What makes it not suitable? The main issue we have is that our medics like to call everything ED even if the patient meets none of the classic signs of it. For that reason there is talk about removing it from our standing orders.


A true excited delirium patient needs a whole lot of Versed. Probably more Versed than I am comfortable giving without risking significant respiratory depression. Ketamine does that have that untoward side effect and also appears to last longer. For someone that's extremely agitated I will start with Versed, but ED with adrenergic agitation is something that needs to be dealt with now and a single dose of 5mg/kg of ketamine stops nearly everyone's reaction. Versed on the other hand seems to be a lot more patient specific and I don't want to wait around and see which dose of Versed is going to work. I get that it _might_ work, but there are just better options with less of a side effect profile.


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## DesertMedic66 (Jan 3, 2018)

Tigger said:


> A true excited delirium patient needs a whole lot of Versed. Probably more Versed than I am comfortable giving without risking significant respiratory depression. Ketamine does that have that untoward side effect and also appears to last longer. For someone that's extremely agitated I will start with Versed, but ED with adrenergic agitation is something that needs to be dealt with now and a single dose of 5mg/kg of ketamine stops nearly everyone's reaction. Versed on the other hand seems to be a lot more patient specific and I don't want to wait around and see which dose of Versed is going to work. I get that it _might_ work, but there are just better options with less of a side effect profile.


Unfortunately we are only able to use Versed. So it’s either Versed or nothing for our ED patients.


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## Tigger (Jan 3, 2018)

DesertMedic66 said:


> Unfortunately we are only able to use Versed. So it’s either Versed or nothing for our ED patients.


That's too bad. It seems like it's hard to get the EMSAs (I think) to the right thing. Poor protocols don't excuse poor care and it's unfortunate that they handcuff providers so badly. Hopefully they will at least require pedi SGAs.


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## DesertMedic66 (Jan 3, 2018)

Tigger said:


> That's too bad. It seems like it's hard to get the EMSAs (I think) to the right thing. Poor protocols don't excuse poor care and it's unfortunate that they handcuff providers so badly. Hopefully they will at least require pedi SGAs.


We shall find out. In my county we have only been carrying King size 3,4,5 and we haven’t had Pedi intubation in well over 7 years. In the county next to us they carry King 2, 2.5, 3, 4, 5 and they just took pedi intubation out. The most odd thing is that both of these counties have the same exact county medical director...


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## CALEMT (Jan 3, 2018)

DesertMedic66 said:


> The most odd thing is that both of these counties have the same exact county medical director...



Yet same but different protocols.


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## Qulevrius (Jan 4, 2018)

DesertMedic66 said:


> Unfortunately we are only able to use Versed. So it’s either Versed or nothing for our ED patients.



It’s the same for us. Which is funny in a sad way, because per protocols it’s 0.1mg/kg with max at 5mg (adults get 5mg flat, unless less than 50kg), but we very commonly see ED or AD patients that are virtually unaffected by Versed.


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## RocketMedic (Jan 4, 2018)

I really like ketamine for its ability to abort the fight quickly. Less chance of something going wrong.


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