California Pediatric Intubation

MackTheKnife

BSN, RN-BC, EMT-P, TCRN, CEN
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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.
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.
 

MackTheKnife

BSN, RN-BC, EMT-P, TCRN, CEN
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I don't think they know what they're doing with adults, let alone kids...
LOL! The state of modern affairs.!!!!!!!
 

MackTheKnife

BSN, RN-BC, EMT-P, TCRN, CEN
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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).
 

MackTheKnife

BSN, RN-BC, EMT-P, TCRN, CEN
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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].
You perhaps noticed I mentioned the lack of a cuff???????
 
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DesertMedic66

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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.
 

Qulevrius

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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.
 

RocketMedic

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Do they have pediatric supraglottics coming onto the trucks instead?
 

VentMonkey

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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.
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

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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.

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.
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
 

MackTheKnife

BSN, RN-BC, EMT-P, TCRN, CEN
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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!
 

GMCmedic

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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

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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.

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.
 

Qulevrius

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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 ?
 

RocketMedic

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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

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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.
 

MackTheKnife

BSN, RN-BC, EMT-P, TCRN, CEN
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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.
Bravo! Couldn't have said it better!
 

RocketMedic

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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.
 

CLCustom1911

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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.
 

Carlos Danger

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@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

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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.
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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