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.
