California Pediatric Intubation

[DesertMedic66]

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*

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.

 

[Carlos Danger]

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*

^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???

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.

 

[StCEMT]

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.

 

[Tigger]

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.

 

[EpiEMS]

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.

 

[Bullets]

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*

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.

 

[VentMonkey]

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....

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.

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.

 

[EpiEMS]

@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?

 

[Qulevrius]

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.

 

[VentMonkey]

@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.

 

[RocketMedic]

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.

 

[Qulevrius]

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.

 

[EpiEMS]

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.)

 

[VentMonkey]

@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.

 

[EpiEMS]

@VentMonkey I think you're spot on here.

 

[VentMonkey]

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

 

[DesertMedic66]

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

 

[CALEMT]

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?

 

[DesertMedic66]

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.

 

[RocketMedic]

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