California Pediatric Intubation

[CALEMT]

not too sure if, or when ICEMA removed it

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

 

[VentMonkey]

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?

 

[RocketMedic]

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?

 

[MackTheKnife]

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.

 

[TXmed]

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.

 

[RocketMedic]

^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?

 

[Qulevrius]

Why not simply keep it as a reserve intervention?

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

 

[DesertMedic66]

^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?

 

[VFlutter]

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.

 

[RocketMedic]

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

 

[TXmed]

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.

 

[VentMonkey]

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.

 

[TXmed]

@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.

 

[jwk]

@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.

Common sense. Love it!

 

[RocketMedic]

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?

 

[DesertMedic66]

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.

 

[EpiEMS]

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.

 

[VentMonkey]

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.

 

[RocketMedic]

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

 

[EpiEMS]

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)