Your aggressiveness

[Dustdevil]

The whole special considerations of pedis aside, AHA has been de-emphasising intubation for years now in all scenarios. Even in a full arrest, they put it way down on the list of priorities. Just following that pattern of thinking along, it becomes pretty obvious where they are headed with that. However, if you have not been watching AHA standards change every two years for the last ten to thirty-five years, I can see how that pattern would not be so obvious. This is one of those situations where just having been around for awhile (not necessarily experience, just longevity) helps your perspective and makes it easier to deduce the "right" answer, or at least the one they want.

There is a fine line between being aggressive and having a hair trigger. Being aggressive can be a very positive thing. It is functioning without hesitation to perform the inevitably necessary without waiting until you are behind the 8-ball to get in gear. It's the ability to foresee what is coming down the pike at you and execute contingencies in a timely fashion. However, on the other side of that fine line is doing things that you "can" do before it is clear that they "should" be done, with the attitude that, if they didn't need it, no big deal. There are things like IVs and O[sub:6679fce627]2[/sub:6679fce627] that you can freely err on the side of caution with. But most other advanced interventions are not so benign, and you have to have more than an aggressive hunch to go on before you take that next step. Intubation is one of those interventions. Intubation is not for every dyspnea, or even every apnea. Intubation is for airway control. That means that, before you sink that tube, you should be able to intelligently articulate the case for it's necessity to airway control well beyond, "well, his sats were low."

It's all about intelligent, educated, critical thinking. Something you don't get out of a 13-week Kalifornia patch factory, or a 10-month Floridia medic mill. While it is tempting to say that this capability eventually comes with experience, the truth is that it doesn't always. In fact, I'd venture to guess that less than half of the medics in this country every become competent at it, regardless of experience.

[VentMedic]

Vent, I did pass PALS, but being the anal-retentive person I am, I want to know WHY I got it wrong. I had instructors with decades of experience telling me that I was correct in my answer as far as the field answer is concerned, but to play, I gotta pass first.

I will look up the protocall next clinical I am on, but going from R36 to R6 very quickly, to me at least, suggests a rapid downhill outcome for my pt, should I not act quickly, and aggressively.

Do you have a link to that study?

Not questioning you, or the study, but I would be interested to see the results.

You got it wrong because you did not answer according to the AHA PALS guidelines. What protocols developed from those guidelines is up to your medical director.

My reference to the study is directly from the PALS book. It is under the BVM part in the airway chapter. The recommendation I posted earlier may have also been part of your packet for current recommendations and changes.

For many paramedics, PALS is about it for advanced life support skills for peds. It would be rare if you are ever given a chance to intubate a child in a controlled situation inside a hospital. Some may not even get the opportunity to intubate a ferret or cat.

Everybody can post one or two "really aggressive" situations but consistency in maintaining skills and education as well as knowing your protocols are better then hearing chest thumping stories which can get as big as the fish they caught sometimes. I learned this after sitting through many Paramedic refresher classes and hearing the same stories from the same people each recert, only more exaggerated than the previous recert. The involvement of your medical director is more important than seeing what the neighbors are doing.

If you want to hear about different comfort zones; in some places RRTs are required at least 100 neonatal intubations before they can even apply for a NICU transport team. Once RNs make the team they are expected to get their number up to that also. And if that RRT also wants to work the PICU transport team, guess what? And then there are many other advanced skills that must be maintained. They should also have a Bachelors degree (A.S. min.) and still must spend hundreds of hours getting more education. These teams allow no room for error and their aggressiveness is hard to beat when it comes to getting a baby or child back to the home base alive from several hundred miles away.

My protocols and "skills competencies" when I am working as a paramedic do not even come close to that. My comfort level is great in the field but I must abide by the protocols of my EMS medical director in the field.

[AnthonyM83]

There are some agencies that should lock the laryngoscopes and ETTs up so their providers can't get ahold of any of them, adult or pediatric. :shock:

Like LA? We had two witnessed cardiac arrests yesterday. One we got to ER parking lot and medic was still insisting to take time to intubate in the crowded van ambulance (en-route only did IV...and she definitely had airway issues...aspirated on her hematemesis)). Second one he spent several minutes without CPR doing his repeated intubation attempts...his partner asked him if he wanted the combitube and reply was "Naw, I don't like those things"....Guess you don't like your patients living, either. Gotta get that tube, right?

Eh, sorry, I'm just ranting again

[AZCEP]

Like LA?

BINGO!

[firedoc5]

Sometimes you have to go with the answer that is more right, and that breaks down to opinion. There were many I worked with that were load & go, and they said I liked to stay & play, too aggressive? I don't' know. I signed up twice for PACS/PALS, once I didn't make it due to kidney stones and the other was canceled due to lack of interest. Luckily there were a couple of docs that took me under their wings and taught me probably just about as much as I would have learned in a class. Peds are always difficult, at least for me.

[captainstandup]

The whole special considerations of pedis aside, AHA has been de-emphasising intubation for years now in all scenarios. Even in a full arrest, they put it way down on the list of priorities. Just following that pattern of thinking along, it becomes pretty obvious where they are headed with that.

Virtually any story that starts with an AHA moniker included is usually troubling at best. I'm sure dust has seen the same trend in dealing with the AHA over this many years, in that they are literally for sale to the highest bidder. One only has to look at the ridiculous science behind the AHA touting of vasopressin and amiodarone over the years to see this clearly!

Then came the LMA and more suspect science but hey the equipment and medication manufacturers received a windfall every time AHA made big changes and ER's and EMS agencies ran out to purchase an entirely new bottle of snake oil.

Little if any verifiable proof ever supported the use of vasopressin and amiodarone and although the LMA is reasonably effective in the OR it's efficacy in a moving vehicle or aircraft is, in my opinion, unacceptable.

Students, especially those from a "patch factory" simply must be cautious in buying into any therapy being hailed as the newest and best thing since the discovery of fire.

There is simply no way to effectively challenge the AHA given the fact it is an organization designed to aid doctors, doctors that prescribe medications to patients, medications from companies that are publicly traded and whose largest shareholders are, of course, doctors. Nice arrangement isn’t it?

Educated providers, such as dust, supported by enlightened physicians make a great deal of difference every day in America and do the right thing for the right reason and based on solid science as opposed to greed or ignorance. Providers should admire and respect these folks and return to school to be worthy of joining their ranks, otherwise we are simply compressing syringes and pushing buttons because an "algorhythm or silly exam said we should"

[Asysin2leads]

I've seen the horrors of paramedics focused too much on getting an intubation, indeed, but I have also seen plenty of providers refuse to administer appropriate care simply because they are either not confident enough in themselves or afraid to perform the appropriate intervention, particularly when it comes to pediatrics.

Of course, the first priority in a pediatric patient should be rapid transport to an appropriate facility. However, given the high incidence of respiratory problems in the critical pediatric patient, coupled with their compensatory mechanisms, if a pediatric patient needs to be intubated, they should be intubated immediately, not after we call telemetry, not after BLS has its say, not after we wait and see if they get better. A pediatric that needs intubating should have it performed ASAP, and there are few very good excuses why it should not take place in the field, when it is warranted.

[jwraider]

I just took PALS also... The protocols I will use during my internship echo what was taught which is "do not intubate if a BLS airway is adequate"

I wish there was more info on why pediatric intubations were discouraged or harmful that would help with understanding when to be aggressive or not.

Is it due to provider lack of experience with the procedure? Poor application of the procedure leading to trauma or hypoxia? Or is there a longterm problem?

[CBEMT]

Is it due to provider lack of experience with the procedure? Poor application of the procedure leading to trauma or hypoxia?

Yes. But, in addition, most providers halt CPR during a procedure that they're not good enough at in adults, nevermind kids. So they take too long, and as we should already know, no CPR = no chance.

[VentMedic]

I just took PALS also... The protocols I will use during my internship echo what was taught which is "do not intubate if a BLS airway is adequate"

I wish there was more info on why pediatric intubations were discouraged or harmful that would help with understanding when to be aggressive or not.

Is it due to provider lack of experience with the procedure? Poor application of the procedure leading to trauma or hypoxia? Or is there a longterm problem?

In the PALS book there were several references to studies and other articles within the airway chapter. If you don't want to read the chapter, you can find a listing of the references at the end of the chapter. If you want the answers to your questions as to "Why?", those references are an excellent place to start. Whenever you are reading something that you think there must be more to the story, look for the reference notations.

Here is the study that is now being sited most often:

Effect of Out-of-Hospital Pediatric Endotracheal Intubation on Survival and Neurological Outcome

A Controlled Clinical Trial

JAMA. 2000;283:783-790.

Marianne Gausche, MD;

http://jama.ama-assn.org/cgi/content/full/283/6/783