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What I learned from managing pediatric airway emergencies

Years in the field has taught this paramedic the do’s and don’ts of pediatric airway emergencies


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By Jonathan Lee for EMS1 BrandFocus

When I began my paramedic training, George Bush was the president of the United States (H., not W.). Since then, I have had the opportunity to work as a 911 paramedic, a flight paramedic, as well as my current role on a pediatric transport team.

Preparing a child for an inter-facility transport is a challenging part of the job. (Image Pixabay)
Preparing a child for an inter-facility transport is a challenging part of the job. (Image Pixabay)

I believe the real growth in my airway management skills came not just from seeing patients, but from working in so many different environments. The realities of caring for a sick child are different in an urban 911 ambulance than in a helicopter, and different again when preparing a child for an inter-facility transport.

With the benefit of hindsight, I can look back at my practice and pick out the mistakes that I have made over the years. Here’s a few things I’ve learned.

1. I got tunnel vision.

I clearly recall the first time I was the paramedic backup to a pediatric cardiac arrest.

I knelt down on the floor at the head of the patient with a shiny laryngoscope in my hand. I was surrounded by police officers, firefighters, a supervisor and the original ambulance response. I remember thinking that each one of them could bag-valve mask this patient, but I was the only one here who could intubate.

I became completely focused on one thing – the skill of intubation. This tunnel vision prevented me from seeing what the patient really needed: good airway management.

2. I didn’t secure the tube.

I am clearly a slow learner, because I have learned this lesson numerous times.

One time I asked an inexperienced provider to ventilate my patient. Or another time I moved a sweaty child to the stretcher and the tape didn’t stick. Lastly, one kid I thought was sedated coughed and out came his tube.

By their very nature, the size of children means the margin of error is smaller. I now have a mental checklist:

  • First saturation and end-tidal monitoring to immediately detect displacement.
  • Second, a very specific ritual involving special cloth tape and adhesive to secure the tube.
  • Third comes medication; analgesia and sedation are a must--neuro-muscular blockade if the intubation was difficult.
  • Finally, patient positioning, which in infants, involves an elaborate combination of tape, towels and blankets to prevent any unwanted movement.

3. I didn’t have a plan.

As I began my flight career, intubation became an increasingly more complex affair. The flight scope of practice introduced a new hazard to my practice: options.

More drugs, more equipment, and more latitude in my scope of practice meant that no two airways were ever managed the same. Flight crew intubation also may include any number of allied health providers, each with a different idea of what intubation should be. This exponentially increased confusion.

This confusion taught me the value of having a plan.

My best airway plans had two important factors. First, they were simple. My airway plans always start and end with good bag valve mask ventilation. In between were simple tools that I was intimately familiar with: laryngoscope, gum elastic bougie and the King LT.  

Second, an airway plan is just an airway dream until it is shared with the team. I adopted the idea of a ‘time out’ from the operating room; taking 30 seconds before beginning any complex procedure to explain the plan and assign roles to everyone involved.

4. I ignored the family.

I suspect most providers would agree that anxiety levels increase when dealing with a sick child.

Worse still, I knew that the having mom or dad witness every detail of my decisions and skills was having a negative effect on the care I was providing; best case I felt scrutinized, worst case I felt defensive.

After working in pediatric transport and embracing the idea of family centred care I realized how badly I was misreading the situation. Parents get tossed into crisis with little time to prepare. Feeling confused and out of control, they are only trying to make sure that their child is getting the best possible care.

I now introduce myself to the family before approaching even the sickest of patients, inviting them to ask questions or engage with me at any time, regardless of what I am doing.

This one simple action allows mom or dad to regain a sense of control. It lets them know we both want the same for their child, reducing anxiety for both them and me.

These are a few of the lessons I’ve learned in my career that have helped me become better at managing pediatric patients effectively and carefully.

 

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