How Many Pedi Airways Do You Guys Average In Training?

[Coastie]

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Had a baddddd experience the other day being called STAT to the pedi ED for a 3 kg baby for a failed airway.

What kind of experience do adult EPs get? What about pedi-fellowshipped guys?

Thanks.

 

[Arch Guillotti]

Had a baddddd experience the other day being called STAT to the pedi ED for a 3 kg baby for a failed airway.

What kind of experience do adult EPs get? What about pedi-fellowshipped guys?

Thanks.

I doubt you are going to get many bites on this.

 

[dchristismi]

It really depends on the program. I trained in conjunction with a major children's hospital, and we spent a chunk of time with the peds anesthesia guys, and I tubed a bunch of kids.

But I don't think it's something any of us really do regularly. Even the PedsEM guys.
I've tubed a handful of kids in the last year. (And I work at a community hospital.) And by handful, probably 2-3. One was 6 days old - that one I remember. Hell, that one I'll never forget. (Not that the airway was bad. It was easy. The rest of the case was bad. But then again, anytime you're tubing a neonate, it's bad.)

 

[tkim]

Had a baddddd experience the other day being called STAT to the pedi ED for a 3 kg baby for a failed airway.

What kind of experience do adult EPs get? What about pedi-fellowshipped guys?

Thanks.

Got about 50 pedi tubes in the OR during residency - mostly T&A's. Couple in the PICU for bad asthmatics or tracheomalacia. Couple in the peds ED for codes and trauma. No neonates, though.

 

[WilcoWorld]

A 3kg airway in the ED is going to be "baddddd" no matter how many tubes one has done.

 

[erin682]

As a matter of style, we are not adult EP's. We are EP's trained in the emergency care of both adult and children.

 

[Stitch]

Had a baddddd experience the other day being called STAT to the pedi ED for a 3 kg baby for a failed airway.

What kind of experience do adult EPs get? What about pedi-fellowshipped guys?

Thanks.

Can you give a little more context? I'm just curious what the situation actually was. A 3 kg kid sounds like a term neonate, and most of those kids can be easily bagged. The exceptions are the congenital malformations with craniofacial abnormalities, and those can be quite difficult. Otherwise I tend to think sepsis, abuse/trauma and cardiac problems if you're tubing a kid that size.

I came from a neo heavy peds residency and had at least 50 or so neonatal intubations during residency (ballpark). That included 24 week premies all the way to term kids, and was mostly in the delivery room with a neonatologist or in the NICU.

I think we get much less airway experience with older (greater than a month) kids. It's not that common to tube a kid in the ED, so most peds residents don't get that much experience except for 2 months in the PICU which can be hit or miss.

Our peds EM fellows usually get a couple (or more) months with anesthesia and they are reporting anywhere from 50-100 tubes over the course of fellowship. As someone else pointed out, they usually hang out in the ENT room, which runs a bunch of cases per day. They are also sent to difficult airway courses.

 

[xaelia]

2.5 years through residency, I can count my pediatric and neonatal intubations on one hand. Two in one month of PICU, zero as far as I can recall in the ED.

Intubation I worry less about. Failed airway in children I worry more about. Jet? Surgical? Not something my training has explicitly covered to this point.

 

[deleted65604]

My experience was similar to xaelia's. The average ER resident doesn't do NICU. Pediatric airways are REALLY few and far between. I'd define pediatric as less than 10 years of age. Above 12-14, they are pretty close to physiologic adults.

 

[Arcan57]

The Hib vaccine and pneumovax have really screwed up our peds airway experience. Some of my older attendings in residency swore they were intubating a kid every week out in community hospitals back in the 70's-early 80's. Now I doubt anyone but peds anesthesia guys get more than 10 tubes/yr on kids. Even at a place like Children's in Cinci, only every fourth/fifth shift would have someone be intubated during it and those intubations were spread out among the ED residents, senior peds residents, and peds fellows.

 

[crewmaster1]

First you must define Pedi tubes, per our new-innovations logging program my pedi tubes are 12 yrs old or younger. I am on the lower end of Pedi tubes because I'm bad at logging procedures, but I have 30 pedi tubes logged, with probably another 10 not logged. I would say 20 in the OR, 10-15 in the ER (just ask to be the back-up for the peds residents and fellows and you'll get plenty!). I have about 5 pedi tubes on Air Care as well. Just remember that OR tubes are a great starting point, but very different from emergency dept. or prehospital tubes!

 

[Coastie]

Show up after STAT call for a 3kg 8 week baby...

No IV access....they had failed multiple IOs, peripherals....we got a 24 while they had a non-rebreather on the baby.

Pedi ED folks refused to send the parents out..nice move...and wanted to induce with etomidate/roc......we gave atropine and roc...no etomidate..

Pedi ED attending wants the fellow to give it a try..this kid has zero reserve, and the Pedi ED attending says the mom gets to be by the airway, beside the fellow, not our attending. Awesome.

Pedi ED fellow mucks around..for a LONG time...It was very hard to get the mom out of the way, had to physically restrain her, and my attending told the Pedi ED fellow to bag the patient, which the fellow refused, until well after the baby was blue and started to brady.."Uh, I see cords, no, wait, uh..." while JAMMING the ETT into the baby's airway. Awesome.

My attending jumped in, bagged the patient, had to DL the patient's now bloody and swollen airway....Got it in, no problem.

I was amazed that this fully trained pediatrician didn't understand baby respiratory physiology....You can de-nitrogenate for a while, but they will still drop like a rock pretty quickly, especially with added lung pathology.

Given that context, I was wondering how many pedi intubations were done by Pedi EM guys and Adult EM guys. If we hadn't been there, the kid would have died. The parents at the bedside lameness is a whole 'nother thread..

Can you give a little more context? I'm just curious what the situation actually was. A 3 kg kid sounds like a term neonate, and most of those kids can be easily bagged. The exceptions are the congenital malformations with craniofacial abnormalities, and those can be quite difficult. Otherwise I tend to think sepsis, abuse/trauma and cardiac problems if you're tubing a kid that size.

I came from a neo heavy peds residency and had at least 50 or so neonatal intubations during residency (ballpark). That included 24 week premies all the way to term kids, and was mostly in the delivery room with a neonatologist or in the NICU.

I think we get much less airway experience with older (greater than a month) kids. It's not that common to tube a kid in the ED, so most peds residents don't get that much experience except for 2 months in the PICU which can be hit or miss.

Our peds EM fellows usually get a couple (or more) months with anesthesia and they are reporting anywhere from 50-100 tubes over the course of fellowship. As someone else pointed out, they usually hang out in the ENT room, which runs a bunch of cases per day. They are also sent to difficult airway courses.

 

[EMRAGE]

I doubt anyone gets enough to feel extremely comfortable. I did quite a few during my Anesthesia month, but I admit, I pucker a bit when I see a really sick kid.

While moonlighting the other day, I actually intubated a neonate (35 weeks) that weighed 2.5 (maybe 3 kg). Smallest hole I had ever seen.

RAGE

 

[KYTNOH]

Simply stated, not a lot. I've only tubed a couple peds patients in the ED. One was ~15 months old and in status epilepticus with respiratory compromise and the other was a 11 or 12 year old trauma with a mouth full of blood and vomit and a c-collar on. Fortunately, truly sick kids are rare thanks to vaccines.

When it comes to peds ED fellows and attendings there are two main varieties. The first is pediatrics trained the peds ED trained. The second is EM residency trained and then peds EM fellowship trained. The first is generally stronger with pediatric physiology and diagnosis, but the second is going to be better in those stressful situations (at least this is from my experience - I know there are exceptions both ways). EM training is going to expose people to a lot more trauma and sick adults. While the disease processes are much different, being comfortable with the "sick" patient is something that crosses age groups and disease processes. Airway (as well as lines, chest tubes, hemorrhage, etc) falls into that category with EM then peds EM trained folks being a LOT more comfortable in those circumstances.

 

[The White Coat Investor]

I think I did ~ 10 in residency. None since. Emergent pediatric intubations are pretty rare in most community EDs. Luckily, they're usually not too bad in my experience. Much easier than a lot of the fatties with cervical pathology we intubate routinely. But with less reserve, a pretty anterior airway, big heads etc it can be challenging.

To the OP-sounds like you were involved in a real cluster there. Multiple IO attempts? I thought everyone had an EZ-IO these days. You've got to work pretty hard to screw those up.

BTW- re the other topic you allude to about parents being out of the room, the data is quite good that it is better overall to let them stay (unless they're acting like the ones in your case were).