Never Enough

As I transition into my new(-ish) role as an emergency physician in a department that sees only the occasional child I worry that my skills are becoming degraded. I am sure that I am not the only one.

So how many critical procedures do clinicians actually practice? Take a look at this paper from the group at Monash:

Nguyen LD, Craig S. Paediatric critical procedures in the emergency department: Incidence, trends and the physician experience. Emergency Medicine Australasia. 2016 Feb 1;28(1):78-83.

This retrospective chart review looked at every paediatric attendance that required a resuscitation cubicle in three Victoria hospitals in 2013. There were a total of 54,633 presentations of which 5,895 (10.7%) were assessed in a resus cubicle. Only 37 children required any sort of critical procedure. This equates to around 7 per 10,000 presentations. The researchers then looked at what sort of procedures were performed. Take a look at the table below to see what we’re talking about.

Data from Nguyen LD, Craig S. Paediatric critical procedures in the emergency department: Incidence, trends and the physician experience. Emergency Medicine Australasia. 2016 Feb 1;28(1):78-83.


Only 53 of these critical procedures were performed over the course of the year and these were performed by only a small group of emergency physicians.  83% of doctors working at these campuses did not perform a single critical paediatric procedure. I work part time in hospital (0.5 EFT) and may see no more than 20 children a week. Going by these figures it might take me 17 months to perform a single critical procedure. This concerns me. (Ed. note: Luckily for those living in my part of Melbourne I’ve reached my quota already so everyone can breathe easily.)

Even then we might not be any good at them anyway.

Endotracheal intubation
Endotracheal intubation of children is a rare event. If we look at Melbourne’s Royal Children’s Hospital, they performed 71 intubations in 66 patients over the same year time period as the Monash study above. We covered this study in our very first paper for Emergency Medicine Australasia. Their first pass success rate was 78% with a number of adverse events recorded. When hypotension or desaturation were taken into account, only 49% of attempts at intubation were without problems. This did not seem to be related to the level of experience of the intubator. Like those intubations performed at Monash, a high proportion were due to medical conditions such as status epilepticus or respiratory compromise.

Table 6 from the study suggests that we could be much better.

This post from Ross Hofmeyr suggests that we need to be performing around 75 intubations a year to maintain currency, at least in an adult population. It would take me 106 years to get that many if I just waited for nature to takes its course.

Intraosseous access 
Intraosseous access was only obtained on 7 occasions during the study period. Studies into its success bear this out. Studies into success rates in a paediatric setting have very small numbers. This Canadian paper suggested that clinicians averaged 1.6 attempts per child with it being successful only 86% of the time.

As you might expect there is no data regarding success rates of chest tube insertion in children.

Arterial lines
Putting an arterial line in a small child can be technically challenging procedure. Only three were inserted in the Monash study and no mention is made of the technique used. An arterial line can be used to guide management but it is not the sine qua non of emergency department resuscitation. Many more are performed in the PICU than the ED. Small studies have found a success rate of around 80% using the traditional palpation technique.

CVC placement
Only one central line was inserted over the entire year studied. With such a low denominator we need to look at PICU data again to determine success rates. Using landmark technique, success has been reported at around 80%, after 2.55 attempts per child. Accidental arterial puncture took place in roughly one in four children.


So what can we do to make us more comfortable performing these low frequency procedures in a safe and effective fashion? If you base your thinking on what Twitter is saying on any given day then you would think that simulation is the answer. But is there any evidence that it actually makes a difference?


Endotracheal intubation
Given the high risk of adverse events cited above it would seem that I have at least a 50% chance of causing hypotension or desaturation in the only paediatric intubation I will be carrying out in the next year and a half.

What about some ‘just in time’ training? This study of 401 intubations in a PICU setting compared non-trained residents (i.e. only undertaken the mandatory training) and those that had taken a thirty minute simulation based refresher at the start of their on-call period. This consisted of 10 minutes of hands-on practice followed by twenty minutes of debriefing. Whilst there was a small procedural component, a lot of the debrief focused on communication and team management. Unfortunately the training seemed to have no impact on degree of first pass success (45.7% vs 54.7%) nor on tracheal intubation associated events (22% vs 19.9%). The only thing it seemed to have an effect on was resident willingness to participate in intubation.

So we might perform better with the aid of simulation but the question then becomes “Does this translate into clinical practice?” Walter Eppich and the team at Harvard provide some evidence in this paper from 2006 but the studies cited all have very small numbers of participants. They also include a study that focuses purely on simulation based training utilising an adult mannequin. Whilst there are some transferable elements (children are anatomically easier to intubate) the study doesn’t take into account the physiological differences between adults and children that lead to adverse events.

Task trainers may improve comfort using unfamiliar equipment but there is little evidence that they increase success rates in real life. Given the low frequency, highly challenging nature of these procedures it is unlikely that any large study is going to happy any time soon.


Nguyen LD, Craig S. Paediatric critical procedures in the emergency department: Incidence, trends and the physician experience. Emergency Medicine Australasia. 2016 Feb 1;28(1):78-83.

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