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     As a member of the national EMS-C task force, I recognize the critical
importance of "golden hour" pre-hospital management of children needing
cardiopulmonary recusitation.  As we are taught in PALS, the cause of
cardiopulmonary collapse in children is almost always primary respiratory
failure.  I agree with the statement that it is uncommon not to be able to
manage an airway AND effectively ventilate/oxygenate with bag-mask
ventilation alone.  Certainly with bradycardia/cqardiac arrest, an
endotracheal tube is superior.
     While there are important anatomic differences between children's and
adult's airways (i.e. cords more cephalad and more anterior, sub-glottic
airway narrowest in children), proficiency at oral intubation is an absolute
must;  esophageal intubation should not happen.  Sorry to be so tough
people, but you've just got to find the trachea!  Cric should not be an
option except when neck trauma destroys the anatomy.
     The City of New York established a program a few years ago in which
paramedic and EMT trainees would practice intubation on cats who were being
anaesthesized with general anaesthesia at a veterinary facility for
neutering.  The cats would have to be intubated anyway, and many people had
the opportunity to pass a tube through living, moving vocal cords, not
unlike the anatomy of a baby.
     Just as we do not tolerate forgetting code drug doses or
neck-immobilizing a trauma victim or how many joules of juice, we must
insist on proficiency in airway management.
 
Ed Frieberg, MD
Tulane Children's Hospital PICU
New Orleans, LA