The Protocol That Doesn't Fit: Online Medical Control and a Pediatric Airway
You are the EMS medical director taking online medical control calls on a Saturday evening. A paramedic unit is on scene with a 6-year-old, 20 kg child who has a suspected foreign-body aspiration. The child is awake but has stridor, drooling, and increasing work of breathing; SpO2 is 88% on room air and falling. The paramedic reports that the child is too small for the agency's adult video laryngoscope and that the pediatric blade is on the other unit, 15 minutes away. The paramedic asks, 'Can I just use the adult blade and try to intubate, or should I bag him to the hospital?' The nearest ED is 9 minutes by ground; a pediatric-capable center is 22 minutes. The agency's protocol says 'contact medical control for pediatric advanced airway.' The paramedic has done 3 pediatric intubations in the last 2 years.
1. What is your immediate answer on the radio, and what is the reasoning?
Read the worked answer
The immediate answer is: do not attempt intubation with an adult blade in a 20 kg child. The geometry is wrong - an adult blade is too long and too curved for a pediatric airway, and the risk of trauma, failed attempt, and worsening obstruction is high. The priority is oxygenation and ventilation, not intubation. Instruct: (1) begin BVM with 100% oxygen and an appropriately sized mask, using two-person technique if possible; (2) consider a supraglottic airway if the child's size permits and the agency carries a pediatric-sized device - but only if BVM is inadequate; (3) transport immediately to the 9-minute ED, which can manage a pediatric airway and call for anesthesia/ENT. The teaching point: 'can I intubate?' is the wrong question. The right question is 'can I oxygenate?' A failed pediatric intubation is worse than a good BVM.
2. The paramedic says, 'The protocol says contact medical control for pediatric advanced airway - I'm contacting you, so can I do it?' How do you handle the protocol-versus-judgment tension?
Read the worked answer
A protocol that requires contact for a procedure does not mean the procedure is automatically authorized once contact is made - it means the medical director must make a patient-specific decision. Here the decision is no. The reasoning: (a) the equipment is not appropriate (adult blade); (b) the paramedic's pediatric intubation experience is low (3 in 2 years); (c) the child is maintaining some airway and can be oxygenated; (d) a 9-minute transport to a capable ED is short. Document the call, the recommendation, and the rationale. The teaching point: online medical control is a clinical decision, not a permission slip. The medical director should also flag the system issue - pediatric equipment not on every unit - for QA follow-up. Do not let the protocol's existence create pressure to perform a low-value, high-risk procedure.
3. What quality-improvement action does this call trigger, and how would you measure whether it worked?
Read the worked answer
The call reveals an equipment-readiness gap: pediatric airway equipment is not standardized across units. QI actions: (a) audit every unit for pediatric blade sizes, pediatric BVM, and pediatric supraglottic devices; (b) add a daily equipment check that includes pediatric airway items; (c) require pediatric airway competency verification (simulation, not just intubation count) for all paramedics; (d) revise the protocol to specify equipment-based decision rules rather than 'contact medical control.' Measures: percentage of units passing unannounced pediatric airway equipment checks, time-to-pediatric-airway-equipment on scene, and simulation pass rates. The teaching point: a single online medical control call is a data point; the medical director's job is to convert it into a system fix with a measurable target.