Posted on 04/20/2008 8:05:56 AM PDT by Dysart
Either that or start importing them form the Third World. Comprendre?
Man, there are so many things to comment about in this article...but I do want to address your point made here.
While I agree with your first paragraph completely, the second paragraph I do not agree with.
An undetected ETT in the esophagus in a medical center setting is indeed malpractice considering the training involved for the providers involved and the equipment you mention. But I'm not certain that in an 'out in the field' setting that necessarily applies.
There are few things that can be as harrowing as trying to establish a patent airway in an emergency setting...it is often a very difficult thing to do. Conditions are rarely optimal, and often patients are already in extremis. If you have a lot of experience in this setting and are making this claim, more power to you...but to say that the problem can be resuced to 'near zero' is in my medical opinion suspect.
It would be nice if we could send highly trained anesthesiologists who are the most expert in performing intubations out on every ambulance run...but it ain't going to happen. To hold EMT's, who while trained, to the same malpractice standards as much more highly trained individuals while operating in some of the most demanding situations is just not right.
It sounds like you're thinking of a blind insertion airway, like the Combi-Tube or an oral obturator airway.
These are not endotracheal tubes, but esophageal airways. That is, the Combi-Tube and OOA are designed to go down the throat in the direction of the stomach. A pair of inflatable cuffs on the Combi-Tube (one down low near the stomach and another up high near the back of the throat) theoretically seal off the region of the trachea and allow air into the lungs. The OOA has a more involved system requiring a tight-sealing face mask, if I remember correctly (haven't seen one of those in ages). With the Combi-Tube, if you have by some insane miracle managed to stuff it into the trachea then you just switch over to the secondary tube and bag from there, it'll bypass the cuffs completely.
The endotracheal airways on the other hand, those require guided insertion. That is, we use this cool doohickey called a laryngoscope to lift the lower jaw up far enough for us to see the larynx, and then we do our damned best to send that tiny little tube screaming past it. In other words, the ET tubes are inserted in past the vocal cords and the inflatable cuff sits right above the lungs (ideally anyway, best laid plans of mice and medics...). And no, you don't want to go trying to rip THAT thing out after the cuff has been inflated :)
All things considered, if the patient needs (and is zonked out enough to tolerate) intubation then they're going to need an ET tube eventually. Might as well get it done right and get it done right now.
The Combi-Tubes might, possibly, be a useful stopgap if you can't get an ETT inserted or if you've got some EMT-Bs working the call in some state like Missouri (damn state wouldn't even let Bs use a glucometer when I was there, let alone play with the scope).
Avoiding paralytics in the emergency situation may make intubation more difficult, but allows the struggling patient to at least get some oxygen. That's better than being paralyzed and having oxygen go only into your stomach. If deep hypoxia occurs in an unparalyzed patient, the patient will stop struggling, and can be intubated then.
There's a saying in emergency medicine, “hypoxia is your friend.” It means that unparalyzed patients can be easily and quickly intubated once they become hypoxic enough to stop struggling. That saying is a justification for NOT paralyzing, and for allowing the patient to make whatever respiratory efforts they can. The caveat is that quick intubation is done if and only if deep hypoxia sets in, or when the patient can be brought to someone who really knows how to intubate.
I myself was trained in anesthesia, so I learned, without really reflecting on it, to intubate difficult airways as a matter of course. When I first heard the saying “hypoxia is your friend,” I thought it was completely insane. Why wait for deep hypoxia, when you can intubate, protect the airway, and keep the patient well oxygenated? I eventually learned that the answer is this: not everyone can intubate. It's not a hard skill, but it is a skill, and some people just can't do it. So, as a matter of routine, when devising protocols for providers to follow, I'd say the bare minimum to seriously consider routine chemical paralysis are these:
a trained anesthesiologist
working suction
an assortment of intubation blades
appropriate endotracheal tubes
and maybe a fiber-optic intubation kit, with someone who knows how to use it.
Most ambulances are missing one or more of these things (usually a trained anesthesiologist, but often working suction as well, and ambulances pretty much never have fiber-optic intubation kits, nor people who know how to use them), so paramedics / ambulance crews should NOT be paralyzing patients as a matter of course. It'll be easy enough to intubate the patient if they become sufficiently hypoxic, and if they're not hypoxic enough to easily intubate, they're really not hypoxic enough to paralyze in the field.
Just my opinion.
What you say is correct...but you should take this further to mention that Medicaid recipients often call for EMT responses for nothing other than convenience, i.e., they need a ride to the ER for some non-emergent problem. Unlike taking a cab, the ride in the Ambulance costs them nothing...so why not take the low-cost alternative to themselves even if the cost to the government and all the rest of us goes up?
Ambulance services are a MONEY LOSER for those that own them (hospitals or communities, it doesn't matter)...here in our town, the local hospital is trying to dump the service on the community, and I cannot say that I blame them as it has cost them a loss of between $500,000 to $1 million/yr.
I think what is wrong with that picture is that a lot of people want to go into the hair dressing business, enter a relatively non-stressful field with the option of being your own boss someday.
Contrast that against being an EMT, an extraordinarily high stress job that does not pay well considering the emotional and physical stress of the job, the long hours on uneven shifts never knowing what your next call is going to be like, and with very few prospects for running your own business.
Just my take on it.
Additionally, putting in a endotracheal tube is no simple matter even if the patient is unconscious, not flailing and there aren’t hysterical family members screaming in your ear, gang members trying to shoot you or tractor trailers whizzing by.
I have worked in medicine for nearly 20 years, and with all medical procedures, I have found that some people are naturally good at things, some people aren’t naturally good at some things but are smart and work hard to become good at it, some are smart and work hard but don’t get to be the best, and some people are either dumb, lazy or have poor judgement and never get to be good at a task like putting in IV’s or endotracheal tubes and they can cause you pain and hurt you.
The problem is, nearly every medical professional at some point makes mistakes.
Sometimes it is poor judgement.
Sometimes it is poor technique or poor training.
Sometimes it is laziness.
Often it is inexperience.
But sometimes, just sometimes, the person is having an off day. It happens. You aren’t as sharp because you aren’t feeling well and might not have slept more than a few hours, you have a lot going on in your personal life, someone called in sick and you are doing twice the work, whatever.
And you make a mistake.
I no longer work in direct patient care. But I was pretty good at what I did, and often when an IV needed inserting on a difficult patient, I would get called on to do it. I was pretty good at it.
One day, I was putting an IV in a patient to perform a test, and I missed. It just blew up on me. I rarely missed twice, so I buckled down and tried again, and missed again. The patient was very understanding, and I got a different setup to try again, and just couldn’t do it. I couldn’t get drawback on the blood. I tried and tried, to no avail. It was awful for the patient because I kept poking him, and emotionally, terrible for me.
After I had been digging around, something I was loathe to do but was desperate in this case, I realized I had left a stopcock in a off position. I had got so flustered after the two misses that blew up and changed equipment that I simply forgot to open it.
I told the patient immediately what I had done, and he forgave me. That was a simple error in a simple procedure. And I made more money and had less stress than EMT’s.
Owamba may be elected POTUS and has little training in anything, but he sure talks a great story.
Moral: If you intend to use "Sucs", you'd damned well better be fully ready to intubate at all costs. I don't know all the reasons behind this story. But I do know that the moment the paramedic pushed succinylcholine, he/she was duty-bound to secure that patient's airway, period, end of discussion.
Someone's head ought to roll for this.
You’re welcome.
Given the normal MSM accuracy in such matters, I figured I’d better ping an expert to find out the real deal.
Rapid sequence intubation should be done oNLY in an OR by an aneasthesiologist. Plain intubation in the field can be argued, I favor an LMA as I have seen too many EMT’s mess up an airway beyond retrieval with repeated attempts to intubate which wastes time and slows transport. Most pts can be adequately bagged, and an LMA is almost idiotproof.
Giving succ in a moving ambulance is stupid beyond belief.
Hopefully they would have secured the airway before they hit the road.
The hypoxic clenching patients in the ER might tend to disagree with you. ;'P
The problem here is not the intubation problems or the RSI, it is the failure to recognize that the tube is not in place, either initially or when it later became dislodged. The whole point of RSI is to put the patient down quickly, but BRIEFLY, while you intubate. The drugs should be chosen to wear off quickly so that if there is a problem with the intubation you can bag the patient until the drugs wear off, and at worst you are back to where you started within minutes.
These paramedics failed to recognize and address the problem of hypoxia, and that is a major failure. In addition to the clinical measures that should be used to verify tube placement, where the heck was the pulse oximetry? I don't know why any ambulance service would not be requiring its continuous use in all respiratory patients. It is the one thing that would have clearly let the paramedics know there was a problem with the tube. Maybe the patient didn't look blue or there was too much noise to properly assess breath sounds, and it seemed like the patient's chest was rising...but if that Pulse Ox is dropping, you have to know there is a problem.
That long time of UNRECOGNIZED hypoxia is the problem, not the actual intubation.
Just my 2 cents,
O2
What really gets me excited about RSIs now is a new tool called the McGrath laryngoscope. Have you heard of it? It's a digital camera with the lens at the end of the blade. The thing is AMAZING. I first saw it in action when we were having trouble securing the airway of a patient in CCU who was in severe respiratory distress and the ED MD could not, for some reason, visualize the vocal cords with a standard laryngoscope. We were getting ready to do an emergency cric on the patient when the anesthesiologist shows up at the last second, whips out a McGrath laryngoscope, and slips a 7.5 down just as neat as you please. He totally saved the day!
He showed me how the McGrath works. He says it had saved a lot of patients from getting "criked" since he started using it. My hospital evidently saw its potential benefits, too. Now our ED, OR, and CCU each have McGraths as standard equipment in our difficult airway kits and it has become the tool of choice, with only a few exceptions where the blades are not long enough.
And here's the real kicker: the guy who invented it wasn't even in the medical profession. McGrath was an engineering student in the UK, and IIRC his capstone project was to invent something. He looked for an opportunity to invent something that would benefit people, and somehow decided to try and improve intubation techniques.
Mr. McGrath came to America last year to assess the effectiveness of his invention, and he actually visited my hospital a few months back. We showed him the statistics r/t before and after getting his laryngoscope. The contrast was stunning. The MDs and anesthesiologists also presented the areas where the McGrath was not effective (longer airways and hyper-morbidly obese patients. He took notes. A few months later, we got new McGrath blades that incorporated his revisions to accomodate the problem patients.
A friend of mine who is an anesthesiologist told me that Mr. McGrath was totally blown away about the effectiveness of his brainchild. She said that McGrath was one of the most self-effacing, humble, genuinely nice people she has ever met. I don't think that McGrath will ever realize how many lives will be saved by his invention. I think there's a special place in heaven for the guy.
But I digress from the subject.
From my particular point of view as an Emergency RN, I have found that even a bad airway is better than no airway at all. At least it's a start. And if a patient is in cardiopulmonary arrest in the field, then an emergency airway should be obtained. LMAs are good, but the rationale that intubation is preferable if it can be done safely is, IMO, a sound one.
There is variation among regions regarding the skill of medics. I think that it would be a good thing to assess the training and skill of each ALS medic and to provide enhanced training for those medics who do not demonstrate proficiency in securing an emergent ETT in field conditions. Maybe providing the McGrath would improve things. Anyway, that's my long-winded response. Have a great day, Doc. Cheers! /Gunner
I’m sorry I misspoke I think RSI should only be done in a fully equipped hospital, not in the field. If you dont have a good airway in the field, I think paralyzing the pt has a lot more potential for making things worse than better.
In a hosp with ED personnel and back up from anesthesia it is a different story. I did not mean to exclude the ED from acceptable places for RSI. I also think the LMA is a good thing. It is brainless enough even I can use it with success!
Have a great week!
The “near-zero” percentage I was referencing was a tube being left in the esophagus. These days with pulse oximetry , capnography in the field, in addition to good post procedure technique (auscultation, etc.) leaving an esophageal placed tube - even in a noisy accident scene - should not occur.
With a properly equipped and trained paramedic crew this still should be a very rare occurrence. I know with a bloody field of view or disturbed anatomy secondary to trauma, or if your intubating a trapped person, etc. intubation can be nearly impossible at times, so I am not knocking the medics.
Hello, Mom MD! No apology is necessary. I completely agree with your positions r/t the risks of paralyzing in the field. As I stated in a previous post, if EMS paralyzes a patient in the field, they had better be ready to secure that airway or face the severest consequences, including civil trial for gross negligence and even criminal prosecution for manslaughter.
with modern day CO2 detectors, listening isnt even necessary. And if you have a pulse oximeter, which most EMS should, there is no excuse for not recognizing esophageal intubation. But my main point was that I do not think RSI or use of paralytics is a field procedure for EMS. Period.
We will just have to agree to disagree. This is an issue where informed people of good will could disagree.
That Mcgrath laryngoscope is so amazing and interesting! I never heard of it...you are a wealth of info!!! thanks :)
Hello again, Mom MD. I wish to respectfully weigh in on the subject of capnometry, if I may.
Current ACLS/TNCC guidelines call for a rapid, three-step methodology for verifying proper ETT placement. First is auscultation at the epigastum for gurgling; second is auscultation at bilateral upper chest at mid-clavicular lines for air movement; third is observation of the CO2 detector for yellow vs. purple.
It may seem redundant, but I have personally caught esophageal intubation in this manner at step one before the capnometer turned purple. It may seem time-consuming at first, but in this case it saved a few seconds. And in a crash, a few seconds can make the difference.
However, I do agree that the capnometer is a valuable tool for verification of ETT placement.
Thank you for your kind indulgence. Have a blessed Sunday!
/Gunner
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