All of this discussion about confirmation of tube placement raises some questions.
You bet.
Why is it so hard to tell where the tube is?
Right. You either see the tube go through the cords, or you don’t.
NO! That is the big problem.
What?
Any magician will tell you that Seeing is Deceiving.
But if you see the tube go through the cords you know it is in the right place.
No. If you think you see the tube go through the cords, then you are more likely to believe the tube is in the right place.
But you either see it or you don’t.
What you think you see is influenced by what you want to see. People are not good at being objective. This is why you need to aggressively try to demonstrate that the tube is in the wrong place.
So, by doing all of the tube confirmation things, we are looking more for evidence that the tube is in the wrong place – rather than evidence that the tube is in the right place?
Sort of.
If you can’t prove that the tube is in the wrong place, then it must be in the right place.
Not exactly, but the signs that the tube is in the wrong place should not be ignored.
You’re saying that people tend to ignore the information that they don’t like.
Yes. If you have a clear sign that the tube is in the wrong place, do not rationalize it, do not ignore it.
Give an example.
I was standing in the door of a room where a patient was having her esophagus intubated.
You mean trachea.
They meant trachea, but the result was not the trachea.
How do you know?
That was their question, since I was about 10 feet away from the patient and I was telling them the tube is not in, trachea-wise.
Well, they were right to question you.
Right to question me? Yes.
How were they wrong?
They didn’t understand what I was telling them.
What did you tell them?
“Look at the belly,” the intestines were clearly defined when looking at the area over the intestines.
That could be old.
That may be one of the ways they were rationalizing this assessment that is inconsistent with proper placement of an ETT (EndoTracheal Tube) in the trachea. Or they just considered it irrelevant.
How do you know it wasn’t already there?
With each squeeze of the bag, the definition and area increased. The leg bone is connected to the ankle bone, but the lung bone is not connected to the intestine bone.
Too simple for people to recognize?
Apparently, but why is that the case?
They only acknowledge information that confirms what they want to believe?
Yes.
We need to always suspect that the tube is in the wrong place.
We need to always be looking for signs that the tube is in the wrong place.
We need to distrust people saying “I saw the tube go through the cords.”
But, if you see the tube go through the vocal cords, you know it is in the trachea.
“I saw the tube go through the cords.”
If there is any evidence that what we saw was inaccurate, we should distrust our eyes.
More in More Intubation Confirmation.
Other posts about this:
RSI Problems – What Oversight?
RSI, Intubation, Medical Direction, and Lawyers.
RSI, Risk Management, and Rocket Science
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So many times the first response, when the intubated patient deteriorates, is to look at the X-ray. I tell them that the X-ray does not spot weld the tube in place.
And, of course, the tube can be in the esophagus directly behind the trachea and the AP will not pick up on that.
“Almost every tube that is misplaced is accompanied by those killer words “I saw the tube go through the cords.””Yup.I’ve heard that so many times that I wonder if most paramedics actually know what vocal cords look like.Of course, you also find many people in hospital that actually think a post-intubation AP chest x-ray rules out esophageal placement.