In response to Prehospital Advanced Airway – Should Paramedics Be Intubating?, was this comment from Divemedic. I am assuming the accuracy of what Divemedic writes, since I was not there and the participants are not identifiable.
Divemedic wrote:About 6 years ago, I had a Doctor in the ER accuse me of missing the tube, because he heard belly sounds. This was a patient who was being paced in a post arrest situation. I showed him my monitor, which was equipped with ETCO2. There was a waveform with a ETCO2 of 34, an SaO2 of 92, and a BP of 120/68.
It is unfortunate, but there are plenty of people who do not have a clue about tube confirmation. Some of them work in the ED (Emergency Department), where the use of waveform capnography has yet to be adopted, at least in my experience. The use of less reliable, less accurate, poorly understood forms of tube confirmation is bad medicine, bad risk management, and illogical.
If it is required for intubations by anesthesiologists in their most familiar setting, the OR (Operating Room), but it is suddenly unimportant in the ED and when used by doctors less experienced at airway management? The ED intubation experience is different from the OR experience, so the ED doctor should be more experienced in the ED setting. My experience has been that, about half of the patients I have seen intubated in the ED have been intubated by anesthesia after a lack of success by the ED doctor. I do not know how difficult these tubes were, since I never attempted to intubate any of these patients. This experience is probably not representative, but it is not encouraging.
Why is waveform capnography so uncommon in the ED?
He presented in a 3deg AVB, went into asystole, and we managed to get a pulse with TCP. We had been bagging him for nearly 10 minutes when we got to the hospital. The Doctor claimed that my evidence was less accurate than his hearing belly sounds, and he pulled the tube, disconnected the monitor, and ordered epi and atropine.
The doctor was wrong in so many ways. Waveform capnography is not infallible, but after over a minute of monitoring, with a good waveform, it is reliable at showing that the tube is not in the esophagus.
Then there is the choice of disconnecting the transcutaneous pacer that appears to be producing an pulse oximetry of 92% and a blood pressure of 120/68. What would justify giving that up to play with epinephrine and atropine? This decision could produce a post all by itself, but I’ll leave it alone and stick to airway.
4 minutes later, the Pt coded again and was dead. In the lobby, I overheard the Doctor talking to the family and blaming EMS for the death. I filed a complaint with the hospital. He complained to the state and tried to have my license taken away.
The secret to success is finding others to blame for one’s failures, at least according to some. This doctor appears to go by that motto.
My medical director backed me up. The Dr still works there.
It is great that your medical director is able to understand what is important and willing to back you up. The problem doctor would probably still be working as a doctor, even if not there. Rather than removing dangerous people from positions, where they can harm people, we tend to just let them move on to new victims in a job that may just provide them with less seniority.
I think a large percentage of “missed tubes” are actually doctor arrogance, not a true missed tube.
I do not think that a significant proportion of the tubes pulled are the result of poor assessment by the ED doctor. I think many doctors actually go out of their way to not embarrass paramedics. You ran into one dangerous doctor. This doctor is not representative of the doctors I have run into in many jobs in several states. I have run into a few similar to this, but probably less than one per year. The most disturbing part is that the doctor did not appear to receive remediation, with the successful completion of the remediation as a condition of avoiding removal of this doctor’s medical license. Of course, if that did happen, we might not know other than by observing an improvement in patient care.
After all, when a Doctor pulls your tube and reinserts it, he gets to bill the patient another $600. Isn’t that how the game is played?
I do not know what the difference in billing would be. I do hear people criticize doctors as having this motivation for redoing things that we have already done. Without hearing this from the person directly, I would only be guessing at the motivation of the doctor. Some doctors debating on the way they enter billing codes and their differing views on the ethics of their decisions. One of the posts in the dialogue is The Hypocrisy of Overbilling by Scalpel or Sword. And this is a dialogue about a different topic from inappropriately extubating and reintubating a patient, but it does give some perspective on the way different doctors approach different billing situations. The claim that somebody is doing something for a particular reason is pretty hard to justify. We do not know why others do things. Even if they tell us, they may be telling us what they want us to hear, or what they think we want to hear.
Back to the comments about the doctor hearing epigastric sounds. I am not suggesting that the tube is never in the right place when there are belly sounds over the stomach. In the initial assessment, the belly sounds should be reason to pull the tube. Once the tube is out, the sounds should be reappraised during BLS ventilation. If the belly sounds are still present during BLS ventilation, the assessment of belly sounds drops in significance. If the second intubation attempt is with the added caution inspired by the belly sounds during the first assesment, it may be reasonable to pay more attention to chest rise and waveform capnography.
I had one patient who filled the ETT with emesis. Clearly, I was in the trachea, since there was nothing left in Linda Blair’s stomach and esophagus at that point. Our assessments are supposed to include the information obtained in earlier assessments.
Why clinicians are natural bayesians[1] gives a good view of how we use further information to modify a differential diagnosis/assessment. If we are not modifying our approach to patient care, as we obtain more information, we are not providing good patient care.
Footnotes:
[1] Why clinicians are natural bayesians.
Gill CJ, Sabin L, Schmid CH.
BMJ. 2005 May 7;330(7499):1080-3. Review. No abstract available.
Erratum in: BMJ. 2005 Jun 11;330(7504):1369.
PMID: 15879401
Free Full Text – not including responses.
Free PDF – including responses. On the PDF go to page 3, about halfway down the page to find the beginning of the letter. The responses follow on page 4.
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