Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Zero Tolerance V – Autopilot Oversight – Sparrowmict comment

sparrowmict left a comment on the post Zero Tolerance I – Basic EMT Oversight of Paramedics. I apologize for taking so long to respond. These are not unimportant points. They get to the heart of what is wrong with a lot of EMS. I just have not felt satisfied with my response:

I am disheartened that my company has also succumbed to the lets record everything rather than take care of the patient. We have fallen onto the capnography bandwagon and unless we have a square waveform in spite of the fact that I just saw the cords as the tube went past them and have chest rise and clear bilateral lung sounds and no epigastric sounds they want me to pull the tube.

First, I think that waveform capnography is the single most important assessment for tube placement. Better than seeing the tube go through the vocal cords, which is probably the single most misleading assessment of tube placement and the most common excuse for an esophageal tube.[1], [2]

Katz and Falk39 evaluated 108 paramedic endotracheal intubation patients arriving at a regional trauma center in Florida. The authors used a systematic physician approach to confirm proper tube placement on ED arrival, including the selected use of direct revisualization. The authors found that more than 25% of the endotracheal tubes were misplaced, two thirds of these in the esophagus. The authors partially attributed the results to noncompliance with out-of-hospital protocols requiring placement confirmation using carbon dioxide detection. Jemmett et al40 conducted a similar study of 109 paramedic endotracheal intubation patients in Maine (an emergency medical services [EMS] system with no carbon dioxide detection protocol) and found a similar tube misplacement rate of 12%. Jones et al41 reported a lower (5.8%) tube misplacement rate for 208 paramedic endotracheal intubation in Indianapolis, but this study occurred in a region serviced primarily by a single EMS agency with close medical oversight.[3]

These are examples of the diversity of medical oversight. I think that the best indicator of medical director oversight may be the intubation success rate. No competent medical director should tolerate low success rate, but many do. Some medical directors do not even know what the success rates of their paramedics is.

Here is a different approach. these medics were excellent at intubation before they used capnography. After capnography, they were even better. After capnography the only esophageal tube was due to the medic ignoring capnography

Prior to 1990, tube placement was confirmed by visualization of the tube passing through the vocal cords and auscultation of the chest, axilla, and abdomen. Confirmation of tube placement after 1990 was assisted with portable mainstream capnography . . . .

Six (0.36%) unrecognized esophageal intubations were discovered in the emergency department or at autopsy. Only one (0.06%) of these occurred since this addition of capnography and a tube aspiration device in 1990. In this patient, a zero reading on the capnograph was ignored and not verified by a tube aspiration device or by removing the tube and re-intubating the patient.[4]

Second, I think that waveform capnography may be the most important tool that is available in EMS. 12 lead ECG is the main competition. Since they tend to come together in the same machine – the monitor/defibrillator/cardioverter/pacer/12-lead/waveform capnography/pulse oximetry/non-invasive blood pressure/et cetera – I am very fond of the combination monitor/automated paramedic. I do not believe that it should be used as an autopilot for EMS.

As much as I like waveform capnography, it is still only one part of the assessment of the airway. To have one assessment automatically superior to all others demonstrates a lack of understanding of airway management.

So much of what we do has to do with keeping an electronic record of what we did rather then what we do to help the patient.

There are people who believe that the most important thing that can be done is to remove the human from important decisions. If humans are fallible, and we all are, then no human decision can be perfect.

Since humans are imperfect, we must eliminate that imperfection from important decisions.

What they do not realize is that computers are incapable of recognizing the difference between valid data and data errors. For example, if a person is being ventilated with good chest rise, equal lung sounds, no belly sounds, and improving skin signs – increasingly pink, warm, and dry; moving away from cyanotic, cool, and moist – then that is a good thing. Even if the data from the capnography is telling a different story.

The capnography sensor can malfunction, especially if the patient has vomited and some of that vomit is in the tube. The connector might not be tightened properly. The sensor might not even be between the tube and the bag. The tubing from the sensor to the monitor may be kinked, preventing sampling of the exhaled gasses. There are many possible failures. Some will have a malfunction warning, but some will just indicate no CO2.

While some of these are operator errors, some are only malfunctions that can be corrected by a human operator. Proper application and interpretation of the information requires an intelligent human operator.

How can a human operator be responsible for application of the device (both the endotracheal tube and the waveform capnography sensor), yet not be allowed to override the cases of equipment malfunction. Even if the malfunction is due to misapplication of the equipment, the trained operator should be able to recognize that there is a problem of bad data.

To prevent the human operator from making these decisions, as your QA/QI/CYA department appears to, is the worst decision QA/QI/CYA could have made. It is great that they have chosen to use waveform capnography. That is an important and very smart decision. That is a decision made by a human, or a group of humans. It is not great that they decided to try to prevent, as much as possible, decision making by the humans trained in airway management.

We no longer have OLMC requirements but that was because none of the hospitals wanted to be saddled with it and our own Medical Director you see when you start our academy then never again.

EMS by autopilot does not work.

High quality EMS depends on well trained providers who care about their patients.

You might get so see one of his cronies when they choose to yell at you and suspend your clinical privileges because you didn’t get the capnography on within 60 seconds. Our protocols are 1.5 inches thick and have 126 sections and 26 pages alone just for a destination protocol. And don’t even get me started on the hospital divert system or the Level 2 trauma rotation that the State cooked up.

If George Orwell[5] were to write a book about an EMS dystopia, he might write about this kind of lack of oversight. EMS should never be the occupation for unthinking and uncaring people.

One last thing, our new incoming Medical Director (who I had high hopes for because he started out as a medic) has decided that because we do not carry LP12’s on our bike team that we can no longer intubate because we cannot capture that magic waveform for the reports that QI generates.

One of the most important decisions a medic can make is – should I intubate this patient?

That is a decision that may change during the treatment of the patient. Maybe the patient is not responding to treatment. Maybe the patient responds so well to treatment, that the decision to intubate is changed. The waveform capnography cannot make that decision.

One of the big problems with RSI (Rapid Sequence Induction/Intubation) is that some places seem to be making this decision to intubate far too often, just because they can. RSI, as with helicopter transport, is something that can be abused by overuse. That is not something that waveform capnography will recognize.

We do have a lot of nifty toys, but it seems that we are taking steps further backward. Yes we can import all of the data from the LP12 better remember to event scroll push everything you do. 12 lead ECG, but have to transmit all of them to the hospitals (BOY DID PHYSIO CONTROL MAKE A FORTUNE OFF OF THIS DEAL) I still have yet to figure out how they got our medical director to say that we cannot use any other electrodes then Physio control brand.

We all have our biases. Biases that allow us to believe that what we are doing is not bad. Hanlon’s Razor is possibly a much more powerful force than any evil –

Never attribute to malice that which can be adequately explained by stupidity.[6]

Maybe they offered him a pen.[7], [8]

I have talked to, and written to, many doctors who care very much about EMS. Some just do not get it. They believe that certain things prevent paramedics from being allowed to make decisions. They just do not understand EMS. Some of these doctors are smart enough that eventually they will realize that there are better ways to provide emergency patient care. Some will never learn. Some already do understand and spend a tremendous amount of time trying to get others to understand.

Unfortunately, there will probably always be a place for the medical director, who feels comfortable being told what to do by a CEO, a hospital administrator, or a fire chief. Some of them justify this by saying, If I don’t do it, then they will get somebody worse. That is so dangerous, it deserves a post of its own. Too bad that attitude is not uncommon.

I also agree that the National Registry has not helped advance us in any way, so far it just seems to be a method that the state uses to not have to come up with testing or recertification requirements of their own and we still have to pay both the state and the NR license fees.

The NR is the embodiment of what your medical director is doing.

Eliminate the human from the equation, since humans are fallible.

Here is an example of a medical director, who does understand EMS oversight.

Following didactic training, each student must successfully complete a minimum of 20 intubations, in the operating room, under the supervision of a board-certified anesthesiologist. Additionally, paramedics are required to successfully intubate at least one patient monthly for three years, post certification, and one per quarter thereafter. At least one intubation, annually, must be performed under an anesthesiologist’s supervision.[9]

Their success rate?

Trauma patients – 1,110 patients – 94.1% successful endotracheal tubes.

Nontrauma patients – 547 – 98.3% successful endotracheal tubes.

Total patients (trauma and nontrauma combined) – 1,657 patients – 95.5% successful endotracheal tubes. The rest managed by alternative airways, except as indicted in the first quote. Footnote [4] and Footnote [9].

I know the complaints that most people will come up with. We can’t afford that. That’s too expensive. Our people are that good without all of that practice.

Never attribute to malice that which can be adequately explained by stupidity.

These are examples of stupidity. As TOTWTYTR likes to point out – There is no cure for stupid.

Any discussion of airway management is incomplete without Kelly Grayson’s article on how to think about airway management.[10]

Some other writing on these topics. If you want to read more of my ranting, and Yes ranting is appropriate for the topic:

Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment II

Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment

Prehospital Advanced Airway – Should Paramedics Be Intubating?

Waveform Capnography vs. Hubris.

RSI, Risk Management, and Rocket Science


^ 1 Waveform Capnography vs. Hubris
Rogue Medic

^ 2 Prehospital Advanced Airway – Should Paramedics Be Intubating?
Rogue Medic
This is commenting on an EMS Garage segment and has 2 follow-up posts.

^ 3 Out-of-hospital endotracheal intubation: where are we?
Wang HE, Yealy DM.
Ann Emerg Med. 2006 Jun;47(6):532-41. Epub 2006 Feb 28.
PMID: 16713780 [PubMed – indexed for MEDLINE]

^ 4 Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

^ 5 George Orwell

^ 6 Hanlon’s Razor

^ 7 Medtronic unwraps gifts. But some say vendor’s role not clearly defined.
Rhea S.
Mod Healthc. 2008 Sep 15;38(37):8-9. No abstract available.
PMID: 18810822 [PubMed – indexed for MEDLINE]

Other industry watchers expressed greater skepticism, saying Medtronic’s disclosure highlights the still deeply entrenched practice of vendors gifting to bolster their sales influence. “Their gifting follows areas of their financial interests,” said David Rothman, president of the Institute on Medicine as a Profession.

^ 8 A great gesture on the part of pharmaceutical companies indeed…
The Pump Handle

^ 9 Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]
This is the same as Footnote [4].

^ 10 The Airway Continuum
Kelly Grayson

^ 39 Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768 [PubMed – indexed for MEDLINE]

^ 40 Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting.
Jemmett ME, Kendal KM, Fourre MW, Burton JH.
Acad Emerg Med. 2003 Sep;10(9):961-5.
PMID: 12957980 [PubMed – indexed for MEDLINE]

^ 41 Emergency physician-verified out-of-hospital intubation: miss rates by paramedics.
Jones JH, Murphy MP, Dickson RL, Somerville GG, Brizendine EJ.
Acad Emerg Med. 2004 Jun;11(6):707-9.
PMID: 15175215 [PubMed – indexed for MEDLINE]