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

- Rogue Medic

Capnography Use Saves Lives AND Money – Part III

Continuing from Capnography Use Saves Lives AND Money – Part I and from Capnography Use Saves Lives AND Money – Part II.

The most common causes for EMS lawsuits are negligent vehicle operation and improper performance of medical procedures. Juries frequently award millions of dollars to patients, and legal fees are typically hundreds of dollars per hour, producing a significant unbudgeted expenditure to an agency. Therefore, capnography is one piece of clinical backup that can assist you in avoiding lawsuits.[1]


At one end – How many multi-million dollar law suits does it take to change that cost/benefit analysis that the managers were using to justify not using waveform capnography?

At the other end – How many thousands of dollars of legal fees, how much for expert witnesses, and how much distraction from running an EMS organization does it take to change the cost/benefit analysis based on no such thing as too cheap after even a small out of court settlement?

Now imagine that you use waveform capnography.

A lawyer shows up representing a patient who claims to have hypoxic brain damage due to a misplaced endotracheal tube. You go through your copies of charts and find the right chart. Part of the printout attached to that chart is copied below. The image is taken from Capnography for Paramedics, an excellent source of information about capnography.


What does this mean?

The sensor for waveform capnography is placed between the end of the endotracheal tube and the BVM bag.

The only way for carbon dioxide to pass through the sensor is for that carbon dioxide to be exhaled by the patient through the endotracheal tube.

At a minimum, I prefer to record the waveform as soon as possible after there is a good waveform, just before removing the patient from the ambulance, and just before moving the patient to the hospital stretcher. They can wait. They are going to pause everything to get a much less reliable confirmation of placement in the hospital, so there is not real rush.

Other times to record the waveform are with each movement. This demonstrates that I am paying attention to the tube placement and avoids the perceived need for a cervical collar. The use of a cervical collar just encourages people to ignore tube placement. Do your patients a favor, continually assess tube placement and leave the cervical collars alone.

If you use the piece of litmus paper in plastic color change device, which has an unreasonably high failure rate, what do you have to demonstrate placement of the tube? Only the medics description after the fact. How well does he document? How good a witness is he on the stand? You do realize that the hospital needs to convince the jury that the damage was done prior to arriving in the ED, right? Believe the doctor? Believe the medic?

With the printout of a good waveform from waveform capnography, the lawyer has no good reason to continue to go after your company for a misplaced tube. Without a printout of a good waveform, it all depends on whom the jury believes after a lot of legal expenses, or it results in an out of court settlement.

Waveform capnography is extremely inexpensive, if we understand patient care and risk management.

One of the most frequent EMS lawsuits involves undetected esophageal intubations. If the ET tube is improperly inserted into the esophagus and this error isn’t recognized and corrected expediently, the result is a devastating hypoxia that causes severe brain injury and, ultimately, death. Continuous monitoring of capnography is the standard of care for detecting esophageal intubations, as well as for detecting subsequent dislodgement of ET tubes.(3)

Settlements for injury and wrongful death resulting from undetected misplaced ET tubes are often in the multimillion-dollar range.[1]


We can avoid esophageal intubations in a few ways.

1. Stop using endotracheal tubes, which is not popular with paramedics, but is likely to be the future of the cut rate EMS services.

2. Provide excellent aggressive medical oversight, which involves a lot of practice on mannequins and the use of waveform capnography as just one critical part of the method of tube placement confirmation.

3. Ignore the problem. This is something we only read about happening to other people.

This is true – right up until it is not. Ask any doctor about being sued for malpractice. Almost all are concerned about malpractice suits. There are many ways of approaching the concern about malpractice, but almost all doctors understand that providing excellent care is one thing that they can do to modify their risk.

If I do what is best for the patient, my long-term liability is lower than if I do what is cheapest in the short-term.

I understand that we will not be able to provide any care for patients, if we cannot afford to stay in business. I also understand that –

1. If the care we provide is bad, then we are not helping patients.

2. Keeping the organization in business just long enough to do some really serious harm to patients, which results in being shut down by a large law suit, is a bad idea.

This focus on the short-term is not really different from the way we approach the use of epinephrine, and other drugs, during cardiac arrest. We act as if the short-term is all that matters, even though there is no reasonable expectation of a long-term benefit.

But aren’t unrecognized esophagal intubations extremely rare?

To be continued in –

Capnography Use Saves Lives AND Money – Part IV
Capnography Use Saves Lives AND Money – Part V

An excellent source of information about waveform capnography can be found at Capnography for Paramedics.


[1] Capnography Use Saves Lives & Money
By Patricia A. Brandt, RN, BSN, MHR



  1. I’m of the mindset that if you don’t have access to Continuous Waveform Capnography you have no business intubating patients…even dead ones. Some folks may say that they need to intubate to protect some class of patients even if they don’t have capnography. This is weak.

    In Cardiac arrest patients? They’re dead. Drop a King and forget about it. Research shows you shouldn’t waste any time with a tube. Wake County NC has amazing numbers: King first.

    What class of patient is left? Probably those you’d need RSI for anyway. This is the patient where it is borderline negligent to NOT obtain waveform capnography on. These patients aren’t dead yet, they need to have a patent airway. If you can’t prove you placed the tube, you shouldn’t place it.


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