Yesterday, I wrote about a study that shows that we are not good at assessing the airway, even if we have the right tools.[1] Today, I am writing about the editorial that accompanied that study.
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As Mick “Crocodile” Dundee was preparing to go on walk-about through the Outback, he had to ask his best mate what day it was so he would know when to return. His mate commented how lucky Mick was, “Doesn’t know; doesn’t care.” In this issue of Annals, Katz and Falk1 describe a similar problem common to many emergency medical services (EMS) systems. It’s not that they don’t care; they don’t care to know.[2]
What does this say about us?
We claim to be doing everything we can for our patients.
Look at the comments about the death of Curtis Mitchell from people who insist they would dig for hours through the snow just to rescue the one patient we know died. This is after the fact and we know that Curtis Mitchell died, so we insist that we would do everything to save him, while delaying treatment of the other patients. We know the other patients did not die in a way that can be tied to delayed response. Of course, if we do that, then maybe somebody else dies due to delayed response.
What we did not do, as is the case with intubation, is use the right tools to help the patient. The right tool for Curtis Mitchell was not a shovel. The right tool is a 4 wheel drive vehicle.
The right tool for the dead patients with the tube in the esophagus was not a fancier stethoscope. The right tool is waveform capnography.
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Where are we when it comes to doing everything we can to find out which patients we are harming and which patients we are helping?
Usually, we are making excuses. After all, we can always sacrifice someone after the fact, when we have identified someone to point a finger at.
Why not find out before we kill someone?
Why not try to do what EMS is supposed to do – prevent deaths?
No. This is EMS. We don’t do that.
We don’t use information.
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There is always the potential of failure to intubate. Even more disastrous is the potential for failing to intubate the trachea and not recognizing it. In every setting, we focus on avoiding such an eventuality. In the operating room, arguably the most controlled setting possible for ETI, this issue has been addressed decisively.5 Detecting and monitoring end-tidal carbon dioxide is the standard of care for patients who undergo ETI. However, there is no such standard or routine practice for EMS systems or even our emergency departments.[2]
Are emergency physicians that much better at intubation, that they do not need to use waveform capnography?
Better than anesthesiologists in the OR?
Are medics that much better than anesthesiologists in the OR?
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It is nothing short of amazing that physicians use the most reliable technology in the environment that can be the most controlled and is the most conducive to effectively examining the patient to determine the success or failure of the procedure. In contrast, we send EMS providers, often with limited experience, into the most treacherous environments, sometimes to places we would never dare to venture, and expect them to perform under conditions we would never tolerate. There, the ability to clinically determine the success of ETI is least. Additionally, valuable tools are not made available or are not used predictably.[2]
Why worry?
It’s just the airway.
The air hole or the food hole –
Wherever the tube ends up –
What matters is that we care –
We just don’t care enough to use the right equipment.
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In the operating room, most intubated patients never move. Control is at a maximum. End-tidal carbon dioxide is monitored throughout each procedure. In the field, EMS providers, when they use them, often rely on various ETI detection devices for single spot determinations. Have we not placed our priority in the wrong place?[2]
But that is what we are best at – placing our priority in the wrong place (and placing a bunch of our endotracheal tubes in the wrong place, too).
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So, for the EMS system Katz and Falk studied, where were the efforts to monitor patient outcomes, individual providers, and EMS system components (eg, the various participating agencies) and processes? Why was the use of available detection devices “sporadic” and what was being done about that? In short, before Katz and Falk, who cared to know? More importantly, who cares to know in each of our own communities?[2]
How many of us have measured the quality of intubation in our systems?
How many of us just muddle along and make a scapegoat out of the medic who intubates the esophagus of a patient and has it make headlines?
I think the group that muddles is much larger than the group that knows its abilities, or knows its disabilities.
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In the operating room, and in the ED, an unrecognized esophageal intubation would be considered a sentinel event, necessitating extensive documented effort to avoid a recurrence.[2]
In EMS, this is not a sentinel event.
In EMS, we have different terminology – Nothing to see here. Move along. Nothing to see here.
We need to change that.
Our patients deserve better.
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Footnotes:
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[1] 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]
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[2] “A” is for airway…also for action.
Delbridge TR, Yealy DM.
Ann Emerg Med. 2001 Jan;37(1):62-4. No abstract available.
PMID: 11145775 [PubMed – indexed for MEDLINE]
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