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

- Rogue Medic

Ambulance Mistake Killed Teen After Skateboard Accident


 
Here is an article about the death of a kid that raises a lot of questions.

The article does not answer many of those questions.

What happened?
 

Melvin says Carteret General sent a respiratory therapist along in the ambulance because they decided to put a breathing tube down the child’s throat. He says Drew was not properly sedated, woke up and pulled out the tube.[1]

 

Not properly sedated?

Unfortunately, this does happen. Dr. Scott Weingart has a couple of podcasts where he rants about this problem.[2],[3]
 

Why avoid sedation?

Maybe the patient is allergic.

Use a different sedative. There are dozens available.

Maybe the patient’s blood pressure is low.

Use ketamine.

What if the patient stops breathing?

Really. This is an excuse that I have encountered with several intubated patients.

Just how stupid are some of the people who graduate from medical school?

The patient is already intubated and on a ventilator (or being ventilated by BVM [Bag Valve Mask] resuscitator).

What do we do for someone who stops breathing?

Ventilate – for example by BVM until an endotracheal tube is placed.

If an endotracheal tube has already been placed, does anyone really care if the patient stops breathing?

And . . .

. . . ketamine.

Ketamine is a sedative that usually does not depress the patient’s respiratory drive.

And there is one more minor point to consider.

Most patients are intubated with the assistance of not just sedatives, but also paralytics.

If you are breathing after receiving a paralytic, somebody did something wrong. A paralytic is supposed to stop every muscle in the body from contracting – except the heart.

It could be that there was an omission of adequate doses of more than two types of drugs – sedatives and paralytics and, as Dr. Weingart will point out, pain medicine, because sedatives do not usually provide pain relief . . .

. . . except for ketamine.

It is a versatile drug, that ketamine.
 

The patient woke up and pulled the tube out.

Which would make you happier?

1. I have to ventilate this patient through the tube that is already in place.

2. I have to place the tube back in the trachea during transport because you neglected to provide adequate sedation. Even if reintubated excellently, intubation has many complications.

That should be the antidote to the argument that sedation is a bad thing (what if he stops breathing?), because it should be obvious that not breathing, but being ventilated is much better than not being sedated and being so agitated that the patient removes his airway.

Just put it back in!

That is the response, except . . .
 

The attorney says when those in the ambulance re-inserted the tube, it went into the teen’s esophagus, rather than his trachea.[1]

 

That happens.

Esophageal intubation is no big deal.

Just ventilate and place the tube in the trache. If the tube cannot be properly placed, we can use the BVM for ventilation or perform a crichothyrotomy. Both are acceptable means of ventilation.
 

He says Drew was given sedatives, and the teen, unable to breathe on his own, went without oxygen for about 35 minutes.[1]

 

Not recognizing a tube that has been placed in the esophagus, or one that has migrated to the esophagus, is just plain bad patient care.

Nobody should be intubating without waveform capnography to confirm placement.

Even without waveform capnography, there should not be a problem. All intubated patients should have continual assessment, which should identify a problem long before brain death.

Again, the worst case is that the patient is ventilated by BVM or crichothyrotomy.

We do not have details about what happened, but the patient appears to have arrived at the hospital without brain function. Was that due to the original injury, with the esophageal intubation only complicating matters?

There is not enough information to tell, but when the tube is left in the esophagus, it is kind of like leaving your fingerprints all over a knife sticking out of a dead guy’s chest. People are not going to spend a lot of time looking for another cause of death.

Capnography has been recommended in ACLS (Advanced Cardiac Life Support) since 2000, if not earlier.[4]

How difficult is assessment for an improperly placed tube (all tubes should be considered improperly placed and continually reassessed)?[5]
 

Melvin says the ambulance crew diverted to CarolinaEast in New Bern, and the ER doctor there immediately recognized the tube was in the wrong place.[1]

 

We like to find evidence that confirms what we believe. (I believe that the tube is where I want it to be. I saw the tube go through the cords.)

This is dangerous.

We need to look for evidence that we are wrong.

If we are not constantly looking for evidence that we are wrong, we will make a lot more mistakes than we should.

Science is a method of looking for evidence that we are wrong. That is why science keeps improving.

We need to take a more scientific approach to patient care. . .

. . . and have I mentioned ketamine? Science shows that ketamine is safe and effective.
 

I have more information here – Further Details on ‘Ambulance Mistake Killed Teen After Skateboard Accident’

Footnotes:

[1] LAWSUIT: Ambulance Mistake Killed Teen After Skateboard Accident
Updated: Wed 9:14 PM, Nov 06, 2013
WITN.com
Article

[2] Intubated ED Patients are Still Not Receiving Sedation
EMCrit
by Scott D. Weingart, MD.
Podcast page

[3] ED patients being intubated and then not sedated or pain-controlled
EMCrit
by Scott D. Weingart, MD.
Podcast page

[4] You had me at ‘Controversial post for the week’ – Part I
Tue, 22 Oct 2013
Rogue Medic
Article

[5] More Intubation Confirmation
Sun, 27 Apr 2008
Rogue Medic
Article

.

Comments

  1. In NC, waveform capnography is required on all RSI’s (I really hope it wasn’t a DFI). It is not yet required on all intubations, instead, “strongly recommended.” You can instead use colorimetric capnometry, from Protocol 2 Adult Airway:

    – Capnometry (color) or capnography is mandatory with all methods of intubations. Document results.
    – Continuous capnographic (EtCO2) is strongly recommended for the monitoring of patients with a BIAD or endotracheal tube.

    More to your point, there are these points just below those two, which these providers could have followed:

    – If an effective airway is being maintained by BVM with continuous pulse oximetry values of ≥ 90%, it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation.
    – For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation.

    Under the RSI protocol:

    – Continuous Waveform Capnography and Pulse Oximetry and are required for intubation verification and ongoing patient monitoring

    …and…

    – Protect the patient from self-extubation when the drugs wear off.

    I hope this tragic case is used to make it mandatory on all intubations.

  2. Aren’t some dosage limits also based on the rate of metabolism and mechanism? Sedating the patient to the point of liver/kidney failure wouldn’t be all that much better. Granted I’m not very familiar with Ketamine, I’ve only seen it used a handful of times, all in surgical applications.

    I have definitely had plenty of patients begin to buck a tube in IFT based on their level of sedation, and the mere bumps in the road being enough to agitate them. Usually just changing vent settings helps to keep them from becoming truly combative, but you still have to watch them pretty closely and possibly add more sedation. Although, many times the transferring facility has them playing the nitro/dopamine drip game, and are also sedated using fentanyl/versed/propofol. This makes it hard to simply add more sedation and not have a lot of juggling of meds to have to continue doing. Have they started using ketamine more often in adults now? I haven’t seen a drip personally where I work.

    I think the bigger problem is in the other posts lately, hospital staff can sometimes be too lackadaisical about a patients level of sedation. In the average patient 1mg of versed an hour is not going to keep the average adult sedated very well. Some are even hesitant to give orders to us for more sedation, at times I’ve heard that they don’t want to inhibit the receiving facilities initial neuro exam… I would hope that if they are sending an unconscious, intubated patient, the receiving neurologist isn’t expecting a walking, talking patient, capable of completing a full neurological exam.

    Always a great topic here with great info, thanks!

    • “Aren’t some dosage limits also based on the rate of metabolism and mechanism? Sedating the patient to the point of liver/kidney failure wouldn’t be all that much better.”

      – Nah, that’s not really an issue in prehospital/ED/early inter-facility transfer (though it is of greater concern in some patients who have been intubated > 48 hrs). In even the most agitated patients you’ll run into BP problems well before hitting the dosage ceiling, especially in the first 12-24 hours of the patient’s care. And if you do happen to find that a particular drug isn’t working with generous dosing (very rare), there’s always several others to try. Propofol, fentanyl, midazolam, dexmedetomidine, ketamine… some combination of those major players is bound to give you results.

      “Some are even hesitant to give orders to us for more sedation, at times I’ve heard that they don’t want to inhibit the receiving facilities initial neuro exam.”

      – Neurosurgeons are actually big on being able to assess the patient’s mental status to guide their treatment, so that is a legitimate concern. The simple solution there is to use a combination of fentanyl and propofol, where the fentanyl gives the patient a basal amount of pain control (what we actually care about, not necessarily sedation) and the propofol can be turned off by the surgeon to do their exam < 5 min later. As a plus, with a good fentanyl drip, the patient won't immediately be in misery when he or she does turn off the propofol and their BP won't spike to 200/110 mmHg.

      "Although, many times the transferring facility has them playing the nitro/dopamine drip game, and are also sedated using fentanyl/versed/propofol."

      – Maybe it's a regional thing, but no-one around here ever plays the nitro/dopamine game anymore, so that simplifies things a bit. The game you will definitely end up playing with the approach I subscribe to is fentanyl-propofol vs. norepinephrine though. The key is to remember that fentanyl is the primary agent you want to titrate up because pain-control will give you the most bang-for-your-buck. A patient is less likely to rip out their ETT if they're comfortable, even if they're not sedated, and comfort is what fentanyl provides. The propofol is just extra to make the whole experience a bit less horrible since they hopefully "sleep" through the miserable ED and transport events. By maximizing your fentanyl dosing you can minimize your dose of propofol and the marked and direct hypotension that results from that.

      As a final note for the scenario RM wrote about, every intubated patient undergoing interfacility transport should have physician orders for restraints and they should be in place in the event all of our pain-control and sedation measures fail. It can be very difficult to dial-in the proper medication levels, especially with the continual sensory bombardment of bumps every 15 seconds that Parastocles mentions, so while the restraints aren't in any way an alternative to a proper sedation package, they're a necessary fail-safe.

      • Yes, definitely restraints applied and tied properly, that’ll keep them from pulling anything out before you can catch that hand. They unfortunately tend to go for foley’s or ETT’s, sometimes the poor little soft restraints can’t handle it though so they should still be watched pretty closely and especially during transport.

        I’ve started to see the levophed use pick up, they’ve even added it back into the drug box for us. Thanks for the insight, will definitely be applying it.

    • Thanks for the link. While I initially wanted to give the crew at least a shred of support because sometimes horrible things just happen in spite of doing the right thing in our line of work, the events described in this article absolutely boggle the mind. They’re still accusations and thus not proven, but they’re pretty damning and the story they put together certainly flows in the way you would expect an airway disaster of this magnitude to occur. If true, this is probably even worse than the case of Elaine Bromiley.

      • It certainly seems that the facts bear that out, as well as the scuttlebutt floating around the area (this happened within our service area though not within our service). We often say things like “we’ll never know the whole story”, but I believe in this case we will, and better care will come from it.

        Like I always teach, putting a tube in the esophagus isn’t bad. I work in a teaching hospital…it happens every day. Leaving a tube in the esophagus is bad. This was bad.

  3. A settlement has been reached in a lawsuit between a local hospital and the family of a teen who died in a skateboarding accident http://www.boardemporium.com.

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  1. […] to Michael Berrier for providing a link to a much more detailed account of what I wrote about in Ambulance Mistake Killed Teen After Skateboard Accident. […]

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