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

- Rogue Medic

Irresponsibility and Intubation – The EMS Standard Of Care

Wed, 09 Aug 2017 11:00:03 -0400 by
 

There is a petition to save EMS intubation, but it claims to be a petition to save patients. The petition is not to save patients.
 


Image source
Details here and here.
 

The petition states that its intent is to protect patients, but it does not provide any evidence. It only makes the same claims that every other quack makes to promote his snake oil.

We are worse than homeopaths, because homeopaths do not actively harm patients by depriving patients of oxygen, as we do when we intubate.
 

 
We are the quack, witch doctor, homeopath, horseshit peddlers Dara O’Briain is describing.

 

Today we are possibly facing the removal of the most effective airway intervention at our disposal as paramedics, endotracheal intubation.[1]

 

Most effective?

There is some evidence that intubation can be – in limited situations, by highly trained, competent people – beneficial. There is also plenty of evidence that intubation is harmful. It is easy to kill someone by taking away the patient’s airway.

Most effective?

No.

This petition does not mention evidence, so it has no credibility when it comes to claims of whether intubation is effective. This petition expects us to believe in a faerie tale of magical improvement with intubation. This petition wants us to clap for Tinkerbell, because If we believe hard enough, it just might come true. Grow up.
 

Please sign this petition so that these patients have a chance to live[1]

 

Prove that requiring higher standards for intubation would take away a patient’s chance to live.

Prove that intubation improves outcomes.

This is a petition to keep standards low for paramedics.

This petition does not mention competence, or even what is involved in competence, because this petition is opposition to competence.

This is the Protect Incompetent Paramedics from Responsibility Petition.

Responsibility is for professionals. In EMS, we reject responsibility.

We are more concerned with whether our shoes are shiny, than whether we are harming, or helping, our patients. The reason EMS exists is to improve outcomes for patients.

We don’t deliver competent care, but only the appearance of competence. We are medical theater, putting on a fancy show. The TSA (Transportation Security Administration) is the same – all appearance and no substance.

Most effective? Maybe intubation is the most effective theater.

The outcomes of our patients are affected, but we refuse to learn if we are helping, harming, or doing equal amounts of harm and help.

We actually oppose learning. We are willfully ignorant – and proud of our defiant stand for ignorance.

How much hypoxia do we cause in our attempts to place the so called gold standard? The actual gold standard is helping the patient to protect his own airway, but who cares what’s best for the patient? Not those who sign the petition.

How much vomiting, and aspiration, do we cause?

How much airway swelling do we cause?

How many airway infections do we cause?

How much harm do we cause?

We don’t know. We don’t care. We oppose attempts to find out.

We are EMS and we believe that our actions should be protected from examination, because we are beautiful and unique snowflakes who demand our participation trophies without doing real work required to be competent.

Go ahead, snowflakes, demonstrate your incompetence by signing the petition, because this protect intubation petition is really a protect incompetence petition.

If we want to continue to intubate, and we want to improve outcomes for our patients, we need to demonstrate that intubation by EMS provides significant benefit and which patients are most likely to benefit. We can’t do that because we don’t care enough about our patients.
 

Brian Behn has a different reason for not signing the petition for low standards – Why I am Not Signing The Petition About Intubation.

Dave Konig also comments on the petition for low standards – Is ET Intubation Joining Backboards In Protocol?

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Footnotes:

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[1] Allow paramedics to continue to save lives with endotracheal intubation!
Anthony Gantenbein United States
Petition site

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Filed Under: Airway Management, Assessment, Critical Judgment, Education, Evidence, Heresy, Intubation, Malpractice, Risk Management, RSI

2016 – Amiodarone is Useless, but Ketamine Gets Another Use

Sat, 31 Dec 2016 03:10:47 -0500 by
amiodarone-edit-1
 

I didn’t write a lot in 2016, but 2016 may have been the year we put the final nail in the coffin of amiodarone. Two major studies were published and both were very negative for amiodarone.

If we give enough amiodarone to have an effect on ventricular tachycardia, it will usually be a negative effect.[1]

Only 38% of ventricular tachycardia patients improved after amiodarone, but 48% had major adverse cardiac events after amiodarone.

There are better drugs, including adenosine, sotalol, procainamide, and ketamine for ventricular tachycardia. Sedation and cardioversion is a much better choice. Cardioversion is actually expected after giving amiodarone.

For cardiac arrest, amiodarone is not any better than placebo or lidocaine. What ever happened to the study of amiodarone that was showing such wonderful results over a decade ago? It still hasn’t been published, so it is reasonable to conclude that the results were negative for amiodarone. It is time to make room in the drug bag for something that works.[2],[3]

On the other hand, now that we have improved the quality of CPR by focusing on compressions, rather than drugs, more patients are waking up while chest compressions are being performed, but without spontaneous circulation, so ketamine has another promising use. And ketamine is still good for sedation for intubation, for getting a patient to tolerate high flow oxygen, for agitated delirium, for pain management, . . . .[4],[5]

Masimo’s RAD 57 still doesn’t have any evidence that it works well on real patients.[6]

When intubating, breathe. Breathing is good. Isn’t inability to breathe the reason for intubation?[7]

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Footnotes:

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[1] The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia
Wed, 17 Aug 2016
Rogue Medic
Article

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[2] Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest
Mon, 04 Apr 2016
Rogue Medic
Article

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[3] Dr. Kudenchuk is Misrepresenting ALPS as ‘Significant’
Tue, 12 Apr 2016
Rogue Medic
Article

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[4] What do you do when a patient wakes up during CPR?
Tue, 08 Mar 2016
Rogue Medic
Article

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[5] Ketamine For Anger Management
Sun, 06 Mar 2016
Rogue Medic
Article

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[6] The RAD-57 – Still Unsafe?
Wed, 03 Feb 2016
Rogue Medic
Article

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[7] Should you hold your breath while intubating?
Tue, 19 Jan 2016
Rogue Medic
Article

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Filed Under: ACLS, Airway Management, CPR, Critical Judgment, Evidence, Excited Delirium, Heresy, Intubation, Ketamine, Masimo, Mythology, Pharmacology, Risk Management, Sedation, Toxicology

‘Narcan by Everyone’ Does Not Seem to be Such a Good Idea

Thu, 22 Dec 2016 22:45:48 -0500 by
 
Now that we have almost everyone giving naloxone (Narcan) to suspected heroin overdose patients, the fatality rate must have dropped. The panacea must have worked. My criticism of the Narcan by Everyone programs must have made me a laughing stock.[1],[2],[3],[4]

No.

Does that mean that I am a prophet and that you should worship me?

No.

Explanations exist; they have existed for all time; there is always a well-known solution to every human problem — neat, plausible, and wrong. H.L. Mencken.

I have been pointing out that the plans assumed that there would not be any unintended consequences. I explained what some of the unintended consequences would be. Many people used logical fallacies to justify ignoring the likelihood of unintended consequences. The reasonable thing to do would have been to study the implementation, so that problems would be noticed quickly.

Misdiagnosis – giving naloxone to people who have a change in level of consciousness that is not due to an opioid (heroin, fentanyl, carfentanyl, . . . ) overdose.
 

Six of the 25 complete responders to naloxone (24%) ultimately were proven to have had false-positive responses, as they were not ultimately given a diagnosis of opiate overdose. In four of these patients, the acute episode of AMS was related to a seizure, whereas in two, it was due to head trauma; in none of these cases did the ultimate diagnosis include opiates or any other class of drug overdose (which might have responded directly to naloxone). Thus, what was apparently misinterpreted as a response to naloxone in these cases appears in retrospect to have been due to the natural lightening that occurs with time during the postictal period or after head trauma.[5]

Bold highlighting is mine.

 

Failure to ventilate – not providing ventilations to a patient who is not breathing. These patients are often hypoxic (don’t have enough oxygen to maintain life) and hypercarbic (have too much carbon dioxide to maintain life). If the patient is alive, ventilation should keep the patient alive, even if naloxone is not given or if the naloxone is not effective. If the patient is dead, giving naloxone will not improve the outcome.[6]

But . . . But . . . But . . . Narcan is the miracle drug!
 


Image credit.
 

In Akron, a small Ohio city, medical examiner Dr. Lisa Kohler has seen over 50 people die of carfentanil since July. Police Lieutenant Rick Edwards says his officers are “giving four to eight doses of [naloxone] just to get a response.”[7]

 

“Every day our paramedics start CPR on someone surrounded by empty naloxone vials… people give the naloxone and walk away,” she (Ambulance Paramedics of BC president Bronwyn Barter) said in an interview.[7]

 

Where should we start?
 

All patients considered to have opioid intoxication should have a stable airway and adequate ventilation established before the administration of naloxone.[8]

 

We keep making excuses for solutions that are neat, plausible, and wrong. Why don’t we start acting like responsible medical professionals and do what is best for our patients?
 

Thank you to Gary Thompson of Agnotology for linking to this for me.

Go read Response: ‘What happens when drugs become too powerful for overdose kits’

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Footnotes:

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[1] The Myth that Narcan Reverses Cardiac Arrest
Wed, 12 Dec 2012 20:45:29
Rogue Medic
Article

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[2] Should Basic EMTs Give Naloxone (Narcan)?
Fri, 27 Dec 2013 14:00:22
Rogue Medic
Article

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[3] Is ‘Narcan by Everyone’ a Good Idea?
Tue, 03 Jun 2014 23:00:38
Rogue Medic
Article

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[4] Is First Responder Narcan the Same as First Responder AED?
Wed, 18 Jun 2014 17:15:43
Rogue Medic
Article

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[5] Acute heroin overdose.
Sporer KA.
Ann Intern Med. 1999 Apr 6;130(7):584-90. Review.
PMID: 10189329 [PubMed – indexed for MEDLINE]

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[6] The Kitchen Sink Approach to Cardiac Arrest
Mon, 16 Feb 2015 16:00:53
Rogue Medic
Article

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[7] What Happens When Drugs Become Too Powerful for Overdose Kits?
Dr. Blair Bigham
Oct 4 2016, 12:11pm
Article

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[8] Naloxone for the Reversal of Opioid Adverse Effects
Marcia L. Buck, PharmD, FCCP
Pediatr Pharm. 2002;8(8)
Medscape (free registration required?)
Clinical Uses

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Filed Under: Airway Management, Assessment, Critical Judgment, Fentanyl, Heresy, Heroin, Naloxone, Narcan, Pharmacology, Research, Risk Management

Should you hold your breath while intubating?

Tue, 19 Jan 2016 20:05:20 -0500 by
 

This is one of the ancient bits of street wisdom common sense about intubating. If you hold your breath while intubating, you will know when the patient needs to take a breath.

As with much of common sense, it is based on mythology.
 

Never take more than 30 seconds per attempt at each intubation!
Hint: Hold your breath while intubating – when you need to take a breath, so does the patient![1]

 

60 pct of the time, it works every time 1
Typical intubation instructor?
 

Obviously, this idea came about long before apneic oxygenation. No, . . . . Wait, it could be that apneic oxygenation came first, since papers were being written about apneic oxygenation long before paramedics were sent out to spread the word of the benefits of unrecognized esophageal intubation close enough for prehospital intubation.[2],[3],[4]

It could be that some anesthesiologists thought breath holding while intubating was a good idea, but I did not find any papers.

Apneic oxygenation can prevent desaturation for much longer than 30 seconds, yet many of us still emphasize fast and bloody, rather than slow and benign.

If the patient can hold her breath for as long as I can, she may be breathing as well as I am breathing, and may not need to be intubated. How do I really know when my patient needs to take a breath?

If I can only hold my breath for as long as a patient who needs to be intubated, then I may be breathing as badly as she is, and I may need intubation more than she does. How long can a paramedic hold his breath before becoming hypoxic and/or confused? How good am I at recognizing this change when I am focused on putting the little plastic tube in the slightly larger cartilage and flesh tube?

If the patient does not need to be intubated, why intubate? If I need to be intubated, should I be the one intubating anyone else? If I can hold my breath longer than the average paramedic, should I take up smoking to make this technique work for me? Should we be testing paramedics on how long a breath can be held as part of the hiring process?

I am shocked that such a simple one size fits all approach fails to consider even one of the many variables that would affect its use. How could that possibly happen in EMS?

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Footnotes:

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[1] Widely circulated, unwritten paper
The Mythbuilders of EMS
Trust us.
We know what we’re doing.

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[2] Oxygen uptake in human lungs without spontaneous or artificial pulmonary ventilation.
ENGHOFF H, HOLMDAHL MH, RISHOLM L.
Acta Chir Scand. 1952 Jul 14;103(4):293-301. No abstract available.
PMID: 12985091

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[3] Pulmonary uptake of oxygen, acid-base metabolism, and circulation during prolonged apnoea.
HOLMDAHL MH.
Acta Chir Scand Suppl. 1956;212:1-128. No abstract available.
PMID: 13326155

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[4] Apneic oxygenation in man.
FRUMIN MJ, EPSTEIN RM, COHEN G.
Anesthesiology. 1959 Nov-Dec;20:789-98. No abstract available.
PMID: 13825447

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Filed Under: Airway Management, Heresy, Intubation, Mythology

Where is the Line Between Good Pain Management and Bad

Sun, 26 Jan 2014 15:00:48 -0500 by
 

Almost everything exists on a continuum. Pain management is no different.

The idea of completely good, or completely bad, pain management may not even be appropriate in describing the extremes, because clear distinctions are imaginary.
 

Anesthesia exists along a continuum. For some medications there is no bright line that distinguishes when their pharmacological properties bring about the physiologic transition from the analgesic to the anesthetic effects. Furthermore, each individual patient may respond differently to different types of medications.[1]

 


Image credit.
 

The definitions of sedation/analgesia as Moderate or Deep provide excellent examples.
 

Moderate
 

Moderate sedation/analgesia: (“Conscious Sedation”): a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. CMS, consistent with ASA guidelines, does not define moderate or conscious sedation as anesthesia (71 FR 68690-1).[1]

 

Deep
 

Deep sedation/analgesia: a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. Because of the potential for the inadvertent progression to general anesthesia in certain procedures, it is necessary that the administration of deep sedation/analgesia be delivered or supervised by a practitioner as specified in 42 CFR 482.52(a).[1]

 

Respond purposefully is in the description of both. Respond purposefully should also be in the description of minimal sedation/analgesia and the description of no sedation/analgesia. The difference is the amount of stimulus required – following repeated or painful stimulus vs. to verbal commands, either alone or accompanied by light tactile stimulation. This is the primary difference.
 

Patients may require assistance in maintaining a patent airway,

Does that mean that a patient who does not require assistance in maintaining a patent airway is not receiving Deep sedation/analgesia?

No.

and spontaneous ventilation may be inadequate.

Does that mean that a patient with adequate spontaneous ventilation is not receiving Deep sedation/analgesia?

No.
 

What if supplemental oxygen is provided in anticipation of the potential for hypoxia, but the patient never becomes hypoxic?

What if supplemental oxygen is provided in response to hypoxia, the hypoxia resolves and does not return, but no ventilatory assistance is provided?
 

Should the following be added to the moderate sedation/analgesia definition?

Because of the potential for the inadvertent progression to deep sedation/analgesia in certain procedures, . . . .

If that is true, then what about adding the following to the definition of minimal sedation?

Because of the potential for the inadvertent progression to moderate sedation/analgesia in certain procedures, . . . .

Only no sedation/analgesia does not qualify for this kind of warning, but my point is not to provide a slippery slope justification for unethically withholding sedation/analgesia.

I am pointing out what a continuum means.

All of this raises the question, What is too much?

We cannot really consider that question without also raising the question, What is not enough?
 


 

How do we differentiate among the various possibilities of sedation/analgesia?

We differentiate according to the response of the patient, not so much according to whether the patient responds to verbal, painful, or repeated stimuli, but by the response to the question, Do you want more pain/sedation medicine?

One determines how we respond to potential ventilation needs of the patient, while the other determines how we respond to the sedation/analgesia needs of the patient.

What is too much?

That seems to depend on where the patient is on the sedation/analgesia continuum as determined by someone other than the patient.

What is not enough?

That seems to depend on where the patient is on the sedation/analgesia continuum as determined by the patient.

We cannot ask one question without implying the other question, so why do we address them in isolation so often?

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Footnotes:

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[1] Revised appendix A, interpretive guidelines for hospitals— state operations manual, anesthesia services.
Centers for Medicare & Medicaid Services (CMS).
Effective December 2, 2011.
Free Full Text Download in PDF Format from CMS.

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Filed Under: Airway Management, Critical Judgment, Heresy, Pain Management, Sedation

Face Down Restraint into a Pillow

Wed, 08 Jan 2014 08:00:45 -0500 by

 

This picture just shows one image from one direction at one instant. A 12 lead ECG provides much more data and many more perspectives.

but . . . .

What it appears to show raises some questions.
 

P is for pillow – best part of paramedic school.

The pillow may not completely obstruct the airway, but this is probably not part of their protocols.
 

The patient’s hands have a bit of a cyanotic appearance, but the ears do not, so I suspect that the hands are discolored due to wrist restraints, not the pillow airway maneuver.

Glove use is fantastic, although there is no apparent need for gloves, but Scene safety, BSI then airway?

Why is the patient is restrained? Probably some charm deficit.

The side of the ambulance has Advanced Life (and maybe Support outside of the image) written on the side, so they should have access to chemical restraints – charm in a syringe.

Are any medications being used for chemical restraint?

Have any medications been used for chemical restraint?

Do protocols allow for any chemical restraint?
 

If you do not think that chemical restraint is important – to protect us and to protect the patient – listen to the EMS EduCast Excited Delirium episode.[1]

After listening to the podcast, imagine how this picture might be used to persuade a jury that you are guilty of murder or negligent homicide.
 

And this is a good time to remind everyone that K is for ketamine – the fastest IM (IntraMuscular) chemical restraint drug we have (after succinylcholine [suxamethonium in Commonwealth countries]). Even laryngospasm should not produce more of an airway problem and laryngospasm is manageable.[2]
 

 

Since one of the reasons for chemical restraint is to protect the patient, since in custody deaths may be die to excited delirium, and restraint asphyxia is one possible cause, why is the airway apparently not being addressed more aggressively?

Only one person is holding a violent patient down?

If one person is capable of restraining the patient, all by himself and with just one knee, is that a good sign?

On the plus side – at least he isn’t hog tied.

Does anyone want to guess at the patient’s heart rate?

Maybe that is the next thing to be done. We cannot tell, but all we can do is guess at the heart rate.
 

The pathogenesis of excited delirium deaths is likely multifactorial and includes positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal arrhythmias. We suggest that these deaths are secondary to stress cardiomyopathy similar to the cardiomyopathy seen in older women following either mental or physical stress.[3]

 

Sedation is my friend.

Sedation is the patient’s friend.

If I cannot handle an overly sedated person, I should not be working in EMS.

Over-sedation (under-stimulation) is a small, but easy to manage problem.

Under-sedation (over-stimulation) is a big problem complicated by a failure to understand the relative risks.

Maybe this is the rhythm –
 


 

Maybe this is the rhythm –
 


 

Maybe it is some other rhythm.

We don’t know.

We can’t tell.
 

It’s all about the little things.

Airway?

Breathing?

Circulation?

All appear to be mysteries for this patient.

Face down restraint is a bad idea.

Obstructing the airway is a bad idea – even if the patient is spitting.
 

How’s that airway?

P is for pillow!
 

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Footnotes:

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[1] Excited Delirium: Episode 72 EMS EduCast
EMS EduCast
September 23, 2010
Web page with link to podcast

While on the topic of podcasts, Dr. Scott Weingart provides the view of the emergency physician on chemical restraint.

Podcast 060 – On Human Bondage and the Art of the Chemical Takedown
by EMCRIT
November 13, 2011
Podcast and page with research links

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[2] Laryngospasm, hypoxia, excited delirium, and ketamine – Part I
Thu, 21 Jun 2012
Rogue Medic
Article

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[3] Excited delirium, restraints, and unexpected death: a review of pathogenesis.
Otahbachi M, Cevik C, Bagdure S, Nugent K.
Am J Forensic Med Pathol. 2010 Jun;31(2):107-12. Review.
PMID: 20190633 [PubMed – indexed for MEDLINE]
 

Unexpected deaths periodically occur in individuals held in police custody. These decedents usually have had significant physical exertion associated with violent and/or bizarre behavior, have been restrained by the police, and often have drug intoxication. Autopsy material from these cases may not provide a satisfactory explanation for the cause of death, and these deaths are then attributed to the excited delirium syndrome. The pathogenesis of excited delirium deaths is likely multifactorial and includes positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal arrhythmias. We suggest that these deaths are secondary to stress cardiomyopathy similar to the cardiomyopathy seen in older women following either mental or physical stress. This syndrome develops secondary to the toxic effects of high levels of catecholamines on either cardiac myocytes or on the coronary microvasculature. Patients with stress cardiomyopathy have unique ventricular morphology on echocardiograms and left ventricular angiography and have had normal coronary angiograms. People who die under unusual circumstances associated with high catecholamine levels have contraction bands in their myocardium. Consequently, the pathogenesis of the excited delirium syndrome could be evaluated by using echocardiograms in patients brought to the emergency centers, and by more careful assessment of the myocardium and coronary vessels at autopsy. Treatment should focus on prevention through the reduction of stress.

 

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Filed Under: Airway Management, Excited Delirium, Heresy, Ketamine, Legal Medicine

If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So – Part II

Tue, 26 Nov 2013 17:30:54 -0500 by
ResearchBlogging.org
 

Continuing from Part I of a paper that could, at best, be described as a convenience sample, since a quarter of patients were excluded from randomization because of attending physician bias.

What were the authors assuming when comparing GVL (GlideScope Video Laryngoscope) with DL (Direct Laryngoscopy) for intubation?
 

Intuitively, devices such as the indirect video laryngoscope should improve intubation performance. As such, this study tested the hypothesis that achieving better visualization during the intubation with the GlideScope Video Laryngoscope would result in a better airway management performance as measured by shorter intubation times.[1]

 

The authors also intuitively assume that shorter intubation times mean better airway management. This suggests that speed is the most important factor in airway management.
 


Image credit.
 

They are probably still preaching the myth of the Golden Hour at Shock Trauma.

Is speed more important than quality?
 

There is an excellent assessment of intubation attempt in this paper.
 

Confirmation of intubation attempt duration and success was identified using closed-circuit video.[1]

 

We should not be relying on self-reported intubation success, unless we aren’t interested in a study of fiction. We do not accurately report intubation success, so an objective measurement of success is essential. This should be applied to EMS, as well.
 

The failed intubation rate was less than 0.5%, but the participants had already excluded over a quarter of the patients, so how impressive is a half a percent failure on 3/4 of patients?

What is the success rate for all patients?
 

For all of the statistics regarding study measures, a p < 0.05 was chosen as the threshold for determining significance.[1]

 

Secondary outcome measures are free shots at finding something “significant,” so they should be required to achieve a higher standard than the 1 in 20 p value of < 0.05.[2]

 

To account for any potential bias from patients not enrolled owing to attending discretion, comparison analysis was performed between the eligible, enrolled patients and the eligible, nonenrolled patients. The data demonstrates that all groups were proportionally similar in their demographics, injury mechanism, ISS, and arrival vital signs (data not shown).[1]

 

And, according to Dr. Newman in the SMART EM podcast, the Mallampati scores of the excluded patients were similar to those of the included patients.
 

Used alone, the Mallampati tests have limited accuracy for predicting the difficult airway and thus are not useful screening tests.[3]

 

We conclude that the prognostic value of the modified Mallampati score was worse than that estimated by previous meta-analyses. Our assessment shows that the modified Mallampati score is inadequate as a stand-alone test of a difficult laryngoscopy or tracheal intubation, but it may well be a part of a multivariate model for the prediction of a difficult tracheal intubation.[4]

 

Do the demographics, injury mechanism, ISS, and arrival vital signs increase the ability of the Mallapati to predicting difficult intubation?
 


Image credit.
 

How do we know that the difficulty was similar between included patients and excluded patients?

Similar Mallampati scores.

How useful are Mallampati scores at predicting difficulty of intubation?
 

The pooled estimates demonstrated that only 35% of the patients, who underwent tracheal intubation with difficulties, were correctly identified with a modified Mallampati test.[4]

 

Does the Mallampati score work well for predicting difficulty of intubation with a video laryngoscope?
 

The clinical use of videolaryngoscopes may change the accuracy of predictors of difficult tracheal intubation and require a different definition of difficult tracheal intubation.[4]

 

The Mallampati score does not appear to be of much use in comparing the excluded patients from the included patients, but that is what the authors use to assure us that the patients are similar.

Mallampati scores compare one aspect of visibility, but how important is visibility for intubation?

To be continued in Part III.

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Footnotes:

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[1] Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial.
Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, Scalea TM.
J Trauma Acute Care Surg. 2013 Aug;75(2):212-9. doi: 10.1097/TA.0b013e318293103d.
PMID: 23823612 [PubMed – in process]

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[2] Do multiple outcome measures require p-value adjustment?
Feise RJ.
BMC Med Res Methodol. 2002 Jun 17;2:8. Review.
PMID: 12069695 [PubMed – indexed for MEDLINE]

Free Full Text from BioMed Central.
 

Standard scientific practice, which is entirely arbitrary, commonly establishes a cutoff point to distinguish statistical significance from non-significance at 0.05. By definition, this means that one test in 20 will appear to be significant when it is really coincidental. When more than one test is used, the chance of finding at least one test statistically significant due to chance and incorrectly declaring a difference increases. When 10 statistically independent tests are performed, the chance of at least one test being significant is no longer 0.05, but 0.40.

 

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[3] A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway.
Lee A, Fan LT, Gin T, Karmakar MK, Ngan Kee WD.
Anesth Analg. 2006 Jun;102(6):1867-78.
PMID: 16717341 [PubMed – indexed for MEDLINE]

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[4] Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients.
Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L’hermite J, Wetterslev J; Danish Anaesthesia Database.
Br J Anaesth. 2011 Nov;107(5):659-67. doi: 10.1093/bja/aer292. Epub 2011 Sep 26.
PMID: 21948956 [PubMed – indexed for MEDLINE]

Free Full Text from Oxford Journals.

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Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, & Scalea TM (2013). Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. The journal of trauma and acute care surgery, 75 (2), 212-9 PMID: 23823612

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Lee A, Fan LT, Gin T, Karmakar MK, & Ngan Kee WD (2006). A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway. Anesthesia and analgesia, 102 (6), 1867-78 PMID: 16717341

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Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L’hermite J, Wetterslev J, & Danish Anaesthesia Database (2011). Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients. British journal of anaesthesia, 107 (5), 659-67 PMID: 21948956

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Filed Under: Airway Management, Ethics, Heresy, Intubation, Research Blogging, Video Laryngoscopy

Further Details on ‘Ambulance Mistake Killed Teen After Skateboard Accident’

Thu, 14 Nov 2013 19:00:02 -0500 by

Image credit.
 

Thank you 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.
 

It (the law suit) alleges the hospital and/or it employees: “failed to keep Drew Hughes properly sedated and restrained; failed to properly re-intubate Andrew Davis Hughes during the transport; failed to perform standard objective tests to verify proper placement of the endotracheal tube; failed to recognize clear signs and symptoms of an esophageal intubation and respond to those signs; attempted to falsify the medical records to cover up their negligence; failed to use their best judgment in the treatment of Drew Hughes; failed to use reasonable care and diligence in the treatment of Drew Hughes and in the application of their knowledge and skill to the care of Drew Hughes; failed to possess the required skill and learning to treat Drew Hughes; failed to practice within the standard of care for respiratory therapists, nurses and/or paramedics in the same or similar communities; and were negligent in such other respects as may be shown at trial.”[1]

 

I mentioned almost all of those problems in what I wrote based on the much more limited information in the article[2] I had read. I missed attempted to falsify the medical records to cover up their negligence; and several of the comments mentioned physical restraints (which I did not mention) in addition to chemical restraint.

Was I so accurate because I am psychic?

No.

Airway disasters happen in predictable ways.

When people fail to recognize an esophageal intubation, it is not difficult to figure out why it happened.

If I were to write about a ball rolling to the edge of a table and falling due to gravity, it would be a similarly predictable scenario.

Airway disasters happen in predictable ways.

There was a failure of assessment, which is also a major part of how the tube was removed in the first place. Proper assessment should have prevented the need for re-intubation.
 

Going back to the beginning, a series of choices led up to the apparently very preventable death of a child.
 

A CT of the head was normal but doctors suspected a possible basilar skull fracture,[1]

 

Intubation seems extreme as prophylaxis for a possible basilar skull fracture without evidence of injury by CT (Competerized Tomographic scan), but there may have been a good reason.

The gold standard for airway protection is not intubation, but the patient protecting his own airway.

Was there some reason to believe that the patient would not be able to protect his airway for the entire trip to the trauma center?
 

The article mentions that the respiratory therapist . . .
 

. . . had been licensed for less than a year at this time and was not properly trained or adequately experienced in intubating a patient outside of a hospital setting.[1]

 

The next paragraph mentions stopping to pick up a paramedic, who then drove the ambulance.

Was the paramedic supposed to handle intubation?

Was the paramedic supposed to handle intubation while driving?

That would indicate great skill, but incredibly bad judgment.

Here is the timeline –
 

11:10                   Ambulance leaves the hospital.

??:??                   Paramedic is picked up.

11:15                   Sedation wears off and tube is pulled out.
 

Did the crew change distract everyone from recognizing the signs of lack of sedation?

Was the patient on a drip, which should have been adjusted up for the increased stimulation of an ambulance ride bouncing down the road in a truck?

Did the hospital just discontinue sedation because they have failed to consider the patient’s needs once the patient is out of their bed?

Was the crew supposed to provide bolus sedation en route?

Were they provided with broad enough orders and enough sedative for the ride?
 

And –

They were within 5 minutes of the sending hospital.

Why didn’t they turn around and head back?

If there are complications, the hospital has more resources to deal with those complications.

Clearly, the plan they were following was not remotely a success.

They had left the hospital, stopped to switch crew members and drivers, and the patient had burned through his sedative and pulled his tube out.

They should still have been able to see the hospital, unless there were a lot of trees, buildings, or something else blocking their view.

What were they thinking?

Things can only get better?

Things did not get better.
 

11:43                   They arrived at the trauma center. Late entry 04:10 11/15/2013 – They diverted to a closer hospital. They did not reach the trauma center until much later.
 

It appears that they could have taken the patient out of the ambulance and pushed the patient back to the sending hospital in less time – without decreasing the quality of care provided.
 

(The paramedic) pulled the ambulance off the road and, according to the ambulance report, all four crew members worked to suction and re-intubate Drew with (the respiratory therapist) being primarily responsible for the attempted re-intubation,” the complaint continues. “Drew was given paralytics and sedatives, which meant he could not breathe on his own. He was completely dependent on the oxygen from the endotracheal tube. Drew was intubated into his esophagus rather than his trachea and was not receiving oxygen and could no longer breathe on his own. At the time of the re-intubation, Drew’s parents were parked in their car immediately behind the ambulance.[1]

 

Within 5 minutes of the hospital.
 

“The crew never used objective testing, such as colormetric testing or capnography, to verify that the endotracheal tube was in his lungs and not his esophagus.[1]

 

Why is anyone still using colorimetry?

It is litmus paper that provides false positive and false negative results that many users fail to recognize as erroneous.

Moisture ruins it and there is moisture in every breath exhaled from human lungs.

Exhalation of moisture is the reason some people use moisture in the tube as an indication of proper tube placement. What they fail to realize is that moisture can also come out of the esophagus, so this is not of much help in confirming tube placement.

The only justification for the colorimetry litmus paper is if there is a malfunction of the waveform capnography that prevents the use of waveform capnography.

According to the article, the crew did not even try to use that inadequate method of tube confirmation.
 

In the comments to my original post, Christopher Watford points out –
 

In NC (this happened in North Carolina), waveform capnography is required on all RSI’s

 

RSI is Rapid Sequence Induction/Intubation – an intubation involving the use of sedatives and paralytics. The intubation in the ambulance is described as using both.

Required, but not used.
 

“Almost as soon as the attempted re-intubation was done, Drew’s heart rate began to drop and they could not find a pulse.[1]

 

What does PALS (Pediatric Advanced Life Support) state about the sudden deterioration of an intubated patient?
 

Reevaluate tracheal tube position and patency in patients who remain agitated despite effective mechanical ventilatory support and each time the patient is moved, such as into or out of a transport vehicle. If the condition of an intubated patient deteriorates, consider several possibilities that can be recalled by the mnemonic DOPE: Displacement of the tube from the trachea, Obstruction of the tube, Pneumothorax, and Equipment failure. If tracheal tube position and patency are confirmed and mechanical ventilation failure and pneumothorax are ruled out, the presence of agitation may require analgesia for pain control (eg, fentanyl or morphine) and/or sedation for confusion, anxiety, or agitation (eg, lorazepam, midazolam, or ketamine).[3]

 

The response should be very simple and obvious –

Pull the tube and ventilate with a BVM.
 


 

If deterioration is due to Displacement, the patient should improve.

If deterioration is due to Obstruction, the patient should improve.

If deterioration is due to Equipment failure, the patient should improve.

If the patient does not improve, that leaves Pneumothorax and the patient should have large bore needles of adequate length to reach the lungs stuck into both sides of the chest to decompress the apparent tension Pneumothorax.

If things deteriorate, we need to become very aggressive very quickly. This is one reason why a prophylactic intubation for transport may be a bad idea.
 

According to the ambulance records, at approximately 11:25 p.m., Andrew’s heart rate is in the 30s and he has no pulse. CPR was started and epinephrine was given.[1]

 

Pediatric bradycardia should automatically suggest one problem much more than any other problem.

Epinephrine does not treat hypoxia. The problem was not a lack of epinephrine.
 

In general, pediatric out-of-hospital arrest is characterized by a progression from hypoxia and hypercarbia to respiratory arrest and bradycardia and then to asystolic cardiac arrest.2 17 18 Therefore, a focus on immediate ventilation and compressions, rather than the “adult” approach of immediate EMS activation or defibrillation, appears to be warranted. In this age group, early effective ventilation and oxygenation must be established as quickly as possible.[3]

 

Four people in the back of the ambulance. Three of them should have taken PALS, or been familiar with the material covered in PALS.

PALS repeatedly recommends BVM ventilation.

Why?

Hypoxia -> Bradycardia -> Cardiac Arrest – > Brain Death.

BVM ventilation can interrupt that deterioration.

Ventilation can prevent the deterioration to bradycardia.

Ventilation can prevent the deterioration to cardiac arrest.

Ventilation can prevent the deterioration to brain death.
 


 

The tube does not appear to have been removed for BVM ventilation.

What would we expect to see if the patient had been ventilated with a BVM prior to losing pulses?

An increase in heart rate.

What would we expect to see if the patient had been ventilated with a BVM after losing pulses?

An increase in heart rate and ROSC (Return Of Spontaneous Circulation).

These improvements would not always happen, but they are the most likely to happen with ventilation.
 

Things get even worse
 

“According to the records a shock is given with a defibrillator at 11:38 p.m.,” the complaint alleges. “CPR was continued. Drew’s heart rate was in the 40s. More epinephrine was given. During this time, the emergency room physician at Carteret General was called to get permission to give Amiodarone. The emergency room physician told the crew to recheck the tube and suction because the arrest may be respiratory related. The crew again failed to verify the tube placement.”[1]

 

I am calling for orders.

I receive orders to do the most important and most obvious assessment – an assessment I should have done over 20 minutes ago – an assessment that should be continued throughout transport, I but still have not done it.

I ignore the orders.

Panic? Tunnel vision?

I see what I want to see – a cardiac arrest that indicates that it is time to give another drug.

I continue to ignore the reassessment that is part of the algorithm.
 

According to the complaint, “The ambulance was diverted to CarolinaEast in New Bern because Drew’s condition was deteriorating. They arrived at Carolina East at 11:43 p.m. according to the ambulance records.[1]

 

Timeline of events –
 

11:10                   Ambulance leaves the hospital.

??:??                   Paramedic is picked up.

11:15                   Sedation wears off and tube is pulled out.

11:25                   Cardiac arrest (tube probably in esophagus).

11:30                   Still dead (tube probably in esophagus).

11:35                   Still dead (tube probably in esophagus).

11:38                  Medical command contact and diversion to hospital five minutes away (tube probably in esophagus).

11:43             Arrival at hospital and tube is pulled out of esophagus following assessment of tube placement.
 

Why did the doctor pull the tube?
 

Drew had no pulse on arrival. Once at CarolinaEast, the emergency room physician documented that Drew’s color was cyanotic, there was no fogging of the ET tube and Drew had rumbling sounds in his stomach. All of these are classic signs of an esophageal intubation.[1]

 

Apparently, even without waveform capnography, it was obvious that the tube was in the wrong place.

Cyanosis and rumbling breath sounds in the stomach?

How do you assess tube placement, observe these signs of esophageal intubation, and come up with excuses to justify leaving the tube in place?

This appears to be an example of cognitive dissonance.

We believe so strongly that we are doing the right thing, that we ignore abundant evidence to the contrary.

He’s blue.

I should check the tube.

Nah! He just needs some amiodarone (which coincidentally can cause skin to turn blue).

It sounds like I am ventilating his stomach.

I should check the tube.

Nah! He just needs to be defibrillated.

Medical command told me to check the tube.

I should check the tube.

Nah! I saw the tube go through the cords.
 

“A respiratory therapist at CarolinaEast immediately extubated and re-intubated Drew on the first attempt,” the complaint continues. “Within a few minutes his blood oxygen saturation level returned to 100 percent and his vitals improved.[1]

 

It appears to have been an easy intubation.

It appears to have been an easy assessment.

Why did the paramedic, respiratory therapist, nurse, and basic EMT not check placement of the tube?
 

Cognitive dissonance theory explains human behavior by positing that people have a bias to seek consonance between their expectations and reality. According to Festinger, people engage in a process he termed “dissonance reduction,” which can be achieved in one of three ways: lowering the importance of one of the discordant factors, adding consonant elements, or changing one of the dissonant factors.[6] This bias sheds light on otherwise puzzling, irrational, and even destructive behavior.[4]

 

This is one of the reasons we need to constantly look for evidence that we are wrong, rather than evidence that we are right.

We tend to be satisfied with inadequate evidence if we only look for confirmation.

We can talk ourselves into almost anything.

At some point we all probably engage in cognitive dissonance. We need to anticipate this and aggressively seek evidence that contradicts what we want to believe.

Our patients’ lives may depend on our ability to avoid cognitive dissonance.
 


 
This is not just a problem for EMS – See also:

What Does it Take to NOT Kill a Patient – Part I – 4/03/2011

What Does it Take to NOT Kill a Patient – Part II – 4/04/2011

What Does it Take to NOT Kill a Patient – Part III – 5/20/2011

What Does it Take to NOT Kill a Patient – Part IV – 5/23/2011

What Does it Take to NOT Kill a Patient – Part V – 5/30/2011

From EMCrit –

EMCrit Podcast 47 – Failure to Plan for Failure: A Discussion of Airway Disasters – 5/09/2011

From Resus.Me –

Anaesthesia’s dirty laundry – let’s all learn from it – 4/03/2011

 

The paramedic, respiratory therapist, nurse, and basic EMT cannot change the outcome, but they can learn from it and make sure others learn the importance of ventilation for children and the importance of looking for evidence that we are wrong.

The family of Drew Hughes cannot get him back, but maybe a part of the settlement can include some attempt to educate medical personnel, so that fewer other families experience the kind of pain they live with.
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Footnotes:

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[1] Lawsuit filed over death of Emerald Isle youth
Posted: Wednesday, November 6, 2013 9:51 am | Updated: 9:56 am, Wed Nov 6, 2013.
22 comments
By Brad Rich, Tideland News Writer
Tideland News
Article

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

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[3] Respiratory System
2000 ECC Guidelines
Part 10: Pediatric Advanced Life Support
Postresuscitation Stabilization
Free Full Text from Circulation.

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[4] Cognitive dissonance
Wikipedia
Article

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Filed Under: Airway Management, Assessment, Heresy, Ketamine, Sedation, Waveform Capnography
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