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’
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Footnotes:
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[1] LAWSUIT: Ambulance Mistake Killed Teen After Skateboard Accident
Updated: Wed 9:14 PM, Nov 06, 2013
WITN.com
Article
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[2] Intubated ED Patients are Still Not Receiving Sedation
EMCrit
by Scott D. Weingart, MD.
Podcast page
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[3] ED patients being intubated and then not sedated or pain-controlled
EMCrit
by Scott D. Weingart, MD.
Podcast page
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[4] You had me at ‘Controversial post for the week’ – Part I
Tue, 22 Oct 2013
Rogue Medic
Article
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[5] More Intubation Confirmation
Sun, 27 Apr 2008
Rogue Medic
Article
.
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