NAP4

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

- Rogue Medic

Post-Intubation Package and Alarms

Thu, 18 Oct 2012 15:05:35 -0400 by Rogue Medic

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What do we do after the tube is in?

No. It is not time to use the laryngoscope blade as a bottle opener. There is a lot still to do.

The quotes are some of the points Dr. Weingart makes. The comments here are mine.

Achieve Adequate Analgesia and Sedation

I won’t belabor this, because I’ve discussed it in so many other podcasts, such as the one about not leaving your patient in a nightmare^[1]

Even a hypotensive trauma patient, who is not adequately sedated, will be worse off without sedation.

Pain is not an appropriate pressor.

Hook Up the ETCO2

You read NAP4 right? Continuous waveform ETCO2 until the ET tube gets pulled^[1]

Maybe we can get away with the carelessness of not using continuous waveform capnography for a long time, but carelessness often shows up in other areas of patient care.

The foolishness of not recognizing the benefit of continuous waveform capnography is the bigger problem.

Alarms do not make up for incompetence.

Have a Plan for Vent Alarms

Treat them like a cardiac arrest announced overhead.^[1]

Alarms are annoying.

That is the idea. If the alarm is not annoying, we tend to ignore it.

Why do we ignore alarms?

There are a variety of reasons.

We may leave all of the alarms on – even the ones we know that we do not care about.

If we are not going to do something about an alarm, because we do not think that the alarm is warning of anything important, we are only training ourselves to ignore alarms.

We become accustomed to alarms going off almost continuously, so the alarms become ironic. They are anything but alarming, when they are alarming.

If an alarm is not going to produce an instant response from staff, turn it off.

The purpose of an alarm is to produce a response.

The response is not to ignore the alarm.

The response is also not to just reset the alarm.

As with pulse oximetry, the response is not to just do something temporary, like turn up the oxygen in response to a low oxygen saturation.

The response is to address the cause of the alarm.

If the sat is low, why is it low?

Why is the same amount of oxygen no longer producing adequate oxygenation?

Or is something decreasing the amount of oxygen the patient is receiving?

Is the patient agitated and in need of more sedation, rather than just turning the oxygen up to meet the increased oxygen demands of an agitated patient?

If we want people to ignore alarms, the best way is to put alarms on every function possible. If it can alarm, it will alarm – then nobody will take alarms seriously.

If those of us responding to the alarms are not smart enough to be able to decide which alarms we should have turned on, then we aren’t smart enough to respond appropriately to the alarms.

Some places already require this level of continuous alarm incompetence.

Alarms on everything – dumbing down patient care to the point where competence is punished.

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Footnotes:

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^[1] Podcast 84 – The Post-Intubation Package
by EMCRIT
October 16, 2012
Web page with links to supporting information and link to mp3 download of podcast

Filed Under: Airway Management, EMCrit, Heresy, Intubation, NAP4

What Does it Take to NOT Kill a Patient – Part VI

Wed, 15 Jun 2011 06:30:03 -0400 by Rogue Medic

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Continuing to look at the review of major airway complications from the UK.

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Poor airway assessment contributed to poor airway outcomes. This was due to omission, incomplete assessment or a failure to alter the airway management technique in response to findings at assessment. Assessment to predict both potential airway difficulty and aspiration risk were equally important.^[1]

How often do we even make an attempt at airway assessment in EMS?

Mallampati score?

Cormack-Lehane score?

These may not be directly applicable to the unconscious patient or the unstable patient, but we can get a quick idea of what we are dealing with.

In Part V I mentioned that one of our problems is that most of us just have a plan – It puts the tube in the hole.

We need a strategy.

A strategy requires assessment.

How difficult is this airway likely to be?

That is one of the parts of a strategy. Most of the strategic thinking begins long before we are near a patient, but assessment is an important bedside skill. Strategy is applying all of our preparation to the management of this patient’s airway, while still paying attention to the rest of what is going on with the patient.

Image credit.^[2]

What about actually taking a peek in the patient’s mouth?

Is it wrong to use a laryngoscope to take a look at what is in the airway to help decide if intubation is appropriate for this patient?

No.

Whether this is an intubation attempt depends on the intent of the person with the laryngoscope – not on whether the laryngoscope passes the patient’s teeth/gums/lips. A simple rule is nice for the people who need simple rules, but airway management is not about simple rules. Airway management is about judgement.

More information, as long as it does not come at the expense of the patient, can be a very good thing.

Having an idea of what I am dealing with can help me decide how to go about managing this patient’s airway.

Maybe I can get the tube. Maybe, even with a very difficult tube, I can get it on the first shot. But is that what is best for the patient? Suppose I get the tube. Is the patient better with a tube?

What if the patient appears to have a bleed inside his/her brain. Maybe just BVM (Bag Valve Mask) ventilation is what will raise ICP (IntraCranial Pressure) the least. Probably without an oral or nasal airway. Even in the hospital, an LMA (Laryngeal Mask Airway) may be a quicker, less invasive way to prepare this patient for a CT scan.

Assessment is about much more than just placing the tube.

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This was due to omission, incomplete assessment or a failure to alter the airway management technique in response to findings at assessment.^[1]

Since we are not likely to change our approach to the management of this airway based on any assessment findings, why waste our time performing an assessment? Right?

–

Assessment to predict both potential airway difficulty and aspiration risk were equally important.^[1]

Assessment for aspiration risk?

We don’t do that. We just use aspiration risk as an excuse when claiming that the patient needs an endotracheal tube, rather than an LMA.

Assessment to predict both potential airway difficulty and aspiration risk are equally ignored.

–

We make the bogus excuse that this does not apply to us.

We continue to kill patients.

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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

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Footnotes:

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^[1] Major complications of airway management in the UK – 2011 NAP4
Royal College of Anaesthetists
Executive Summary (page 1/3)
Page with link to various full text pdf versions of report, press release, executive summary, and full report.

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^[2] Rapid airway access
Sérgio L. AmantéaI; Jefferson P. PivaII; Malba Inajá RodriguesIII; Francisco BrunoIV; Pedro Celiny R. GarciaV
Print version ISSN 0021-7557
J. Pediatr. (Rio J.) vol.79 suppl.2 Porto Alegre Nov. 2003
doi: 10.1590/S0021-75572003000800002
Free Full Text Article from Jornal de Pediatria.

Filed Under: Airway Management, Heresy, NAP4, Risk Management

What Does it Take to NOT Kill a Patient – Part V

Mon, 30 May 2011 06:30:40 -0400 by Rogue Medic

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Continuing to look at the review of major airway complications from the UK.

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Poor planning contributed to poor airway outcomes. When potential difficulty with airway management is identified a strategy is required. An airway plan suggests a single approach to management of the airway. A strategy is a co-ordinated, logical sequence of plans, which aim to achieve good gas exchange and prevention of aspiration. Anaesthetists should approach airway management with strategies rather than plans.^[1]

The highlighting is in the original.

This is the difference between following inflexible protocols and having protocols that are written with the understanding that the paramedic will use critical judgment to determine the appropriate treatment for the patient.

We will be faced with many types of patients with needs for different types of airway management.

The mindless application of poorly written protocols limits our options and kills our patients.

An example of a very simple plan is –

Less than 8 – intubate!

How many patients have been killed following that plan?

We don’t know.

Anaesthetists are assessing their bad outcomes. As Dr. Cliff Reid of Resus.Me puts it in the title of his post – they are washing their dirty laundry in public.

In EMS, we occasionally take a look at intubation.

We almost always end up with results that are embarrassing for us (evidence that we are killing our patients).

We make the bogus excuse that this does not apply to us.

We continue to kill patients.

We need to stop protecting our image and start protecting our patients.

We need to get rid of the administrators/bureaucrats who are more concerned with our image than with our patients’ reality.

We are killing our patients in order to be politically correct.

When we think that Plan A is all we have, we may find out that Plan B is a body bag.

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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

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Footnotes:

–

Filed Under: Airway Management, Ethics, Heresy, NAP4, Risk Management

What Does it Take to NOT Kill a Patient – Part IV

Tue, 24 May 2011 06:30:54 -0400 by Rogue Medic

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This is a review of bad outcomes by anaesthetists (anesthesiologists in the US), not paramedics, so we should expect that, because of much less experience, paramedics would have much worse outcomes in similar circumstances.

We need to learn from this.

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You can’t ignore the impact of your own thinking, tuned to normal, routine success, and the impact of those around you when things turn nasty.^[1]

But we do ignore the impact of our own thinking.

We ignore what we do not want to know.

Ignorance motivates us to avoid change.

Ignorance motivates us to avoid improvement.

Ignorance motivates us to harm our patients.

We expect success.

We plan for success.

When success does not happen, we blame the individual, rather than our culture of ignorance.

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Failure to plan for failure. In some circumstances when airway management was unexpectedly difficult the response was unstructured. In these cases outcome was generally poor.^[2]

Generally poor?

Hypoxia.

Ischemia.

Injury.

Infarction.

Death.

These are the poor outcomes that can result from failure to plan for failure.

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We continue to harm patients by following protocols designed by administrators/bureaucrats to protect the organization from our patients.

We get away with this because we do not see the results.

NAP4 shows us some of those results.

NAP4 shows us some of the blood on the hands of the administrators/bureaucrats and on our own hands.

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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

–

Footnotes:

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^[1] Major complications of airway management in the UK – 2011 NAP4
Royal College of Anaesthetists
Forward (page 7/54 – Section 1)
Page with link to various full text pdf versions of report, press release, executive summary, and full report.

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^[2] Major complications of airway management in the UK – 2011 NAP4
Royal College of Anaesthetists
Executive Summary (page 1/3)
Page with link to various full text pdf versions of report, press release, executive summary, and full report.

Filed Under: Airway Management, Heresy, NAP4, Risk Management

What Does it Take to NOT Kill a Patient – Part III

Fri, 20 May 2011 06:30:12 -0400 by Rogue Medic

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There is a must listen to podcast at EMCrit in combination with Resus.Me. Dr. Cliff Reid is interviewing one of the authors of the study,^[1] Dr. Jonathan Benger –

EMCrit Podcast 47 – Failure to Plan for Failure: A Discussion of Airway Disasters

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Dr. Cliff Reid – In the ED and the ICU, what are the take home messages for us?

Dr. Jonathan Benger – The take home messages are that as you would expect it’s dangerous and there is a significant rate of complications.^[2]

If we do not realize that intubation is dangerous, we should not be intubating.

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Dr. Jonathan Benger – What we know is that there were a number of significant events and that the case fatality rate was much higher. In fact it was highest in critical care, and then second highest in emergency departments, and lowest in anesthesia environments. So there is a clear risk of major complications and those complications are more likely to be fatal.^[2]

We should expect that the fatality rate for emergency airway management is much higher for EMS, than for anywhere in the hospital.

If we understand that, we should be less aggressive in using methods that take away an airway that allows us to do what we need it to do – oxygenate and ventilate.

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Dr. Jonathan Benger – If you undertake advanced airway management outside of the operating theater, you’re working in a difficult environment, where the risks are significantly higher to the patients involved. That means that we need to make sure that the standard of care is as high as feasibly possible in those environments.^[2]

The standard of care is not an endotracheal tube.

The standard of care is a competently managed airway that works.

Our patients should not be subjected to a lower standard of care, just because paramedics like to say that we intubate.

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Dr. Jonathan Benger – It’s absolutely clear that capnography, as a universal tool in any patient who is intubated, is appropriate.^[2]

A bit of British understatement.

Continuous waveform capnography should be mandatory.

Anyone who thinks otherwise should not be allowed to use any advanced airway.

If we cannot afford continuous waveform capnography, we cannot afford to risk our patients’ lives on intubation.

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Dr. Jonathan Benger – It’s absolutely clear that if you don’t use capnography, in advanced airway management (intubation, tracheostomy care, et cetera, et cetera) then there is an increased risk to patients as a result of complications. And the obvious one, of course, is unrecognized esophageal intubation.^[2]

Maybe I should stop criticizing medics who insist that we should not take their endotracheal tubes away.

The endotracheal tube is not really the problem.

Operator error is the problem.

People too reckless to use continuous waveform capnography are the problem.

These dangerous medics do not want us to take away their unrecognized esophageal intubations.

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Dr. Scott Weingart – To pound home what Dr. Benger and Cliff have said. If you are in an ED, or an ICU, or on an ambulance, and you are intubating without waveform capnography – I don’t mean color change capnometry – I mean waveform capnography – you are doing your patients a disservice. This should be standard care for any intubation in the three environments I just mentioned.^[2]

Doing your patients a disservice?

Dr. Weingart is not British and is usually a bit more blunt than this.

If we are intubating without continuous waveform capnography, we are killing our patients.

Maybe I will not kill a patient, but I will set an example for someone who will. I am then responsible for convincing others that reckless airway management is acceptable.

How many patients can we kill before we decide that killing our patients is bad?

Not using continuous waveform capnography is reckless airway management.

Even for anesthesiologists.

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Listen to Dr. Weingart’s explanation of the possible reasons that there would be no waveform on the display. This is at 16:15 of the podcast.

There is also a discussion of the various forms of crichothyrotomies, needle/cannula vs. surgical. This leads to an interesting debate in the comments with Minh Le Cong, that should lead to a podcast debate about the relative benefits of surgical vs. needle/cannula crichothyrotomies.^[2]^[3]

I will not discuss that here, but I expect to have Dr. Weingart go over that in more detail in a future podcast.

Dr. Benger also describes the problem of continuing to try to intubate when there is no reason to expect that using the same failed method over and over and over and over will somehow eventually lead to a successful outcome. The result –

Can’t Intubate, CAN Ventilate deteriorates to Can’t Intubate, Can’t Ventilate which often deteriorates to death.

We convince ourselves that the goal is a tube.

No.

The goal is an airway that allows us to ventilate and oxygenate.

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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

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Footnotes:

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^[1] Major complications of airway management in the UK – 2011 NAP4
Royal College of Anaesthetists
Page with link to various full text pdf versions of report, press release, executive summary, and full report.

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^[2] EMCrit Podcast 47 – Failure to Plan for Failure: A Discussion of Airway Disasters
EMCrit
Podcast and Article with comments

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^[3] Anaesthesia’s dirty laundry – let’s all learn from it
Resus.Me
Article with comments

Filed Under: Airway Management, EMCrit, Heresy, NAP4, Risk Management, Waveform Capnography

What Does it Take to NOT Kill a Patient – Part II

Mon, 04 Apr 2011 06:30:51 -0400 by Rogue Medic

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The use of simulation is a valuable tool because it allows us an insight into ourselves when the odds are stacked against us. Every pilot has screwed up in the simulator, and those events allow us to develop more resilient and reliable ways of thinking and working so when things really do turn bad we have a much greater chance of success. But this is an insight that many of you won’t have experienced. Sitting around a coffee table anaesthetists will tell me how they wouldn’t have behaved in the way the anaesthetists did on my late wife’s case. It’s incomprehensible. But place those same anaesthetists and colleagues into the simulator a week later; you’d be surprised how many do follow the same path when presented with the same stressors and human factors.^[1]

This is not about checklists.

This is about creating an environment that makes harm to our patients much less likely.

Do any of us want aviation to regress to the safety level of 40 years ago?

The IOM (Institute Of Medicine) report on deaths due to medical error estimated that there are between 44,000 and 98,000 patients killed by all of us in medicine in an average year.

Even if the numbers are wildly inaccurate, the aviation fatality numbers from decades ago have nothing on medicine.

Are we adding to the deaths due to medical error?

Are we working to prevent deaths due to medical error?

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Modern medicine is becoming too complex and too fast paced to ignore the human factors that can turn a disaster into an heroic save, or vice versa.^[1]

We didn’t need waveform capnography back in the old days, and we don’t need it now!

This attitude kills.

The truth is that waveform capnography improves our ability to assess placement of the endotracheal tube (and it has plenty of other uses).

We don’t need simulations. Are you trying to suggest that we don’t know what we’re doing?

The truth is that in well done simulations, we can learn the mistakes that we are likely to make during even routing cases, when something happens a little bit differently from the way we expect it to.

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Give us the tools that make it easy to get it right, give us the processes that give safety a better chance, and give us the training so that we can use these and behave in a way to make a quantum leap in safe practice.

NAP4 gives us good data on the scale and nature of the problem,^[1]

Why are so many of us so opposed to making mistakes less likely to happen?

The simple answer is that we think that we are too good to make these mistakes. That is the blame it on the hubris answer, but it is also an overly simplified answer.

We just need to improve safety and get rid of the obstacles to improved safety, even if these obstacles are the people who believe they are perfect. Remediation is nice, but patients’ lives are more important than the feelings of dangerous medics.

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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

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Footnotes:

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^[1] Major complications of airway management in the UK – 2011 NAP4
Royal College of Anaesthetists
Mr Martin Bromiley, founder Clinical human factors group
Forward (page 7/54 Section 1)
Page with link to various full text pdf versions of report, press release, executive summary, and full report.

Filed Under: Airway Management, Heresy, NAP4, Risk Management

What Does it Take to NOT Kill a Patient – Part I

Sun, 03 Apr 2011 06:30:00 -0400 by Rogue Medic

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The cause of death was barotrauma as a result of perforation of the right lung as a complication of anaesthetic administration. The relevant underlying condition was a fracture of the distal phalanx of the right little finger…^[1]

This seems a bit complicated, but it becomes much more clear in the last 2 sentences.

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The most striking feature of this Inquiry was that none of the three experienced anaesthetists in attendance gave any consideration to the fundamental option of waking the patient, particularly having regard to the minor nature of the surgery involved. Anaesthetists need to be actively aware of that option, particularly, in anaesthesia for elective procedures for minor or non-essential surgery.^[1]

There were many problems with the management of the patient by these three experienced anaesthetists, but the common sense decision to stop digging never seems to have occurred to them.

Sometimes, all it takes to not kill a patient is to stop killing the patient.

Just stop.

Too many times we will proceed on the same course, as if we have passed a point of no return. Why? Because to change our minds is not something that is well taught in EMS schools. Is it any more rare for some organization, like the National Registry of EMTs to test for our ability to change our minds?

We are trained to fit the patient to the protocol, then stick to the protocol.

We are not taught to understand the obvious.

Our treatments are expected to produce changes in patient presentation. We are expected to reassess our patients, but how many of us are taught how to respond to unexpected, or undesirable, changes in patient presentation?

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I still talk with people who are shocked that I did not complete all of the treatments listed in a protocol. Even after I point out to them that the patient was responding in a way that made continuing with the protocol seem dangerous – dangerous for the patient.

How many of us just do not care about the patient, but will protocol the patient to death?

How many of us have been taught that we will never get in trouble as long as we stick to the protocols?

How is a paramedic less responsible for killing a patient by taking actions that are entirely to protect the paramedic and not protect the patient?

How is it possibly ethical to mistreat our patients to protect ourselves from legal responsibility for our actions?

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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

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Footnotes:

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^[1] Major complications of airway management in the UK – 2011 NAP4
Royal College of Anaesthetists
Quotation (page 8/54 Section 1)
Page with link to various full text pdf versions of report, press release, executive summary, and full report.

Filed Under: Airway Management, Heresy, NAP4, Risk Management