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

- Rogue Medic

Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury – Summary

Thu, 01 Sep 2011 06:30:08 -0400 by

ResearchBlogging.org
Also posted over at Paramedicine 101, which is now at EMS Blogs, and at Research Blogging.

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Go check out the excellent material at those sites.

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In response to my post If We Were Really Serious About Intubation Quality was a comment from drastic suggesting that I take a look at a couple of studies that demonstrate that Australian paramedics do not need to improve their intubation skills and that intubation improves outcomes.

One of the studies does show a lot of positives for intubation. The big problem is the lack of statistical significance. A larger study needs to be done to confirm the results, an LMA (Laryngeal Mask Airway) or other group should be added. Otherwise, this appears to be a great study.

Does EMS RSI (Rapid Sequence Induction/Intubation) lead to better outcomes than delaying intubation until arrival at the trauma center for patients with TBI (Traumatic Brain Injury)?

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Click on the image to make it bigger.

The difference in outcomes would no longer be statistically significant whether one more patient had a positive outcome in the treatment group (P = 0.059) or one less in the control group (P = 0.061).[1]

That limitation is very important, since 13 patients were lost to follow-up (10 in the hospital intubation group and 3 in the EMS RSI group), because their families lost contact with them. This apparent independence suggests, but certainly does not prove, that these patients would not have fallen into the more severely impaired categories. Even if all of the EMS RSI patients did have severe disabilities, while all of the hospital intubation patients had good neurological outcomes, the hospital intubation group would only come up to 43% (66/152) with a good neurological outcome, which is still less than the possible 50% (80/160) for the EMS RSI group. Therefore, the results would not change to the point of demonstrating worse outcomes with EMS RSI, but the results would no longer be statistically significant.

More likely is that they all have good neurological outcomes and the results would change to 52% (83/163) vs. 43% (66/152). Both outcomes improve, but the results are still not statistically significant.

All EMS RSI patients had waveform capnography, which may explain why the results are so different from the results of the study by Davis on EMS RSI for TBI. This study raised a bunch of questions about those results, which showed worse outcomes for EMS RSI. One hypothesis was that the much higher incidence of hypocapnea contributed to the bad outcomes even though the EMS intubation success rates more than doubled for TBI patients.

Conclusion: Paramedic RSI protocols to facilitate intubation of head-injured patients were associated with an increase in mortality and decrease in good outcomes versus matched historical controls.[2]

airway management success rates for severely head-injured patients in our prehospital system increased from 39% in the pre-trial period to 86% during the trial.20,21[2]

In this study, the intubation success rate for TBI patients was 97%, which is dramatically higher than 86%. 1/7 lack of success vs. 1/33.

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Does this study demonstrate good outcomes with paramedic intubation for TBI?

Yes.

Does this study demonstrate excellent intubation success with RSI for TBI?

Yes.

There is a lot more to discuss about this study, but I will go into more depth later.

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Footnotes:

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[1] Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.
Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, David, Taylor, Smith K, Patrick I, Edington J, Bacon A, Rosenfeld JV, Judson R.
Ann Surg. 2010 Dec;252(6):959-65.
PMID: 21107105 [PubMed – indexed for MEDLINE]

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[2] The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury.
Davis DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T, Marshall LK, Rosen P.
J Trauma. 2003 Mar;54(3):444-53.
PMID: 12634522 [PubMed – indexed for MEDLINE]

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Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, David, Taylor, Smith K, Patrick I, Edington J, Bacon A, Rosenfeld JV, & Judson R (2010). Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Annals of surgery, 252 (6), 959-65 PMID: 21107105

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Filed Under: Airway Management, Critical Judgment, Ethics, Heresy, Intubation, RSI

Comment on Drug-Assisted Intubation in the Prehospital Setting – Part I

Tue, 28 Jun 2011 06:30:21 -0400 by
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In the comments to Drug-Assisted Intubation in the Prehospital Setting is this by BackToBasics –
 

We have DAI at my EMS agency; a nice concoction of Etomidate, Succs pre-intubation, then followed up with Fentanyl & Ativan for post-intubation sedation maintenance. There is rumor we are getting rid of it because of the lack of skills. Only a few people don’t know how to use it, or refuse to remediate their incompetance but the rest of the people have to suffer. Wonderful.

 

This is an excellent example of the medical director/management having the wrong priorities or having absolutely no understanding of risk management.

Should we choose to eliminate something that is unsafe in the hands of a few?

Or –

Should we eliminate/remediate the few unsafe people?

The answer should be very clear.

Get rid of the lowest common denominators.
 

So far we have lost several medications due to incompetance…….Lopressor for AMI, Propofol for post-intubation maintenace (went to Fentanyl / Ativan cocktail), Lasix for CHF-crisis; now we are going to lose our Etomidate & Succs. Next we will lose the ET tubes…….

 

The reasons for the elimination of some of these may have nothing to do with dangerous medics, but with research demonstrating that the treatments do not work.

Beta blockers, such as metoprolol (Lopressor), for MI does not seem to improve outcomes.[1]


 

Using propofol (Diprivan) is unusual in EMS. This is a drug that is often restricted to anesthesia personnel, so that may have something to do with it. If your emergency physician cannot give it, don’t expect to be able to give it in an ambulance. This is also not a drug that has been studied in EMS, that I am aware of. Fentanyl is a great drug for pre-intubation pain management/sedation in addition to post-intubation pain management/sedation.[2]
 

The use of furosemide (Lasix) by EMS is almost always a bad idea. We have treatments that actually are very effective for the emergency patient. Furosemide is for chronic CHF (Congestive Heart Failure), not for ADHF (Acute Decompensated Heart Failure or CHF-crisis).

With furosemide, the important decision is which tube goes first – Foley tube or endotracheal tube?

Better treatments than furosemide avoid both tubes – especially the endotracheal tube.

If the patient has CHF and if the patient has peripheral edema and if the patient is stable – then furosemide is not likely to cause harm, but that is a lot of ifs to deliver a potentially harmful treatment to stable patients. What happened to the E in EMS (Emergency Medical Services)?

We should be using treatments that actually make a difference in the emergency setting. CPAP (Continuous Positive Airway Pressure), high-dose nitrates for hypertensive ADHF, and ACE Inhibitors (Angiotensin Converting Enzyme Inhibitors). All three of these treatments have been shown to decrease the rate of intubation in the emergency setting – furosemide has not.[3],[4],[5]
 

To be continued later in Part II.

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Footnotes:

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[1] Beta Blockers for Acute Heart Attack (Myocardial Infarction)
the NNT
Article

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[2] EMCrit Podcast 21 – A Bad Sedation Package Leaves your Patient Trapped in a Nightmare
EMCrit
by Dr. Scott Weingart
Podcast and Supplementary Information

Pushing some ativan followed by vecuronium is no longer an acceptable strategy to manage post-intubation sedation. A good analgesia and sedation package is essential if you care about your patient’s comfort and well-being. We need to move to PAIN-FIRST paradigm. Optimize analgesia and then add in sedative agents as a bonus.

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[3] Prehospital therapy for acute congestive heart failure: state of the art.
Mosesso VN Jr, Dunford J, Blackwell T, Griswell JK.
Prehosp Emerg Care. 2003 Jan-Mar;7(1):13-23. Review.
PMID: 12540139 [PubMed – indexed for MEDLINE]

Free Full Text PDF

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[4] Modern management of cardiogenic pulmonary edema.
Mattu A, Martinez JP, Kelly BS.
Emerg Med Clin North Am. 2005 Nov;23(4):1105-25. Review.
PMID: 16199340 [PubMed – indexed for MEDLINE]

Free Full Text PDF

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[5] EMCrit Podcast 1-Sympathetic Crashing Acute Pulmonary Edema
EMCrit
by Dr. Scott Weingart
Podcast

Supplementary documentation on CHF treatment

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Filed Under: Airway Management, Heresy, Intubation, Research, RSI

Drug-Assisted Intubation in the Prehospital Setting

Wed, 22 Jun 2011 06:30:03 -0400 by
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This is nothing new. This is a reaffirmation of the policy of these organizations from almost 6 years ago.

The American College of Emergency Physicians (ACEP), American College of Surgeons Committee on Trauma (ACS-COT), and the National Association of EMS Physicians (NAEMSP) recognize that expert prehospital airway management by trained, non-physician, EMS providers is of paramount importance in the treatment of critically ill and injured patients.[1]

However –

DAI is an advanced airway procedure that should not be considered mandatory, nor is it appropriate, for many prehospital EMS systems.[1]

The same statement is true for intubation without the assistance of drugs.

If we are not going to develop and maintain our intubation skills, should we be fumbling around with patients’ airways?

Absolutely not.

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I highlighted a few points.

Is there any good reason to avoid continuously monitoring at least a 3 lead ECG?

No.

Is there any good reason to avoid continuously monitoring pulse oximetry?

No.

Is there any good reason to avoid continuously monitoring waveform capnography?

No.

But people still do. Doctors, nurse, and medics who do not understand airway management will avoid continuously monitoring the condition of patients who require emergent intubation.

Before,   during,   and   after   intubation.

Airway management is not a set it and forget it treatment.

Continuing quality assurance, quality control, performance review, and, when necessary, supplemental training

Can we have too much airway training?

In theory – Yes.

In practice – I doubt it.

Imagine if we had one hour each workday for airway practice. Many medics would be complaining.

Is that a lot?

No.

Definitely not, but people would complain that this is too much.

Too much? This may be what some EMS Agencies need to prevent having intubation removed from their scope of practice. Even this might not be enough. Too much?

No, this is not too much. This is just one part of what we should be doing to improve and maintain our airway management skills.

Go read the whole position paper. It is only one page worth of writing, and it is free, so it is also not too much to read.

Remember that these points are just what they consider to be the absolute minimum required for prehospital Drug-Assisted Intubation..

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Footnotes:

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[1] Drug-assisted intubation in the prehospital setting.
American College of Emergency Physicians; American College of Surgeons Committee on Trauma; National Association of EMS Physicians.
J Am Coll Surg. 2005 Oct;201(4):585. No abstract available.
PMID: 16183498 [PubMed – indexed for MEDLINE]

Reaffirmed by the ACEP Board of Directors April 2011

Originally approved by the ACEP Board of Directors January 2005

PII: S0196-0644(11)00471-9

doi:10.1016/j.annemergmed.2011.05.005

Free Full Text from Annals of Emergency Medicine with link to PDF Download

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Filed Under: Airway Management, Critical Judgment, Heresy, Intubation, Risk Management, RSI

Guess I’ll Just Jump On In! – EMS Outside Agitator

Mon, 11 Oct 2010 22:17:12 -0400 by
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Russ, over at EMS Outside Agitator writes Guess I’ll Just Jump On In!

Go read what he wrote first. I will have my comments here. There is a lot to comment on, but just to give you an idea – this is the first sentence –

Here’s a doozy!

He is not exaggerating.

Go read his post.

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Now that you have read that – From the original discussion forum –

His blood pressure is slightly elevated at 142/90, heart rate is 110 and he is breathing at 24 times a minute. He is showing a sinus tachycardia with no ectopy, and his SpO2 is 97% on room air.

His only complaint is pain to the face at the time of your initial exam, pain score 10/10. He denies any respiratory distress, and his lungs sound clear. When you open his mouth to examine his throat you note that he is a Mallampati Class 3 airway, with the soft & hard palate clearly visible. You note no soot, redness or irritation to the muscosa in the throat when he opens his mouth for you to inspect it.

. . . .

5-10 minutes into transport he begins to complain of shortness of breath, and you notice he is coughing quite a bit. You note his Sp02 is now 95% on room air, and when he coughs he has a slight barking quality to it. His respirations are now 28, and he does appear to have some mild difficulty breathing. He is becoming anxious, but has no history of anxiety, and states he is scared because he cannot breathe.

The medic later mentions that he had already given fentanyl, no idea what dose, and it only brought the pain down from 10/10 to 7/10. Starting with fentanyl is good. Continuing with fentanyl might be better. Maybe add some midazolam to calm the patient if not able to talk the patient into calming down.

If the problem is hyperventilation, why do we want to intubate?

I have never intubated a patient for rapid breathing and anxiety. I do not think that this patient would be one I would start with. For hyperventilation, I usually calm the patient down and get a refusal – an extensively documented, well informed refusal, after a thorough assessment and history.

I would reassess lung sounds, because what does a written description of a cough with a slight barking quality mean?

I would reassess the airway. Assuming that things have changed, or that things have not changed, is not an assessment. Intubating this awake and alert and talking patient without further assessment is not a good idea.

When has it ever been appropriate for anyone to intubate a patient for the SpO2 dropping from 95% to 97%?

W T F ?

An agitated hyperventilating patient probably not keeping his hands still.

More from the original forum, a later post –

After initial contact, the patient was medicated with fentanyl for pain, prior to complaint of shortness of breath, which initially only brought the pain level to a 7/10. The patient was checked for signs of allergic reaction to the fentanyl and ruled out as a cause, just FYI

During laryngoscopy some mild redness was noted to the area above the glottic opening. the cords did not appear swollen or burned. There was some slight swelling of the airway.

Intubation was performed on the first attempt with minor difficulty. The patient was adequately preoxygenated with a NRB mask for 5 minutes prior to induction, and was ventilated via BVM post induction for approx 2 minutes.

And then Clark takes off his glasses, steps into a nearby phone booth (he is old enough to remember them), and –

In his mind, he’s got the backing of his EMS peers. In my mind, 14 out of 17 responders are nuts and the only three who get away with it were those who didn’t make a call!

Amen!

However, there are a few things that I view a bit differently.

#1. Mechanism of injury; blast of steam to the face from a radiator of a car that had ALREADY COOLED DOWN for 1/2 hour.

What does time mean in EMS?

Did that seizure last 15 seconds or 15 minutes? Reports of time should generally not be considered reliable.

If the radiator discharged steam onto his face, then there may still have been some boiling going on. And, does this guy decide to wait 30 minutes, because somebody told him to wait 30 minutes? In which case, he might be as patient as kids on a car ride – Are we there, yet? 5 seconds later. How about, now? 5 seconds later. Are we there, yet?

#4. Alert, conscious, talking 1/2 hour AFTER the fact,

This is where I get to harp on one of my favorite targets.

Mechanism Of Injury vs. patient assessment.

This appears to be a case of intubation due to Mechanism Of Injury.

If you think that destination decisions based solely on MOI are acceptable, how about invasive airways? Where do we draw the line?

#5. Minimal visible signs of injury,
#6. Only complaint of pain…AROUND THE EYES!

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No. I did not give up a promising career as an artist to work in EMS.

Pain around the eyes – there is an I in airway, even if there isn’t in team, he is treating the eye in airway! A new addition to the ABCs.

#7. Time elapsed w/o incident; at least 40 minutes from time of incident until medic feels need to take action

The golden titanium 40 minutes.

#8. Complaint prompting action; “states he is scared because he cannot breathe”
WHERE ON GOD’S GOOD EARTH DOES PROTOCOL SAY “INTUBATE FOR FEAR”?

Right there. You just wrote it. 😉

I always wonder about this part – “states he is scared because he cannot breathe”

How do you know the patient could not breathe?

He told me so.

While I have had patients gasp out similar statements and some of them have been close to respiratory arrest:

This is a young, otherwise healthy guy (no meds, no hx, no allergies) breathing at 28 times a minute and the worst part is that his sat just dropped from 97% to 95%.

I’ve been out of the field for twenty-five years. I do not understand what capnography is and don’t know how wave forms are related to it. I never used Albuterol or Solu-medrol, and never administered anything other than IV Valium or Morphine to sedate. The idea of using or even needing to use paralytics in the field to intubate gives me the Screaming Willies because I know (humbly) if I couldn’t intubate, paralytics wouldn’t help.

Things have changed a lot. RSI may be the thing that allows you to be more successful intubating, or it may be the thing that allows us to be more harmful.

The most common thread amongst the responses; “Sedate, paralyze, intubate.”

If our OP doesn’t realize WHY everybody is watching and waiting for medics to screw up and is ready to pounce when they do, he’s going to learn Damn Fast!!

Maybe I’M the one who’s nuts!?

You do not provide sufficient information for anyone to make an informed statement about that..

How the hell did the OP talk a conscious patient into getting intubated? That makes me wonder now if any consent was obtained and what the patient’s experience of the whole thing was?

This is EMS.

We don’t do informed consent.

In order to obtain informed consent, we would have to provide accurate information about the known risks and benefits of treatments.

I have never observed patients provided with information about spinal immobilization other than – If you don’t get on the board, you’re going to be paralyzed!

Sometimes it is not as adamant as that, but this coercion is based on what?

According to the narrative of the OP, the only treatment the patient needed at the time the OP chose to go for the throat was a reassuring hand and a few moments of connection.

I should have been doing that all along.

Here’s where you get to really learn. This suggests to me you need to take a real good look at what you know, what you don’t and why you jump to extreme paramedic/Doctor when being a humble EMT would suffice.

Here is my opinion.

Every intubation should be treated as a sentinel event. There should be review with the doctor in the ED. There should be review with the medical director. This does not mean punitive review, but a review of whether intubation was appropriate.

If I cannot justify to a doctor why I intubated a patient, is there any reason to believe that intubation was appropriate?

The same should be true for every other aggressive treatment. This is where oversight takes place, not some magic phone call, where you paint the picture you want the doctor to see. That is a pure fantasy.

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(I welcome feedback in how I’m communicating with you. If I’m sounding like an old, used-up war veteran with nothing but inaccurate memories based on an infant’s experience of a profession, tell me. Otherwise, I’m open to suggestions as my intent is to build bridges of understanding, while still staying true to my animal nature!)

You seem to have overcome that introversion problem. I am having trouble believing that you ever worked in EMS. We are usually so hesitant to speak write our minds.

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Filed Under: Airway Management, Critical Judgment, Heresy, Intubation, RSI

RSI, Risk Management, and Rocket Science

Sun, 04 May 2008 23:49:00 -0400 by

This is the way that RSI (Rapid Sequence Induction, or Rapid Sequence Intubation) starts out. An impressive presentation. Usually by means of a PowerPoint presentation.

Sometimes there will be problems that cannot be handled in the normal fashion.

Competent preparation includes the ability to bail out, such as the use of rescue airways, as necessary.

When that preparation is not handled competently, even the rescue airway is not really available to the less-than-prepared.

The search for the highest level person to take the fall for the superiors becomes the focus of the aftermath. Those who create the environment that encourages this failure rarely suffer any significant consequences.

Why should I use the example of the Challenger (STS-51-L), January 28, 1986?

Unreasonably optimistic claims of safety.

Irresponsible oversight.

Failure.

The blame is focused away from the dominant cause.

NASA claimed that the reliability of the Space Shuttle was so great that the risk of an accident was 1/100,000 flights. With this kind of reliability, they could fly twice a week for a thousand years with only one serious failure. The Rogers Commission found that even a 1/100 flight accident rate was unreasonably optimistic.

NASA was claiming that the missions were more than 1,000 times safer than they had any reason to believe. Did they learn from this and improve? Dr. Richard Feynman wrote his own appendix to the findings of the Rogers Commission.

If a reasonable launch schedule is to be maintained, engineering often cannot be done fast enough to keep up with the expectations of originally conservative certification criteria designed to guarantee a very safe vehicle. In these situations, subtly, and often with apparently logical arguments, the criteria are altered so that flights may still be certified in time. They therefore fly in a relatively unsafe condition, with a chance of failure of the order of a percent (it is difficult to be more accurate).

Official management, on the other hand, claims to believe the probability of failure is a thousand times less. One reason for this may be an attempt to assure the government of NASA perfection and success in order to ensure the supply of funds. The other may be that they sincerely believed it to be true, demonstrating an almost incredible lack of communication between themselves and their working engineers.

And he concluded with:

For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.[1]

After all, everyone was watching their performance, how could they continue to make bad decisions that resulted in deaths?

February 1, 2003. Columbia (STS-107). 17 years and only 88 flights later.

“It’s just a flesh wound.”

Not a laughing matter, but the way that NASA has handled risk assessment has been one big example of what not to do. In some places, medical oversight of RSI appears to be following a similar path, just on a much lower budget.

The advantage of hindsight, and the opportunity to second-guess decisions made since February 2003, permeates these observations. All of them were, however, written prior to the launch of STS-114.[2] It is also important to recognize that the behaviors and attitudes described here were not chance occurrences that were observed only once or twice, but that emerged numerous times throughout the Task Group’s interaction with NASA. The intent of these observations is to help NASA leadership identify and rectify these concerns. We will address four main areas: rigor, risk, requirements, and leadership.[3]

How does a medical director not know that medics are not using waveform capnography to assess placement of endotracheal tubes?

A. They use it. I just know.

B. I follow up with the hospital staff to find out what they saw as good and bad about the packaging and care of unstable patients, especially RSI patients.

C. We can’t afford waveform capnography. We use something “just as good.”

D. What’s waveform capnography?

Only one of these is an acceptable answer.

Imagine if you had a device that could monitor the patient’s ECG (ElectroCardioGram) and 12-lead ECG, NIBP (Non-Invasive Blood Pressure), pulse oximetry, and waveform capnography. All with the ability to store the records for dozens of patients, so they can be recovered, or transferred to other media, later.

Printer problem? No problem. Can you say accountability?

Now imagine that you can use waveform capnography to prove that the ETT (EndoTracheal Tube) was not in the esophagus.

If a medical director is responsible for the oversight of paramedic intubation and is not using waveform capnography, there is a serious lack of understanding of risk management.

“We can’t afford waveform capnography.”

Show a lawyer the evidence that the tube was not in the esophagus – a waveform capnography recording from just after the tube was placed, repeated recordings while en route, and another recording just prior to moving the patient to the hospital stretcher – the lawyer will realize that there is no money to be made from this EMS organization.

When that is not the case, it is just your word against an expert witness. An expert witness is someone who gets paid a lot of money (something you claim not to have) to go all over the country to testify that the patient care was incompetent. There are a lot of very persuasive, charming expert witnesses. They make a lot of money. They are good at convincing juries that the patient care was incompetent. Juries love hearing that a simple device, although expensive, was available, but not used. The medical director decided the patients’ lives were not worth this much. Or the EMS agency made that decision and the medical director did not have enough sense or integrity to challenge the medical orders of the EMS agency.

Is waveform capnography idiot-proof?

Nothing is idiot-proof, especially in EMS, but waveform capnography is as close as you are going to get to idiot-proof in airway management.

If EMS is to be improved, we need to get more medical directors who understand risk management and waveform capnography.

This should not even be a topic for debate. There is no valid argument against waveform capnography.

If you cannot afford waveform capnography, then you cannot afford to intubate.

If you decide that intubation should be done anyway, you do not deserve any compassion when your actions result in disability and/or death.

Idiocy is not a valid excuse.

Leadership?


For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.[4]

If you prefer, you may substitute God for the term nature.

All of the images used are in the public domain.

Some other posts about this:

RSI, Intubation, Medical Direction, and Lawyers.

RSI Problems – What Oversight?

More RSI Oversight

Misleading Research

Intubation Confirmation

More Intubation Confirmation

Footnotes:

^ 1 Report of the Presidential Commission on the Space Shuttle Challenger Accident (Also known as The Rogers Commission Report)
Volume 2: Appendix F – Personal Observations on Reliability of Shuttle
by R. P. Feynman
Conclusions
http://history.nasa.gov/rogersrep/v2appf.htm

^ 2 STS-114
Wikipedia
Article

^ 3 Return to Flight Task Group Final Report 8/17/05
A.2 Observations by Dr. Dan L. Crippen, Dr. Charles C. Daniel, Dr. Amy K. Donahue, Col. Susan J. Helms, Ms. Susan Morrisey Livingstone, Dr. Rosemary O’Leary, and Mr. William Wegner.
Page 188
http://www.nasa.gov/pdf/125343main_RTFTF_final_081705.pdf This is an automatic download.
If that does not work, or you do not want to download the file, try:
http://www.scribd.com/doc/349834/NASA-125343main-RTFTF-final-081705

^ 4 The same as footnote 1
http://history.nasa.gov/rogersrep/v2appf.htm

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By Rogue Medic
Filed Under: Airway Management, Critical Judgment, Heresy, Intubation, Physician Oversight, RSI Tagged With: , , , , ,

RSI, Intubation, Medical Direction, and Lawyers.

Mon, 28 Apr 2008 19:35:00 -0400 by

There has been a discussion of the article High-risk EMS procedure gets a low level of oversight[1] on TexasEMT.com. The forum on RSI (Rapid Sequence Induction or Rapid Sequence Intubation) has been very active. It presents a variety of views, including mine.

One of the physician/medics on the list included some posts from another site. The posts provide a lot of good evidence for the safety of RSI. I will eventually review a lot of the intubation research. There will be special places for the examples of research from Dr. Wang and Dr. Yealy that are discouraging good airway management.

The gist of the discussion between me and another person has been the level of medical director responsibility. He does not see the problem with medical directors as serious.

I see bad medical direction as the essence of airway problems.

His most recent post finishes up with this statement.

So, if you’re right, and failed tubes are the fault of bad medical directors, then the studies quoted above represent incontrovertable evidence of excellence in medical direction. After all, a 95% success rate and only 3 surgical airways in over 1500 attempts shows that they clearly have in-touch doctors.[2]

The 95% success rate refers to intubation success. The airway management success rate was 99.7% and it improved with the addition of capnography.[3]

I agree with him. The problem is that these are only some of the systems that intubate. Dr. Wang and Dr. Yealy will find you places with much lower success rates.

The bigger problem is that systems with poor intubation success rates are not hard to find. While we should be encouraging the excellent systems, where is the outrage at the incompetence of systems that do far worse?

If you are Dr. Wang or Dr. Yealy, looking at paramedics in Pennsylvania where every town that has its own traffic light needs to have its own paramedics, why correct the problem of too many ALS services, too many medical directors, and too many bad medical directors? Instead, use this situation to justify criticism of paramedics’ intubation skill.

Why are we not gathering pitchforks and torches and demanding better than the bad airway management encouraged by Dr. Henry Wang, Dr. Donald Yealy, Dr. Robert Kowalski, Dr. S. Addison Beeson, Dr. Cynthia Simmons, Dr. Paul Pepe, Dr. Robert Simonson, Dr. Frankenstein, . . . .

“If you have a good medical director, somebody who’s actively engaged and involved in EMS, you can kind of push the envelope,” said Bryan Bledsoe, a Midlothian emergency physician and the author of several EMS textbooks. “The problem is a lot of these services have someone who just signs the chart.”(article)

Just signing a chart, or just looking at flagged charts, is not medical oversight. These service should not have ALS unless they have a real medical director.

“I’ll say this flat out: There is no excuse for a misplaced tube,” said William E. Gandy, an EMS educator in Tucson, Ariz., who is known nationally for his expertise in airway management. “We have the means to verify that a tube is in the right place. There’s no excuse for not verifying.”(article)

Can anybody make a good case that he is wrong?

I can’t.

Who is responsible for these three cases of, not RSI problems, but intubation confirmation problems?

All of these cases were problems with the confirmation of the placement of the endotracheal tube – not with the use of the medications to paralyze the patient.

Very basic stuff for an ALS airway.

While it is difficult to know how widespread such problems might be, many familiar with EMS issues say the incidents that reach the legal system are likely just the tip of the iceberg.

R. Jack Ayres, an Addison attorney who holds a paramedic’s license and has long been involved in EMS at the state and local levels, said he knows of at least 50 cases in which botched intubations caused death or disability.(article)

People have been saying that this is only a matter of 3 cases.

People have been saying that this is a matter of only RSI problems.

They don’t know what they are talking about. If you have a system that has the ability to check exhaled CO2, (carbon dioxide), but people don’t check exhaled CO2,, then this is a huge problem.

Each of these cases would have been prevented by simply checking exhaled CO2,, and placing an alternative airway if the medic could not get the tube in the right place.

How difficult is it to teach that you check CO2, continuously on every intubated patient?

How hard is it to make sure, as medical director, that this is done on every intubation?

If you show up at the emergency department and you do not have a device for checking exhaled CO2,, nobody notices?

Allen was intubated seven minutes before the helicopter landed at the United Regional Health Care center in Wichita Falls, according to records. The tube became dislodged before she was treated in the emergency room, the records indicate.

Both the flight nurse and the paramedic acknowledged in depositions that they did not use carbon dioxide monitoring, even though it was available.

The medical director for Air Evac’s Wichita Falls base at the time was S. Addison Beeson, a Tulsa emergency physician. She did not respond to messages from the Star-Telegram.(article)

It isn’t as if you sneak into the emergency department with these patients and nobody notices. Intubated patients are high priority patients. They require extra staff and equipment.

None of the nurses, doctors, techs, respiratory therapists, janitorial staff, . . . notice this?

One problem is that it isn’t much better in the emergency department. When I bring in a patient with waveform capnography attached, the first thing that staff will tend to do is pull the tubing, because it is “in the way.” Would they go into the ICU (Intensive Care Unit) and do the same? There is a lot more stuff “in the way” in the ICU.

One reason for this is that, in the ICU, more stuff is considered better care. More EMS stuff, even though it is helping EMS to provide a higher level of care than than the emergency department, is viewed as just “in the way.”

What doctor, nurse, or respiratory therapist throws away the best method of confirming tube placement without using it?

OK, that is a bit unfair. I have never seen a respiratory therapist do this. The respiratory therapists are often as interested in this as in any other new gadget, and they understand its value. Why don’t the doctors and nurses? OK, still a bit unfair. It is only some doctors and nurses that do this, but why do any do this? If you do not know what it is, ask before removing it. Hmm, this pin is “in the way” on this hand grenade, better remove it.

What is extremely rare is that the doctor, or nurse, will use the waveform capnography to check tube placement. Instead, they will be running circles around themselves to use all sorts of inferior methods of confirming placement. They will completely ignore the most reliable method of confirming placement.

This is wrong.

This is where EMS learns to not use capnography, or the slightly-better-than-useless color change device.

“If they don’t use this stuff in the hospital, why do we have to use it?”

Clearly, anyone who would say this, does not understand patient care and should not be intubating. In EMS there are too many of these idiots. The medical directors, the essence of airway problems, do not seem to do a good job of removing them.

Simonson said records he has reviewed at CareFlite show that the air medical service regularly has to “bail out” ground EMS crews that fail to intubate paralyzed patients.(article)

So, they couldn’t intubate the patient. This happens. Did they use an alternative method of managing the airway?

That is what matters.

None of these cases in the article were about RSI, they were about airway management.

There are places where the medics have no clue about airway management, but are allowed to intubate. Is this acceptable? Should this be acceptable?

What kind of person knows that his people cannot manage an airway, but allows them to intubate (RSI or no RSI)?

Dr. Simonson goes on to say:

Simonson said he has come to believe that RSI “needs to go away” when it comes to ground EMS. To that end, he has removed it from the protocols of all but two of the units under his direction because, he said, only those units had the necessary experience.(article)

Has he taken intubation away from the inexperienced ground services?

Has he done anything to educate them, to improve their experience level?

With only a few sentences out of hours of comments, it is difficult to determine what his approach is.

The problem remains a failure of the most important part of airway management in three cases. The problem was not with the medications that cause temporary paralysis (RSI).

Here are the reasons, given by the medical directors for two large cities, for not using RSI.

Arlington: Short transportation times and the inability to train a large number of paramedics are cited by Cynthia Simmons, the local medical director for the city’s ambulance provider, American Medical Response.(article)

In other words, the medical director can’t train a large number of medics in advanced airway management.

Dallas: Paramedics in a large system don’t have enough opportunities to sharpen their intubation skills, according to medical director Paul Pepe.(article)

He used to be medical director for the state of Pennsylvania, home of Dr. Wang and Dr. Yealy. What kind of illogic is this? If the medics in a large system “don’t have enough opportunities to sharpen their intubation skills,” who does?

What kind of medical oversight do they have that keeps them lacking in “sharp?”

Bad airway management, RSI or not, is a reflection of the quality of the medical director.

Other RSI/airway/tube confirmation posts of mine:

RSI Problems – What Oversight?

More RSI Oversight

Misleading Research

Intubation Confirmation

More Intubation Confirmation

RSI, Risk Management, and Rocket Science

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Footnotes:

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^ 1 RSI procedure gets low level of oversight in Texas
The Star-Telegram article is no longer maintained at their site, but EMS1.com has what I believe is the full article on their site. This was published in various abbreviated formats by various news organizations. The abbreviated articles usually were attributed to AP or some other news organization, rather than to Danny Robbins.
High-risk EMS procedure gets a low level of oversight at JEMS.com

Now apparently only available at Free Republic.

–

^ 2 TexasEMT.com Forum Index » Open EMS/EMT Discussion » RSI

–

^ 3 Wayne MA, Friedland E.
Prehospital use of succinylcholine: a 20-year review.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

.

By Rogue Medic
Filed Under: Airway Management, Critical Judgment, Dr. Bryan Bledsoe, Heresy, Intubation, Physician Oversight, RSI

More Intubation Confirmation

Sun, 27 Apr 2008 05:13:00 -0400 by
 

In the last post Intubation Confirmation, you stated that we should not trust our eyes.

Not when other confirmation methods suggest that the tube is in the wrong place.

And I suppose not using other tube confirmation methods is a bad idea.

Beyond bad.

So, what should we trust?

There is no one perfect assessment to trust. Multiple methods should be used to confirm placement.

Such as?

Lung sounds.

Of course, that is the most important assessment.

No, belly sounds are more important.

Why?

We are looking for any sign that the tube is in the wrong place. Lung sounds do not provide that information. Lung sounds may be referred, or absent, or ambiguous, or . . . , they are not good at telling you the tube is in the esophagus.

But we want to know that the tube is in the trachea.

It is more important to know if the tube is in the esophagus.

Why?

The esophagus is a route to the stomach contents. The stomach is expected to be full of all sorts of yucky foods that are not good for the lungs. The stomach also contains hydrochloric acid. Lung tissue is delicate and does not respond well to a hydrochloric acid challenge.

So it is better to avoid filling the stomach with air that will act as a propellant and fill the airway with food and acid and other nastiness.

Also, there is great entertainment value in watching the way people listen to lung sounds. First they listen to one lung for a while, then they listen to the other lung for a while, then they go back to the first lung . . . .

As if listening longer is going to encourage the tube to move to a more acoustic spot.

Precisely, and the stomach is just becoming more and more distended during this time of self deception.

So you listen to the stomach first?

I don’t. You don’t really expect me to be like everyone else, do you?

Not even in assessing tube placement. Oh, well.

I place my hand over the stomach and both lungs at the same time. Sound causes vibration that can be felt with the hands, called tactile fremitus. This allows me to assess all three locations simultaneously and makes it easier to differentiate among referred sounds.

That must take practice.

What assessment method doesn’t?

OK. I suppose it helps to have big paws.

Woof. One of the reasons I do this is too find out as quickly as possible where the tube is, because each squeeze of the bag places about half a liter of gas into the patient.

So, if this gas is going into the stomach, the stomach is going to fill up in just a few breaths.

Yes, it is. Sometimes, just one breath.

And something that fills up quickly can empty quickly?

Quickly, perhaps violently, but in a way that distracts everyone from airway management.

Then you’d better tell about other assessments tube placement, because nobody likes being vomited on.

Emetophiliacs might.

Eww!

Another method of assessment is to look for belly rise.

That means that the tube is in the wrong place.

No. Normal diaphragm movement will result in pressure on the intestines and stomach and some belly rise. That belly rise should return to the same level at the end of exhalation, if the tube is in the trachea. If the tube is in the esophagus, the belly rise may decrease with exhalation, but will probably not return to its original dimensions. Some distension will usually remain. And if the patient starts vomiting through the tube that is usually a pretty big clue about tube position.

You want to pull that tube pretty quickly.

No. The tube is helping to protect the airway if the stomach contents are coming out of the tube, instead of ending up in the airway. When attempting to place another tube it can guide you to the trachea, which should be higher than the tube already in place.

Then you pull the other tube after you have confirmed that the new one is in the trachea.

Still, no. The tube is directing the stomach contents to a safer place, at least for the patient, not necessarily for the bystanders. So, try not to direct this at any of your coworkers. You can mess with them later, when you are not trying to manage an airway.

It is good that we covered all of these confirmation methods.

No, we aren’t even half way there.

More posts to come?

Of course.

Other posts about this:

RSI Problems – What Oversight?

More RSI Oversight

Misleading Research

Intubation Confirmation

RSI, Intubation, Medical Direction, and Lawyers.

RSI, Risk Management, and Rocket Science

.

Filed Under: Airway Management, Critical Judgment, Heresy, Intubation, RSI

Intubation Confirmation

Fri, 25 Apr 2008 20:46:00 -0400 by
 

All of this discussion about confirmation of tube placement raises some questions.

You bet.

Why is it so hard to tell where the tube is?

Right. You either see the tube go through the cords, or you don’t.

NO! That is the big problem.

What?

Any magician will tell you that Seeing is Deceiving.

But if you see the tube go through the cords you know it is in the right place.

No. If you think you see the tube go through the cords, then you are more likely to believe the tube is in the right place.

But you either see it or you don’t.

What you think you see is influenced by what you want to see. People are not good at being objective. This is why you need to aggressively try to demonstrate that the tube is in the wrong place.

So, by doing all of the tube confirmation things, we are looking more for evidence that the tube is in the wrong place – rather than evidence that the tube is in the right place?

Sort of.

If you can’t prove that the tube is in the wrong place, then it must be in the right place.

Not exactly, but the signs that the tube is in the wrong place should not be ignored.

You’re saying that people tend to ignore the information that they don’t like.

Yes. If you have a clear sign that the tube is in the wrong place, do not rationalize it, do not ignore it.

Give an example.

I was standing in the door of a room where a patient was having her esophagus intubated.

You mean trachea.

They meant trachea, but the result was not the trachea.

How do you know?

That was their question, since I was about 10 feet away from the patient and I was telling them the tube is not in, trachea-wise.

Well, they were right to question you.

Right to question me? Yes.

How were they wrong?

They didn’t understand what I was telling them.

What did you tell them?

“Look at the belly,” the intestines were clearly defined when looking at the area over the intestines.

That could be old.

That may be one of the ways they were rationalizing this assessment that is inconsistent with proper placement of an ETT (EndoTracheal Tube) in the trachea. Or they just considered it irrelevant.

How do you know it wasn’t already there?

With each squeeze of the bag, the definition and area increased. The leg bone is connected to the ankle bone, but the lung bone is not connected to the intestine bone.

Too simple for people to recognize?

Apparently, but why is that the case?

They only acknowledge information that confirms what they want to believe?

Yes.

We need to always suspect that the tube is in the wrong place.

We need to always be looking for signs that the tube is in the wrong place.

We need to distrust people saying “I saw the tube go through the cords.”

But, if you see the tube go through the vocal cords, you know it is in the trachea.
 

Almost every tube that is misplaced is accompanied by those killer words –

“I saw the tube go through the cords.”
 

So, we shouldn’t trust our eyes?

If there is any evidence that what we saw was inaccurate, we should distrust our eyes.
 

 

More in More Intubation Confirmation.

Other posts about this:

RSI Problems – What Oversight?

More RSI Oversight

Misleading Research

More Intubation Confirmation

RSI, Intubation, Medical Direction, and Lawyers.

RSI, Risk Management, and Rocket Science

.

Filed Under: Airway Management, Critical Judgment, Heresy, Intubation, RSI
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