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

- Rogue Medic

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


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

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.

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.

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.

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.

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.

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.

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.

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

Footnotes:

[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.

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

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

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