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

- Rogue Medic

Where is the Line Between Good Pain Management and Bad

 

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?

Footnotes:

[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.

.

Face Down Restraint into a Pillow


 

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!
 

Footnotes:

[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

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

[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.

 

.

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

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.

Footnotes:

[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]

[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.

 

[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]

[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.

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

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

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

.

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


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.
&nbsp


 

Footnotes:

[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

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

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

[4] Cognitive dissonance
Wikipedia
Article

.

Ambulance Mistake Killed Teen After Skateboard Accident


 
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’

Footnotes:

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

[2] Intubated ED Patients are Still Not Receiving Sedation
EMCrit
by Scott D. Weingart, MD.
Podcast page

[3] ED patients being intubated and then not sedated or pain-controlled
EMCrit
by Scott D. Weingart, MD.
Podcast page

[4] You had me at ‘Controversial post for the week’ – Part I
Tue, 22 Oct 2013
Rogue Medic
Article

[5] More Intubation Confirmation
Sun, 27 Apr 2008
Rogue Medic
Article

.

Comment on If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So – Part I

 

In the comments to If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So – Part I, TexasMedicJMB writes the following –
 

I look at the approach of what works for the person performing the intubation is best.

 

No.

What is best for the patient is what is best.

Research to find out what is best for the patient is important.
 

The goal isn’t to satisfy keeping a low-tech approach, the goal is to maximize patient care.

 

That is why we need research.

We can’t just assume that we know what is best without valid evidence. If we are honest about doing what is best for our patients and if we are to behave ethically, we need to find out what is best for our patients.
 

If a difficult airway is encountered and the decision to use a Bougie (flex-tube introducer) is made does this qualify as witchcraft?

 

That depends.

What do I mean by witchcraft?

By witchcraft, I mean treatments that are based on superstition, wishful thinking, and/or anecdote, rather than valid evidence.

Is the decision to use a bougie based on valid evidence?

If not, then the decision may qualify as witchcraft, as I use the term.
 


 

However, you entirely missed the point of my criticism of the opposition to learning by these anesthesiologists.

These witches anesthesiologists refused to participate in research designed to answer a question that has not yet been answered and may affect patient survival.
 

If an anesthesiologist opts to use a Mac 0 on a pediatric pt rather than a text-book suggested Miller 0 is this witchcraft?

 

The textbook recommendation appears to be witchcraft, but feel free to provide valid evidence to support either opinion.
 

If the doctor opts to use VGL because the pt is perceived difficult due to morbid obesity, known CA tumor, etc. why is this witchcraft?
I call it prudent judgement.

 

Is there valid evidence that the GVL (GlideScope Video Laryngoscope) improves outcomes?

If not, then what you describe is not prudent judgement, but mere wishful thinking and therefore witchcraft, as I use the term.
 

From the article at http://www.ncbi.nlm.nih.gov/pubmed/22042705: Compared to direct laryngoscopy, Glidescope(®) video-laryngoscopy is associated with improved glottic visualization, particularly in patients with potential or simulated difficult airway.

 

That is great for someone selling video laryngoscopes

These are only surrogate endpoints, which do not matter.

Surrogate endpoints are just hypothesis generators for studies that will determine if the video laryngoscope actually improves outcomes that matter.

Surrogate endpoints are excellent for self-deception.

Where is the evidence of improved outcomes that matter?
 

From http://ccforum.com/content/17/5/R237: In the medical ICU, video laryngoscopy resulted in higher first attempt and ultimate intubation success rates and improved grade of laryngoscopic view while reducing the esophageal intubation rate compared to direct laryngoscopy.

 

Where is the evidence of improved outcomes that matter?

According to the paper I am writing about,[1] video laryngoscopy resulted in longer intubation attempts and dramatically more hypoxia.

Are we curing the disease, but killing the patient?

Blood-letting also improved surrogate endpoints, while it increased the likelihood of death for patients treated with blood-letting.
 

Physicians observed of old, and continued to observe for many centuries, the following facts concerning blood-letting.

1. It gave relief to pain. . . . .

2. It diminished swelling. . . . .

3. It diminished local redness or congestion. . . . .

4. For a short time after bleeding, either local or general, abnormal heat was sensibly diminished.

5. After bleeding, spasms ceased, . . . .

6. If the blood could be made to run, patients were roused up suddenly from the apparent death of coma. (This was puzzling to those who regarded spasm and paralysis as opposite states; but it showed the catholic applicability of the remedy.)

7. Natural (wrongly termed ” accidental”) hacmorrhages were observed sometimes to end disease. . . . .

8. . . . venesection would cause hamorrhages to cease.[2]

 

I am sorry that your child died, but we consider surrogate endpoints to be more important than the lives of our patients.
 

This paper could have helped to answer that question, but a bunch of anesthesiologists witches decided that they just know and they don’t care about reality or outcomes. In other words, surrogate endpoints are more important than the lives of their patients.
 

As you point out, the article you linked just leaves the sub-group in question at “discretion, unspecified”.

 


 

As Dr. David Newman stated in the podcast,[3] he contacted the corresponding author and was told that all of the attending physician discretion, unspecified patients were because there are some anesthesiologists who refuse to use anything other than a video laryngoscope.

In other words, their patient care depends on prejudice – as does witchcraft.
 

Is the discretion the witchcraft and psychics? Maybe. Is it likely these pt’s were indeed difficult airways the physician felt more comfortable using VGL?

 

Again, according to Dr. Newman, some anesthesiologists insisted on intubating all of their patients with video laryngoscopes, regardless of difficulty. They consider themselves too smart to learn, so they refused to participate.
 

Is the physician truly practicing witchcraft because he chose to perform a procedure known to lower time to intubation, improve first-pass success, etc?

 

Does lowering intubation time improve outcomes?

If video laryngoscopes shorten intubation time, then why did it take longer to intubate patients with the video laryngoscopes?

Valid research could help answer that.
 

Would it have been better if he’d have ignored the VGL device and made several attempts at DL to pass the ETT?

 

Why do you assume that would be the outcome?

Do you have any valid evidence?

One thing this paper does make clear is that there is no good reason to assume that use of video laryngoscopes improve outcomes.
 

The usage of VGL doesn’t appear to be a tool of witchcraft. This is evolution of medicine.

 

You appear to be defending the preventable deaths of patients in order to promote the continuing expansion of witchcraft in medicine.

We do not know what is best, but the anesthesiologists are defending their opinions and protecting their opinions from evidence that may contradict those opinions.

That is witchcraft superstitious nonsense.

Footnotes:

[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]

[2] Blood-Letting
Br Med J.
1871 March 18; 1(533): 283–291.
PMCID: PMC2260507

[3] SMART Literature Update
SMART EM podcast
Friday, October 11, 2013
Dr. David Newman and Dr. Ashley Shreves
From about 45:45 to 1:11:00 in the podcast is on this paper.
Podcast page.

.

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

ResearchBlogging.org
 

This study starts out looking good, but there is a huge problem with the design.

If the person intubating felt that he needed to use the video laryngoscope to get the tube, then the patient was not randomize into the study.

How was this paper accepted for publication with such an obviously violation of research methodology?

Did the authors at least track the violations of ethics, so that some analysis of all patients could be attempted?

Maybe this is not really GVL (GlideScope Video Laryngoscope) vs. DL (Direct Laryngoscopy), but a comparison of intubation of the not-so-difficult airway with GVL vs. DL.

What is not-so-difficult? Whatever did not get the doctor to cry, I could not possibly manage that airway safely with a regular laryngoscope!

833 patients would have been randomized, but the person in charge of the airway cried uncle in 210 (just over 25%) of these cases.
 


Image credit.[1]
 

Has airway management really deteriorated to the point where doctors do not feel competent managing 25% of airways without an electronic toy because they are superstitious and believe the toy has magical powers?
 


 

Maybe.

A study could be set up with some sort of objective criteria for excluding the most difficult airways and still be valid, but how do we objectively assess the need for an electric rabbit’s foot?

Did the doctors read their horoscopes and determine that it was a bad day and they needed to use all of their voodoo powers that day?

Did the doctors consult with psychics?

We do not know, because the criteria for superstition are not explained.

This is just a reminder that medicine, and perhaps especially trauma medicine, is still a very superstitious field. It wasn’t that long ago that these patients would have been treated with blood-letting to get rid of the bad humors that prevent healing. Humorous medicine.

Dr. David Newman and Dr. Ashley Shreves describe this in a SMART EM podcast.[2] Dr. Newman corresponded with one of the authors and states that some of the anesthesiologists at Shock Trauma are biased in favor of the video laryngoscope and refuse to use anything else. Were the 210 patients excluded just because some attending anesthesiologists are too biased to learn what works and those anesthesiologists were just throwing a tantrum for all of their patients?

The mythology of I know it works because I’ve seen it work.[3]

Are 25% of the attending anesthesiologists at Shock Trauma too biased to learn?[4]

Or have we improved to the point where only 25% of attending physicians in a specialty are to biased to learn?

To be continued in Part II.

Footnotes:

Image credit for witch’s hat.

[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]

[2] SMART Literature Update
SMART EM podcast
Friday, October 11, 2013
Dr. David Newman and Dr. Ashley Shreves
From about 45:45 to 1:11:00 in the podcast is on this paper.
Podcast page.

[3] I’ve Seen It Work and Other Lies
Tue, 21 Jun 2011
Rogue Medic
Article

[4] It would be the anesthesiologists managing just over 25% of the intubations, rather than 25% of the anesthesiologists, but no information is provided to clarify how many anesthesiologists that would be.

The result of the bias affects just over 25% of patients.

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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Do We Have a ‘Bigotry of Low Expectations’?

Kelly Grayson writes that –
 

The biggest obstacle to the advancement of our profession is not the limitations imposed upon us by others, but the lies we tell ourselves[1]

 

Image credit.
 

Is this an unreasonable assessment?

No, it may be too subtle for most to understand, because Kelly does not appear to have received the usual hate mail that comes with the exposure of EMS problems.

What lies do we tell ourselves?

 

“We don’t diagnose.”[1]

 

We have no idea of what we are doing, but we give deadly drugs and perform deadly procedures based on this no idea.
 

“We work under the physician’s license.”[1]

 

Using similar logic, when I drive a car, truck, ambulance, . . . I am driving on the Governor’s driver’s license. If I drive dangerously, the Governor will share liability, since I am driving on his license.

It may state in the health code that medics in some states do practice on the license of the medical director, but please provide some evidence of action against that license because of a paramedic’s actions.

Where is the command responsibility?[2]
 

“The protocol says…”[1]

 

This is usually followed by misinterpretation.

This is not because protocols are so well written that they do not encourage bad treatment, but the approach is to find absolute rules to prevent the person from thinking. The person is afraid of his own thinking. This does not suggest that he does a good job of thinking. Therefore, whatever interpretation he makes can be expected to be a misinterpretation.
 

“Right or wrong, he’s the doctor. We have to follow orders.”[1]

 

That excuse has failed before.
 

despite the fact that the medication was ordered by a physician, each of these individuals knew from the Advanced Cardiac Life Support guidelines that the medication could have “lethal,” “disastrous” consequences when administered to someone like the plaintiff, and they recognized that the standards of care applicable to them required that they exercise independent judgment and not just “blindly follow a doctor’s order that they knew posed an extreme degree of risk to the patient”

Columbia Medical Center of Las Colinas v. Bush, 122 S.W.3d 835 (Tex. App.—Fort Worth 2003, pet. denied).[3]

 

We are responsible for our actions.

If you are looking to avoid responsibility, you should not be in any position of trust.
 
 

Where does all of this lowering of standards lead?
 

Never mind all that. We can’t meet our goal. Let’s lower the standard.

Allow me paint for you a little self-fulfilling prophecy:

  1. Paramedics gripe because they are underpaid and disrespected, and have difficulty obtaining reciprocity in other states.
  2. ED physicians complain because we bring them patients whose airways are poorly managed.
  3. . . . .[1]

 

Where does this lead?
 

Go read the full article.
 

Footnotes:

[1] The bigotry of low expectations – The biggest obstacle to the advancement of our profession is not the limitations imposed upon us by others, but the lies we tell ourselves
By Kelly Grayson
EMS1.com
August 13, 2013
Article

[2] Command responsibility
Wikipedia
Article

[3] Malice/gross negligence.
Thornton RG.
Proc (Bayl Univ Med Cent). 2006 Oct;19(4):417-8. No abstract available.
PMID: 17106507 [PubMed]

Free Full Text from PubMed Central.

.