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

- Rogue Medic

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

.

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.

.

Factors associated with failed intubation attempts in the ED – Difficult Airway

ResearchBlogging.org
 

As with any procedure, each attempt at intubation increases the chance of harm to the patient.

What can we do to minimize the possibility of making more than one attempt at intubation?
 

The aim of this study was to identify factors associated with successful second and third attempts in adults following a failed first intubation attempt to support an effective rescue attempts strategy in the ED.[1]

 

Click on images to make them larger.
 

The success rate for each attempt was about 80% for the first, second, and third attempts. Several factors seem to have influenced that success rate, but the most important appears to have been the presence of a difficult airway.
 

The 6 academic EDs were equipped with core airway devices and drugs, one or more extraglottic devices, one or more video laryngoscopes and fiberscopes, RSI drugs, and one or more cricothyrotomy sets or kits.[1]

 

All intubations were supervised by a senior physician, so they should be well prepared for difficult airways.
 

A difficult airway was defined as a case in which the first intubator anticipated the difficult airway considering 3 dimensions of difficulty: difficult laryngoscopy and intubation, difficult bag-mask ventilation, and difficult cricothyrotomy.[1]

 

In the discussion, the authors suggest that they may have come up with higher rates of difficult airways for the first intubation attempt due to using three criteria to identify difficult airways.

This should not suggest that their conclusions about difficult airways are weakened. The opposite is more. They were less likely to miss a difficult airway. Difficult bag-mask ventilation may not be predictive of a difficult airway, but the increasing proportion of difficult airways among the failed intubations suggests that these airways were difficult.
 


 

Perhaps if we view the difficult airways as a proportion of the successes and failures of each intubation attempt, it will make things more clear.
 


 

Only 26.3% of first intubation attempt failures, but 36.5% of second intubation attempt failures, and increasing dramatically to 64% of third intubation attempt failures.

This does raise the question of why 36% of third intubation attempt failures were not considered difficult intubations?

Were they only going by the initial assessment of difficult intubation?

Shouldn’t we be reevaluating as we get further information as the Reverend Thomas Bayes advises?[2]

Footnotes:

[1] Factors associated with successful second and third intubation attempts in the ED.
Kim JH, Kim YM, Choi HJ, Je SM, Kim E; on behalf of the Korean Emergency Airway Management Registry (KEAMR) Investigators.
Am J Emerg Med. 2013 Jul 29. doi:pii: S0735-6757(13)00395-1. 10.1016/j.ajem.2013.06.018. [Epub ahead of print]
PMID: 23906622 [PubMed – as supplied by publisher]

[2] Bayesian inference
Wikipedia
Article

Kim JH, Kim YM, Choi HJ, Je SM, Kim E, & on behalf of the Korean Emergency Airway Management Registry (KEAMR) Investigators (2013). Factors associated with successful second and third intubation attempts in the ED. The American journal of emergency medicine PMID: 23906622

.

Airway Instruction – Episode 171 of the EMS EduCast

 

We want to be permitted to intubate.

True.

We don’t want to have to practice.

Sadly, that also appears to be true.

Fortunately for those of us who hate to practice, it is difficult to get paramedics time in the OR to practice on live people.

Not true.

Listen to Bill Toon, PhD/Paramedic explain how he was able to set up a system for all of the paramedics to rotate through the OR (Operating Room) to obtain practice and continuing education on real people.
 

Go listen to the podcast.
 


Image credit.
 

Bill Toon, Greg Friese, Rob Theriault, and David Blevins discuss ways of improving airway skills.
 

What if we do not work in a system that is set up like Johnson County Med-Act? Are we out of luck?

No, but we just have to work a bit harder to be good. Bill Toon did not accomplish this overnight, so do not despair that you do not have something already. Get to work on setting one up. It will take time, initiative, and the ability to ignore the people who say it cannot be done.

I would be surprised if Bill did not know some people who know some of the anesthesiologists where you would be trying to set this up. Talking to people who have done this and not been visited by plagues of blood, frogs, locusts, others, and the deaths of their firstborn might help to get them to at least consider trying this.

Do not expect things to happen immediately. That is one of the important lessons bill discusses in airway management.

Slow down!

Work on the skill and ignore the speed. After we have developed skill, then we can work on speed.

Speed without skill is dangerous, but that is the way many of us have been taught.

Panic about the amount of time it might take.

Hold your breath, and when you need to take a breath you may be too hypoxic to remember what you were doing.

Talk to a martial artist. They work on the skill first, then the speed.

Talk to someone who races motorcycles. They work on riding smoothly, then add the speed.
 

Even if you cannot set up a similar OR program, we can practice on mannequins, but most of us seem to lack the imagination and the understanding to put in the thousands of mannequin intubations that we should.

There are some excellent references provided as well.
 

Airway World The only virtual knowledge and collaboration center dedicated to airway management.

Airway Cam: Practical Solutions for Emergency Airways

Johnson County Med-Act

The Power of Video Recording from JAMA

 

Go listen to the podcast.
 

.

What Laryngoscope Blade Do You Use? – Why?


 

Which laryngoscope blade is your favorite?

Does length matter?

Does strength matter?[1]

Dr. Minh LeCong asks this at his blog PHARM – PreHospital And Retrieval Medicine.

There is also a video that provides some information on blade size.
 


 

One of the problems with the video is the hand position. The laryngoscope should be held so that the hand is touching the blade. I prefer to have my ring finger touching the blade.

The higher the hand is on the handle, the more likely that the handle is used like a slot machine handle, as I demonstrate below.
 


 

The way to intubate is to position the patient before even picking up the laryngoscope (and premedicating with oxygen and whatever else is appropriate), then only advance the blade as far as necessary for each step of laryngoscopy.

1. Find the tongue.

Yay! That was easy.

2. Advance the laryngoscope and find the epiglottis.

Not as easy, but just more important.

3. Lift up (either in the valecula or under the epiglottis – it does not matter) and find the arytenoid structures. The vocal cords are above the arytenoid structures, so there is no need to lift up any farther.

4. Advance the bougie/tube over the arytenoid structures without touching anything else. It isn’t about cleanliness. The biggest problem I see people have when trying to intubate is that they do not avoid everything else in the mouth and end up trying to force the tube.

Force should never be used in the airway.

We should not arm wrestle with the airway. We will lose.

Go ahead and try to force this airway. I double dog dare you.
 


Image credit. It is all in the positioning.
 

The goal of airway management is to out-think the airway, not to out-muscle the airway.

As with martial arts, strength improves with repetition due to the development of muscle memory, even if there is no increase in strength. Technique requires a lot of repetition.

If you have not intubated a mannequin over a thousand times, you are still learning technique. We can always learn more.

We tend to be satisfied with very little practice, as if the patient owes it to us to inhale the tube.

This is ridiculous, but I find that for almost every class I have taught, I intubated the mannequin more times than everyone else in the class combined. I offer to let students practice as much as they want. I offer to help or to leave them alone.

Why is intubation of the airway of another human being so unimportant to so many of us?

Why do so many of us pretend that we are good at intubation?
 

Intubation shouldn’t be that hard, but research repeatedly shows us that we become airway stupid when things do not go as planned – and we are often the cause of the problems with our plan. Even if our plan is not just having the patient inhale the tube.
 

Most adults can be intubated with a #2 Mac or a #2 Miller. A longer blade is only necessary for a patient with an unusually long mandible.

Understanding of the airway is more important than blade size. Any spatula will do.

A blade should be relatively wide and flat. A tongue depressor would work well, but this would require some practice to manipulate the tongue with a tongue depressor. A tongue depressor is wider and flatter than a Miller, so a tongue depressor is better designed than a Miller to lift the tongue out of the way.

Why isn’t the Miller blade designed to lift the tongue out of the way? Was Miller in cahoots with the trial lawyers?

I prefer a Grandview, but a lower profile Grandview would be nice.
 


 

This is from Dr. Richard Levitan’s Airway Cam series.

Dr. Levitan is one of the top airway doctors in emergency medicine. Notice how low his hand is on the blade. It may be someone else manipulating the laryngoscope, but probably someone who has received input from Dr. Levitan on intubation technique.

The wrist is lower than the blade. This makes it more difficult to pull back on the blade and easier to lift up with the blade.

Intubation is not about a long blade, or a strong arm, or pulling back, but many people attempt to intubate using all three of these mistakes.

Intubation is about thinking, preparation, positioning, technique, and lifting the tongue up.

Footnotes:

[1] PHARM Poll : Blade choice in direct laryngoscopy – does length or strength matter?
by rfdsdoc
on May 2, 2013
PHARM – PreHospital And Retrieval Medicine
Article

.

Free Transport Ventilator Class from CentreLearn and Jim Hoffman This Thursday

 

Is this important if we do not do interfacility transport?

Yes.

Eventually, we will be using ventilators for almost everything where we currently use a BVM (Bag Valve Mask).

Why?

Because we humans are pathetic at bagging patients.

If you have not seen a doctor/nurse/respiratory therapist/paramedic/EMT basic bagging a patient at 60 breaths per minute, you have not been paying attention.

Since we seem to be resistant to education, the protocol writers are starting to make this something that is not corrected by education, but is prevented from happening by putting it in the hands of machines.

Needless to write, but this will have plenty of unintended consequences. The best way to avoid these unintended consequences (assuming that we do not magically develop excellent BVM skills, which would be the subject of other posts) is to be as familiar as possible with the use of transport ventilators and the kinds of problems that we can cause.
 

Original image credit.
 

The goal of medical care is to make things better, or to not make things worse.

The three most basic points, that apply just as much to BVM use as to ventilator use.

1. How to assess the patient for the cause of a sudden deterioration of the intubated patient. Everyone should know this. It is a part of every PALS/NRP class. If it is not, it was supposed to be. It should also be a part of every ACLS class, since these are some of the preventable causes of cardiac arrest.

DOPE – DOPE (or POET for the more politically correct) stands for Dislodged, Obstructed, Pneumothorax, Equipment failure. I have discussed these elsewhere.[1]

2. Hypotension – Even in a trauma patient, hypotension is often resolved by correcting the ventilation, rather than by adding fluid to the blood vessels.

3. Waveform Capnography – Continuous waveform capnography should be mandatory for the movement of all intubated patients anywhere. The same is true for extraglottic devices (LMAs, CombiTubes, King Airways, et cetera).

This is from CentreLearn and Jim Hoffman.
 

CentreLearn Webinar: Automatic Transport Ventilators in EMS
Thursday, April 25, 2013 8:30 PM – 9:30 PM EDT
 

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Footnotes:

[1] Origins of the Dope Mnemonic
Wed, 26 Jan 2011
Rogue Medic
Article

[2] Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation.
Aufderheide TP, Lurie KG.
Crit Care Med. 2004 Sep;32(9 Suppl):S345-51.
PMID: 15508657 [PubMed – indexed for MEDLINE]

Free Full Text Download in PDF format from burndoc.net.

[3] Capnography Use Saves Lives AND Money
Rogue Medic

Part I
Fri, 10 Dec 2010

Part II
Mon, 13 Dec 2010

Part III
Thu, 16 Dec 2010

Part IV
Thu, 16 Dec 2010

Part V
Tue, 04 Jan 2011

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