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

- Rogue Medic

Is EMS a Trade or a Profession?


In the current issue of JEMS, there is an article by Dr. Bryan Bledsoe that does an excellent job of identifying many of the problems with low standards in EMS – at least if the quality of care is important.

Also, if you will note, the welding curriculum was revised in 2011.

The paramedic curriculum was last revised in 2009. Which trades would you say have had the most changes in the last eight to 10 years? Certainly changes in EMS have occurred much more frequently and are much more significant than those that have occurred in welding.[1]

trade vs profession 1

In some places, EMS has been more aggressive in changing treatment guidelines/protocols to improve the care delivered to patients. In other places, change has been resisted.

Backboards are rarely used in the places that have admitted that we do not have any valid evidence that backboards improve outcomes, while we do have good evidence that backboards cause harm. Even more important is the evidence that manipulating the patient’s spine in order to stabilize the spine is wishful thinking that encourages us to do exactly what we claim to be trying to prevent.

High dose NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries) is becoming much more widely used for acute CHF/ADHF (Acute Decompensated Heart Failure), because high dose NTG dramatically improves survival and decreases the perceived need for aggressive airway manipulation.

Likewise, furosemide is being eliminated from the CHF/ADHF guidelines/protocols, because furosemide does not do what it is supposed to do and furosemide causes harm that it is not supposed to cause.

Ketamine is becoming the drug for many indications. Ketamine may be the best sedative, best analgesic, best agitated delirium treatment available to EMS.

How do we know that we have been harming patients?

Enough people stopped listening to the old timers, the QA/QI/CYA people who don’t understand quality, the brand new if it were dangerous, it wouldn’t be in the protocol people, and other opponents of quality care.

People are paying more attention to the evience, rather than making excuses for the absence of evidence.

What is important is whether or not the graduating paramedic is competent and ready to assume the important role of prehospital care.[1]


Many states use the NREMT (National Registry of EMTs) test to determine if a paramedic is ready to become a new hire paramedic with no experience, some day to be able to work without a supervisor present. Some states continue to require this babe in the woods test of outdated material as their goal for even experienced paramedics.

The NREMT is holding EMS back.

It is time for the national standard curriculum to go away. We must meet and decide what the core competencies of a paramedic will be. We must validate these core competencies through scientific study. Then, we should leave it up to the educators to determine how best to educate their students in these core competencies.[1]


The paramedic curriculum, revered by the NREMT, harms patients.

Why are we protecting a curriculum that harms patients?


[1] Is EMS a Trade or a Profession?
Thu, Jul 28, 2016
ByBryan Bledsoe, DO, FACEP, FAAEM, EMT-P
JEMS Editorial Board member
Journal of EMS (JEMS)


Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest


This study is interesting for several reasons.

In a system that claims excellence, the most consistent way to identify the study group is by documentation of a protocol violation – but it is not intended as a study of protocol violations.

This may hint at some benefit from epinephrine (Adrenaline in Commonwealth countries), but that would require some study and we just don’t study epinephrine. We only make excuses for not studying epinephrine.

The atropine results suggest that the epinephrine data may be just due to small numbers, or that we may want to consider atropine for drug overdose cardiac arrest patients, or . . . .

The Sodium Bicarbonate (bicarb – NaHCO3) results suggest a flaw in EMS education (probably testing, too). If the patient is acidotic, this is one type of cardiac arrest where hyperventilation may be beneficial. Bicarb is the part of the drug that doesn’t do much, especially if the patient is dead. The sodium is what works, such as when the patient has taken too much of a sodium channel blocker, such as a tricyclic antidepressant or a class I antiarrhythmic. Acidosis is treated by hyperventilation. Use capnography.

Most important – antidotes probably don’t work as expected during cardiac arrest. Not even naloxone (Narcan).

Despite clear differences in the etiology of suspected OD [OverDose] and non-OD OHCA [Out of Hospital Cardiac Arrest], the International Liaison Committee on Resuscitation guidelines published in 2010 do not specify different treatments for suspected OD-OHCA patients during resuscitation,and state that there is no evidence promoting the intra-arrest administration of the opioid antagonist naloxone.8 [1]


What did they find in the study?

They may have located the highest concentration of heroin overdose in the country. 93% of OD-OHCA patients were treated with naloxone.

We relied on either naloxone administration or clear description of circumstantial evidence in the PCR [Patient Care Recod] to identify a suspected OD. Clear descriptions are also rare, and most (93%) of the cases were identified by naloxone administration. Naloxone during cardiac arrest is not part of any regional protocol, and all of these administrations are deviations from recommended practice. There may be other cases in which paramedics suspected OD, but did not deviate from protocol to administer naloxone. Therefore, it is impossible to be certain whether the actual number of OD cases is larger or smaller than the reported number. However, the use of naloxone as a proxy indicator of suspected OD has been supported in the literature.11 [1]


The EMS approach to naloxone still appears to be –

Image credits – 123

These results seem to show better response to the prehospital drugs in the OD-OHCA patients, but that ignores the ROSC (Return Of Spontaneous Circulation) rates.

Click on images to make them larger.

Why would OD-OHCA patients do better than non-OD-OHCA patients if they get a pulse back?

The average non-OD-OHCA patient is 20+ years older. These older patients may not be as capable of recovery nor as capable of tolerating the toxicity of the drugs they were treated with.

The change after ROSC is dramatic. Is that the important point of this study?

Are they doing anything special for OD patients in the hospital, or is it just a matter of That which does not kill me by anoxic brain damage, may allow me to recover twice as often as a typical cardiac arrest patient.

Do drugs (antidotes, antiarrhythmics, . . . ) work the same way in dead people as in living people?

Pharmacologic insults are just so massive and normal metabolism and physiology so deranged that no mere mortal can make a meaningful intervention. The seriously poisoned who maintain vital signs in the ED have the best, albeit never guaranteed, chance of rescue from a modicum of antidotes and intensive supportive care.[2]


We should understand that normal metabolism is irrelevant to cardiac arrest.

We should understand that we do not need to ventilate adult cardiac arrest patients, when the cause is cardiac. An absence of ventilation would not be appropriate in a living adult, but dead metabolism is not normal. If something as basic as oxygen changes, when the patient is dead, how much less do we understand the behavior of other drugs in dead patients?


[1] Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest.
Koller AC, Salcido DD, Callaway CW, Menegazzi JJ.
Resuscitation. 2014 Jun 26. pii: S0300-9572(14)00581-4. doi: 10.1016/j.resuscitation.2014.05.036. [Epub ahead of print]
PMID: 24973558 [PubMed – as supplied by publisher]

[2] Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions
Emergency Medicine News:
October 2011 – Volume 33 – Issue 10 – pp 16-18
doi: 10.1097/01.EEM.0000406945.05619.ca
Roberts, James R. MD

Roberts, J. (2011). InFocus: Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions Emergency Medicine News, 33 (10), 16-18 DOI: 10.1097/01.EEM.0000406945.05619.ca

Koller, A., Salcido, D., Callaway, C., & Menegazzi, J. (2014). Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest Resuscitation DOI: 10.1016/j.resuscitation.2014.05.036


Fall With Dementia and No Change from Baseline Mental Status


This happens many times every day. A patient falls and may have hit her head, but there is no change from her normal mental status. To complicate matter, she takes an anticoagulant.

There are no clear signs of serious trauma. so should we automatically go to the trauma center?

What can help us decide?

Patients were not excluded because of dementia, aphasia, or any cognitive or neurologic deficit that was determined by the physician caring for the patient to be the patient’s baseline.[1]


The conclusion of the study is useful, but I would reverse the emphasis.

Signs of trauma to the head and face or loss of consciousness is predictive of ICI.[1]


An absence of Signs of trauma to the head and face or loss of consciousness is predictive of an absence of ICI (IntraCranial Injury).

The study is not perfect, for example it is not clear what is included in the signs of trauma to the head, but it does strongly suggest that these patients should not be diverted to a trauma center just for anticoagulants, or for dementia, or for being old.

A patient was determined to have no significant acute head injury (1) if he/she had a negative result on head CT performed, (2) if the patient was admitted to the hospital and had no sequelae at discharge, (3) if review of his/her medical record revealed repeat hospital visits unrelated to falls with no sequelae or concerns related to the index visit,or (4) if the patient had no concerns at 30 days postinjury in telephone follow-up.[1]


These clearly are not the patients who needed to be trauma alerts.


Anticoagulants did not matter. While a trend is probably just statistical noise, the trend for anticoagulants other than aspirin was toward less likelihood of ICI.

While Signs of trauma to the head and face increased the likelihood of ICI, History of hitting head had a trend toward less likelihood of ICI.

The sensitivity and specificity for signs of trauma to the face/head or loss of consciousness were 92.6% (74.2-98.7) and 40.2% (36.8-43.8), respectively. The positive predictive value in this“low-acuity”cohort was 5.2% (3.4-7.6), and the negative predictive value was 99.4% (97.4-99.9).[1]


Should we start to write protocols based on this, or triage patients based on this? We should find out more, but patients with dementia and no change in mental status probably should not be triaged differently from patients with no change in mental status who just happen to not have dementia.

We already knew that, but we did not have evidence to support that bit of common sense.

A recent prospective study concluded that 26% of elderly patients presenting to the ED exhibited evidence of cognitive impairment[13].[1]


If a quarter of elderly patients have cognitive impairment, this can have a big effect on EMS.

The following figure that confused me. The percentages in red on the far right are the percentages of each category. That is what I would want to know, when looking at the data. The totals are not explained. Maybe someone will see what I am missing. How did 799 patients become 783, or did they become 783, and what happened to the other 16 patients if the number is now 783?


Regardless of my confusion with the figure above, this paper is one more reason for me to feel comfortable transporting patients with dementia and no obvious head injury (and no loss of consciousness) to the local hospital.


[1] Characteristics of elderly fall patients with baseline mental status: high-risk features for intracranial injury.
Hamden K, Agresti D, Jeanmonod R, Woods D, Reiter M, Jeanmonod D.
Am J Emerg Med. 2014 May 12. pii: S0735-6757(14)00318-0. doi: 10.1016/j.ajem.2014.04.051. [Epub ahead of print]
PMID: 24929771 [PubMed – as supplied by publisher]

Hamden K, Agresti D, Jeanmonod R, Woods D, Reiter M, & Jeanmonod D (2014). Characteristics of elderly fall patients with baseline mental status: high-risk features for intracranial injury. The American journal of emergency medicine PMID: 24929771


Details on the Recent Patient Prematurely Pronounced Dead


Recently, I wrote about a patient who was declared dead by EMS, but was found to be alive by the coroner.[1],[2] Some details have been released about the circumstances.

“I think my wife has died,” Tygart’s husband is heard telling a Bluegrass 911 dispatcher on an audio recording of his call. “She’s not responding. I just woke up about five minutes ago. She’s in the floor. I was hollering for her and she’s in the floor. And she’s cold and she’s not doing anything.”[3]


Not an unusual call, but nothing to discourage a full assessment.

“Do you want to try CPR on her?”
“I already have. I don’t know how long she’s been laying in the floor.”


Unresponsive to CPR seems further evidence of death, but what do we know about anything that we hear over the radio/telephone?

Accuracy is not a strong point. Dispatchers have this problem, too. They are trying to obtain important information from a stressed called in as short a time as possible, then relay that information to EMS. It should be surprising when they get a lot of accurate information about an unstable event from someone who is not a repeat caller.

Do we base our treatment on the information from dispatch?

No. We should bring in extra equipment, but we should only use it if our assessment indicates that we should.

What about assessment?

We can certainly prioritize parts of our assessment based on information from dispatch, but we should probably not eliminate assessment based on what dispatch tells us.

After 3-4 minutes on scene, the medic calls for a coroner and cancel the ambulance.

Shortly after the deputy sheriff and Deputy Coroner Floro arrive on the scene, the deputy sheriff calls back to dispatch — about 30 minutes after Tygart’s husband first called — “We (inaudible) need a West Lincoln ambulance back on-scene ASAP at this time.”[3]



While the ambulance was en route, the dispatcher called Floro to find out what happened at the scene.
“What did you do? Go up there and lay healing hands on her or something?” the dispatcher asks on the recording.

“No, she was breathing before I even touched her,” Floro says.

The dispatcher asks about “1200” (the medic) calling for a coroner.

“I know, but he didn’t have a truck and he didn’t have a monitor,” Floro says. “She had no pulse and she had extremely faint breath sounds and she was over in between a bed and a wall … I couldn’t tell she was alive until we pulled her out from the bed and I could see her and I heard breath sounds.[3]


No monitor, but he is a medic?

If I do not have a monitor, and the rest of my ALS equipment with me, I should not be identifying myself as a medic. I am only able to respond at the BLS level, or the AFA (Advanced First Aid) level. We are not our tools, but we are not able to even fully assess patients without a full set of tools.

Apparently, she was cold and did not have palpable pulses, but that does not mean that a person is dead.

Since the coroner determined that she died of a subdural hematoma, there may not have been anything that could have been done if she had been treated immediately, but hypoxia is not good for head injuries either.

Was there something that gave the impression of rigor mortis?

Until the Kentucky Board of EMS finishes its investigation, we will not have all of the information. Even after the investigation, KBEMS may not release all of the information.


[1] She’s Not Quite Dead Yet
Fri, 25 Apr 2014
Rogue Medic

[2] WKYT Investigates: Can paramedics declare someone dead?
Sun, 27 Apr 2014
Rogue Medic

[3] Lincoln Paramedic Called For Coroner While Woman Was Still Alive
Posted: Tuesday, April 29, 2014 10:33 am
By Ben Kleppinger


WKYT Investigates: Can paramedics declare someone dead?

Friday, I wrote about a patient apparently pronounced dead a bit hastily.[1] Today, the news has more information.

What is death?

Clinical death means that the heart has stopped. When we attempt to resuscitate a patient, it is because the person appears to be only clinically dead.

What about pronouncing death?

However, a question has been raised: Can a paramedic declare someone to be dead?

“Paramedics are trained very thoroughly in determination of death, and there are certain procedures that we go through,” answered Poynter.[2]


Mike Poynter is the Executive Director of the Kentucky Board of Emergency Medical Services (KBEMS).

Paramedics can declare death in Kentucky. They may have to make medical command contact, but that is not stated in the story.

This leader (Poynter) also has experience as a paramedic and says sometimes the call goes deeper than what the rules say.[2]



But EMS is about the superficial (if it isn’t specifically stated in the protocol, it is wrong) and (there is one best answer).

Is this rhythm asystole?


Some people would argue that the ECG strip above is asystole.

Looking at just one lead might miss a rhythm that is there, because sometimes the electrical axis of the heart is perpendicular to the lead being looked at, which would make the rhythm invisible on the monitor. Looking at any other lead, especially one of the other limb leads (I, II, III) should make any such rhythm visible on the monitor.

Above is lead V2, cut from a 12 lead and pasted end to end to give a longer strip.

A 12 lead ECG is not necessary to get two different leads.

Running 12 leads to document death would suggest either a very bizarre patient or a lack of competence.

“It’s stated that you should determine two different leads with an EKG, unless there are signs of trauma,” he continued.[1]


Here is lead V2, from above, in the context of V1 and V3.

Perspective is important.


V1 and V3 are being recorded from the same heart at the same time as V2, but they look completely different.

Below is the full 12 lead ECG with V2 highlighted. The leads are expected to show more of a continuum from V1 to V6, so there may be a problem with the placement of the lead, but this is a lead hooked up to a patient with an easy to recognize rhythm in 11 of the leads and almost nothing showing on one lead. This is not common, but it is reasonable to check another lead, even if it is not required.

Image credit. Click on images to make them larger.

Did the paramedic hook the patient up to the monitor?

We do not know, but the description of the assessment by the husband suggests otherwise. The husband was probably distraught at the time and may not have noticed a full assessment, because of the stress of the situation. Eyewitness accounts of stressful situations are notorious for unbelievable inaccuracies, except unbiased information shows that we should believe that the eyewitness truly was wildly inaccurate.

Few kinds of evidence are as compelling, or as damning, as eyewitness testimony: A human being, frequently a victim, takes the stand, looks at the defendant, and says, “He did it.” Eyewitness testimony is a staple element of criminal cases. In 1999, eyewitness identifications led to 75,000 prosecutions in the United States.1 Unfortunately, juries’ acceptance of faulty eyewitness identifications is also a leading cause-possibly the leading cause-of wrongful convictions.2 [3]


The documentation should solve that problem. Even if the paper printout is lost, the monitor should retain a long history of time stamped ECGs. This should not be a choice of whom to believe.

While I usually mock the cliche, If it isn’t documented, it wasn’t done, this is one case where that is true. Waveform capnography for endotracheal tube confirmation is another.

If the medic documents that rigor mortis was present, then his assessment is going to be very difficult to explain. While rigor mortis does wear off, it is an irreversible muscle breakdown that occurs after death. I don’t know of any documented cases of breathing returning after rigor mortis.

Could it have been the agonal breathing of a dead body? That would be much more likely, if the patient were pronounced dead upon arrival at the ED, but that was not the case.

According to Lincoln County Deputy Coroner Tony Floro, the breathing was faint but Tygart was still unresponsive. The victim was rushed to nearby Ephraim McDowell Hospital and was then flown to UK hospital, where she died the next day.[4]


EMS arrived on scene at 10:06. The coroner arrived about half an hour later. She was treated at the local hospital, then flown to a university hospital. A lot of people would have to have to not notice/ignore obvious death for a long time – or she was not really dead. It is possible for even doctors to ignore reality. I have seen doctors push repeated doses of succinylcholine to try to relax the jaw for the intubation. This was the jaw of a child in rigor mortis. They stopped after about an hour. Maybe they ran out of succinylcholine, or maybe they finally accepted reality.

EMS -> ED -> Flight crew -> ED over more than half a day, with no recognition of death? They should be able to provide ECG strips from the second ambulance and the hospitals.

See also –

She’s Not Quite Dead Yet – 4/25/2014

Details on the Recent Patient Prematurely Pronounced Dead – 5/05/2014


[1] She’s Not Quite Dead Yet
Fri, 25 Apr 2014
Rogue Medic

[2] WKYT Investigates: Can paramedics declare someone dead?
Updated: Thu 11:54 PM, Apr 24, 2014
By: Tim Johnston

Still he was able to answer questions about procedures and requirements and he said since 1998, paramedics have been trained in the procedures about declaring a person to be dead.[2]


[3] Beyond Admissibility: A Practical Look at the Use of Eyewitness Expert Testimony in the Federal Courts
JL Overbeck
NYUL Rev., 2005

Free Full Text in PDF Download format from nyulawreview.org

[4] Lincoln Co. paramedic pronounces woman dead, later found breathing
Updated: Thu 6:28 PM, Apr 24, 2014
By: Tim Johnston


She’s Not Quite Dead Yet


I occasionally comment about how useless down time is in our assessment of cardiac arrest.

“He just looked at her and felt her and said, ‘She’s gone.’ I said, ‘No way! No, no, no, that’s not possible.’ He said ‘Yes, she’s gone.’ He threw a blanket over her and walked out and shut the door behind me,” he described.[1]


Here is one more example of down time not meaning what we would expect it to mean. The paramedic pronounced the patient dead and the coroner showed up to find her still alive 25 minutes later.

Does that down time mean anything?

This is not as rare as we would like, so why does this happen?

Was the paramedic too lazy to perform a full assessment?

Was the paramedic too poorly educated to be able to perform a competent assessment?

Did the paramedic develop too many bad habits to be able to perform a competent assessment?

Was the patient presenting in a way that was indistinguishable from death?

I was not there, so I cannot tell.

I have had patients awake and talking to me, even though I have not been able to palpate a pulse anywhere.

According to Lincoln County Deputy Coroner Tony Floro, the breathing was faint but Tygart was still unresponsive. The victim was rushed to nearby Ephraim McDowell Hospital and was then flown to UK hospital, where she died the next day. According to the Fayette County Coroner’s office, the report said she died of a closed head injury from a fall.[1]


Neurologists would be the best to comment on the futility of resuscitation in this case, but being unresponsive following a closed head injury is not something that suggests that the outcome would have been different if the best medic had arrived and provided excellent treatment, rather than quickly pronouncing her dead. There would have been one difference to us. This would not have been an article about the quality of patient care, but an article about a tragic death. The family of Kristal Tygart has my condolences.

The article does not mention a lot of things that might be relevant, such as if she was any kind of anticoagulant medication. However, I have written about this paramedic before. Bad luck or bad medic? I don’t know.

See also –

WKYT Investigates: Can paramedics declare someone dead? – 4/27/2014

Details on the Recent Patient Prematurely Pronounced Dead – 5/05/2014


[1] Lincoln Co. paramedic pronounces woman dead, later found breathing
Updated: Thu 6:28 PM, Apr 24, 2014
By: Tim Johnston


Drunk? or Auto vs. Pedestrian With Major Injuries?


Sometimes we miss things that we are expected to miss, such as an atypical presentation of an uncommon condition.

Other times we miss something that even a rookie should not miss.

A paramedic has been suspended for a year after he mistook as drunk a man who had in fact been victim of a hit-and-run, suffering a broken back and 12 broken ribs.[1]


Suspended for a year is a serious punishment, right?

Maybe not if the medic is retiring anyway – after 30 years on the job.

How does someone with 30 years of experience miss those injuries?

A passerby found Mr Wonnacott at 4am on November 20, 2011, and the paramedic failed to establish any of his injuries and made him walk into the ambulance.

While en route to hospital, Mr Gaiger called Mr Wonnacott’s parents and said he was “absolutely plastered” and it was only on arrival to the hospital that his injuries were discovered.[1]


Image credit.

4 AM on a Sunday morning is a time when we expect to see a higher percentage of drunks.

I have missed things on scene, only to identify them during transport, and I have continued to miss things during transport, but, . . .

Maybe if there were only 11 rib fractures, it would be understandable.

Maybe if it were only 2 vertebrae.

Maybe if both the liver and the spleen hadn’t been lacerated.

Maybe if there hadn’t been a pneumothorax.

Maybe these injuries were actually quite subtle.

David Rosenbaum was just another drunk in Washington, DC.[2]

Except that he wasn’t drunk. He had a head injury and died before anyone realized that he was not drunk.

“This is not a witch hunt. I just don’t want another family or patient to go through what we have been made to go through as a result of Mr Gaiger’s actions.”[1]


The Rosenbaum family said the same thing.

We don’t want money. We want to fix the system so that this does not happen again.

Did anything really change at DC Fire and EMS?

Will anything really change at South East Coast Ambulance Service?

This is a medic they have employed for 30 years. Was this the first time something like this happened? Was this the first time that the news media became aware of the problem? Was he burned out after 30 years? Was he having a horrible day – although a day infinitely better than his patient was having? Out of sight, due to retirement, out of mind? The articles have not been very helpful.

Maybe Mr Wonnacott was gently run over, by someone who really was drunk, and suffered a brain injury that made him appear to be drunk, and only the hospital people could identify the multiple fractures and brain injury.

Maybe, but maybe we should discourage people from concluding a patient is just a drunk, or that the epigastic pressure is just indigestion, or that the hyperventilation of the young female is just hysteria, or . . . .

Hmmmm. Those are things I learned in my original paramedic class that have not changed.


[1] Chessington paramedic suspended for a year after treating seriously Esher injured man as though he were drunk
By Laura Proto
6:10am Thursday 20th March 2014
Elmbridge Guardian

[2] The Death of David Rosenbaum
By Colbert I. King
Saturday, February 25, 2006
Washington Post


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?


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.


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.



[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.
By Brad Rich, Tideland News Writer
Tideland News

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

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

[4] Cognitive dissonance