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

- Rogue Medic

Capnography Use Saves Lives AND Money – Part IV

Continuing from Capnography Use Saves Lives AND Money – Part I and from Capnography Use Saves Lives AND Money – Part II as well as from Capnography Use Saves Lives AND Money – Part III.
 

Here are some recent case examples:
•In Ohio, a medical malpractice suit was filed against an EMS agency after the death of a 2-year-old boy. The patient died following a hospital transfer during which his ET tube became dislodged but wasn’t detected. The final settlement wasn’t made public.
•In Texas, a 41-year-old female suffered severe brain damage and died following an undetected esophageal intubation. Capnography wasn’t in use. The case settled out of court for $500,000.
•A Florida-based air ambulance service was sued when a 58-year-old female suffered severe brain damage and died when an ET tube became dislodged and was undetected. Capnography wasn’t in use. The case was settled out of court for an undisclosed sum.
[1]

 

This just shows how rare unrecognized esophageal intubations really are!

Not really.
 

(12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not.[2]

 

There is good news and bad news in this.
 

The bad news is that unrecognized esophageal intubations are not at all rare, even though they should never happen.

The good news is that the outcome for these patients was not worse than the outcome for the patients successfully intubated.

I wouldn’t look at either of these as typical. They are indications of possible outcomes.

Unrecognized esophageal intubations are not at all rare, but I certainly hope that most organizations do not have this big of a problem.

1 out of every 8 1/2 intubations in the wrong hole?

Imagine if an airline’s planes crashed on 1 out of every 8 1/2 flights, but the outcome for the passengers on the flights that crashed was not clearly worse than the outcome on the flights that did not crash.

Would anyone fly that airline?
 

The good news is that the unrecognized esophageal intubations seem to be happening to spontaneously breathing patients, because that is the most reasonable explanation for these patients surviving in spite of EMS trying to remove the patient’s airway.

We cannot rely on this to protect us from bad airway management. Quite the opposite.

We are probably too aggressive with intubation, since so many patients survive in spite of treatment expected to kill any patient in need of intubation.

Those medics worst at intubation are the ones most likely to intubate patients who would be better off without intubation.

That these patients survive in spite of aggressive attempts by incompetent medics to kill these patients is not a reason to ignore the problem.
 

And then there are the patients who are the most dead and the easiest to intubate –
 

Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.[3]

 

According to the AHA (American Heart Association) and plenty of other organizations –

Assessment is not good enough.

The evidence for this is Class I, LOE A.[4]

Evidence does not get much better than this.

To be continued in –

Capnography Use Saves Lives AND Money – Part V

An excellent source of information about waveform capnography can be found at Capnography for Paramedics.

Footnotes:

[1] Capnography Use Saves Lives & Money
By Patricia A. Brandt, RN, BSN, MHR
JEMS.com
Article

[2] Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed – indexed for MEDLINE]

Free Full Text Article from Anesth Analg. with links to Free Full Text PDF download

[3] Advanced Airways
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.1: Adjuncts for Airway Control and Ventilation
Free Full Text Article with links to Free Full Text PDF download

[4] Ethics, Research, and IRBs – Part II
Rogue Medic
Article
.

Capnography Use Saves Lives AND Money – Part III

Continuing from Capnography Use Saves Lives AND Money – Part I and from Capnography Use Saves Lives AND Money – Part II.
 

The most common causes for EMS lawsuits are negligent vehicle operation and improper performance of medical procedures. Juries frequently award millions of dollars to patients, and legal fees are typically hundreds of dollars per hour, producing a significant unbudgeted expenditure to an agency. Therefore, capnography is one piece of clinical backup that can assist you in avoiding lawsuits.[1]

 

At one end – How many multi-million dollar law suits does it take to change that cost/benefit analysis that the managers were using to justify not using waveform capnography?

At the other end – How many thousands of dollars of legal fees, how much for expert witnesses, and how much distraction from running an EMS organization does it take to change the cost/benefit analysis based on no such thing as too cheap after even a small out of court settlement?
 

Now imagine that you use waveform capnography.

A lawyer shows up representing a patient who claims to have hypoxic brain damage due to a misplaced endotracheal tube. You go through your copies of charts and find the right chart. Part of the printout attached to that chart is copied below. The image is taken from Capnography for Paramedics, an excellent source of information about capnography.
 


 

What does this mean?

The sensor for waveform capnography is placed between the end of the endotracheal tube and the BVM bag.

The only way for carbon dioxide to pass through the sensor is for that carbon dioxide to be exhaled by the patient through the endotracheal tube.

At a minimum, I prefer to record the waveform as soon as possible after there is a good waveform, just before removing the patient from the ambulance, and just before moving the patient to the hospital stretcher. They can wait. They are going to pause everything to get a much less reliable confirmation of placement in the hospital, so there is not real rush.

Other times to record the waveform are with each movement. This demonstrates that I am paying attention to the tube placement and avoids the perceived need for a cervical collar. The use of a cervical collar just encourages people to ignore tube placement. Do your patients a favor, continually assess tube placement and leave the cervical collars alone.

If you use the piece of litmus paper in plastic color change device, which has an unreasonably high failure rate, what do you have to demonstrate placement of the tube? Only the medics description after the fact. How well does he document? How good a witness is he on the stand? You do realize that the hospital needs to convince the jury that the damage was done prior to arriving in the ED, right? Believe the doctor? Believe the medic?

With the printout of a good waveform from waveform capnography, the lawyer has no good reason to continue to go after your company for a misplaced tube. Without a printout of a good waveform, it all depends on whom the jury believes after a lot of legal expenses, or it results in an out of court settlement.

Waveform capnography is extremely inexpensive, if we understand patient care and risk management.
 

One of the most frequent EMS lawsuits involves undetected esophageal intubations. If the ET tube is improperly inserted into the esophagus and this error isn’t recognized and corrected expediently, the result is a devastating hypoxia that causes severe brain injury and, ultimately, death. Continuous monitoring of capnography is the standard of care for detecting esophageal intubations, as well as for detecting subsequent dislodgement of ET tubes.(3)

Settlements for injury and wrongful death resulting from undetected misplaced ET tubes are often in the multimillion-dollar range.[1]

 

We can avoid esophageal intubations in a few ways.

1. Stop using endotracheal tubes, which is not popular with paramedics, but is likely to be the future of the cut rate EMS services.

2. Provide excellent aggressive medical oversight, which involves a lot of practice on mannequins and the use of waveform capnography as just one critical part of the method of tube placement confirmation.

3. Ignore the problem. This is something we only read about happening to other people.

This is true – right up until it is not. Ask any doctor about being sued for malpractice. Almost all are concerned about malpractice suits. There are many ways of approaching the concern about malpractice, but almost all doctors understand that providing excellent care is one thing that they can do to modify their risk.

If I do what is best for the patient, my long-term liability is lower than if I do what is cheapest in the short-term.

I understand that we will not be able to provide any care for patients, if we cannot afford to stay in business. I also understand that –

1. If the care we provide is bad, then we are not helping patients.

2. Keeping the organization in business just long enough to do some really serious harm to patients, which results in being shut down by a large law suit, is a bad idea.
 

This focus on the short-term is not really different from the way we approach the use of epinephrine, and other drugs, during cardiac arrest. We act as if the short-term is all that matters, even though there is no reasonable expectation of a long-term benefit.
 

But aren’t unrecognized esophagal intubations extremely rare?

To be continued in –

Capnography Use Saves Lives AND Money – Part IV
Capnography Use Saves Lives AND Money – Part V

An excellent source of information about waveform capnography can be found at Capnography for Paramedics.

Footnotes:

[1] Capnography Use Saves Lives & Money
By Patricia A. Brandt, RN, BSN, MHR
JEMS.com
Article

.

Capnography Use Saves Lives AND Money – Part II

Continuing from Capnography Use Saves Lives AND Money – Part I.

Patricia A. Brandt writes –
 

Another common cause of EMS lawsuits is injuries or deaths resulting from emergency vehicle crashes. In 1997, more than 15,000 accidents related to emergency calls occurred with emergency vehicles in the U.S. resulting in 8,000 injuries, 500 fatalities and millions of dollars in liability claims and vehicle repairs.(4) One area in which these types of emergency transport crashes can be reduced is by not transporting nonviable cardiac arrest patients.[1]

 

Why do we transport cardiac arrest patients who have no chance of being resuscitated?

This is where we admit our ignorance. Most of us have no idea what the difference between merely dead and most sincerely dead or between mostly dead and all dead.

Mostly dead is slightly alive. With all dead, well, with all dead there’s usually only one thing you can do.

Go through his clothes and look for loose change?

No. Stop resuscitation.

Continuing resuscitation, by transporting from the scene to the hospital, only endangers living people without providing any possibility of an improved outcome for the all dead person.

Mostly dead is what chest compressions and defibrillation are for.

All dead is what funeral homes are for.
 

Civil rules, administrative concerns, medical insurance requirements and even reimbursement enhancement have frequently led to requirements that indicate the transport of all cardiac arrest patients to a hospital or emergency department. If these requirements are nonselective, they’re inappropriate, futile and ethically unacceptable. Cessation of efforts in the out-of-hospital setting, following system-specific criteria and under direct medical control, should be standard practice in all EMS systems.(5) [1]

 

So how does waveform capnography fit into this?
 

One component of cardiac arrest termination protocols is a sustained EtCO2 of less than 10 mmHg, often secondary to asystole present after two rounds of cardiac arrest drugs.(5) The continuous monitoring of capnography can confirm a EtCO2 reading of less than 10 mmHg, along with your protocols and other clinical assessment parameters, and assist you in terminating resuscitative efforts and prevent unnecessary, and often dangerous, emergency transport.[1]

 

We are discussing the use of waveform capnography as a tool to protect people from those, who are too cheap to provide equipment for appropriate care, but are also too afraid to make any decisions they do not understand.

The problem is that they misunderstand what they misunderstand.

In other words, they don’t know what they think they know, but they also don’t know what they think they don’t know.
 

Can anyone demonstrate that more people are resuscitated with a waveform capnography reading of less than 10 than are killed by EMS transporting these same patients?

Killed by EMS transport of patients with EtCO2 <10 vs. People with EtCO2 <10 resuscitated.

Would anyone like to place a bet on this?
 

How many people have ever been resuscitated after good CPR and appropriate defibrillation do not raise EtCO2 to 10 or higher? Not just ROSC (Return Of Spontaneous Circulation), but leaving the hospital with good brain function.

Should we continue to endanger everyone, just so that we can say that –

We gave it our all

We gave it that college try

Rah! Rah! Rah!
 

Here is a rough translation, from EMS to English, of that pathetic phrase – We did everything we could.

What we are really saying is – So we kill the occasional kid crossing the street, or some people in an oncoming vehicle, or a family member in a car following us, or one of our partners.

What really matters is that we tried.

I’m sure that at the eulogy for a dead child, sacrificed to the EMS mantra of We did everything we could, the parents will say, What is most important is that EMS flogs a dead horse until even those around the horse are dead.

To be continued in –

Capnography Use Saves Lives AND Money – Part III
Capnography Use Saves Lives AND Money – Part IV
Capnography Use Saves Lives AND Money – Part V

An excellent source of information about waveform capnography can be found at Capnography for Paramedics.

Footnotes:

[1] Capnography Use Saves Lives & Money
By Patricia A. Brandt, RN, BSN, MHR
JEMS.com
Article

.

Capnography Use Saves Lives AND Money – Part I

There is an article in JEMS that looks at capnography from the point of view of the manager only interested in what it is going to cost. How do we persuade these people to do what is best for patients?
 

Capnography: A Cost-Benefit Analysis
The evaluation of the benefits vs. the costs of using capnography can be categorized into two primary areas:
1. Benefit vs. cost of providing appropriate treatment; and
2. The avoidance of medical malpractice lawsuits/settlements.
[1]

 

An important point to notice. Patricia A. Brandt states –

1. Benefit vs. cost of providing appropriate treatment;

Appropriate, not feel good, or cool, or what the cool EMS organizations are doing.

We can also look at this from a different perspective.

Cut Rate Patient Care: A Cost-Benefit Analysis
The evaluation of the benefits vs. the costs of using cut rate patient care can be categorized into two primary areas:

1. Benefit vs. cost savings of providing cut rate treatment; and

2. The extra costs of medical malpractice lawsuits/settlements,

PLUS

3. The harm to the organization’s reputation (although, maybe they do want to be known for cheapness and low quality).

4. The possibility of driving away better EMS personnel to organizations that place patient care above back of the envelope cost/benefit analyses.

5. The reputation among the lawyers, that will have these lawyers salivating at any mention of the organization in the news. In advertising, there is a saying that, There is no such thing as bad publicity. EMS isn’t advertising. When it comes to legal liability, there definitely is bad publicity.

6. Will a lawyer have a harder time convincing a jury that an organization with a reputation for cutting corners has done something bad or an organization without that reputation?

7. Will that lawyer have a hard time getting a large settlement out of that jury?

8. What about just convincing the organization’s lawyer that a large settlement is cheaper than going to court, paying a lot of legal fees, and possibly a much larger settlement?

9. What about just placing a bull’s eye on the organization as one to go after, because you never know what will turn up during discovery.

10. What kind of witness will your employee, who encouraged you to improve the quality of care, be if that employee is still around and called to testify under oath?

11. What will happen to the organization’s insurance rates?

Yes. Mine go to 11. 😉

These organizations often do not consider most of the ramifications of their money saving decisions. I am not accusing the author of that. She is just trying to find a way to explain things to these cut rate EMS organizations and to persuade the bean counters to do what is best for patients.

To be continued in –

Capnography Use Saves Lives AND Money – Part II
Capnography Use Saves Lives AND Money – Part III
Capnography Use Saves Lives AND Money – Part IV
Capnography Use Saves Lives AND Money – Part V

An excellent source of information about waveform capnography can be found at Capnography for Paramedics.

Footnotes:

[1] Capnography Use Saves Lives & Money
By Patricia A. Brandt, RN, BSN, MHR
JEMS.com
Article

.

Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment II

In the comments to Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment, keepbreathing wrote:

I love waveform capnography and I think it’s vastly underutilized.

What’s not to love about waveform capnography. For me, it was love at first complicated airway.

And for what it’s worth, I’ll defend EMS tube placement to the ER docs. I’ve yet to have a medic hand me an unrecognized esophageal intubation, and at the facility I work at we confirm tube placement prior to sliding the patient from the EMS stretcher to the ER bed. That way if the tube turns out to be in the esophagus later, we know it happened in the ER, not in the truck.

One of the nice things about waveform capnography is that it helps to decrease the incidence of esophageal tubes even for those most skilled at intubation. Actually, I don’t think it is fair to call anyone skilled at intubation if they choose not to use waveform capnography.

Checking the tube on the EMS stretcher is one of the variables that some airway researchers ignore, when evaluating EMS intubation. They claim that this does not make a difference, but they cannot prove this claim. Since there is no evidence to support their position, that the move to the ED stretcher is not a variable, the only reasonable thing for an objective researcher to do is to assess the tube placement on the EMS stretcher. Many do not.

Therefore, I believe that these airway researchers are not objective, or not reasonable, or maybe they just object to reason.

If one were to suggest to ED physicians, that their tubes would be evaluated after arrival in the OR, or ICU, or anywhere else, but not on their ED stretcher, they would probably not consider this suggestion to be reasonable or objective.

So, why the sudden onset of let’s make this research worthless in the places that refuse to evaluate the EMS tube on the EMS stretcher?

Few understand EMS. Even in EMS, few seem to understand EMS. Out-of-hospital care is different from in-hospital care. People only accustomed to in-hospital care may not grasp that there are essential differences, or they do not believe that the differences are significant, never mind essential.

The role of the researcher is to design the study to control for all of the potential variables possible. If you already know the result, maybe you should not be involved in the research.

.

Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment

In response to Prehospital Advanced Airway – Should Paramedics Be Intubating?, was this comment from Divemedic. I am assuming the accuracy of what Divemedic writes, since I was not there and the participants are not identifiable.

Divemedic wrote:

About 6 years ago, I had a Doctor in the ER accuse me of missing the tube, because he heard belly sounds. This was a patient who was being paced in a post arrest situation. I showed him my monitor, which was equipped with ETCO2. There was a waveform with a ETCO2 of 34, an SaO2 of 92, and a BP of 120/68.

It is unfortunate, but there are plenty of people who do not have a clue about tube confirmation. Some of them work in the ED (Emergency Department), where the use of waveform capnography has yet to be adopted, at least in my experience. The use of less reliable, less accurate, poorly understood forms of tube confirmation is bad medicine, bad risk management, and illogical.

If it is required for intubations by anesthesiologists in their most familiar setting, the OR (Operating Room), but it is suddenly unimportant in the ED and when used by doctors less experienced at airway management? The ED intubation experience is different from the OR experience, so the ED doctor should be more experienced in the ED setting. My experience has been that, about half of the patients I have seen intubated in the ED have been intubated by anesthesia after a lack of success by the ED doctor. I do not know how difficult these tubes were, since I never attempted to intubate any of these patients. This experience is probably not representative, but it is not encouraging.

Why is waveform capnography so uncommon in the ED?

He presented in a 3deg AVB, went into asystole, and we managed to get a pulse with TCP. We had been bagging him for nearly 10 minutes when we got to the hospital. The Doctor claimed that my evidence was less accurate than his hearing belly sounds, and he pulled the tube, disconnected the monitor, and ordered epi and atropine.

The doctor was wrong in so many ways. Waveform capnography is not infallible, but after over a minute of monitoring, with a good waveform, it is reliable at showing that the tube is not in the esophagus.

Then there is the choice of disconnecting the transcutaneous pacer that appears to be producing an pulse oximetry of 92% and a blood pressure of 120/68. What would justify giving that up to play with epinephrine and atropine? This decision could produce a post all by itself, but I’ll leave it alone and stick to airway.

4 minutes later, the Pt coded again and was dead. In the lobby, I overheard the Doctor talking to the family and blaming EMS for the death. I filed a complaint with the hospital. He complained to the state and tried to have my license taken away.

The secret to success is finding others to blame for one’s failures, at least according to some. This doctor appears to go by that motto.

My medical director backed me up. The Dr still works there.

It is great that your medical director is able to understand what is important and willing to back you up. The problem doctor would probably still be working as a doctor, even if not there. Rather than removing dangerous people from positions, where they can harm people, we tend to just let them move on to new victims in a job that may just provide them with less seniority.

I think a large percentage of “missed tubes” are actually doctor arrogance, not a true missed tube.

I do not think that a significant proportion of the tubes pulled are the result of poor assessment by the ED doctor. I think many doctors actually go out of their way to not embarrass paramedics. You ran into one dangerous doctor. This doctor is not representative of the doctors I have run into in many jobs in several states. I have run into a few similar to this, but probably less than one per year. The most disturbing part is that the doctor did not appear to receive remediation, with the successful completion of the remediation as a condition of avoiding removal of this doctor’s medical license. Of course, if that did happen, we might not know other than by observing an improvement in patient care.

After all, when a Doctor pulls your tube and reinserts it, he gets to bill the patient another $600. Isn’t that how the game is played?

I do not know what the difference in billing would be. I do hear people criticize doctors as having this motivation for redoing things that we have already done. Without hearing this from the person directly, I would only be guessing at the motivation of the doctor. Some doctors debating on the way they enter billing codes and their differing views on the ethics of their decisions. One of the posts in the dialogue is The Hypocrisy of Overbilling by Scalpel or Sword. And this is a dialogue about a different topic from inappropriately extubating and reintubating a patient, but it does give some perspective on the way different doctors approach different billing situations. The claim that somebody is doing something for a particular reason is pretty hard to justify. We do not know why others do things. Even if they tell us, they may be telling us what they want us to hear, or what they think we want to hear.

Back to the comments about the doctor hearing epigastric sounds. I am not suggesting that the tube is never in the right place when there are belly sounds over the stomach. In the initial assessment, the belly sounds should be reason to pull the tube. Once the tube is out, the sounds should be reappraised during BLS ventilation. If the belly sounds are still present during BLS ventilation, the assessment of belly sounds drops in significance. If the second intubation attempt is with the added caution inspired by the belly sounds during the first assesment, it may be reasonable to pay more attention to chest rise and waveform capnography.

I had one patient who filled the ETT with emesis. Clearly, I was in the trachea, since there was nothing left in Linda Blair’s stomach and esophagus at that point. Our assessments are supposed to include the information obtained in earlier assessments.

Why clinicians are natural bayesians[1] gives a good view of how we use further information to modify a differential diagnosis/assessment. If we are not modifying our approach to patient care, as we obtain more information, we are not providing good patient care.

Footnotes:

^ 1 Why clinicians are natural bayesians.
Gill CJ, Sabin L, Schmid CH.
BMJ. 2005 May 7;330(7499):1080-3. Review. No abstract available.
Erratum in: BMJ. 2005 Jun 11;330(7504):1369.
PMID: 15879401 [PubMed – indexed for MEDLINE]
Free Full Text – not including responses.
Free PDF – including responses. On the PDF go to page 3, about halfway down the page to find the beginning of the letter. The responses follow on page 4.

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Prehospital Advanced Airway – Should Paramedics Be Intubating?

Prehospital Advanced Airway – Should Paramedics Be Intubating?

That is the title of the latest post from Prehospital 12 Lead ECG. What does intubation have to do with 12 Lead ECGs, prehospital, ED, or in the cath lab?

Funny you should ask. The post is about how we approach patient care decisions. Tom B. transcribes a bit of the unfortunately ignored 2003 ACLS Reference Textbook and Experienced Provider Manual and some of The EMS Garage from 11/21/08 on Airway Control.

Tom B. highlights some excellent points as far as assessing quality is concerned. Too many of us ignore intubation quality, unless it is forced on us. Maryland is currently facing this problem with their helicopter program and I have been finding no end of things to criticize there. If we think that we do not need to provide aggressive oversight of all potentially risky interventions, we will harm patients unnecessarily. Not that it is necessary to hurt patients, but some problems will be unavoidable, even with excellent oversight.

Tom B. lists some systems that provide excellent oversight. Even they could be better. This is a job that should have a goal of continual improvement. This is not a job of good enough.

Pennsylvania state protocols[1] require all ALS services to have waveform capnography as of November 01, 2008. This is an excellent move toward eliminating the usual excuses for killing patients with misplaced tubes. The main excuses are:

We can’t afford to do the job the right way.

We’re too good to need that equipment.

We were able to intubate before waveform capnography and airways haven’t changed. So we don’t need that stuff.

Here are the minimum oversight standards from the Pennsylvania ALS protocols:

Performance Parameters:

A. Review all ETI and Alternative Airway Device insertions for documentation of absence of gastric sound, presence of bilateral breath sounds, and appropriate use of a confirmation device.[1]

I also appreciate that they have the assessment of gastric sounds appropriately ahead of assessment of lung sounds. You can listen to lung sounds and not hear anything that will make an immediate difference in treatment. If you listen over the stomach and hear gurgling, is there any reason to leave the tube in place for even one more squeeze of the bag? It does not matter if you think you saw the tube go through the cords.

Teaching people to trust seeing the tube go through the cords is one of the most dangerous things that is taught in EMS. This is incompetence. Almost all misplaced tubes are accompanied by the killer saying, I saw the tube go through the cords.[2]

B. If systems have the capability of recording a capnograph tracing, review records of all intubated patients to assure that capnograph was recorded.[1]

What would be the point of having waveform capnography that does not have the capability of recording?

C. Document ETCO2 reading immediately after intubation, after each movement or transfer of patient and final transfer to ED stretcher.[1]

Also an excellent oversight approach. While waveform capnography does not confirm that the tube is in the trachea (it can be above the cords and less secure, not that we should be using the word secure), it does confirm that the tube is not in the esophagus. This is essential. If you are going to court, that should be enough to convince a lawyer that there is no big money case – at least not against EMS for airway management problems.

One of the quotes that Tom B. provides from The EMS Garage is about how we have come to define paramedics by the ability to intubate.

“I think that’s true, and I hate to say this, but shame on us, because we are the only health care provider group that defines ourself by what we can do that’s unique rather than what good we do the patients.”[3]

This is the most important part of determining what our protocols and scope of practice should be. Does the patient benefit from the intervention? If the treatment is beneficial, are the side effects and complications low enough, when used by EMS, that it is in the best interest of the patient to have EMS use this treatment?

Posts continuing the discussion from this post:

Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment

Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment II

Footnotes:

^ 1 Pennsylvania State ALS Protocols
Page 2032 – ALS – Adult/Peds; 12/121 in the pdf page window.
Free PDF
Every ALS ambulance service must carry and use an electronic wave-form ETCO2 detector device1 for confirmation of endotracheal tube/ alternative airway device placement.

The footnote for the excerpt from the protocols is:
1 Colorimetric ETCO2 detectors may give false negative results when the patient has had prolonged time in cardiac arrest. EDD aspiration devices may give false negative results in patients with lung disease (e.g. COPD or status asthmaticus), morbid obesity, late stages of pregnancy, or cardiac arrest. ALS services may consider carrying colorimetric ETCO2 detectors or EDD aspiration devices as back-ups in case of electronic device failure, but must primarily use the wave-form ETCO2 detector as described in this procedure.

^ 2 Waveform Capnography vs. Hubris
Rogue Medic
Article

^ 3 The EMS Garage
11/21/08
Airway Control.

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I’m Leaving on a TransTracheal Jet Plane

Vince picked up on my TTJV (TransTracheal Jet Ventilation) comment, that it is not ventilation, in Helicopters and Airways.

He wrote in the comments:

Transtracheal Jet Oxygenation (it is not ventilation).

HEHEHEHEEEEHEHEHE AMEN Brother! I remember talking to a Brand New Medic and having the “Jet” discussion. He was super impressed and told me:

he had a friend, who knew someone, whose housekeeper dated the neighbor of a medic who “saved this guy’s life with one of those”

I tried to explain the physics involved and it reminded me of the trying to teach a pig to sing paradigm. In the end I told him to take a 14g catheter and attempt to breath through it for..oh, say a minute.

I began to respond in the comments, but soon realized that, again, a Vince comment has led to something that really needs its own blog post. For those unfamiliar with the internal dimensions of a 14 gauge catheter it is capable of moving a bit more air than a swizzle stick. So:

But, but, but, but what if something happened to him? You could face murder charges. At least have to demonstrate that the brain damage was there long before you met him. Although there is a case to be made for TTJV, he was not going to be the one to make it. He would also be incapable of recognizing it.

The other thing about jets is that they are cooler than helicopters. They just require a bit more landing zone – “We’re going to drive you to the aircraft carrier, they will fly for about a minute before they launch you over the hospital, and the crew on the ground should be able to retrieve you and bring you inside within the Bogus Hour.”

Or they could use a jet helicopter. Whacker Pants-Soiling Heaven, right there. 🙂

TTJV- except that it is “V for Ventilation” (almost sounds as if it should be a movie title). Ventilation requires the removal of CO2, (Carbon diOxide, di meaning 2). In medical school they probably used the following overly complicated terminology, but I reproduce it here in the hope that some of you may understand: “Out with the bad air.”

TTJV is pretty good at the opposite end of things: “In with the good air,” except for one slight problem. If you keep putting oxygen in, but do not remove much of anything, sooner or later something is going to give. Don’t worry, if we cause a tension pneumothorax we can put a big needle in the chest to let the air out. This is true, but even Rube Goldberg would be embarrassed at the prospect of explaining this cluster. Never mind the effect the extra thoracic pressure has on the return of blood to the heart. At this point we may need to use a device to force blood into the heart. Not a jet device, since the turbines would make the hemoglobin very Humpty Dumpty at this point. While that is one way to get rid of the need for oxygen, I don’t expect anyone other than ex-doctor Kevorkian to recommend it.

This is not a problem if the airway is not obstructed, because you can force the bad air out by high pressure. As long as there is a way for the bad air to get out the high pressure is creating ventilation. So, it can be ventilation, but only if there is a patent airway, which raises the question of why this patient cannot be ventilated by more conventional means. And why is it usually in EMS protocols for obstructed airway treatment?

The high pressure can also make it easier to identify where the epiglottis/glottis/trachea/vocal cords are during subsequent attempts at intubation. It might make it easy to use the BAAM (Beck Airflow Airway Monitor) to direct the tube, whether with oral intubation or nasal. It may be a starting point for using a Seldinger technique for retrograde intubation.

If the airway truly is obstructed, obstructed above the trachea, so that the needle is not being placed into or above the obstruction, then the pressure is not really helping to remove the CO2, or anything else. One recommended way to deal with this complete airway obstruction is to place several more large bore catheters into the trachea to act as exhaust ports for the pressure. If you are going to do that, you should probably perform a surgical, or semi-surgical crichothyrotomy. But those are for another post as is TTJV technique.

TTJV can provide ventilation when the airway is not completely obstructed. TTJV does have its place in airway management, but it is not the panacea that some in EMS suggest.

Here are links to the full texts of two papers that describe some successful use of TTJV. The first is on 29 uses, 23 successful. The second is on 2 examples of successful use where the TTJV probably made intubation success possible, where it might not be otherwise. They also recommend the use of capnography to confirm placement of the catheter.

Chest. 1999 Dec;116(6):1689-94.
Percutaneous transtracheal jet ventilation: a safe, quick, and temporary way to provide oxygenation and ventilation when conventional methods are unsuccessful.
Patel RG.

Br J Anaesth. 2005 May;94(5):683-6. Epub 2005 Feb 11.
* Br J Anaesth. 2005 Oct;95(4):560-1; author reply 561.
Percutaneous transtracheal jet ventilation as a guide to tracheal intubation in severe upper airway obstruction from supraglottic oedema.
Chandradeva K, Palin C, Ghosh SM, Pinches SC.

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