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

- Rogue Medic

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

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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Maryland Helicopter EMS Panel Supports Fewer Medevac Flights

Apparently I misjudged the independence of the panel that met briefly to review the way the Maryland flight program is operated. I apologize. Perhaps I misjudged those in charge of things in Maryland (Dr. Bass and Dr. Scalea), as well. I hope to be writing more apologies as the panel’s recommendations are implemented.

Maryland’s emergency medical helicopters could fly fewer accident victims to hospitals without reducing survival or affecting quality of care for patients, a panel of experts told state officials yesterday.[1]

This is certainly not news to anyone with a broader experience of EMS than just MIEMSS (Maryland Institute for Emergency Medical Services Systems) and/or Shock Trauma (R Adams Cowley Shock Trauma Center – University of Maryland Medical). Dr. Bass is the CEO of MIEMSS and Dr. Scalea is the trauma surgeon in charge of Shock Trauma.

Shock Trauma brought us the concept of the trauma center. It is named after Dr. R Adams Cowley. Dr. Cowley is the marketing mind behind the Golden Hour. I refer to it as the Bogus Hour, because it is not based on anything other than a desire to sell.[2]

Sell the trauma center concept.

Sell the HEMS (Helicopter EMS) concept.

Sell the R Adams Cowley concept.

If there had been some research behind the Golden Hour, I would not be referring to it as the Bogus Hour. If there were some response to the evolving research, by those running the trauma franchise, many others would not be so critical of the Maryland way of Fly everyone and let Shock Trauma sort them out.

Late addition (11/27/08) – ParaCynic has a great post on the Golden Hour from a different perspective. Go read City Slickers 2: The Legend of Cowley’s Gold.

“We felt there are too many helicopters – not just in Maryland but in the Washington-Baltimore-Philadelphia corridor,” said Dr. Bryan Bledsoe, a professor at the University of Nevada School of Medicine. “That said, there’s no clear definition of what is a correct number.”[3]

“A level of overtriage is occurring that exceeds that of comparable systems,” said panel chair Dr. Robert C. MacKersie, director of trauma services at San Francisco General Hospital. “There is a high likelihood that opportunities exist for reduction in Maryland’s (helicopter) transport of trauma patients without compromising patient outcomes or the quality of care.”

But what were the actual recommendations?

•Reconsider whether Maryland needs 12 helicopters and eight bases. Several members called the fleet excessive.[4]

That would seem to be obvious. If the flights are down by more than half, the state should not need anywhere near as many helicopters. It is a small state.

•Adopt national accreditation guidelines mandating two health care providers on each flight, instead of the single paramedic used now.[4]

Absolutely. How has MSP (Maryland State Police) been able to convince people otherwise? Take a medic off the job of paramedic for a year, so that the medic can work just as a trooper. Then return this trooper to patient care and retrain the trooper as a trooper/medic. And the punch line is that this extra training as a trooper means that the trooper/medic is supposed to be better than the nurse and paramedic crews on all of the other helicopters in the region. Apparently the trauma specialists did not get the joke.

•Monitor recent changes in triage to see if they continue to reduce the number of patients flown. Fewer patients can probably fly without affecting outcome.[4]

If you believed the scare stories that have been coming from a lot of people supporting the status quo, you should have bought up all of the body bags that you could. Shockingly, there has not been a sudden increase in the need for body bags, although flights are down by almost two thirds. Are injuries down, too?

It is beginning to look as if the only need for body bags was for the crew members and patient in the recent crash. If the patients had been driven to the hospital, the pilot, trooper/medic, local EMT, and the patient who died, all would probably be alive and well.

The surviving patient would not have had a lower leg amputation, a couple of months in the ICU, and prolonged rehab. How is it that this patient is too badly injured to be transported by ambulance, yet survives a helicopter crash, is lying on the ground, in the rain, in the woods, and without care for almost 2 hours until rescue crews find the wreckage and her, and she survives an ambulance ride to the hospital?

Those are not signs of a seriously injured patient. At least she does not appear to have been seriously injured before entering the helicopter.

•Comply with the same FAA standards as commercial helicopters.[4]

MSP has been claiming that they need to protect the patients in Maryland from the big bad commercial helicopter services. After all, they will charge you money for the flight, while MSP will tell you there is a free lunch. Free. Free. Free.

Why is it that they are not operating at even close to the standards of the private helicopters in the area?

Only one person to provide patient care. Yes, they can take somebody from the scene. Of course, the personnel they take from the scene are the lowly ground providers, that they have been telling us patients need to be rescued from. I suspect that plenty of ambulances in the area have better staffing in the patient compartment than the helicopters do.

How have they been able to get away with such shortcuts?

How have they been able to convince people that they were setting the standards for the rest of the country to copy?

And the panel called for something of a cultural shift, saying Maryland’s trauma and helicopter system is overly focused on speed and not enough with quality and appropriateness of care before patients reach a hospital.[4]

Gosh. If only we were to focus on providing high quality EMS, things might be a lot better. As The Erstwhile Medic has stated, instead of worrying about spending the hundreds of millions of dollars on the flight program, maybe we should spend some money on better educating the ground providers.

Dr. Robert R. Bass, executive director of the Maryland Institute for Emergency Medical Services Systems, said he expects the system’s board members, who will formally receive the report in several weeks, to give the findings strong consideration.

Only strong consideration?

Maybe I am naive, but I don’t think the people of Maryland are going to continue to buy what he’s selling. Low standards. High cost in money. High cost in lives.

The MSP troopers deserve better.

The people of Maryland deserve better.

“We do think we’re a model for other systems, and we want to continue to be a model,” Bass said.

Perhaps he means a model of how not to operate a flight program.

Footnotes:

[1] Panel supports fewer medevac flights

November 26, 2008
Baltimore Sun
Article

[2] The golden hour: scientific fact or medical “urban legend”?
Lerner EB, Moscati RM.
Acad Emerg Med. 2001 Jul;8(7):758-60. Review.
PMID: 11435197 [PubMed – indexed for MEDLINE]

Link to Free Full Text Download in PDF format from Academic Emergency Medicine

[3] Panel: Md. flies too many medevac helicopters
By BEN NUCKOLS, AP
Nov 25, 2008 5:42 PM (1 day ago)
examiner.com
Article

[4] Panel supports fewer medevac flights This is the same as footnote [1]

Baltimore Sun
Article

.

Secrecy and EMS Policy are a Bad Combination

More shenanigans in EMS oversight in Maryland.

The panel of seven national experts is set to meet next week and could dramatically change how and when a state Medevac is called into service, but they’ll deliberate behind closed doors, 11 News reporter David Collins said.[1]

Why does this need to be secret?

Will they only release the majority opinions?

Will everyone be sworn to secrecy as a condition of participating?

In other Maryland HEMS news:

A Maryland medevac pilot and would-be whistle-blower who was fired last week plans to appeal his dismissal from the Maryland State Police, union officials said yesterday.

According to police, Peter Peterson was fired for refusing to cooperate with an internal safety probe stemming from his September warning to federal authorities that the police-operated medevac fleet was not safely operated. Peterson’s e-mail to the U.S. Transportation Department’s inspector-general came days before a helicopter crash killed four people in Prince George’s County and led to a reform of the state emergency medical system’s operations.[2]

And from an anonymous comment to Update on the Maryland Crash and Unnecessary Helicopter Transport on Nov. 1 the recordings of the dispatch communications and stories about the release of these recordings:

The NTSB just released their first preliminary report as well as audio recordings:

Report (NTSB)

Report (WJZ-TV)

Audio:

WJZ-TV

Baltimore Sun (WARNING embeds 80MB WAV file)

And the Baltimore Sun continues to provide good investigate coverage:

On the crash

And on HEMS misuse

It will be interesting to see the outcome of this committee.

The helicopter that crashed was involved in an earlier crash with damage that was not completely repaired, according to the pilot who was fired. This pilot criticized the flight program a day, or two, before the crash.

The dispatch recording suggests that the EMS service calling for the flight rarely drives the short distance to the trauma center. The investigation by those in charge found that the rate of HEMS use is not higher than expected for this EMS service, but they will not release the numbers for others to be able to confirm these results.

The initial dispatch was for category D trauma, but after the crash it was up graded to Category C.

Here are the Category C criteria.

High Risk Auto Crash
• Intrusion greater than 12 in. occupant site; greater than 18 in. any site
• Ejection (partial or complete) from vehicle
• Death in same passenger compartment
• Vehicle telemetry data consistent with high risk of injury
• Rollover without restraint
• Auto v. pedestrian/bicyclist thrown, run over,
or with significant (20 mph) impact
• Motorcycle crash greater than 20 mph

Falls greater than 3 times patient’s height

Exposure to blast or explosion[3]

It is important to understand that these only apply when there is no sign of significant injury. The first 2 categories, A and B, are for patients actually showing signs of injury.

In other words, categories C and D are only for apparently stable patients. How many might deteriorate? We don’t know. Dr. Scalea doesn’t know. That won’t stop him from acting like a high pressure salesman in pitching his Miracle Oil. We are told it is impossible for paramedics to assess these patients. Perhaps, but if Dr. Bass and Dr. Scalea did a better job of oversight, maybe they would not be saying that they have not trained their paramedics well.

Is there something wrong with paramedics in Maryland? Dr. Bass and Dr. Scalea seem to think so.

As I read the Maryland ALS protocols, I wonder why they are so restrictive? Is it that paramedics cannot safely provide these treatments without a magic phone call? No, these are just the kinds of protocols that allow bad medical directors to feel comfortable. The protocols are a reflection on the medical directors. Bad protocols are not an indication of what the paramedics are capable of.

Here are Category D criteria.

Age less than 5 or greater than 55

Patient with bleeding disorder or patient on anticoagulants

Dialysis patient

Burns without trauma mechanism go to burn center

Pregnancy greater than 20 weeks

EMS provider judgment[4]

If you are in an automobile collision and any of these apply, they would feel it is acceptable to fly you to a trauma center, because you might die if you were to be transported by ground ambulance. They do not point to research to support their position. They use scare tactics – What if it were your child? Quick buy your tin foil hat now, before the aliens take over your brain – before it is too late. The panel will probably be looking at research, but their meeting will only result in an official statement to the press. It looks as if the 5 hour meeting will be kept under a cloak of secrecy.

Let’s assume that the change in trauma category, of the patients from the September helicopter crash, was not done just because the patients were involved in a helicopter crash and they want to make it look almost appropriate to fly these patients. I believe the criterion was greater than 18 inch intrusion to any site.

Where are the pictures of the vehicle?

If we are more concerned about the damage to the vehicle, than to the patient, we should ask to see the pictures. Everybody takes pictures these days, so the surprise would be if they do not exist. Is this just because of a big dent. It is important to understand that newer vehicles are designed to deform and absorb the impact to avoid having the impact transmitted to the occupants. Basing triage on the amount of deformity, when the deformity is part of the design, is not wise.

This is one of the big problems in EMS. Many paramedics transport patients to the trauma center and are asked questions about the vehicle the patient was in, or the speed the vehicle was traveling, or whether the patient was wearing a helmet. Sometimes I do not see the vehicle myself. I am not trained in accident reconstruction, so for me to estimate the speed of the vehicle is silly. If the motorcyclist did not hit his head, why does the trauma team care if he was wearing a helmet? It is true that the trauma team was not on scene and does not have anything other than pictures to look at. Why don’t they assess the patient first. Then ask about mechanism?

The only purpose of mechanism is to suggest areas to reassess carefully after a thorough assessment.

If the trauma surgeon is going to have the entire assessment done by CT, ultrasound, MRI, and an auto mechanic, do we even need to have the trauma surgeon there?

I am not the only one noticing this trend. Here are some papers wondering if trauma surgeons are needed initially.

American College of Surgeons criteria for surgeon presence at initial trauma resuscitations: superfluous or necessary?
Pascual J, Sarani B, Schwab CW.
Ann Emerg Med. 2007 Jul;50(1):15-7. Epub 2006 Dec 18. No abstract available.
PMID: 17178171 [PubMed – indexed for MEDLINE]

Do the American College of Surgeons’ “major resuscitation” trauma triage criteria predict emergency operative management?
Steele R, Gill M, Green SM, Parker T, Lam E, Coba V.
Ann Emerg Med. 2007 Jul;50(1):1-6. Epub 2006 Nov 1.
PMID: 17083993 [PubMed – indexed for MEDLINE]

Mandatory surgeon presence on trauma patient arrival.
Green SM, Steele R.
Ann Emerg Med. 2008 Mar;51(3):334-5; author reply 335-8. No abstract available.
PMID: 18282532 [PubMed – indexed for MEDLINE]

The impact of managing moderately injured pediatric trauma patients without immediate surgeon presence.
Groner JI, Covert J, Lowell WL, Hayes JR, Nwomeh BC, Caniano DA.
J Pediatr Surg. 2007 Jun;42(6):1026-9; discussion 1029-30.
PMID: 17560214 [PubMed – indexed for MEDLINE]

Is there evidence to support the need for routine surgeon presence on trauma patient arrival?
Green SM.
Ann Emerg Med. 2006 May;47(5):405-11. Epub 2006 Jan 18.
PMID: 16631973 [PubMed – indexed for MEDLINE]

Clinical decision rules for secondary trauma triage: predictors of emergency operative management.
Steele R, Green SM, Gill M, Coba V, Oh B.
Ann Emerg Med. 2006 Feb;47(2):135. Epub 2006 Jan 4.
PMID: 16431223 [PubMed – indexed for MEDLINE]

Trauma management outcomes associated with nonsurgeon versus surgeon trauma.
Ahmed JM, Tallon J, Petrie DA.
Ann Emerg Med. 2008 Mar;51(3):332-4; author reply 335-8. No abstract available.
PMID: 18282531 [PubMed – indexed for MEDLINE]

Triage, initial assessment, and early treatment of the pediatric trauma patient.
Yurt RW.
Pediatr Clin North Am. 1992 Oct;39(5):1083-91. Review.
PMID: 1523018 [PubMed – indexed for MEDLINE]

Trauma management outcomes associated with nonsurgeon versus surgeon trauma team leaders.
Ahmed JM, Tallon JM, Petrie DA.
Ann Emerg Med. 2007 Jul;50(1):7-12, 12.e1. Epub 2006 Nov 15.
PMID: 17112634 [PubMed – indexed for MEDLINE]

Validation of new trauma triage rules for trauma attending response to the emergency department.
Tinkoff GH, O’Connor RE.
J Trauma. 2002 Jun;52(6):1153-8; discussion 1158-9.
PMID: 12045646 [PubMed – indexed for MEDLINE]

Examining the applicability of guidelines promulgated in 2003 by the American College of Surgeons’ Committee on trauma.
Cone DC, Domeier R.
J Trauma. 2005 Nov;59(5):1273; author reply 1273-4. No abstract available.
PMID: 16385316 [PubMed – indexed for MEDLINE]

Footnotes:

[1] Medevac Meetings To Be Private: Some Legislators Unhappy, Call For More Transparency
WBAL TV 11
Nov 17, 2008
Article

[2] Fired medevac pilot to appeal decision

November 11, 2008
Article

[3] MIEMSS Maryland Medical Protocols
Effective July 1, 2008
Page 142/348
Free PDF

[4] The same page as [3]
MIEMSS Maryland Medical Protocols
Effective July 1, 2008
Page 142/348
Free PDF

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RSI, Risk Management, and Rocket Science

This is the way that RSI (Rapid Sequence Induction, or Rapid Sequence Intubation) starts out. An impressive presentation. Usually by means of a PowerPoint presentation.

Sometimes there will be problems that cannot be handled in the normal fashion.

Competent preparation includes the ability to bail out, such as the use of rescue airways, as necessary.

When that preparation is not handled competently, even the rescue airway is not really available to the less-than-prepared.

The search for the highest level person to take the fall for the superiors becomes the focus of the aftermath. Those who create the environment that encourages this failure rarely suffer any significant consequences.

Why should I use the example of the Challenger (STS-51-L), January 28, 1986?

Unreasonably optimistic claims of safety.

Irresponsible oversight.

Failure.

The blame is focused away from the dominant cause.

NASA claimed that the reliability of the Space Shuttle was so great that the risk of an accident was 1/100,000 flights. With this kind of reliability, they could fly twice a week for a thousand years with only one serious failure. The Rogers Commission found that even a 1/100 flight accident rate was unreasonably optimistic.

NASA was claiming that the missions were more than 1,000 times safer than they had any reason to believe. Did they learn from this and improve? Dr. Richard Feynman wrote his own appendix to the findings of the Rogers Commission.

If a reasonable launch schedule is to be maintained, engineering often cannot be done fast enough to keep up with the expectations of originally conservative certification criteria designed to guarantee a very safe vehicle. In these situations, subtly, and often with apparently logical arguments, the criteria are altered so that flights may still be certified in time. They therefore fly in a relatively unsafe condition, with a chance of failure of the order of a percent (it is difficult to be more accurate).

Official management, on the other hand, claims to believe the probability of failure is a thousand times less. One reason for this may be an attempt to assure the government of NASA perfection and success in order to ensure the supply of funds. The other may be that they sincerely believed it to be true, demonstrating an almost incredible lack of communication between themselves and their working engineers.

And he concluded with:

For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.[1]

After all, everyone was watching their performance, how could they continue to make bad decisions that resulted in deaths?

February 1, 2003. Columbia (STS-107). 17 years and only 88 flights later.

“It’s just a flesh wound.”

Not a laughing matter, but the way that NASA has handled risk assessment has been one big example of what not to do. In some places, medical oversight of RSI appears to be following a similar path, just on a much lower budget.

The advantage of hindsight, and the opportunity to second-guess decisions made since February 2003, permeates these observations. All of them were, however, written prior to the launch of STS-114.[2] It is also important to recognize that the behaviors and attitudes described here were not chance occurrences that were observed only once or twice, but that emerged numerous times throughout the Task Group’s interaction with NASA. The intent of these observations is to help NASA leadership identify and rectify these concerns. We will address four main areas: rigor, risk, requirements, and leadership.[3]

How does a medical director not know that medics are not using waveform capnography to assess placement of endotracheal tubes?

A. They use it. I just know.

B. I follow up with the hospital staff to find out what they saw as good and bad about the packaging and care of unstable patients, especially RSI patients.

C. We can’t afford waveform capnography. We use something “just as good.”

D. What’s waveform capnography?

Only one of these is an acceptable answer.

Imagine if you had a device that could monitor the patient’s ECG (ElectroCardioGram) and 12-lead ECG, NIBP (Non-Invasive Blood Pressure), pulse oximetry, and waveform capnography. All with the ability to store the records for dozens of patients, so they can be recovered, or transferred to other media, later.

Printer problem? No problem. Can you say accountability?

Now imagine that you can use waveform capnography to prove that the ETT (EndoTracheal Tube) was not in the esophagus.

If a medical director is responsible for the oversight of paramedic intubation and is not using waveform capnography, there is a serious lack of understanding of risk management.

“We can’t afford waveform capnography.”

Show a lawyer the evidence that the tube was not in the esophagus – a waveform capnography recording from just after the tube was placed, repeated recordings while en route, and another recording just prior to moving the patient to the hospital stretcher – the lawyer will realize that there is no money to be made from this EMS organization.

When that is not the case, it is just your word against an expert witness. An expert witness is someone who gets paid a lot of money (something you claim not to have) to go all over the country to testify that the patient care was incompetent. There are a lot of very persuasive, charming expert witnesses. They make a lot of money. They are good at convincing juries that the patient care was incompetent. Juries love hearing that a simple device, although expensive, was available, but not used. The medical director decided the patients’ lives were not worth this much. Or the EMS agency made that decision and the medical director did not have enough sense or integrity to challenge the medical orders of the EMS agency.

Is waveform capnography idiot-proof?

Nothing is idiot-proof, especially in EMS, but waveform capnography is as close as you are going to get to idiot-proof in airway management.

If EMS is to be improved, we need to get more medical directors who understand risk management and waveform capnography.

This should not even be a topic for debate. There is no valid argument against waveform capnography.

If you cannot afford waveform capnography, then you cannot afford to intubate.

If you decide that intubation should be done anyway, you do not deserve any compassion when your actions result in disability and/or death.

Idiocy is not a valid excuse.

Leadership?


For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.[4]

If you prefer, you may substitute God for the term nature.

All of the images used are in the public domain.

Some other posts about this:

RSI, Intubation, Medical Direction, and Lawyers.

RSI Problems – What Oversight?

More RSI Oversight

Misleading Research

Intubation Confirmation

More Intubation Confirmation

Footnotes:

^ 1 Report of the Presidential Commission on the Space Shuttle Challenger Accident (Also known as The Rogers Commission Report)
Volume 2: Appendix F – Personal Observations on Reliability of Shuttle
by R. P. Feynman
Conclusions
http://history.nasa.gov/rogersrep/v2appf.htm

^ 2 STS-114
Wikipedia
Article

^ 3 Return to Flight Task Group Final Report 8/17/05
A.2 Observations by Dr. Dan L. Crippen, Dr. Charles C. Daniel, Dr. Amy K. Donahue, Col. Susan J. Helms, Ms. Susan Morrisey Livingstone, Dr. Rosemary O’Leary, and Mr. William Wegner.
Page 188
http://www.nasa.gov/pdf/125343main_RTFTF_final_081705.pdf This is an automatic download.
If that does not work, or you do not want to download the file, try:
http://www.scribd.com/doc/349834/NASA-125343main-RTFTF-final-081705

^ 4 The same as footnote 1
http://history.nasa.gov/rogersrep/v2appf.htm

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