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 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.

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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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