Forcing the Tube

[Bieber]

Hi everyone. I've been busy lately, but I had an interesting call the other day and I wanted to get your guys' opinion on it, because it's been a while since I've read up on airway management but I've had a lot of experiences with difficult airways lately, including the most recent one.

To start off, I'll give some background on myself and my service. During my clinical rotations I had 29 successful intubations out of 32 attempts, and during internship I had 4 successful intubations out of 5 with the fifth one being a difficult airway due to a very anterior trachea.

Since getting my big boy paramedic patch, I've had three attempts and one semi-successful intubations.

-Attempt #1: Code blue female in her late twenties, airway was all full of vomitus. My error: failure to suction deep enough to adequately clear the trachea of vomitus enough to visualize the cords.

-Attempts #2: Semi-successful intubation. Late 50's male code blue. I successfully intubated but at the time I was uncertain of the patency of it due to excessive chest wall tissue diminishing lung sounds. I saw it go through the cords but didn't trust my eyes and pulled the tube unnecessarily.

-Attempts #3: Most recent attempt. Early 80's female code blue. Initial rhythm was PEA that quickly turned into a pulsatile sinus tachycardia with chest compressions and BVM ventilations alone almost immediately upon our arrival. No meds given, and after we retriaged her code red (critical), I attempted to intubate. She fought the tube and was biting it and I wasn't able to pass the tube. My partner was, however.

This most recent attempt, however, got me thinking. I'm not sure if intubation under those conditions was really desirable or advisable due to the fact that while she had an uncontrolled airway, she was coming around very quickly and fighting the tube. I believe that if we WERE going to tube her, it would have been best done under RSI; however we don't have RSI at my service--the best we could have done was sedate her first. She WAS breathing spontaneously (though poorly), but I think that we might have been better served by either managing her airway via the BVM or getting some sedation on board initially. I don't like having to fight a patient to force a tube down their throat, and I question whether we should be trying to tube someone if we have to fight with them for it. I WAS at least able to convince my partner and my captain to get some sedation on board AFTER my partner successfully passed (see, forced) the tube, but my captain commented that, "I hate to knock out her respiratory drive right after we got it back."

The problems I see with that comment are these: I am NOT, I absolutely am NOT, going to leave someone with an ET tube down their throat without giving them some sort of sedative--not if they're awake or conscious in any way. That's beyond inhumane and cruel as far as I'm concerned. Secondly, if we're going to insist on jamming a tube down their throat, we're not going to be concerned about their respiratory drive. We've already made the decision that WE are going to be responsible for their airway, so WE are going to be the ones to take care of it. If we insist on forcing a tube down their throat, we're not going to leave them in pain because we want to preserve their respiratory drive. Either we're going to assist them in breathing for themselves, or we're going to breathe for them--not some perverted mix of the two. We've got the tube, we've got a BVM, the hospital has a ventilator. We can make them apneic if we have to and be all right. (Though I didn't "snow" her with the sedative, or knock out her respiratory drive with it.)

So, yeah. Tubing folks who are conscious enough to fight the tube?! Am I the only one who sees a problem with this? Someone call me out if I'm wrong here, but if we're going to be tubing folks who are capable of fighting us, shouldn't we have adequate RSI in place before that? Is it acceptable to force a tube down a fighting person's throat? Am I totally off base here?

Thanks guys,

-Bieber

[RaceMedic]

After reading your post ... WOW your captain refused sedation even AFTER SECURING THE AIRWAY ??????

In my opinion you are correct, I feel that with the way PT was coming around you would have been better served to maintain with BVM to support what respiration's she had. No need to force the tube down her throat. but i am still hung up on not giving sedation, especially before forcing it in the airway. Not to mention that it hurts to be intubated. I wonder if you went in to interview her if she would remember the event? you might be surprised. Unless she did not survive the entire event.

I will refer to current and even the last update of ACLS. Intubation is well down the list of initial activities to be performed and again the way you present the case you would have been correct supporting the airway with the BVM. However with anything i was not there and hate to armchair the call.

Still though, worried about knocking out the resp. drive of a PT that was just intubated and by force at that ... WOW ...

[Bieber]

Race, thanks for piping in! I appreciate hearing your opinion, and I know it's hard to give one when you weren't there. This was very much a "secondary arrest" code blue, patient had a history of COPD and was complaining of dyspnea before she collapsed so I think that she one hundred percent needed the oxygen, I'm just not sure that the tube was appropriate in this situation. She was far from alert by the time we got her to the hospital, but she was biting on the tube and moving her eyes and I think she's going to end up being a clinical save, though it's too soon to tell. Hopefully she won't remember the event, but if she does then I hope I get the chance to apologize to her for the discomfort we put her through--I know that the wimpy little 2 mg of Ativan I gave her wasn't enough, and I wish I'd gone ahead and given 4 mg.

I think this was, as I've noticed is very commonly the case (at least around here), a case of us rushing too much to go, go, go when we should have taken a bit more time preparing the patient for transport. That's another thread in and of itself, but for a brief glimmer into that soapbox I'll just say that I think we try too hard to race to the hospital unnecessarily most of the time instead of taking a bit longer to ensure that we're giving the full amount of care that we're able to in the field and THEN moving on to the hospital.

Also, I see there's been almost a thousand views of this page already. Stop just looking and start posting, folks!

[fiznat]

Absolutely, sedation is in order if the patient is gagging on the tube.

That said, I don't think a little gag is necessarily a contraindication for intubation. Gag reflex is not the same thing as consciousness, and it does not mean that the patient is entirely protecting their airway. It is a judgement call of course, which is why you get paid the big bucks to wear that patch haha. What you need to do is balance how well you think this person is protecting their airway against the possibility that you could cause harm with the procedure. High risk for harm or low clinical benefit = don't tube. You should use that same reasoning for all of your interventions, really.

Keep doing this. Reviewing your calls and your clinical decisions is one of the most effective things you can do to improve yourself in this field. It won't eliminate mistakes, but it will definitely increase their value.

[DwayneEMTP]

(Edit- Redundancy due to posting at the same time as the others.)

What was your working diagnosis on this patient? Why were you called? When you say that she was coming around quickly, coming around from what?

It sounds to me that this patient was intubated for the sake of someone wanting to get a field tube. I don't really see the indication for intubation here, though of course it's just a sketch of the call review so perhaps the indications were there.

It also sounds like we have so many cooks in this kitchen that we ended up making a Kemche diet Latte abortion burger instead of a souffle.

I've intubated struggling patients before, but nasally, not orally. Some with sedation, and some without, but all were resp issues near exhaustion. Why wasn't a nasal intubation done instead? I'm guessing that the answer is that most folks are scared of them.

And it does sound as though once intubation was considered that patient care went out of the window. And I'm sorry Brother, but I have to include you in this as well though I know your passion for the subject, as the argument should have been strongly, even forcefully made to withold the proceedure when it was apparent that it might not be necessary any longer and in fact, from the outside looking in, wasn't necessary to begin with.

What are you feelings on intubation of geriatrics in general? Do you see a difference between putting a geriatric in a position to be intubated and placed on a resperator as opposed, say, a 20 year old?

You're thinking on this subject seems spot on to me. Why wasn't your logic followed on this call? And to worry about retarding the resp drive on an intubated patient is pretty ridiculous unless you believe that you will be extubating this patient before hand off at the hospital...and I don't really see that happening.

I notice that you say that you didn't snow her with meds...depending on your working diagnosis, and what you used for sedation, snowing her was likely the kindest thing that you could have done. Being intubated sucks physiologically speaking, knowing that you're intubated sucks much, much worse. This was a lightly medicated trauma, right? Treat it as the trauma that it certainly is unless contraindications exsist to disallow it.

Great, brave post. In fact follows in the footsteps of the Fiz of days gone by.. I have a lot of respect for the fact that you posted this in the spirit of allowing others to learn from it despite the near certainty that it was going to get your ass kicked. That's in the best spirit of EMS in my opinion.

Dwayne

[RaceMedic]

Your welcome Beiber. Even with your response i would have Still help off with the tube. COPD exacerbation does not necessarily require intubation however if she was breathing and chewing on the tube i think she may be more than a clinical save.

sounds like you arrived quickly with an almost immediate conversion from PEA to sinus tach with compressions and BVM alone, you had positive results. I agree with Dwayne's assessment of your partners wanting a field tube. But i still can not speak for the Capt's complete lack of basic compassion for the PT.

As Dwayne said also, YOU need to stand firm and force the issue if you believe what they were doing was not in the best interest of the PT. Remember just because your new does not mean your wrong or will not be listened to. You will gain more respect from your colleagues. Do not follow the status quo !!! Trust will come in time.

[ORmedic65]

It makes absolutely no sense to me to tube a patient and not provide some sort of sedation afterwards, especially to those that need it. In my opinion, it's cruel, inhumane and just plain negligent to intubate a patient without providing the appropriate sedation/paralysis before and after, especially if they're already fighting the tube.

The whole worry about "wiping out their respiratory drive" is ridiculous to me; I mean, once you've intubated them, you're already at the end of the protocol so to speak. You've intubated the patient because they weren't ventilating well enough for themselves, so why be worried about wiping out an already insufficient respiratory drive? If you're going to be taking over someone's airway then you must be prepared to take it over completely, or not at all. At least that's my opinion on the matter.

I'm not going to begin to critique your last call, as I was not there, however, I will say that it sounds as though you have the right idea about airway management. Good post.

Edited October 20, 2011 by ORmedic65

[RaceMedic]

I will say that it sounds as though you have the right idea about airway management. Good post.

Agreed !!!

[fiznat]

the Fiz of days gone by..

Hey!

[DwayneEMTP]

Hey!

Heh...speaking only of your balls to the wall, perfectly honest or nothing approach to the way you used to present call reviews. Man...my behavior here is so much more honest and brave based on your example.

The intelligence and kindess of your posts never changes...But I do miss your call reviews.

Dwayne