Oesophageal Intubation: Still occurs in this day & age.

[chbare]

I was once told regarding malpractice, kill them, don't maim them. Malpractice judgments are higher when the patient survives and is crippled than when they die outright.

The move for ETCO2 monitoring/detection became standard in EMS only a few years ago, so while the colormetric devices were available, they weren't necessarily in widespread use. The question is, was the tube dislodged, or misplaced in the first place? That's why waveform capnography is so helpful in cases like this; it's written proof of proper placement, and warns you of dislodgement or other problems.

There are other issues here which are not clear. Remember that the lawyer will paint everything in the worst light possible. It helps their case to paint the responders as complete idiots to generate negative sentiment against those who don't know them (as this article has done here). Remember that juries generally LIKE EMS providers and firefighters. In order to overcome their generally positive regard, the lawyer has to make them look like complete buffoons. They also (in many states, not sure if IL is one of them) have to overcome a standard of "willful or wanton neglect".

It is entirely possible that this patient was already very unstable. An asthmatic who has to be intubated has a very high likelihood of death. Intubation is not particularly helpful unless you can paralyze them, extend the i:e ratio, and maybe give Heliox. The medics were already dealing with a critically ill patient for whom they had few remedies beyond IM epi.

Never hang anyone out to dry just based on what's said by the plaintiff's attorney.

'zilla

I agree for the most part and that is why I came back to point out when this occurred because things are quite different now.

[Kiwiology]

I still say intubating an asthmatic patient is bad ju ju

Our medical director has stated it is the consensus opinion of himself (a consultant anaesthetist + consultant intensevist), three other consultant emergency physicians and another consultant intensevist who collectively make up our clinical management group that it's something they do not want us doing, even with our near-perfect* RSi program

* yet to be proven but highly likely, not valid with any other offer, 150mg of ketamine maximum per customer, no rainchecks, batteries not included

[chbare]

Ketamine isn't exactly popular out of hospital in the United States now let alone ten years ago.

[Kiwiology]

True. I think these Paramedics kind of nunngered this one up real good, makes me wonder how many Paramedics out there would attempt to intubate such a patient and /or how many would bag the snot out of them because their ETCO₂ is very high and it needs to be "bought down to normal" and/or the good ole ambo trick of "more is better" so lets cram 10-20 manual ventilations per minute down their gob because "they needz more of teh oxygen!"

We have had enough problems with people wrapping their heads around permissive hypercapnea here ...

[systemet]

Secondly, I guess I can't speak for paramedics, the only thing we're trained for is a combitube (non-visualized airway device) and once it's in place if you don't hear breath sounds in the lungs OR you hear air in the abdomen you immediately swap the bag to the other tube and listen again. Now, before everyone gets mad, I admit I've never done this to a live patient on a rig, and obviously paramedics have had a helluva lot more training than me. I simply can't picture this happening around here. I did several ride-along days with the ALS unit of our fire department and between calls I heard about a ton of crazy calls and screw ups they had run into in the last 25 years but this is terrible. On the other hand, if those guys ever did something like that they probably wouldn't tell me.

There's a few problems with this:

* It can be really hard to hear decent lung sounds in a status asthmaticus patient.

* In kids, it's easy for sounds to be heard in distant regions, e.g. transmitted from the epigastrum to the lungs & vice versa.

Auscultation is unreliable. It's much better to have the proper technology. It's just taken a while for this to get on to the trucks.

The things with these stories, like all the "patient declared dead by paramedics, alive 3 hours later" stories, is everyone assumes that the guys involved were idiots. And some of the time they are. But it's also possible to have a good person having a bad day make a series of small errors, any of which on their own would be unlikely to have a substantial influence, and have them combine together to produce a tragic outcome.

The real test of a mature provider is their ability to sit back, and go, "Could that happen to me?" and not immediately dismiss the idea with "Well, I graduated from Frank's school of Ambulance Driving, Haberdasheri and Goat molesting, so it's simply not possible". We need to develop a better ability to sit back, critically evaluate these situations, and think, what errors led to this outcome, and how could they have been prevented? How can I avoid doing the same thing?

That being said, it's awesome to see that the site as a group isn't jumping on the people invovled.

* Just want to add, I'm not attacking Bill here, I'm just talking about generalities.

[Ridryder 911]

It's easy to read a blurb from a news report and armchair quarterback... Sounds like a cluster call, glad I was not on it! Hmm... a seriously ill child, i.e asthmatic (even the most seasoned medics nightmare) and then to have a vehicle contact while transporting... Are there potential errors and things that could have been changed to have a better outcome... yes.

Before we start reviewing assessment and treatment modalities, let's remember this was ten (10) years ago.. and yes, EtCo2 was not a routine assessment (Paramedic should remember Co2 entrapment ) and albeit one would prefer to delay intubation if possible, (again 10 years ago) securing an airway was a priority.

Delaying transport.. sure we all can say, what we would do differently. Did they make the right decision.. apparently not. Yet again, I was not there nor know the internal policies and politics, which will not be described or published also...

Main point, is to learn and not repeat the same mistake (if any) ..

R/r 911

[Kiwiology]

Glad to see you still come round here mate

Now just to reiterate for y'all

If you're going to intubate, anaesthetise and paralyse, use a bougie and ETCO₂ or don't do it at all

Intubating an asthmatic patient is bad ju ju

If you do decide to intubate an asthmatic patient (nb aforementioned bad ju ju) ignore ETCO₂ and allow permissive hypercaponea

Ventilate them slowly at 6 breaths per minute and allowing for a prolonged expiratory phase is critical to avoid hyperinflation and cardiac arrest

Once again, intubating an asthmatic patient is bad ju ju

Thanks for listening