Things you shouldn't say to the ER doctor when you bring in a patient

[ERDoc]

So, after a less than stellar performance by a crew the other day I was reflecting on what happened and wanted to share (as much as HIPAA allows) to help others not make the same mistakes. Feel free to make this go both ways as it can be educational for EMS/RNs/MDs/DOs. The purpose is NOT to bash but to learn from others mistakes. Think of it as an unofficial M&M conference.

Paramedic "I'm not sure if the tube is in right."

60s y/o male who coded in front of family. FD first responders did CPR for a minute and got a pulse back. Upon EMS arrival, pt was still unconscious and they were able to drop a tube. 15 minutes out from the hospital the pt goes into arrest again. Asystole upon arrival at the ER. We hear a whooshing sound when we are bagging. At this point the paramedic makes the above comment. Take a look and the balloon is sitting in the back of the throat. Pt pronounced shortly after arrival.

Take home point: If you are not sure the tube is good, make it good or get it out. NEVER have a questionable tube.

[Curiosity]

Running these high energy calls can be stressful and chaotic but there is so much emphasis put on tube confirmation, reconfirmation there is no reason for this to happen. Do they have etco2? Maybe I'm obsessed with this but my tube is my baby. If I worked that hard to get it in, you can guarantee it I will be anal about keeping it in, and keeping it in the right place.

[ERDoc]

Most of the services around here have ETCo2, I'm not sure if they do but if they do, I do not think they were using it. I agree that these things can be chaotic, but that is no excuse. That is why you are trained to do this. I also agree about the tube. When you tube someone, it is your tube, your lifeline. You do not let go until it has been secured. Someone else can listen to the initial lung sounds to confirm placement. I had a resident the other day who let go of the tube before it was secured to grab her stethoscope. I cringed and grabbed the tube. We talked about it afterwards. The scary part about the original call was that they had secured the tube with one of the Tomas holders.

[Arctickat]

My process for tube confirmation:

1. Watch the tube pass through the cords
   
2. Look at the measurement on the tube and compare it to the teeth, not the lips.
   
3. Watch for chest rise and fall
   
4. Watch for fogging in the tube during exhalation
   
5. Listen to the lungs
   
6. etCO₂ Capnography
   
7. SPO₂
   

Even so, I have arrived in the ER and realise there was a problem with the tube. In this case the seal had leaked and blowby was occurring. Being able to hear subtle changes in airway sounds from the tube is pretty much impossible while in transit, but even during a code I will often find a few seconds to check the tube placement on a regular basis, even just to check the measurement and if it fogs up.

[ERDoc]

I wouldn't exactly describe these airway sound changes as subtle.

[DFIB]

I wouldn't exactly describe these airway sound changes as subtle.

Every tube I have heard leaking was pretty obvious.

[ERDoc]

The only way I can describe it was it sounded like when you blow into a dogs mouth/nose. Same tone and volume.

[DFIB]

The only way I can describe it was it sounded like when you blow into a dogs mouth/nose. Same tone and volume.

You do this frequently?

[ERDoc]

You do this frequently?

This isn't about me.

[Arctickat]

I wouldn't exactly describe these airway sound changes as subtle.

No, a fully dislodged tube would be quite easy to hear even when travelling down the road with a sound environment in the 90+ db range. I was thinking of things less obvious.

I suppose that is one significant detriment to being perfect at placing tubes...I've never heard what one sounds like when there are complications so I'd never know what to listen for.

Edited December 15, 2012 by Arctickat