# "Ambulance Attendants Sued"



## jochi1543 (Mar 7, 2009)

http://www.edmontonsun.com/News/Columnists/Blais_Tony/2008/12/21/pf-7819526.html




> A High Prairie woman has launched a $6.76-million lawsuit against Peace Country Health and two ambulance attendants after alleging she was left permanently brain damaged and lost her eight-month-old unborn child as a result of negligent care following a highway crash.
> ...
> Carifelle was knocked unconscious in the crash and ended up being treated by ambulance attendants working on behalf of Peace Country Health.
> ...
> They also allegedly lacerated her spleen and poked a hole in her diaphragm with the incorrectly placed tube and then failed to notice and correct the situation.


----------



## ffemt8978 (Mar 7, 2009)

> They also allegedly lacerated her spleen and poked a hole in her diaphragm with the incorrectly placed tube and then failed to notice and correct the situation.



Okay, I'm really curious as to HOW they could lacerate her spleen and poke a hole in her diaphragm while intubating her.:wacko:


----------



## medic417 (Mar 7, 2009)

Wonder if any of theses damages actually occured in the wreck?  

Now the missed tube left in place is inexcusable, if that in fact occured.


----------



## PapaBear434 (Mar 7, 2009)

jochi1543 said:


> http://www.edmontonsun.com/News/Columnists/Blais_Tony/2008/12/21/pf-7819526.html



Wow.  If that is true, it sounds like they REALLY sucked at their job.



ffemt8978 said:


> Okay, I'm really curious as to HOW they could lacerate her spleen and poke a hole in her diaphragm while intubating her.:wacko:



I was wondering that myself.  Used a 20 mm tube, apparently.


----------



## jochi1543 (Mar 7, 2009)

ffemt8978 said:


> Okay, I'm really curious as to HOW they could lacerate her spleen and poke a hole in her diaphragm while intubating her.:wacko:



Yeah, that's why I posted this here...we've been discussing it at my practicum, but none of us here are ALS, so we are not experts on the topic.


----------



## Epi-do (Mar 7, 2009)

ffemt8978 said:


> Okay, I'm really curious as to HOW they could lacerate her spleen and poke a hole in her diaphragm while intubating her.:wacko:



I can't see how that would happen either.  I mean, they would have not only misplaced the tube, but made it disappear altogether. (Not to mention the fact that there should have been a hole somewhere in her digestive tract as well, if this actually happened.)  "And now, for my next magic trick...."


----------



## Aidey (Mar 7, 2009)

How long was that ET tube? Or were they trying to insert it in her belly button? 

The misplaced ET tube sounds like it was possible. However for negligence they have to prove that the patient was damaged by the event, and by the sounds of her numerous other injuries they are going to have a hard time saying any brain damage she received was from a misplaced tube, and not from the accident.


----------



## VentMedic (Mar 7, 2009)

Aidey said:


> How long was that ET tube? Or were they trying to insert it in her belly button?


 
An adult ETT can be 33 cm in length plus up to an additional 4 cm for the connector. By 8 months of pregnancy the diaphragm may have risen as high as 4 cm from its normal position. With abdominal and diaphragm displacement of an eight month pregnancy, the damage mentioned here could be possible if the lady is relatively short. 

Knowing the lengths of the ETTs is something everyone who intubates should know. It prevents you from ramming the thing in too deep and doing extreme damage. Also, if your tube is buried to the hub and has met not resistance, chances are you have entered the esophagus. There are other situations where you must be extremely aware of tube length when intubating people who have relatively short vocal cords–carina distance. This is particularly true in the Asian population. The ETT could be hitting the carina at 17 - 18 cm in some smaller Chinese adults while in others who are the same height would require a placement of 22 cm for correct tube position with 25 cm to the carina. 

This is all just part of basic airway assessment that should be acknowledged before attempting intubation. You should already have a cm mark in mind before you stick a piece of fairly rigid plastic into someone's throat. You should also be aware of how long a 6.0 tube is before you attempt to nasally intubate someone who is 6 ft 4 inches. Chances are the cuff will not be below the cords.


----------



## daedalus (Mar 7, 2009)

No good deed shall go unpunished.

Try and save a life and lose your livelihood. While VentMedic is on to something, I really really doubt that the ETT breached her spleen. Her brain damage and miscarriage were caused by the accident, not the paramedic's care.


----------



## VentMedic (Mar 7, 2009)

daedalus said:


> No good deed shall go unpunished.
> 
> Try and save a life and lose your livelihood. While VentMedic is on to something, I really really doubt that the ETT breached her spleen. Her brain damage and miscarriage were caused by the accident, not the paramedic's care.


 
Unrecognized intubation of the esophagus is enough to end this person's life or quality of life regardless of what damage was done to the spleen. This is the one thing that has gotten ETI taken away from some ALS services and have put procedures such as RSI into question because some EMS providers don't take the time to confirm correct tube placement even if they do have the equipment.

When you become a medical professional, you will be expected to be accountable for your mistakes. This is where you will learn the differences between errors that can be corrected or do little harm and mistakes that cause permanent damage and/or death. 

If you do more damage by not doing your job correctly, you have done harm and have done very little to save that person's life.


----------



## ffemt8978 (Mar 7, 2009)

Vent,

Please correct me if I'm wrong, but even IF the diaphragm is moved up due to pregnancy, and even if the patient is short, how could they put a hole in the diaphragm while intubating, regardless of whether or not they were in the trachea or not?  Wouldn't they have to punch through the trachea or esophagus first, in order to get to the diaphragm?


----------



## Aidey (Mar 7, 2009)

Yeah, it seems like they would have to push the ET tube through a lot, and it would take quite a bit of force even if it is physiologically feasible.


----------



## Epi-do (Mar 8, 2009)

Epi-do said:


> I can't see how that would happen either.  I mean, they would have not only misplaced the tube, but made it disappear altogether. (*Not to mention the fact that there should have been a hole somewhere in her digestive tract as well, if this actually happened.*)  "And now, for my next magic trick...."






ffemt8978 said:


> Vent,
> 
> Please correct me if I'm wrong, but even IF the diaphragm is moved up due to pregnancy, and even if the patient is short, how could they put a hole in the diaphragm while intubating, regardless of whether or not they were in the trachea or not?  *Wouldn't they have to punch through the trachea or esophagus first, in order to get to the diaphragm?*



Great minds think alike, huh?


----------



## VentMedic (Mar 8, 2009)

Epi-do said:


> Great minds think alike, huh?


 
It is not that difficult to tear the esophagus even with just a misplaced tube. And no you don't have to go through the wall of esophagus and then into the trachea to get to the diaphram. The angle of the stylet will determine the direction and the damage.

One can also go through the tracheal wall into the esophagus. This was even discussed on this forum at great length in the "Blew up like a balloon" thread. These are all complications that should have been taught to you when you were learning to do ETI.


----------



## daedalus (Mar 8, 2009)

Vent, I am not saying that they should not be held accountable for an unrecognized esophageal intubation, but that this women's claims seem outlandish. I agree with the above, the tube would have to puncture the trachea, bronchus or esophagus, than puncture the diaphragm, and than enter the spleen.


----------



## VentMedic (Mar 8, 2009)

Aidey said:


> Yeah, it seems like they would have to push the ET tube through a lot, and it would take quite a bit of force even if it is physiologically feasible.


 
No, it doesn't take much force to damage internal tissues especially with an ETT and stylet.


----------



## ffemt8978 (Mar 8, 2009)

Okay, that makes sense...but they would still have to tear through one or the other, and if that was the case, I think it would have been mentioned in the article.


----------



## VentMedic (Mar 8, 2009)

ffemt8978 said:


> Okay, that makes sense...but they would still have to tear through one or the other, and if that was the case, I think it would have been mentioned in the article.


 
Is it really necessary to publish the entire autopsy?   I think the real issue here is the lady is *FUBAR* as the result of a misplaced tube.


----------



## daedalus (Mar 8, 2009)

VentMedic said:


> Is it really necessary to publish the entire autopsy?   I think the real issue here is the lady is *FUBAR* as the result of a misplaced tube.


Wait, did she die?


----------



## VentMedic (Mar 8, 2009)

daedalus said:


> Vent, I am not saying that they should not be held accountable for an unrecognized esophageal intubation, but that this women's claims seem outlandish. I agree with the above, the tube would have to puncture the trachea, bronchus or esophagus, than puncture the diaphragm, and than enter the spleen.


 

If the tube goes into the esophagus, with a slight angle on the stylet and tube, it can easily pierce the esophagus and diaphragm with the displacement from the pregnancy.  The Paramedic may not have been expecting such a displacement and may even have given an extra  "push".  I have seen way too many providers  grip an ETT like they are stabbing something rather then gently advancing.


----------



## ffemt8978 (Mar 8, 2009)

VentMedic said:


> Is it really necessary to publish the entire autopsy?   I think the real issue here is the lady is *FUBAR* as the result of a misplaced tube.



No, it's not necessary but since they accused the attendants of lacerating her spleen also it just surprises me that they didn't mention it.  I agree, a misplaced tube is a FUBAR.


----------



## Epi-do (Mar 8, 2009)

VentMedic said:


> It is not that difficult to tear the esophagus even with just a misplaced tube. And no you don't have to go through the wall of esophagus and then into the trachea to get to the diaphram. The angle of the stylet will determine the direction and the damage.
> 
> One can also go through the tracheal wall into the esophagus. This was even discussed on this forum at great length in the "Blew up like a balloon" thread. These are all complications that should have been taught to you when you were learning to do ETI.



Thanks for the info, Vent.  It continues to become more and more painfully obvious to me how inadequat the respiratory portion of my class truly was.  There has been info in several of your recent posts that I have read and then said, "I didn't realize that" or "I wish we had discussed X to that degree."  I have several bookmarks added to my favorites list of things to read/review as I have extra time.


----------



## VentMedic (Mar 8, 2009)

daedalus said:


> Wait, did she die?


 
Don't know but the entire medical history doesn't have to be in the newspaper.  If this case did get settled, more details may be part of the court record if someone wants to dig that up.

However, instead of tearing this article apart to find all of its reporting faults, LEARN SOMETHING FROM IT.   

Review ETI.  Learn to document to CYA.  Improve on your asssessment skills with each patient.

ETI is NOT something to be taken lightly.


----------



## VentMedic (Mar 8, 2009)

Time to review ETI and esophageal intubation:

*Legal Lines: The 'ABCDs' of Documenting Endotracheal Tube Placement *

http://www.emsvillage.com/articles/article.cfm?ID=967

*A Lesson in ‘Negligence’*
(good article but with one "slight" error noted)
http://www.jems.com/news_and_articles/columns/Maggiore/A_Lesson_in_Negligence.html

*Verification of Tube Placement *

http://www.emsvillage.com/articles/article.cfm?ID=69

*Guidelines Based on the Principle "First, Do No Harm" *

*New Guidelines on Tracheal Tube Confirmation and Prevention of Dislodgment *

*Richard O. Cummins, MD; Mary Fran Hazinski, RN, MSN *

http://circ.ahajournals.org/cgi/content/full/102/suppl_1/I-380

Sidenote: For those interested in learning more about pediatrics, Mary Fran Hazinski's textbooks are EXCELLENT.


----------



## VentMedic (Mar 8, 2009)

Fortunately, these extreme cases are rare. But, the "Blew up like a balloon" thread did bring up a case that was interesting even though it resulted in death.

However, we do see esophageal tears from intubation as well as tracheal/bronchial injuries. I have also seen my share of misplaced NG tubes that have gone through the right bronchus. I have seen many fractures of the larynx that were caused by ETI. I have also seen many soft palate and dental injuries. And, I have even seen nasal tubes go places they should not have.

ETI is one skill that needs both extensive training and education.


----------



## 2easy4u (Mar 8, 2009)

*Airway,airway,airway*

I am with Ventmedic for the most part. Visualization through the cords CO2 and SPO2 monitoring along with BB/S and chest rise and fall. If all of that is good then you have an airway. And be sure to recheck all of it each time the patient is moved, and before you leave the patient @ the ER. Document,document,document, the whole thing just the way it happened. And as far as the tube being too deep, which does happen,usually from a move not placement. Pull it back and recheck it. I can see on a rare occasion that it might be possible to get into the diaphragm but conditions would have to be like VentMedic was speaking of. The lacerated spleen is very doubtful. None of us were there and not privy to the documentation. I would hold back on being critical until I know all the facts.
:sad:


----------



## Aidey (Mar 8, 2009)

I can see where it may not take much force to puncture the esophagus, but to puncture the diaphragm and the spleen? That is the part I would think would take a bit of force. Especially during a procedure where no force is needed.


----------



## daedalus (Mar 8, 2009)

Epi-do said:


> Thanks for the info, Vent.  It continues to become more and more painfully obvious to me how inadequat the respiratory portion of my class truly was.  There has been info in several of your recent posts that I have read and then said, "I didn't realize that" or "I wish we had discussed X to that degree."  I have several bookmarks added to my favorites list of things to read/review as I have extra time.



Amen, EpiDo.

Reading the Bledsoe O2 article, I am really hoping that one day I can grasp these concepts.


----------



## VentMedic (Mar 8, 2009)

Aidey said:


> I can see where it may not take much force to puncture the esophagus, but to puncture the diaphragm and the spleen? That is the part I would think would take a bit of force. Especially during a procedure where no force is needed.


 
Picture this: You've got a baby pushing one way and a tube's bevel with stylet being pushed from another direction. The diaphragm/esophagus is literally caught between a rock and a hard place. The tube may not have punctured the diaphragm but may have followed the path of the esophagus and exited near the stomach which is the area of the spleen. There are a lot of possibilites here but without knowing the shape and size of the woman, ETT size used and other details not mentioned in the article, we are just speculating or guessing.

The message I am trying to convey is that this could be possible in the right (wrong) circumstances. I just want those who intubate to be aware of the tube length, pre-intubaton assessment and the risks of ETI.


----------



## daedalus (Mar 8, 2009)

Vent's Diaphragm displacement example


----------



## Aidey (Mar 8, 2009)

Pushing is exactaly my point though. I totally understand that physiologically it's not impossible, but when you intubate there is no resistance. There is going to be resistance going through the diaphragm and into spleen. When intubating normally, there is no pushing involved unless you are intubating someone with a lot of swelling in the trachea. 

And Daedalus. 

Fail. 


/shudders


----------



## Fragger (Mar 8, 2009)

Here in this warzone we use the "Combitube " no error"

http://www.youtube.com/watch?v=WQRJ...m=1&ie=UTF-8&ei=p7azScybEJKWsQPgzOCUAQ&sa=X&o


----------



## Veneficus (Mar 8, 2009)

Any chance the damage to the diaphagm and spleen was do to a thoracotomy tube that the reporter didn't mention?

I would think that the damage to the spleen was probably an original injury not caused by the care providers considering the normal risk of injury. 

They certainly should be held accountable for a misplaced ET tube I think.


----------



## medic417 (Mar 8, 2009)

Fragger said:


> Here in this warzone we use the "Combitube " no error"
> 
> http://www.youtube.com/watch?v=WQRJ...m=1&ie=UTF-8&ei=p7azScybEJKWsQPgzOCUAQ&sa=X&o



You may want to research before you get to comfortable with that statement.  If you meant that sarcastically I apologize.


----------



## medic417 (Mar 8, 2009)

Veneficus said:


> They certainly should be held accountable for a misplaced ET tube I think.



Even if none of the rest occured this alone is grounds for losing.


----------



## enjoynz (Mar 8, 2009)

I might be barking up the wrong tree here, but has anyone thought that maybe the hole in the diaphragm and spleen
may have been caused by another injury and treatment....
chest drain for instances???
Just a thought!

Cheers Enjoynz


----------



## Fragger (Mar 8, 2009)

Exactly!!!!!!!!!!!!!!!





enjoynz said:


> I might be barking up the wrong tree here, but has anyone thought that maybe the hole in the diaphragm and spleen
> may have been caused by another injury and treatment....
> chest drain for instances???
> Just a thought!
> ...


----------



## ffemt8978 (Mar 8, 2009)

Veneficus said:


> They certainly should be held accountable for a misplaced ET tube I think.



Assuming, of course, that it even was an ET tube and not some type of multi-lumen airway.

Considering that there has only been one article on this suit so far, we just don't know enough about what happened.


----------



## medic417 (Mar 8, 2009)

enjoynz said:


> I might be barking up the wrong tree here, but has anyone thought that maybe the hole in the diaphragm and spleen
> may have been caused by another injury and treatment....
> chest drain for instances???
> Just a thought!
> ...



Several posts have mentioned similiar thoughts.


----------



## enjoynz (Mar 8, 2009)

medic417 said:


> Several posts have mentioned similiar thoughts.



I missed reading down all the posts, sorry...was the first thing that I thought of, when I read the article!

Cheers Enjoynz


----------



## VentMedic (Mar 8, 2009)

ffemt8978 said:


> Assuming, of course, that it even was an ET tube and not some type of multi-lumen airway.


 
When it comes to the airway, it doesn't matter what the tube is. It could be a Combitube, ETT, EOA, King or LMA.    The EMS provider who is supposed to be trained for the device has an obligation to check placement.     

If you say it is a Combitube, which can also cause serious damage, does not make you less liable if you fail to know what you are doing when attempting to secure an airway.


----------



## medic417 (Mar 8, 2009)

enjoynz said:


> I missed reading down all the posts, sorry...was the first thing that I thought of, when I read the article!
> 
> Cheers Enjoynz



Me too.  Would be neat to find more info on this case.


----------



## ffemt8978 (Mar 8, 2009)

VentMedic said:


> When it comes to the airway, it doesn't matter what the tube is. It could be a Combitube, ETT, EOA, King or LMA.    The EMS provider who is supposed to be trained for the device has an obligation to check placement.
> 
> If you say it is a Combitube, which can also cause serious damage, does not make you less liable if you fail to know what you are doing when attempting to secure an airway.



My point was that if it was a multi-lumen, perhaps it was in the esophagus,  but that doesn't mean it was incorrectly placed, and it doesn't mean that her brain damage was the result of tube placement.

How do you differentiate between the patient's injuries secondary to inadequate care, and her injuries secondary to her vehicle accident?  Especially when you consider she was knocked unconscious with 





> ... allegedly suffered multiple injuries, including a traumatic head and brain injury



If the attendants made a mistake, then they should be held accountable for it.  However, we do NOT know that this is the case in this situation.


----------



## VentMedic (Mar 8, 2009)

ffemt8978 said:


> My point was that if it was a multi-lumen, perhaps it was in the esophagus, but that doesn't mean it was incorrectly placed, and it doesn't mean that her brain damage was the result of tube placement.


So you think you just shove in a tube meant for the esophagus and it is idiot proof?


Let me rephrase this one more way. 

A lacerated spleen can be removed.
A lacerated diaphragm can be repaired.
It is riskier for a pregnant woman because of the anesthesia and how it will affect the baby but both problems can be dealt with.

Hypoxia permanantly damages the brain and other organs. It can also cause death.

You can debate the article all you want. But cockiness in thinking something is fool proof or serious injuries can not happen is what gets EMS providers into problems. You can attempt to blow off whatever other problems but if the tube was misplaced, regardless of the other injuries, that did the irreversible damage. That should be brought out when the case is presented. Trying to smoke screen your own screw up won't release you from some responsibilty. This news article may not have presented all the facts but the one statement that was presented was a misplaced tube and was responsible for oxygen deprivation. The other injuries can be disputed but her surgeons will make those points. All I did was describe how some of these injuries can occur by discussing the LENGTH of an ETT and the diaphragm/organ displacement of a pregnant woman.  I did that because some appeared to not know their equipment very well or understand what happens during pregnancy.

Often, for many complications that occur from ETI, it is just taken as a complication of rescue. The trach or laryngectomy fixes whatever screw ups some providers do when intubating. We have medical helicopters with advanced providers that can quickly move a patient from one hospital to another for a tracheal and esophageal repair by open chest. These problems can be fixed but unless they are recognized, the results of hypoxia can not be fixed. 

For those who think the combitube is idiot proof. 
http://pdm.medicine.wisc.edu/21-2%20PDFs/calkins.pdf


----------



## ffemt8978 (Mar 8, 2009)

Vent, I actually agree with you.  My point of contention is the lack of information in the article, that's all.


----------



## VentMedic (Mar 8, 2009)

ffemt8978 said:


> Vent, I actually agree with you. My point of contention is the lack of information in the article, that's all.


 
When articles are vague like this, there is still much information that can be used in discussion to learn something from it to make one a better healthcare provider and not a lawyer.

At least now some will know how long an adult ETT is.


----------



## medic417 (Mar 8, 2009)

VentMedic said:


> So you think you just shove in a tube meant for the esophagus and it is idiot proof?
> 
> For those who think the combitube is idiot proof.
> http://pdm.medicine.wisc.edu/21-2%20PDFs/calkins.pdf



Wow 16-28% failure rate depending on how you look at it.  Regardless not really that good a percentage of success.  Plus damages to the patient with it.  Really need that out of the basics hands, and even from the lesser educated Paramedics.


----------

