# Sorry excuse for flight medics or anyone in this field.



## Chewy20 (Sep 13, 2014)

This happened a while ago, but I just came across this article. Sad that this crew who is supposed to be the "tip of the spear" in this field did not preform basic procedures that would have saved her life. Never be lazy!

http://www.emsworld.com/article/12003557/failed-intubation-leads-to-teens-death


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## DesertMedic66 (Sep 13, 2014)

We have had a couple of incidents with flight crews. One crew never check for bleeding on a trauma pt (pt had a lacerated femoral). The second crew took 30 minutes to land in the middle of a desert with a cleared LZ for a critical pedi patient.


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## Carlos Danger (Sep 13, 2014)

Chewy20 said:


> This happened a while ago, but I just came across this article. Sad that this crew who is supposed to be the "tip of the spear" in this field did not preform basic procedures that would have saved her life. Never be lazy!
> 
> http://www.emsworld.com/article/12003557/failed-intubation-leads-to-teens-death



Sadly, things like this are not actually uncommon. It's the dirty little secret of paramedicine.

I would be willing to bet that a scenario similar to this plays out _at least_ once a day, every day, somewhere in the US. The only thing that keeps it from being glaringly obvious is that it's very often unclear (or at least not evident) that the EMS crew was to blame because they don't show up at the ED with a tube in the goose. And even when it is obvious to the clinicians involved, it gets swept under the rug.

As long as we keep deluding ourselves into thinking that we are doing patients a favor by forcing a risky intervention on them that is rarely truly necessary and has never been proven beneficial when done in the field, and as long as we keep lying to ourselves that we are qualified to do so because we intubate a manikin quarterly or drop a couple tubes in the OR once a year, then things like this will keep happening a lot more often than we'd like to admit.


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## chaz90 (Sep 13, 2014)

The fact that this incident occurred with a flight crew really doesn't have any bearing on the situation. Failure to recognize an esophageal tube is inexcusable for anyone who ever performs any sort of intubation, let alone RSI. 

I very much feel for the author's loss and would agree from this article at least that the lawsuit is 100% justified. I think the point she makes to consider other options prior to RSI and continually reassess all patients is spot on and completely appropriate. Unfortunately, it also sounds like she's (understandably) emotionally compromised since she's personally invested in this particular situation. Her judgment of whether the initial decision to intubate her daughter was appropriate or not isn't really related to the rest of her argument. Two negligent providers who failed to follow basic medical procedures or protocols and never used any of their available safeguards or tools should not serve as an example for the rest of the profession.


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## jrm818 (Sep 13, 2014)

Remi said:


> Sadly, things like this are not actually uncommon. It's the dirty little secret of paramedicine.
> 
> I would be willing to bet that a scenario similar to this plays out _at least_ once a day, every day, somewhere in the US. The only thing that keeps it from being glaringly obvious is that it's very often unclear (or at least not evident) that the EMS crew was to blame because they don't show up at the ED with a tube in the goose. And even when it is obvious to the clinicians involved, it gets swept under the rug.
> 
> As long as we keep deluding ourselves into thinking that we are doing patients a favor by forcing a risky intervention on them that is rarely truly necessary and has never been proven beneficial when done in the field, and as long as we keep lying to ourselves that we are qualified to do so because we intubate a manikin quarterly or drop a couple tubes in the OR once a year, then things like this will keep happening a lot more often than we'd like to admit.



I don't disagree with the sentiment per se, but I don't think it's truly accurate to say that prehospital RSI has never been proven to be beneficial.  In fact the only RCT of which I am aware found a benefit in neurological recovery after TBI: http://www.ambulance.vic.gov.au/Med...10-73ad4108-1a88-43ff-b911-1be15c7cd334-0.pdf.

Of course there are several caveats: non-US study with intubation success that is higher than US studies have historically found, higher training than many/most US services, actually using your freaking tools (capnography etc.).  That said, while it is only one study, it is the best yet conducted.

In the end, if the events as reported in that article are correct, this sounds like a failure of both the individual providers and possibly the EMS sytem as a whole to create a culture of high-quality care, but not really an indictment of prehospital RSI as a concept.


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## Carlos Danger (Sep 13, 2014)

jrm818 said:


> I don't disagree with the sentiment per se, but I don't think it's truly accurate to say that prehospital RSI has never been proven to be beneficial.  In fact the only RCT of which I am aware found a benefit in neurological recovery after TBI: http://www.ambulance.vic.gov.au/Media/docs/RSI Annals Surg 2010-73ad4108-1a88-43ff-b911-1be15c7cd334-0.pdf.
> 
> Of course there are several caveats: non-US study with intubation success that is higher than US studies have historically found, higher training than many/most US services, actually using your freaking tools (capnography etc.).  That said, while it is only one study, it is the best yet conducted.
> 
> In the end, if the events as reported in that article are correct, this sounds like a failure of both the individual providers and possibly the EMS sytem as a whole to create a culture of high-quality care, but not really an indictment of prehospital RSI as a concept.



There have been literally dozens of studies done in the US on RSI, with most showing no benefit, and some showing increased mortality.

Sure, if we staffed ambulances with anesthesiologists, we'd probably have better outcomes in the US, too. So I suppose you are right that the problem has less to do with RSI as a procedure, and more to do with RSI routinely being performed by individuals woefully unqualified to do it.

The biggest problems I see are:

Paramedics being taught that everyone whose had their bell rung needs to be intubated, and that prevention of aspiration (which usually doesn't happen on its own and when it does, actually carries a very low risk of mortality in young, healthy patients) is worth any risk to the patient, and

Lack of basic airway skills. Paramedics simply don't know how to use a BVM and suction, so they aren't confident unless they have an ETT in place. When the only tool you have is a hammer, everything starts to look like a nail.


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## avdrummerboy (Sep 13, 2014)

We're starting to get away fro tubing so much as of late, many so called 'critical' calls being run in with 'BLS' airways and they do just fine, even seen a fair number do full recovery's.


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## jrm818 (Sep 13, 2014)

Remi said:


> There have been literally dozens of studies done in the US on RSI, with most showing no benefit, and some showing increased mortality.
> 
> Sure, if we staffed ambulances with anesthesiologists, we'd probably have better outcomes in the US, too. So I suppose you are right that the problem has less to do with RSI as a procedure, and more to do with RSI routinely being performed by individuals woefully unqualified to do it.
> 
> ...



Again, I agree with your list of problems, but not with your interpretation of the literature.  

There are no other randomized controlled studies of RSI of which I am aware.  The studies I assume you refer to are either case-controlled or uncontrolled and really can't speak to comparative mortality of RSI vs no RSI.  All of Dr. Wang's papers come to mind - that evidence certainly implies problems with the performance of US EMS services in terms of airway management as whole, but don't make RSI as an intervention a bad idea.   It wouldn't take staffing with anesthesiologists, just better trained medics in a better system.  I am sure that many or most US systems are currently too poor to perform at this level, but I also suspect that some services could produce similar results to our southern-hemisphere bretheren.

 The proof of concept exists - the only study done shows that well trained medics in a good system can improve outcomes with RSI.   The goal should be to get to that level, not throw out the whole idea.


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## Jim37F (Sep 13, 2014)

Wait a second? Did I miss something in the article? Why was an awake, albeit altered, but still breathing on their own patient a candidate for so much as an NPA, much less an ET tube?


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## chaz90 (Sep 13, 2014)

Jim37F said:


> Wait a second? Did I miss something in the article? Why was an awake, albeit altered, but still breathing on their own patient a candidate for so much as an NPA, much less an ET tube?


I can't speak to the specifics of this situation, but an altered/combative patient secondary to head injury who is being flown to a trauma center is certainly a candidate for RSI. Again, this is in general as I know nothing beyond this article about this patient. The whole point of RSI is to apply it to patients who are breathing on their own with varying degrees of intact airway reflexes.

I think jrm818 more succinctly made the point I was trying to clarify earlier. This was undoubtedly a failure by these providers, but I don't think it speaks to the validity of pre-hospital RSI when indicated and performed appropriately.


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## Rick Tresnak (Sep 13, 2014)

Even though this has been beaten like a stubborn horse, the use of equipment to verify placement is essential.  Once when I was flying we were moving the patient a 3 year old to the helicopter, the medic on scene was bagging the patient until we could get to the vent.  He stumbled briefly and said.  "Huh at least I saved the tube."  Yeah famous last words.  In the dead of night, I loaded the 3 year old male and as we got under the lights in the bird I noticed he was not looking as pink.  I used direct visualization and saw the tube was dislodged.  Put it back in place and finished the flight.  

Even if this wasn't noticed and the patient was placed on the vent and Co2 detection was not available and any service intubating needs ETCo2 at a minimum, this should never have happened.  (referring to the news article at the beginning of this thread)


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## Handsome Robb (Sep 14, 2014)

Without being there or having the other side to the story we cannot MMQB that crew.

With that said, if the article is factual that Medic and RN need have have their licenses pulled and the mom has a negligence suit set up....not that it'll bring her daughter back.


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## Carlos Danger (Sep 14, 2014)

jrm818 said:


> Again, I agree with your list of problems, but not with your interpretation of the literature.
> 
> There are no other randomized controlled studies of RSI of which I am aware.  The studies I assume you refer to are either case-controlled or uncontrolled and really can't speak to comparative mortality of RSI vs no RSI.  All of Dr. Wang's papers come to mind - that evidence certainly implies problems with the performance of US EMS services in terms of airway management as whole, but don't make RSI as an intervention a bad idea.   It wouldn't take staffing with anesthesiologists, just better trained medics in a better system.  I am sure that many or most US systems are currently too poor to perform at this level, but I also suspect that some services could produce similar results to our southern-hemisphere bretheren.
> 
> The proof of concept exists - the only study done shows that well trained medics in a good system can improve outcomes with RSI.   The goal should be to get to that level, not throw out the whole idea.



A handful of points:

This RCT was not "the only study done". There have been lots of quality studies done that show poor rates of airway management success in the US. You cannot simply ignore a large amount of data just because most of it is not randomized and prospective.

The RCT that you refer to is positive, but it is not overwhelmingly convincing. The improvements in the prehospital RSI group were barely statistically significant and probably not clinically significant. There was absolutely no difference in initial pH, Pa02, Pc02, Sp02, or vital signs, which raises the question of what the point of intubation is in the first place. It is also concerning that there was a five-fold increase in the number of cardiac arrests in the prehospital RSI group.

Importantly, given the substantial difference in training of Australian vs. American paramedics, the results of any study done overseas can not be extrapolated to the US anyway, no matter how positive it is.

I realize that there is wide variation in the quality of airway management across the US. This is reflected in the published literature, and I have also seen non-published data from several HEMS programs that shows truly impressive airway management stats. But collectively these make up a small percentage of EMS agencies.

Our approach to airway management is still based largely on assumptions rather than facts, and we tend to ignore things that don't support what we want to be true. Aspiration is probably much less of a risk in most patients than we were taught, for instance, and known risks for secondary brain injury (hypoxia, hypercarbia, hypotension) are common during prehospital airway management. 



jrm818 said:


> The goal should be to get to [a higher] level, not throw out the whole idea.



I think our goal should simply be to do what is best for our patients. Until we start looking for ways to do what is best instead of looking for ways to justify what we want to do, stories like the one the OP posted are going to be commonplace.


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## chaz90 (Sep 14, 2014)

Handsome Robb said:


> Without being there or having the other side to the story we cannot MMQB that crew.
> 
> With that said, if the article is factual that Medic and RN need have have their licenses pulled and the mom has a negligence suit set up....not that it'll bring her daughter back.


The family received a settlement and the crew member(s?) were reprimanded and had their licenses removed. Yes, I wasn't there to witness any of it myself, but with the following points I think a judgement call is fair in this case.

A. Eyewitness ground medic on scene who told the crew they had missed the trachea and was promptly ignored due to "seeing the tube pass the cords."

B. Documented positive check of capnography equipment at morning shift change with mysterious failure during call.

C. Failing to use SpO2 or cardiac monitoring prior to intubation.

D. Failure to reassess or trouble shoot tube placement as patient rapidly deteriorated with a distending abdomen and development of cyanosis.

We all know strange things can happen on calls and many procedures don't go perfectly either pre-hospitally or in hospital. I agree that Monday morning quarterbacking is rarely appropriate and we often lack the information to even have an opinion on calls in which we weren't directly involved. In this case though, the overwhelming evidence from this and additional sources is that the flight crew displayed gross negligence and incompetence in failing to recognize what turned out to be a fatal error.

As always, I remain open to new details.


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## Handsome Robb (Sep 14, 2014)

chaz90 said:


> The family received a settlement and the crew member(s?) were reprimanded and had their licenses removed. Yes, I wasn't there to witness any of it myself, but with the following points I think a judgement call is fair in this case.
> 
> A. Eyewitness ground medic on scene who told the crew they had missed the trachea and was promptly ignored due to "seeing the tube pass the cords."
> 
> ...



Never finished the article, went back and re-read it. 

I definitely agree. 

Your magic rotor dust doesn't automatically make you right...the fact the BLS Student on scene recognized it and they didn't makes it even worse.


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## Brandon O (Sep 14, 2014)

There are a lot of forgivable mistakes and gray areas out there, but in this day and age, walking into a hospital with a misplaced tube should not be one of them unless it got dislodged at the ED threshold.

There is a Swami quote that may apply here. "There are three unforgivable sins in emergency medicine – laziness, stupidity and arrogance. It’s preferable to have none of these. If you have one, you may be able to squeak by. If you have two, you are a waste of space." I think it's the perception of arrogance that chafes most in these stories. (Just the perception, because of course we don't know what truly happened.)


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## Rialaigh (Sep 14, 2014)

This speaks volumes to the QA departments at some of these "Critical care" services. I would hope that at our local service if you tube a patient and don't place capnography you would at a minimum be sent home a shift.


Take everything else out of this story and just absorb this point.

Endotracheal intubation was preformed and pulse ox and capnography were not placed when procedure was completed -

Frankly this ought to be grounds for home without pay for a first time offender, if you repeat this offense your a waste of space and dangerous and ought to be terminated.


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## avdrummerboy (Sep 14, 2014)

In terms of consequences for this crew, definite termination, they disregarded EVERY known protocol for ETT placement, they used nothing at their disposal, even though all of it was known to be working. As to the reasoning, can you drop a tube wrong? Sure. Get one dislodged? Absolutely. But when even the EMT STUDENT on scene takes note of it and points it out, it may be time to check placement!


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## Bearamedic (Sep 15, 2014)

I used to be a basic in a state that let basics intubate. I am glad they took the ability to intubate away from basics. During the transition, a lot of people got a genuine statistical lesson on just how (not) beneficial intubations actually are.


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## usalsfyre (Sep 15, 2014)

Somewhat familiar with the case as it happened in my state. The flight crew didn't place ETCO2 which is absolutely, unequivocally inexcusable. They screwed up, period. 

That said, the patient was certainly a candidate for RSI. Anyone who's ever tried to restrain a combative patient in the back of an ambulance knows how futile that can be, regardless of size. Now imagine shrinking it into the back of an aircraft.


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