# YIKES! Gut Tubed in Rhode Island x 12



## KingCountyMedic (Dec 4, 2019)

EMS Crews Brought Patients to the Hospital With Misplaced Breathing Tubes. None of Them Survived.
					

In the world of emergency medicine, an unrecognized esophageal intubation is a “never event,” meaning that it shouldn’t happen under any circumstances. In Rhode Island, it’s occurred 12 times in the last three years. In each case, the patient died.




					www.propublica.org
				




Places to never vacation. This is absolutely appalling.


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## mgr22 (Dec 4, 2019)

I think this quote from the article makes it even more appalling:

_But a coalition of Rhode Island’s EMS practitioners, municipal fire chiefs and a city mayor pushed back. They said the “ET tube,” as it’s known, saves lives. Taking it away, as one fire chief put it, “would be a sin.” A lobbyist for the firefighters union lambasted the doctors for not consulting more of its members before proposing such changes, saying, “We’re the experts ... not the doctors!”_


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## PotatoMedic (Dec 4, 2019)

It's interesting to read what the Rescuing Providence guy has to say about it.  https://m.facebook.com/story.php?st...6791&id=273947562721391&fs=0&focus_composer=0


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## Carlos Danger (Dec 4, 2019)

mgr22 said:


> I think this quote from the article makes it even more appalling:
> 
> _But a coalition of Rhode Island’s EMS practitioners, municipal fire chiefs and a city mayor pushed back. They said the “ET tube,” as it’s known, saves lives. Taking it away, as one fire chief put it, “would be a sin.” *A lobbyist for the firefighters union lambasted the doctors for not consulting more of its members before proposing such changes, saying, “We’re the experts ... not the doctors!”*_


That’s one of the most obvious and public displays of the Dunning-Kruger effect that I’ve ever seen.


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## E tank (Dec 4, 2019)

Providence has a certain culture that can make certain problems...er...disappear....


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## VentMonkey (Dec 4, 2019)

E tank said:


> Providence has a certain culture that can make certain problems...er...disappear....


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## medichopeful (Dec 4, 2019)

Does anybody have access to the full "We're the experts... not the doctors" quote?  I'm curious about what all was said.


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## mgr22 (Dec 4, 2019)

medichopeful said:


> Does anybody have access to the full "We're the experts... not the doctors" quote?  I'm curious about what all was said.



I took that paragraph from the article linked by the OP. It's all there for you to read.


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## medichopeful (Dec 4, 2019)

mgr22 said:


> I took that paragraph from the article linked by the OP. It's all there for you to read.



My apologies, I should have been more clear.  I'm wondering what the "..." is standing in for.


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## Tigger (Dec 4, 2019)

mgr22 said:


> I think this quote from the article makes it even more appalling:
> 
> _But a coalition of Rhode Island’s EMS practitioners, municipal fire chiefs and a city mayor pushed back. They said the “ET tube,” as it’s known, saves lives. Taking it away, as one fire chief put it, “would be a sin.” A lobbyist for the firefighters union lambasted the doctors for not consulting more of its members before proposing such changes, saying, “We’re the experts ... not the doctors!”_


The airway mismanagement is egregious. 

The use of intermediatesque providers with minimal educational standards to provide the vast majority of ALS is even worse.

But the above takes the cake for most appalling.


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## E tank (Dec 4, 2019)

VentMonkey said:


> View attachment 4668


So you've been to Providence, then?


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## VentMonkey (Dec 4, 2019)

E tank said:


> So you've been to Providence, then?


I know a thing or two about a thing or two...

In all honesty? No, but I picked up what you were putting down.

Back on topic: deplorable, just deplorable. I real don’t know much about this system.


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## SandpitMedic (Dec 4, 2019)

To clarify- These are not Paramedics who were doing this. This is giving all of EMS and all Paramedics a bad rap and requires very clear public statements and illustrations. They are EMT-Cardiacs; a unique construct by Rhode Island fire departments. 

It is basically a watered down and lowly trained version of a psuedo-Paramedic.  From what I gathered, FF unions had a lot to do with it, so that their firefighters wouldn’t have to become paramedics to provide “ALS” services. They have lobbied to prevent the application of true ALS training, education, and certification. 

And over on aisle 10 you can get some clown shoes.


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## Peak (Dec 5, 2019)

medichopeful said:


> Does anybody have access to the full "We're the experts... not the doctors" quote?  I'm curious about what all was said.



I really hope it was taken out of context, because wow. 

I also feel like they probably meant exactly what they said.


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## Tigger (Dec 5, 2019)

SandpitMedic said:


> To clarify- These are not Paramedics who were doing this. This is giving all of EMS and all Paramedics a bad rap and requires very clear public statements and illustrations. They are EMT-Cardiacs; a unique construct by Rhode Island fire departments.
> 
> It is basically a watered down and lowly trained version of a psuedo-Paramedic.  From what I gathered, FF unions had a lot to do with it, so that their firefighters wouldn’t have to become paramedics to provide “ALS” services. They have lobbied to prevent the application of true ALS training, education, and certification.
> 
> And over on aisle 10 you can get some clown shoes.


But really, don't we think there are probably plenty of paramedics in systems with really, really crappy oversight as demonstrated here? The initial airway training that paramedics get is not required to be anything approaching thorough and while most programs require a few live tubes, is that enough to make a substantive difference if the providers are left to their own devices?

I see this as a systematic failure of an entire system, not as a provider level issue, though that certainly doesn't help.


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## SandpitMedic (Dec 5, 2019)

Tigger said:


> But really, don't we think there are probably plenty of paramedics in systems with really, really crappy oversight as demonstrated here? The initial airway training that paramedics get is not required to be anything approaching thorough and while most programs require a few live tubes, is that enough to make a substantive difference if the providers are left to their own devices?
> 
> I see this as a systematic failure of an entire system, not as a provider level issue, though that certainly doesn't help.


Then you are using adverse outcomes which occurred in a specific jurisdiction under very unique and well defined circumstances as a straw mans argument for an issue that you perceive to be a bigger issue than it actually is. 

Most paramedics are not goosing the tubes, and with the widespread knowledge and use of ETCO2 as the gold standard, we are course correcting to almost no medics leaving a tube in the wrong hole.

Should there be more training, yes, absolutely, we agree. Perhaps if education were extended to allow more airway training in something like paramedic degree programs.


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## mgr22 (Dec 5, 2019)

medichopeful said:


> My apologies, I should have been more clear.  I'm wondering what the "..." is standing in for.



While the "..." could mean something was omitted from the quote, I think it's just showing a pause in speech in that context.


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## Aprz (Dec 5, 2019)

I think the people who post here are likely better and more humble than most EMTs and paramedics. I wouldn't be surprised if this is a nation wide problem that has gone unrecognized or ignored.


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## E tank (Dec 5, 2019)

Tigger said:


> I see this as a systematic failure of an entire system, not as a provider level issue, though that certainly doesn't help.



Agree with this...EMS is the most bizarre set up in all of health care in the US. It is the only provision of what can be advanced medical care that is partly ignored by the physicians that have responsibility for it.

 From firemen interfering with care on scene to stuff like this, those responsible for the direction and success of their delegated care blissfully and willfully remain ignorant until the patient rolls through the doors of the hospital as if the care he has received, good or bad, doesn't matter and just gets considered along with all of the other presenting factors. 

Broad generalization, yeah, but it is a major element in pre-hospital care in this country.


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## KingCountyMedic (Dec 5, 2019)

Looking into the FB page of one of their EMT cardiac folks (wannabe medics) their level of incompetence is nothing compared to their level of arrogance. 12 patients are dead, transported with GUT tubes and they just don’t get it! One guy said “Doctors miss tubes too”
I’m baffled that this goes on in 2019 American EMS.


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## SandpitMedic (Dec 5, 2019)

KingCountyMedic said:


> Looking into the FB page of one of their EMT cardiac folks (wannabe medics) their level of incompetence is nothing compared to their level of arrogance. 12 patients are dead, transported with GUT tubes and they just don’t get it! One guy said “Doctors miss tubes too”
> I’m baffled that this goes on in 2019 American EMS.


No one likes to admit they’re wrong. No one wants to make big changes. Even when it’s clear that it is needed. What a sad state of affairs.


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## akflightmedic (Dec 6, 2019)

Posted by a Rhode Island EMS contributor....think this mentality is endemic in the area, leading to less Medics and more EMT-Cardiacs, which then leads to dumbing down of education and missed tubes?


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## Summit (Dec 6, 2019)

Wow the comments in the article... the discussion on that FB page... wow

4% rate or unrecognized esophageal intubations... that is beyond appalling.


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## Tigger (Dec 6, 2019)

akflightmedic said:


> Posted by a Rhode Island EMS contributor....think this mentality is endemic in the area, leading to less Medics and more EMT-Cardiacs, which then leads to dumbing down of education and missed tubes?
> 
> View attachment 4672


Just by the by, Steve Berry lives and works in Colorado and not Rhode Island. I use to work with him at a part time spot.


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## VentMonkey (Dec 6, 2019)

Tigger said:


> Just by the by, Steve Berry lives and works in Colorado and not Rhode Island. I use to work with him at a part time spot.


Hmmm, Pridemark? I haven’t heard or seen his name is quite some time. Then again, I don’t read or subscribe to _Jems_ any longer.


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## Tigger (Dec 6, 2019)

VentMonkey said:


> Hmmm, Pridemark? I haven’t heard or seen his name is quite some time. Then again, I don’t read or subscribe to _Jems_ any longer.


No he's worked at the same, small rural service for decades.


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## Summit (Dec 6, 2019)

He gave a decent lecture at EMSAC this year


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## akflightmedic (Dec 6, 2019)

Tigger said:


> Just by the by, Steve Berry lives and works in Colorado and not Rhode Island. I use to work with him at a part time spot.


Aware....my comment was this was posted (shared) by a RI individual. Just saying....drawing relevance to the thought process of the topic at hand.


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## Tigger (Dec 6, 2019)

akflightmedic said:


> Aware....my comment was this was posted (shared) by a RI individual. Just saying....drawing relevance to the thought process of the topic at hand.


Gotcha I misunderstood.

That state really disdains paramedics. I believe you can bill ALS with EMT-Cs onboard, which is going to delay the change as well. Why put someone that you have to pay more on the truck when you get reimbursed the same? I'd like to think it's because folks see the value in paramedics, but man, the comments from those sitting in oversight positions make you think that's not the case.


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## SandpitMedic (Dec 6, 2019)

The memes online against Rhode Island EMS are nothing short of spectacular.


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## Summit (Dec 6, 2019)

SandpitMedic said:


> The memes online against Rhode Island EMS are nothing short of spectacular.


OK I wish to enjoy this... where do I find them?


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## SandpitMedic (Dec 6, 2019)

Summit said:


> OK I wish to enjoy this... where do I find them?


There’s a FB page called “Hittin’ it hard from the ambulance barn”....
Hilarious! You will love it, Summit.

PSA: If you’re sensitive—- you know how I feel about your sensitivities so don’t go “reporting” the funnies okay...


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## Summit (Dec 6, 2019)

SandpitMedic said:


> There’s a FB page called “Hittin’ it hard from the ambulance barn”....
> Hilarious! You will love it, Summit.
> 
> PSA: If you’re sensitive—- you know how I feel about your sensitivities so don’t go “reporting” the funnies okay...



My wife was wondering what I kept laughing at

Fav:


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## DrParasite (Dec 6, 2019)

SandpitMedic said:


> To clarify- These are not Paramedics who were doing this. This is giving all of EMS and all Paramedics a bad rap and requires very clear public statements and illustrations. They are EMT-Cardiacs; a unique construct by Rhode Island fire departments.


So I guess New York State's EMT-CC doesn't exist?  nor Virginia's Advanced EMTs?  or North Carolina's EMT Intermediates?  

using the term "EMT-Cardiac" might be unique to Rhode Island, however they are far from the only state that has an EMT level that is sort of ALS, but not a full paramedic. 

That all being said, the sheer number of unidentified esophageal intubations is appalling.  ETCO2 is the standard to verify that the tube is in the right place; why wasn't this used?   I could see mistakes when listening for lung sounds and belly sounds; but ETCO2 is an objective assessment tool... was it never checked?    

Just because the providers in question are firefighters or not full paramedics is really irrelevant; the fact that this was never checked showed a serious systemwide failure on the QA side, a failure at the state level mandating ETCO2 for all intubations, and a failure on the provider for not even bothering to check.


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## E tank (Dec 6, 2019)

DrParasite said:


> That all being said, the sheer number of unidentified esophageal intubations is appalling.  ETCO2 is the standard to verify that the tube is in the right place; why wasn't this used?   I could see mistakes when listening for lung sounds and belly sounds; but ETCO2 is an objective assessment tool... was it never checked?



ETCO2 is an indicator of, not verification for endotracheal intubation. The only practical ways to "verify" placement is direct visualization of the upper esophagus and glottis via DL or a chest XR.

Breath sounds, ETCO2,  "gastric auscultation" all fail and are only as good as the individuals being able to contextualize them to the whole picture. No substitute for training and experience and when things get technically difficult, those kinds of chops are not possible to have in a great many settings.


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## SandpitMedic (Dec 6, 2019)

DrParasite said:


> So I guess New York State's EMT-CC doesn't exist?  nor Virginia's Advanced EMTs?  or North Carolina's EMT Intermediates?
> 
> using the term "EMT-Cardiac" might be unique to Rhode Island, however they are far from the only state that has an EMT level that is sort of ALS, but not a full paramedic.
> 
> ...


I’m not getting into another beef with you.
It is what it is.

It matters _very_ much that they were firefighters because it was the fire union who lobbied to perpetuate the process and keep the status quo instead of allowing changes such as ETCO2 and video laryngoscopy. And then they doubled down on the whole thing by not acknowledging their failure.

Secondly, it is very relevant that they are not  “full” paramedics when this story will be used as a argument for potentially removing intubation from the scope nationwide. (What is not full” paramedic- you either are one or you are not one- there are no fractional paramedics???)

Also, advanced EMTs, EMT- Cardiacs, and Intermediates et al. are not “Advanced Life Support.” They are _Intermediate_ Life Support. It doesn’t matter that they exist elsewhere; what matters is that no other jurisdictions allow intubation by ILS. ILS folks get supraglottic airway devices- not intubation.

The only thing we agree on is it was appalling. Don’t worry, we aren’t bashing them because they are firemen.


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## DrParasite (Dec 6, 2019)

SandpitMedic said:


> I’m not getting into another beef with you.
> You don’t know what you don’t know and you routinely display that with seething arrogance.


 dude, you made ANOTHER ignorant statement and got called on it.  stop making BS claims and you won't be called out on it.  get it?  good.


SandpitMedic said:


> It matters _very_ much that they were firefighters because it was the fire union who lobbied to perpetuate the process and keep the status quo instead of allowing changes such as ETCO2 and video laryngoscopy. And then they doubled down on the whole thing by not acknowledging their failure.


you mean the EMT-cardiac's can't do ETC02?  i would imagine than an EMT cardiac can obtain a 12 lead.... unless your saying the RI lifepak's are special and they removed the ETCO2 feature.....


SandpitMedic said:


> Secondly, it is very relevant that they are not  “full” paramedics when this story will be used as a argument for potentially removing intubation from the scope nationwide. (What is not full” paramedic- you either are one or you are not one- there are no fractional paramedics???)


do you honestly think the state won't be looking at any other studies (esp the ones from SoCal) that show any other instances where fully certified paramedics miss intubations?


SandpitMedic said:


> Also, advanced EMTs, EMT- Cardiacs, and Intermediates et al. are not “Advanced Life Support.” They are _Intermediate_ Life Support. It doesn’t matter that they exist elsewhere; what matter is that no other jurisdictions allow intubation by ILS. ILS folks get supraglottic airway devices- not intubation.


ok, now I know you have no idea what you are talking about.... plenty of jurisdictions allow ILS folks to intubate. Maybe when you actually do some research you will find out how you really should stop making stuff up to make yourself sound smart. a simple google search would show you how wrong you are

Here, I decided to do some work for you: here is the NC EMS airway protocol: https://www.ncems.org/protocols/AR 1 Adult Airway Protocol Final 2017 Editable.pdf  look at who can do intubation.....  hint it, it doesn't start at the paramedic level.  you're welcome for the education.


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## SandpitMedic (Dec 6, 2019)

DrParasite said:


> dude, you made ANOTHER ignorant statement and got called on it.  stop making BS claims and you won't be called out on it.  get it?  good.
> you mean the EMT-cardiac's can't do ETC02?  i would imagine than an EMT cardiac can obtain a 12 lead.... unless your saying the RI lifepak's are special and they removed the ETCO2 feature.....
> do you honestly think the state won't be looking at any other studies (esp the ones from SoCal) that show any other instances where fully certified paramedics miss intubations?
> ok, now I know you have no idea what you are talking about.... plenty of jurisdictions allow ILS folks to intubate. Maybe when you actually do some research you will find out how you really should stop making stuff up to make yourself sound smart. a simple google search would show you how wrong you are
> ...


Here you go bud. From NREMT.org and EMS.gov



			https://www.ems.gov/education/EMSScope.pdf
		










						Advanced Emergency Medical Technicians | National Registry of Emergency Medical Technicians
					

The primary focus of the Advanced Emergency Medical Technician is to provide basic and limited advanced emergency medical care and transportation for critical and emergent patients who access the emergency medical system.



					www.nremt.org
				




Again- it does not matter that they exist. It is not a national standard of care for any level under that of paramedic to perform endotracheal intubation. Is that clear enough for you?

Yes- They should be doing continuous ETCO2 capnography. CAN they- I guess they can’t or they wouldn’t be having this issue. You ranting about the capabilities of a Lifepak is not germane to the conversation. The point is it is the standard of care.


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## VentMonkey (Dec 6, 2019)

For two highly educated providers, this is getting ridiculous. I’m out.


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## SandpitMedic (Dec 6, 2019)

VentMonkey said:


> For two highly educated providers, this is getting ridiculous. I’m out.


We get heated, but I’d have a beer with him.


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## SandpitMedic (Dec 7, 2019)

http://www.ncems.org/pdf/NCCEPandNCMB-List-Combined-Revised.pdf
		


@DrParasite its correct that NC has AEMTs that _can_ intubate.
They do not require that they can intubate as a skill, only that they allow for certain medical direction to allow for it at certain agencies. You would know better than I how often it is to see an AEMT intubating as you live there and I don’t.

For paramedics it is a required skill.
It is also a requirement to utilize continuous ETCO2 monitoring.

You are correct about NC, thank you for the education. _Some_ ILS systems allow for intubation-  I still say it is not the national standard, and the standard educational curriculum of AEMTs (screen shotted above) would suggest that as well.

We must not digress too much- these EMT Cardiacs are not AEMTs, so our side debate is really of little value to the conversation. Also- I was actually retracting/editing my initial opening statement towards you because I realized it was inflammatory, and I wanted to avoid an interweb dual. But you saw it just too soon.


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## Carlos Danger (Dec 7, 2019)

SandpitMedic said:


> The memes online against Rhode Island EMS are nothing short of spectacular.


Holy **** you were not kidding. Those are amazing.


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## DrParasite (Dec 7, 2019)

SandpitMedic said:


> _Some_ ILS systems allow for intubation-  I still say it is not the national standard, and the standard educational curriculum of AEMTs (screen shotted above) would suggest that as well.


you'd be surprised (or likely not) how many EMS systems don't follow the so called "national standard."  I think I read on here that Colorado EMTs could intubate, if they have a little extra training and got an endorsement from their medical director (but I could be wrong, I'm not sure)?  and last I heard, texas EMTs can do whatever they want, provided their medical director says they can (again, based on what I read on emt life).  And I'm sure there are other states that still have AEMTs or EMT-I's, but it's not as uncommon as you might think.


SandpitMedic said:


> We must not digress too much- these EMT Cardiacs are not AEMTs, so our side debate is really of little value to the conversation.


So if the EMT Cardiacs aren't AEMTS, what are they?  After checking out https://www.rapidsafety.com/rhode-island-cardiac-ric, which was the first site the showed up on a web search, this is how they describe the program:





> *Rhode Island Cardiac: RIC*
> Rhode Island Cardiac: RIC (Pre-requisite: AEMT)
> This is the entry level Advanced Life Support (ALS) course that is unique to the state of Rhode Island. It incorporates additional training in emergency cardiac pharmacology, electrophysiology and trauma management. The curriculum, although based on the national AEMT model, is uniquely incorporated by the State of Rhode Island. The minimum course hours for classroom are approximately 160 hours. National EMS Institute has adopted a 220 hour curriculum before pre-hospital patient contact requirements. The candidate will have to master ECG monitoring and treatment, patient assessment advanced skills and many other areas of study. National EMS Institute delivers the Rhode Island Cardiac course as a stand-alone course for those seeking licensure in Rhode Island and as a combination of AEMT/Cardiac.


I have no first hand knowledge about this, and can only go off what I find on the Net. 

it's bad that this happened, that it wasn't checked, and it looks like there is some education that was lacking or QA that failed in these 12 situations.  And a massive systemic failure if this was an accepted practice.


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## silver (Dec 7, 2019)

Remi said:


> That’s one of the most obvious and public displays of the Dunning-Kruger effect that I’ve ever seen.



Yes!! When ego, the desire to feel heroic, and the glorification of intubating completely blinds multiple groups of people. 
As Ronnie Coleman said "Everybody wants to be a bodybuilder, but nobody wants to lift no heavy-*** weights." Everyone wants to tube but not put in the education and training to become an expert on airway management.


Do you really only have to be successful on 8 manikins to be approved by the state?  https://www.ri.gov/SOS/businessassi.../get/EMTOrotrachealEndotrachealIntubation.pdf


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## KingCountyMedic (Dec 7, 2019)

This Doc in the article found this over a 2-3 year period. How long has this really been going on, and how many patients have really died I wonder?!? I know I come from the land of "You cough in front of me I'm tubing you" but at least we are pretty good at it. I've missed a tube every now and again over the years but even in the old days before ETCO2 we had proper training and a stethoscope, the ESO Bulb syringe detector and the color change ETCO2 thing. We would never be guilty of transporting a gut tube. It just doesn't happen when you have people that are Physician Trained and practice/know what they're doing. The claims of these morons that "they are the experts" or that they think these patients were accidently extubated and the tube went into the gut after transferring the patient to the hospital bed is just absolutely ridiculous. I have seen tubes pulled accidentally  over the years but for 12 cuffed tubes to be pulled and then accidentally reinserted into the esophagus...........Like I said: note to self, never go to RI, EVER.

They should pull charts from at least the last 10 years and investigate this further. People should probably lose their jobs and elected officials should probably get fired as well. Possibly even charges filed. If it was a family member of mine I'd get a bad *** Lawyer immediately.


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## E tank (Dec 7, 2019)

silver said:


> https://www.ri.gov/SOS/businessassi.../get/EMTOrotrachealEndotrachealIntubation.pdf



What does "Orotracheal/Endotracheal intubation" mean? Is there some distinction? That ambiguity on the part of the authorizing agency doesn't engender much confidence either...


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## SandpitMedic (Dec 7, 2019)

Yup, everyone seems to be on the same page- except those in RI.

Funny how their online description says nothing about intubation in their skill set, yet they intubate (poorly). It says they follow/base it on the national AEMT curriculum with additional cardiac related training, so what gives???

I have never been a real big fan of lawyers, but I too hope there are going to be some subpoenas going out for years of records.


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## SandpitMedic (Dec 7, 2019)

Remi said:


> Holy **** you were not kidding. Those are amazing.


 Haha! Oh yeah, with no sign of letting up.


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## Summit (Dec 7, 2019)

KingCountyMedic said:


> This Doc in the article found this over a 2-3 year period. How long has this really been going on, and how many patients have really died I wonder?!?
> ...
> They should pull charts from at least the last 10 years and investigate this further. People should probably lose their jobs and elected officials should probably get fired as well. Possibly even charges filed.


Filing charges is a ****ty way to go. Firing people over malpractice from 10 years ago isn't going to engender reporting. The ENTIRE system is broken. Reporting and education need to be coupled with responsibility and consequences.

RI clearly has a ****ed up system perpetuated by stupid people invested in, and made by, that ****ed up system.

Sure, I agree they should do a retrospective quality review... but why? Why bother?

RI just had plenty of evidence for change and the reaction was to circle the wagon and kick anyone supporting change out of the decision process.


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## SandpitMedic (Dec 7, 2019)

Summit said:


> RI just had plenty of evidence for change and the reaction was to circle the wagon and kick anyone supporting change out of the decision process.


To me, you answered your own question. If they won’t change on their own- bring in the lawyers and legal system. It is clear that Rogue Island EMS and FD are not going to police themselves.

It will be interesting to see if this story just goes away like so many do, or if additional investigations or overhaul will be pursued.


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## E tank (Dec 7, 2019)

SandpitMedic said:


> To me, you answered your own question. If they won’t change on their own- bring in the lawyers and legal system. It is clear that Rogue Island EMS and FD are not going to police themselves.
> 
> It will be interesting to see if this story just goes away like so many do, or if additional investigations or overhaul will be pursued.



Legal system? Like lawyers? How about some doctors sacking up and doing something? WTF do lawyers have to do with this?


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## KingCountyMedic (Dec 7, 2019)

I'm by no means a fan of lawyers... BUT

If you have a system so screwed up and supposedly it has been for years if not decades, and the folks running it have zero desire for change or improvement, what then? It sounds as if Physicians are almost run out of town if they speak up on behalf of patient care. 11 "gut tubes" with fatal outcomes in less than 3 years. If I had the attorney card I'd be looking for cases from the last 10 years or more and be looking into class action stuff.


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## SandpitMedic (Dec 7, 2019)

E tank said:


> Legal system? Like lawyers? How about some doctors sacking up and doing something? WTF do lawyers have to do with this?


I believe the doctors tried, but they can’t get past the fire unions. Like we’ve pointed out- they have doubled down on how they do business and their “capabilities.”

Let’s start getting some negligence investigations going. Let’s get some legal injunctions and investigations; let’s see if it’s more than just the few noted in the news. Let’s get some folks on the record. Let’s start punishing these hacks for allowing this to happen.

You can get a lawyer to chase an ambulance for a fender bender or a slip and fall... I’d say the lawyers can have a lot TF to do with it at this point. Med control failed, QA failed, EMS failed, and the FD has the balls to say they are smarter than everyone else and everything is fine.

Survivable codes negated by malpractice. Burn it down.


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## Lo2w (Dec 8, 2019)

DrParasite said:


> I think I read on here that Colorado EMTs could intubate, if they have a little extra training and got an endorsement from their medical director (but I could be wrong, I'm not sure)?



Not sure about the mountains but out of the protocols I looked at while job hunting on the front range I don't recall seeing anything about ETs for EMTS. IIRC I seem to remember supraglotic is the primary airway. At least for my vollie protocols and the service I'm hoping to get hired on. 

Colorado does allow IVs for EMTs with an additional class and some of the more rural services allow a broader range of medications at the EMT scope with the med director waiver.


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## Summit (Dec 8, 2019)

No intubation by EMT or AEMT in CO. We do have IVs for EMTs with a state compliant class (48+hr course with clinical). Because of this we have almost no AEMT courses or demand for them.

CO still has some leftover EMT-I/99 that kept up their state certs. They can intubate in some systems.

From what I can Google, RI EMT Cardiac is a 150 hour course over EMT


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## Lo2w (Dec 8, 2019)

Summit said:


> No intubation by EMT or AEMT in CO. We do have IVs for EMTs with a state compliant class (48+hr course with clinical). Because of this we have almost no AEMT courses or demand for them.
> 
> CO still has some leftover EMT-I that were Nremt I99s and kept up their state certs. They can intubate in some systems.



PCC is doing an AEMT this coming semester in Pueblo but that's all I could find.


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## Ensihoitaja (Dec 8, 2019)

Red Rocks has an AEMT program, as well. They market it more as a “paramedic prep” course, though.


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## DrParasite (Dec 9, 2019)

Summit said:


> No intubation by EMT or AEMT in CO. We do have IVs for EMTs with a state compliant class (48+hr course with clinical). Because of this we have almost no AEMT courses or demand for them.


I stand corrected.  I knew they could do something that started with I with a class; it was IV only, not Intubation.  


Summit said:


> From what I can Google, RI EMT Cardiac is a 150 hour course over EMT


Considering the NC EMT class is 200+ hours, I'm pretty shocked that RI has a kinda AEMT course that is only 150 hours.  And after reviewing the state protocols for RI (found at http://health.ri.gov/publications/protocols/StatewideEmergencyMedicalServices.pdf) it looks like they use the AEMT and EMT-C pretty interchangeably.

That's, ummmm, well, I'm glad I don't live in RI... that's pretty scary.  even the NYS EMT-CC was about 300-400 hours on top of the initial EMT training.


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## Bullets (Dec 9, 2019)

KingCountyMedic said:


> This Doc in the article found this over a 2-3 year period. How long has this really been going on, and how many patients have really died I wonder?!?


And he wasnt even looking for it, he was looking for data about scene times in cardiac arrests and HAPPENED upon these 11 cases. Imagine if he was looking

@DrParasite i think Maine or NH has AEMTs. When i went to NH for my NRP psychomotor there were a bunch of AEMTs testing out too and they were from that region.


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## SandpitMedic (Dec 10, 2019)

DrParasite said:


> I'm glad I don't live in RI...


You can say that again.


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## akflightmedic (Dec 10, 2019)

Maine indeed has AEMTs....cheaper by the dozen! The BIG skill, protocol change for this year regarding AEMTs is...wait for it....they are now allowed to give ODT Zofran!!! Woot Woot!!!


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## PotatoMedic (Dec 10, 2019)

akflightmedic said:


> Maine indeed has AEMTs....cheaper by the dozen! The BIG skill, protocol change for this year regarding AEMTs is...wait for it....they are now allowed to give ODT Zofran!!! Woot Woot!!!


Very risky!  Gotta be careful about that QT prolongation. 🙄


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## DrParasite (Dec 10, 2019)

PotatoMedic said:


> Very risky!  Gotta be careful about that QT prolongation. 🙄


yeah, that's what I have always been told, which is why it is a paramedic only drug....

that being said, I have yet to find a single medic who has ever seen it in the field, and IM Zofran (or PO even) would make an awesome addition to the EMT drug skill set!!!! And as a former recipient of it, it's awesome and makes patients feel a lot better.


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## Lo2w (Dec 10, 2019)

DrParasite said:


> IM Zofran (or PO even) would make an awesome addition to the EMT drug skill set!!!!



Come to Colorado


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## PotatoMedic (Dec 10, 2019)

DrParasite said:


> yeah, that's what I have always been told, which is why it is a paramedic only drug....
> 
> that being said, I have yet to find a single medic who has ever seen it in the field, and IM Zofran (or PO even) would make an awesome addition to the EMT drug skill set!!!! And as a former recipient of it, it's awesome and makes patients feel a lot better.


I hope you know I was being sarcastic.  Zofran at the bls level would be amazing.


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## Tigger (Dec 10, 2019)

akflightmedic said:


> Maine indeed has AEMTs....cheaper by the dozen! The BIG skill, protocol change for this year regarding AEMTs is...wait for it....they are now allowed to give ODT Zofran!!! Woot Woot!!!


My impression from visiting (parents live there) is that Paramedics are at least utilized through much of the state compared to RI and VT. 

Zofran ODT is standing orders for Colorado EMTs, those with the IV endorsement add it IM and IV. I can't imagine going back to a world where my partner couldn't handle some nausea/vomiting, but so it goes I guess.

Interestingly, there is finally a push in Colorado to expand the number of AEMTs. There are some significant corollaries to what has/is happened in Rhode Island. 

The IV endorsement came to be in Colorado to expand the rural EMTs scope of practice. In reality, the course is a near requirement to be a paid EMT and many employers see the value in having their EMTs be good "paramedic assistants." While their are rural providers who have the endorsement, it ended up being somewhat rare. It was a solution to a problem that didn't really exist either, as I think we all know that IVs aren't exactly lifesaving.

There is no "official" curriculum for the IV endorsement curriculum, which in addition to IV and IO access adds NS/LR boluses, Dextrose IV, and Narcan IV. There is no actual hour requirement. There is a recommendation for 10 "live sticks" but precious little additional clinical rotation guidelines. Some of these classes get run in eight hours. 

See any similarities to Rhode Island? A class constructed to the "needs" of the state with apparently precious little oversight. These providers have invasive skills in their toolbox, but no idea how to properly utilize them. Obviously poor IV technique does not hold a candle to esophageal intubation. But some education groups in Colorado (Pikes Peak CC among others for those local), are no longer comfortable with signing off on EMTs to start IVs as there is no demonstrable standard for what IV training for EMTs should look like. There is however, a standard for NR AEMTs which of course includes IV initiation. As such, we are trying to encourage departments that want IV classes to instead look to a hybrid AEMT class that will at least meet a national standard for EMS education. Yes, it's more hours for (essentially) the same scope of practice, and that's ok. It's at least vetted.


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## Summit (Dec 10, 2019)

Tigger said:


> There is no "official" curriculum for the IV endorsement curriculum, which in addition to IV and IO access adds NS/LR boluses, Dextrose IV, and Narcan IV. There is no actual hour requirement. There is a recommendation for 10 "live sticks" but precious little additional clinical rotation guidelines. Some of these classes get run in eight hours.


Wow, I thought there were more standards. The class I took 15 years ago was 2 college credits and was 30+ hours of lecture and lab including vascular A&P, acid base balance, fluid/electrolyte balance, cell respiration, diffusion/osmosis, osmolality/osmolality, complications, conditions, indications, medications, complications, technique, practice on IV manakin arms, practice on classmates, then 10 successful live sticks minimum in the DG ED.

Sure, you can teach the psychomotor skill in 8 hours. Army includes IV in their 40 hour CLS course... and needle decompression as well. But skills only isn't what we want.

It should be noted that most RNs are not taught IV _skills_ in school, although they get all the requisite educational theory. They may do them in clinical under the supervision of RN preceptors. RN schools decided that RN students practicing IVs on each other is too risky. IVs are generally learned as OJT after hire.

Medical Assistants start IVs too and this is mostly OJT, not program taught.

The reason why goes back to the simple fact: *establishing peripheral venous access, though invasive, is very low risk. It is what you do with that access that is high risk and truly invasive.*


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## Tigger (Dec 10, 2019)

Summit said:


> Wow, I thought there were more standards. The class I took 15 years ago was 2 college credits and was 30+ hours of lecture and lab including vascular A&P, acid base balance, fluid/electrolyte balance, cell respiration, diffusion/osmosis, osmolality/osmolality, complications, conditions, indications, medications, complications, technique, practice on IV manakin arms, practice on classmates, then 10 successful live sticks minimum in the DG ED.
> 
> The reason why goes back to the simple fact: *establishing peripheral venous access, though invasive, is very low risk. It is what you do with that access that is high risk and truly invasive.*


At my CC's program, that's about the curriculum we teach so we can offer it for credit. But not everyone does that of course.

I understand that it is relatively low risk but I think as healthcare moves forward we are going to have to move away from OJT education to a degree. That is not something I necessarily like, but with so many entities wanting more "proof" of procedures and policy, we won't have a choice.


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## Ensihoitaja (Dec 11, 2019)

There is a Colorado state IV Course Curriculum. Also TIL that IOs are included now.


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## Tigger (Dec 11, 2019)

Ensihoitaja said:


> There is a Colorado state IV Course Curriculum. Also TIL that IOs are included now.


I think the issue is that you do not actually have to follow this. There is no oversight from the state regarding these classes. If you're an education group, you can offer it.

As for IOs, my understanding is there is no more waiver for EMTs obtaining IO access in cardiac arrest.


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## SandpitMedic (Dec 16, 2019)

Ah, and now the mayor (retired FF) is also siding with the FF unions that they don’t need better training. At an EMS meeting last week the FF unions tripled down saying the study showing 12 deaths due to the gutted tubes was ... get this... _“FAKE NEWS!”_

They accused the physicians desiring more EMS training of “having an agenda.”

What a freaking joke in Rogue Island! Um, yeah, an agenda of having good EMS!

Again, bring on the class action lawsuits and negligence charges and burn that whole system down for a hard reset.









						Commentary: Firefighters Need Better EMS Training
					

Rhode Island firefighters are fighting back against a report from The Public's Radio and ProPublica on misplaced breathing tubes that have cost lives. The Public’s Radio political analyst Scott MacKay says it’s time for fire officials to face reality and work for better training for emergency...




					thepublicsradio.org


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## DrParasite (Dec 16, 2019)

I have a question (and it's a request for information only): 





> he had identified 11 patients with botched intubations that were not recognized by EMS first responders over about two and a half years. They all died.


What is the "accepted" margin of error in heathcare or in the hospitals for esophageal intubations?  Is 1 per year an acceptable "margin or error"I mean, statewide, that's 12 in 2.5 years (another was found after the research was given to the state), and why didn't the ER's immediately identify the esophageal intubations and fix the issue?  Yes, we should aim for 0, however what do the risk people say is an acceptable number before those skill should be taken away, because the risk is too great?

I will also agree this statement by the union: the physicians "don’t know what it is like to respond to emergencies because they work in hospitals, with bright lights and a lot of people helping them."  it's a lot easier to perform when you have all the light and space you could want, and can move the patient to make things easier. HOWEVER, that is no excuse for not utilizing various methods to verify that you didn't intubate the stomach.  putting a tube in the esophagus WILL happen; not recognizing it and not correcting its placement is an unforgivable error.


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## Summit (Dec 16, 2019)

@DrParasite the "accepted" margin for UNRECOGNIZED is zero. The study didn't quantify corrected situations, only unrecognized ones.

And as to the ER, the accounts from the original article are clear that the ERs tried to "fix" the issue, but you know very well that there isn't any fixing to be done when someone has been gut tubed for a 20 minutes.


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## Lo2w (Dec 16, 2019)

Funny enough when you try to google "eti error rates in hospital" it kicks back a whole page of EMS issues.

I know the RSIs I've seen in the ER, the doc is tubing with RT and RN at bedside, confirmed by auscultation and radiology is outside with the portable xray to visually confirm placement.


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## akflightmedic (Dec 16, 2019)

I am unsure if you are pro or con regarding the claim that no *unrecognized *intubations should ever occur.

All the tools, lights, and staff in the world still does not excuse or justify a failed intubation. Have I tubed the esophagus before? Absolutely...but when recognized by using the tools provided, I removed the tube and started over.

The fact that failed tubes made it thru transport before being caught is abysmal. Just thinking of the timing involved, of course the patients died. Let's say a generous 8 minutes from time patient drops until EMS arrives. Intubation within 3-5 minutes. Working the call, moving to the unit, transporting, moving patient inside and transferring care....seriously, we are easily a solid half hour of belly breathing if not more.

Why did no reassessments catch this? Every time they were moved, lung sounds rechecked? Capnography? Etc...failure all around and no justification for not observing a failed intubation.

And why are they transporting??? Entirely different discussion, but as backwards as Maine is, here we do not transport unless ROSC occurs. 20 minute codes is normal. The other week I worked one for about 35 minutes and that was only because he stayed in persistent fine vfib. Finally called the doc and informed him what was going on, he said up to you guys...if we agree to terminate, we terminate. Hung up phone, askedall crew if anyone objects, said we will do one more round then terminate. That is what we did.


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## DrParasite (Dec 16, 2019)

Summit said:


> @DrParasite the "accepted" margin for UNRECOGNIZED is zero. The study didn't quantify corrected situations, only unrecognized ones.


not disagreeing with you, but that means if ANYONE in the hospital performs an unrecognized esophageal intubations, than that means EVERYONE loses the ability to intubate, hospital wide.   that decision needs to be made at the agency or higher level as to what type of error is an acceptable risk.  There are differences between a goal (what we are looking for, which is 0) and an acceptable risk (how many we will allow before we start taking action and removing said skill to prevent the issue from ever occuring).


Lo2w said:


> I know the RSIs I've seen in the ER, the doc is tubing with RT and RN at bedside, confirmed by auscultation and radiology is outside with the portable xray to visually confirm placement.


Which is the advantage of intubating in the hospital... you have get an xray confirming placement moments later.... most of us don't have that ability in the field... and they have better toys to visualize that we don't have access to.

Most intubations are handled by anesthesia, so I did find these articles and studies:








						Complications and failure of airway management
					

Summary. Airway management complications causing temporary patient harm are common, but serious injury is rare. Because most airways are easy, most complication




					academic.oup.com
				





			https://medpharm.tandfonline.com/doi/full/10.1080/22201181.2018.1435385
		


I'm not saying the RI guys should get a pass on these epic screwups; but there are differences between a controlled or semi-controlled intubation and what prehospital providers often encounter. But these EMT-Cardiacs screwed up big time, and something needs to be done about it.


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## SandpitMedic (Dec 16, 2019)

DrParasite, are you playing devil's advocate here? I'm not sure what you're trying to get at.
Comparing the training of EMTs to that of ER physicians and anesthesia; that calculus just doesn't work out in my head... Maybe I just haven't had enough coffee.
I never needed a chest Xray to know if I was in or not, nor have others according to their posts...that's an ER thing because they have that capability and it is a nice check in the box... just saying.


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## SandpitMedic (Dec 16, 2019)

Also, I dont think it matters in this circumstance what ERs and hospitals do. Let's just simply compare them to other EMS systems, and we see there is a huge problem. Multiple problems based on their official responses.


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## Summit (Dec 16, 2019)

Post-intubation  x-ray is NOT to confirm that the placement is tracheal vs esophageal. Hospitals use etCO2, auscultation, chest rise, and patient assessment for that. Just like the RI EMT Cardiacs should have.


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## DrParasite (Dec 16, 2019)

As was mentioned earlier by a more experienced provider than me when I mentioned verifying proper placement by ETCO2:


E tank said:


> ETCO2 is an indicator of, not verification for endotracheal intubation. The only practical ways to "verify" placement is direct visualization of the upper esophagus and glottis via DL or a chest XR.
> 
> Breath sounds, ETCO2,  "gastric auscultation" all fail and are only as good as the individuals being able to contextualize them to the whole picture. No substitute for training and experience and when things get technically difficult, those kinds of chops are not possible to have in a great many settings.


I'm not playing devil's advocate, but I'm trying to be realistic: if the procedure, drug, or tool is too risky, when the NNT (number needed to treat) isn't as beneficial as it needs to be to outweigh the risk, than it gets removed. basic risk management and how we can advance medicine and try new things (or take away stuff that doesn't work or help most people).

If we are going to look at intubation by EMS, there are plenty of studies that show that we, in general, suck at it.  now, there are reasons for that (and I think many of them are location specific, but I digress), but if we consider medicine as a whole, and consider ourselves part of medicine, than we need to look at what others do, and what the standards of the medical community are when it comes to intubation.  Last I checked, the only people who intubate are paramedics and anesthetist (and CRNA), with the occasional ER doc.  but most don't.  So we need to expand our sample circle, beyond what we do, to see what others in healthcare do.

and @Summit, I agree with you, the RI EMT-Cs should have used ETCO2 to confirm... I'd like to know why they didn't.


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## SandpitMedic (Dec 16, 2019)

ETCO2 is the metric. 
I'd also like to see an official statement from the RI fire departments on why they don't utilize it or utilize it incorrectly if at all.


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## Peak (Dec 16, 2019)

An unrecognized gut tube in the hospital is a sentinel event, and for us requires a report to the state.

We gut tube people all of the time, especially during messy codes. We also recognize that about two breaths in. Then we pull the tube and start over.


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## E tank (Dec 16, 2019)

DrParasite said:


> I'm not playing devil's advocate, but I'm trying to be realistic: if the procedure, drug, or tool is too risky, when the NNT (number needed to treat) isn't as beneficial as it needs to be to outweigh the risk, than it gets removed....
> 
> If we are going to look at intubation by EMS, there are plenty of studies that show that we, in general, suck at it.  now, there are reasons for that (and I think many of them are location specific, but I digress), .... we need to look at what others do, and what the standards of the medical community are when it comes to intubation.  Last I checked, the only people who intubate are paramedics and anesthetist (and CRNA), with the occasional ER doc.  but most don't.  So we need to expand our sample circle, beyond what we do, to see what others in healthcare do.



I don't think this is a process problem, ie, we can solve our problems by looking at successful groups that intubate, emulate them, problem solved. There a false notion of passing a certain number threshold of intubations in order to arrive at competency. Pick a number. That's false because it's only valid for one type of situational/anatomic presentation.

So say 40 straight forward tubes= competency for easy intubations. Now 40 are needed for soiled airways, 40 for obese, no neck airways, 40 for obese, no neck soiled airways...and the list goes on and on and the multipliers become more and more complex.

The best services can intubate easy airways first try as well as any in-hospital intubator...The best services that can't intubate a difficult airway are lumped in with RI when RI can't intubate an easy one and there's no teasing out the difference when taking a 10,000 foot view of the issue of "pre-hospital intubation".

There are supraglottic airways now...the writing is on the wall...


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## Carlos Danger (Dec 16, 2019)

DrParasite said:


> I have a question (and it's a request for information only): What is the "accepted" margin of error in heathcare or in the hospitals for esophageal intubations?


Zero. The "accepted" incidence of unaddressed esophageal intubations is zero. Zero in the field, zero in the ED, zero in the OR. Zero.

We aren't talking about doing everything right and still failing to successfully manage a difficult airway that was beyond your capability due to lack of tools and experience, we are talking about _making a choice_ not to use simple and reliable methods to ensure that the ETT ended up where it is supposed to be. Not doing so is malpractice, plain and simple. It is not a simple mistake. It borders on criminal negligence, IMHO.



DrParasite said:


> that means if ANYONE in the hospital performs an unrecognized esophageal intubations, than that means EVERYONE loses the ability to intubate, hospital wide.


No, that is completely absurd. There is no logic whatsoever in that idea. However, what IS logical, and what you WOULD see if people in the hospital were routinely gut-tubing patients and not recognizing it, is a removal of intubation from the credentialing of the group that is guilty of the screwups.



DrParasite said:


> Which is the advantage of intubating in the hospital... you have get an xray confirming placement moments later.... most of us don't have that ability in the field... and they have better toys to visualize that we don't have access to.


No, a chest x-pray  is absolutely NOT used to rule out a gut tube. It takes long enough to get and read a portable CXR that you'd routinely see profound desaturation, regurgitation with aspiration, and a lot more post-intubation cardiac arrests if imaging were being relied on to tell the intubator whether or not the tube was in the right hole.

Post-intubation CXR's are useful for confirming the ETT tip in relation to the carina, as well as assessing all sorts of anatomical and clinical factors. Getting a chest x-ray on a patient who required intubation is like getting a BMP on a generally sick patient: it's cheap, it's quick, it's noninvasive, and it could very well tell you something important that you wouldn't otherwise know. If nothing else, it gives you a baseline to compare subsequent assessments to.

But the NUMBER ONE reason why CXR's are routinely done immediately post intubation is to COVER THE *** OF THE INTUBATOR. Precisely because there is no justifiable reason whatsoever for failing to recognize a tube in the goose, you WANT that photograph which objectively proves that you put the tube in the right place. That way, when a half hour later the staff dislodges the ETT when they are moving the patient from the ED stretcher to the ICU bed, you don't have to worry about anyone claiming that it was your fault because the tube was never properly placed to begin with.


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