# Unrecognized esophageal intubation



## Carlos Danger (Mar 28, 2017)

I remember reading about this incident shortly after it happened. It wasn't far from where I was going to grad school at the time. Just came across this video on FB, though. I'm sure some of you have seen it already. 

I'd like to believe this type of gross incompetence is rare, and I do think UEI is a lot less common than it was years ago, but I still think this type of thing happens much more than we realize, or want to admit. 





__ https://www.facebook.com/video.php?v=659035010950649


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## GMCmedic (Mar 28, 2017)

We had a local incident where a new paramedic RSI'd a combative patient. Thats a big no no around here. No paralytics were given but enough benzos with an UEI. Patient ended up with an Anoxic brain injury.

He and his partner argued that the hospital pulled the tube but they failed to use capnography so they had no back up. 

His cert was pulled thankfully. 

Sent from my SAMSUNG-SM-G920A using Tapatalk


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## EpiEMS (Mar 28, 2017)

I have to wonder how often this (*unrecognized* intubation failures) is happening these days, given that ETCO2 is sort of de rigueur for intubation.


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## DrParasite (Mar 28, 2017)

I was kinda working that myself..... intubating the esophagus is bad, but it happens... with all the objective toys (ETCO2 being the big one for me), plus listen for noise over chest chest and stomach, and the color changing thing, and moisture in the tube (and still the ETCO2, which is nearly impossible to misread), how often do these things happen?  

and more accurately, is it happening because the provider isn't given the proper tools (which is an agency issue), or because the provider failed to use the tools that were given to them (which is a provider issue)


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## EpiEMS (Mar 28, 2017)

DrParasite said:


> and more accurately, is it happening because the provider isn't given the proper tools (which is an agency issue), or because the provider failed to use the tools that were given to them (which is a provider issue)



That's a good question.

I would say, though, that if you don't have the proper tools to verify a correctly placed ETT/identify an incorrectly placed ETT, you shouldn't be performing ETI, right?


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## Eden (Mar 28, 2017)

So basically they tubed him and didnt use capnography?
Paralyzing without capnography...that is some next level stupidity.
And i think that if you rsi, colormetric detector is not enough. Only real time capnography.


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## VentMonkey (Mar 28, 2017)

EpiEMS said:


> I would say, though, that if you don't have the proper tools to verify a correctly placed ETT/identify an incorrectly placed ETT, you shouldn't be performing ETI, right?


Absolutely correct.


GMCmedic said:


> We had a local incident where a new paramedic *RSI'd* a combative patient. *No* *paralytics were given* but enough benzos with an UEI.





Eden said:


> So basically they tubed him and didnt use capnography?
> *Paralyzing* without capnography...that is some next level stupidity.


Just for clarification this is *NOT* an RSI. It's an often dangerously poor way to go about "assisting" an intubation in the prehospital arena. 

Otherwise @Eden you are correct, Litmus paper alone is not reliable, and has more variables to produce erroneous readings over ETCO2. Not to mention being able to utilize ETCO2 to assist in guiding your ventilation strategies.


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## Eden (Mar 28, 2017)

O


VentMonkey said:


> Absolutely correct.
> 
> 
> Just for clarification this is *NOT* an RSI. It's an often dangerously poor way to go about "assisting" an intubation in the prehospital arena.
> ...


Mmm, yea i get what they did now.
Thanks.


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## StCEMT (Mar 28, 2017)

I would agree. Are there services with intubation in their protocol that dont actually even have EtCO2 adapters?


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## hometownmedic5 (Mar 28, 2017)

If you're an intubating service, etco2 should be mandatory. It's 2017. Anything less is simply unacceptable. 

If you have etco2 and have an unrecognized esophageal intubation, you are grossly incompetent and deserve to have your card revoked on the spot. 

When in doubt, pull it out. There is no acceptable excuse for this to happen. None.


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## TXmed (Mar 28, 2017)

Ran one something very similar to this a few months back. Teenager old auto-ped. Ground crew chose to RSI prior to us getting their (probably because they wanted the tube) and it was UEI. The worse part was they had ETCO2 hooked up and it showed no waveform, so they pulled it off before we got in the back ( I printed off their code summery) and we had to re-intubate. As an educator, paramedics making mistakes does not bother me at all, i use it as teaching moments for them and also myself. But I have no tolerance for paramedics who are neglectful.


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## NomadicMedic (Mar 28, 2017)

StCEMT said:


> I would agree. Are there services with intubation in their protocol that dont actually even have EtCO2 adapters?



Yes. Happens frequently. And a service close by me has a ghetto intubation protocol that allows for Etomidate intubation, no paralysis.


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## E tank (Mar 28, 2017)

Wow...buzz kill...I have teenagers...

...none of that would have happened if he didn't extubate himself in the first place. Very few details  in the video, but for a teenager to be electively intubated without being adequately sedated (which means comatose) +/- muscle relaxant and sent for an hour and a half ground ride is kind of crazy. An unrecognized esophageal tube during a thrash in the ICU or ER isn't beyond imagination let alone in the back of a cramped ambulance. 

Yeah, sounds like poor training and lack of experience contributed greatly to this kid's death, but staying out of trouble requires as much training and experience as getting out of trouble.  Fail X 2.

BTW, the dialogue in that video was very realistic...would have found myself half wondering if that weren't  actual footage were it not for the fact that the kid never turned blue.


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## StCEMT (Mar 28, 2017)

NomadicMedic said:


> Yes. Happens frequently. And a service close by me has a ghetto intubation protocol that allows for Etomidate intubation, no paralysis.


What reason could there possibly be to not have it besides lazyness? 

Pardon the ignorance, but what makes that ghetto? (I too have the ghetto protocol with a Ketamine backup/alternative).


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## EpiEMS (Mar 28, 2017)

FYI - NAEMSP issued a position paper back in 1999 stating: "In the patient with a perfusing rhythm, end-tidal CO, detection is the best method for verification. In the absence of a perfusing rhythm, capnography may be extremely helpful, and may be superior to colorimetric methods."


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## NomadicMedic (Mar 28, 2017)

StCEMT said:


> What reason could there possibly be to not have it besides lazyness?
> 
> Pardon the ignorance, but what makes that ghetto? (I too have the ghetto protocol with a Ketamine backup/alternative).



A drug facilitated intubation without a paralytic is a horrendously bad idea. 
You're not paralyzing them to make sure they don't get up and run away, you're paralyzing them to prevent vomiting and aspiration. Most patients that require an RSI haven't been NPO for the last several hours, so the chances of all that pizza and beer ending up in the lungs are pretty good.


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## E tank (Mar 28, 2017)

EpiEMS said:


> FYI - NAEMSP issued a position paper back in 1999 stating: "In the patient with a perfusing rhythm, end-tidal CO, detection is the best method for verification. In the absence of a perfusing rhythm, capnography may be extremely helpful, and may be superior to colorimetric methods."



Its only as good as the people using it.


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## VentMonkey (Mar 28, 2017)

NomadicMedic said:


> You're not paralyzing them to make sure they don't get up and run away, *you're paralyzing them to prevent vomiting and aspiration*.


@StCEMT 1,000 x this^^^. It facilitates first pass success, and makes for (in theory) a less trauamtic experience. I'm sure the CRNA's here can elaborate further, but I believe it is/ was one of the primary reasons for its implementation in the first place. 

I wouldn't necessarily call it cheating so much, but if it is in your formulary, you should have a firm grasp on it as an entire process (alpha and omega) to include not assuming rapid is taken quite literally. 

Also, St do you guys do DSI with your Ketamine protocols? Color me jealous, but I think I would prefer this method for ground units more so than an RSI protocol in most cases (yeah, yeah, I know @Handsome Robb, y'all have cookies...).


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## StCEMT (Mar 28, 2017)

@NomadicMedic, understood. 

@VentMonkey, it's not actually specified as DSI. Our intubation protocol just says to use Ketamine if we don't have etomidate or if ketamine would be more appropriate. DSI is essentially what I would do if I opted to use Ketamine for whatever reason.


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## EpiEMS (Mar 28, 2017)

E tank said:


> Its only as good as the people using it.



Absolutely, and I think you'd agree that therein lies the argument to limit its use by underqualified practitioners (like myself ).


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## E tank (Mar 28, 2017)

EpiEMS said:


> Absolutely, and I think you'd agree that therein lies the argument to limit its use by underqualified practitioners (like myself ).



Absolutely not..."qualified" can mean a lot of things (see above video) but there is no substitute for training and probably more importantly, experience. 

I've seen more Charlie Foxtrot's than I care to count and I can say there is no error too egregious that can't be missed simply by wishing  hard enough for it not to be there. 

The doc on the phone in that scenario picked up on the esophageal tube. Remember how convinced the medic sounded that it was in the trachea? Makes me wonder if the folks in the back of that ambulance would have done anything different if they had some kind of ETCO2 indicator. Especially after blowing a bunch of gas into that kids stomach with the bag.


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## EpiEMS (Mar 28, 2017)

@E tank Fair enough - so it is a story of inadequate training, more than anything else?


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## E tank (Mar 28, 2017)

EpiEMS said:


> @E tank Fair enough - so it is a story of inadequate training, more than anything else?



Well, training without experience, or at least regular drilling, is only as good as it is fresh in mind, which is about a day or two. The military, for all of its faults has perfected that idea. Most of what they train for, they never have to do, but they drill like hell in case they do have to do what they trained for and it really works. That's why interactive patient simulators are getting so popular in residency/anesthesia training programs. They're good for everyone, not just trainees.


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## Carlos Danger (Mar 28, 2017)

E tank said:


> The doc on the phone in that scenario picked up on the esophageal tube. *Remember how convinced the medic sounded that it was in the trachea? Makes me wonder if the folks in the back of that ambulance would have done anything different if they had some kind of ETCO2 indicator. *Especially after blowing a bunch of gas into that kids stomach with the bag.



And this is exactly why simply mandating another piece of equipment isn't enough to prevent this kind of thing.

I don't know if they didn't have Etc02 available, or if they had Etc02 available and just didn't use it, or if they had it available, used it, and ignored the results because it didn't match their ideation that the tube was properly placed. It really doesn't matter; I've seen it go down each of those ways.

I'll (sort of) give the crew the benefit of the doubt and assume that they did not have Etc02 available. But given everything else, I kind of find it hard to believe that it even would have mattered much. To start with, the person holding pressure said "I don't feel you". Secondly, the intubator obviously did _not_ actually see the cords, but was convinced that she did. Next, the BVETT feels completely different when you are ventilating the esophagus vs. the trachea. Also, in a thin 13 year old, breath and/or epigastric sounds should have been easy to auscultate. Then the Sp02 started to fall. Then it fell further. Then it kept falling, and the HR followed. Given that the crew chose to ignore each of these tell-tale signs, I'm think we have no reason to believe that one more sign (etc02) would not have been ignored also.

When you combine all of that with some of the other things that happened and were said (giving vec without a sedative, "I'm sure it's just all the pressure in his head" when his sats kept falling, etc.), a picture is painted of a crew who simply had no idea what they were doing, and had no business transported an intubated patient, never mind performing it themselves.

There are other problems here, too. Why was this kid intubated in the first place? Maybe there was a good reason, they never say in the videos, but supposedly he was awake and lucid and cooperative in the referring ED, and was just intubated "for transport". I have long thought that "well, ya know, they might need it later" is a stupid reason to perform a potentially hazardous medical procedure when it isn't indicated. Also, why wasn't a long-acting NMB used? I know my opinion on this is unpopular, but this very scenario is exactly why I always argue every intubated patient should be paralyzed for transport.

If that video is an accurate portrayal of what actually happened in that ambulance, then IMO that crew's actions were so incompetent, and so negligent, that they should probably be considered a criminal act.


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## NomadicMedic (Mar 28, 2017)

Remi said:


> And this is exactly why simply mandating another piece of equipment isn't enough to prevent this kind of thing.
> 
> I don't know if they didn't have Etc02 available, or if they had Etc02 available and just didn't use it, or if they had it available, used it, and ignored the results because it didn't match their ideation that the tube was properly placed. It really doesn't matter; I've seen it go down each of those ways.
> 
> ...



Rather than cut and paste, here's the whole story. https://www.doitfordrew.org/what-happened


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## E tank (Mar 28, 2017)

If that is a full and  accurate account of what happened to that poor family, there is way more wrong than the incompetence of the transport team. It's also a reason for parents to let medical professionals do their jobs. According to the dad, the CT showed nothing that implied any emergency. 

Intubate this kid? WTF? For an ambulance ride? No indication for doing that at all. Then, he extubates himself in the er, is reintubated and they didn't make absolutely sure he wouldn't do it again enroute? Then he does it enroute and everyone is surprised?

What a cluster from beginning to end. Dad should have kept out of it, and the kid should never have been intubated.


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## FiremanMike (Mar 29, 2017)

This entire issue can most appropriately be summed up with poor crew resource management.  There are absolutely training issues that need to be addressed here, but the fact of the matter is that there were indicators of esophogeal intubation that were dismissed/ignored on top of the lack EtCO2 verification.  People are unlikely to question peers in these types of scenarios, which is why they progress in such a poor manner.

For those of you who are ready to progress in your career, involvement in run review/QI is an eye opening experience that will show you just how common these scenarios can be.


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## VentMonkey (Mar 29, 2017)

FiremanMike said:


> This entire issue can most appropriately be summed up *with a poorly educated crew, period*.  There are absolutely training issues that need to be addressed here, but the fact of the matter is that there were indicators of esophogeal intubation that were dismissed/ignored on top of the lack EtCO2 verification.  *People are unlikely to question peers in these types of scenarios*, which is why they progress in such a poor manner.


I agree CRM is certainly worth it, especially with high-risk infrequently performed procedures as such, but in the face of no clinical reason to intubate a person I think we need to start there. 

Again, echoing the lack of airway management skills in most paramedic schools curriculum fosters a "let's tube" mindset...ok, now what?

How about why should or shouldn't we be doing such a risky procedure? That reflects a truly mature, sound-decision on behalf of the lead (paramedic) provider. More so than just training, it's formal education.


FiremanMike said:


> For those of you who are ready to progress in your career, involvement in run review/QI is an eye opening experience that will show you just how common these scenarios can be.


Agreed, abysmally scary, and humbling. Kinda makes you see why we have no business performing out-of-hospital ETI, ya?


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## EpiEMS (Mar 29, 2017)

FiremanMike said:


> People are unlikely to question peers in these types of scenarios, which is why they progress in such a poor manner.



I agree (and I think that this smacks of a cultural problem throughout our industry). CRM would be a good practice to implement.

@VentMonkey Do you see a cultural or clinical issue (not that the cultural issue doesn't lead to clinical problems, but that the origin is cultural) as being paramount here?

I see two main cultural issues:
1) People defining their profession by their skills
2) Team dynamics that don't support making comments/asking questions (legacy of the paramilitary tradition?)


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## DrParasite (Mar 29, 2017)

Just throwing this out there: according to the website, the paramedic didn't intubate the child, the RT did.


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## VentMonkey (Mar 29, 2017)

DrParasite said:


> Just throwing this out there: according to the website, the paramedic didn't intubate the child, the RT did.


When was the last time the RT did? I gotcha, my post implies lead being any poorly trained (for the specific skill at hand) provider.

Should the RT have been a bit better, you bet, but I'm not alone when I say many of them fall victim to complacency in-hospital too, and focus more on vent adjustments (often in accordance with their respective attendings), and rounding for ABG's, and breathing tx.

Perhaps this was such an RT? If so, who knows the last time they performed an ETI.


EpiEMS said:


> @VentMonkey Do you see a cultural or clinical issue (not that the cultural issue doesn't lead to clinical problems, but that the origin is cultural) as being paramount here?
> 
> I see two main cultural issues:
> 1) *Mostly paramedics* defining their profession by their skills
> ...


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## Carlos Danger (Mar 29, 2017)

I don't care who screwed up the intubation. RRT, EMT-P, RN, MD, whatever. Call it poor CRM, call it incompetence on the part of the intubator, blame it on the ED doc who tubed someone who didn't need to be tubed and then ordered an inappropriate dose of maintenance meds. Whatever. Tubing someone who doesn't need it is bull&hit. An unrecognized esophageal intubation in 2013 is inexcusable. Period. Full stop.

It looks to me like they all fu%ked up. The whole thing smacks of incompetence.

CRM is a great concept and I think it's very applicable to aviation (which it was designed for), but when applied to clinical situations, more often then not it is used as an excuse to explain away poor performance. "Oh, well, they weren't using good CRM, so....you can't really blame them...it was the lack of training that caused the poor outcome".

Uh, no. Just no. Someone is responsible. When you work in a field where your job is literally to deal with life and death situations, you need to have your %hit straight. Crap or get off the pot. You either know what you are doing, or you take a step back and ask for help from someone who does. It just isn't the place for a coward, or a show-off. "Fake it till you make it" kills healthy, 13 year-old boys in this setting.

This is serious stuff, man. I feel like lots of people just don't get that.


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## VentMonkey (Mar 29, 2017)

@Remi I get it man, I do. You're absolutely right, poignant post.


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## NomadicMedic (Mar 30, 2017)

Amen. You can't play loose and fast with this stuff, and all too often we do. (I know I have in the past)


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## TXmed (Mar 30, 2017)

Im all about CRM and team dynamics. Such an under utilized and under educated subject of emergency care. Eventually a skill will fail you. But leadership, team work, and CRM will save you and the patient.


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## RocketMedic (Mar 30, 2017)

If I recall correctly, they did have waveform capno available but did not use it.

CRM discussion reminds me of the Korean airliner that flew into a mountain on Guam because the copilot was too polite to correct the captain.


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## zzyzx (Mar 31, 2017)

Wow that's awful. 
The RT may have intubated but the paramedic is equally at fault. 
The fact that the pt was not restrained nor properly sedated is the first of several inexcusable fails. 
I can't imagine how terrible it must be to be a parent and know that your child died in such an awful way.


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## Carlos Danger (Mar 31, 2017)

NomadicMedic said:


> Amen. You can't play loose and fast with this stuff, and all too often we do. (I know I have in the past)



As have I. The culture at one place in particular where I used to work was very much "tube 'em all - let the ED sort 'em out". And we pretty much did. After a few years of that I began to question whether we were really doing the right thing, and now I know for sure that we were not. Fortunately, to my knowledge, our enthusiasm for succinylcholine never resulted in the type of outcome that happened in this story , but who knows. I'm sure there were plenty of less-dramatic yet still unavoidable and completely unnecessary complications.


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## FiremanMike (Mar 31, 2017)

Remi said:


> I don't care who screwed up the intubation. RRT, EMT-P, RN, MD, whatever. Call it poor CRM, call it incompetence on the part of the intubator, blame it on the ED doc who tubed someone who didn't need to be tubed and then ordered an inappropriate dose of maintenance meds. Whatever. Tubing someone who doesn't need it is bull&hit. An unrecognized esophageal intubation in 2013 is inexcusable. Period. Full stop.
> 
> It looks to me like they all fu%ked up. The whole thing smacks of incompetence.
> 
> ...



Allow me to make this clear, I am not saying "no one is to blame", I'm saying "everyone is to blame", including the system.  Furthermore, it is an unfortunate (although not uncommon) mindset that each person should be an expert at everything which has stalled CRM from reaching its way into EMS and ignores the origins and intent of CRM in the first place.  CRM was developed in the aviation industry to explicitly move away from the mindset that the PIC is the sole expert on everything in the aircraft and that they should never be questioned, even when the aircraft is literally crashing.

While I hate passing judgement on a poorly acted recreation in a viral video on facebook, lets discuss the case as it was presented.  We have a poor decision to intubate a patient with a stable airway for the sole purpose of patient transport.  We have a poorly calculated maintenance dose of sedation.  We have a poor choice of chemical restraint once the patient became combative.  We have an esophogeal intubation with numerous queues that were even pointed out but ignored because the person who intubated stated it was good tube.  Finally, and most importantly, we don't have a single person stand up throughout this entire ordeal who is empowered to say "no, stop, this is a bad idea" as well as a decision maker who says "hmm, maybe you're right."

Because of the dangerous mindset that everyone must be an expert every time, we have conditioned ourselves to ignore the very obvious errors in front of us simply because we feel uncomfortable challenging those around us.  The aviation industry recognized that this type of thinking is a very real and extraordinarily dangerous approach to critical event management and they took steps to fix it.  The focus here should not have been on the single fault of the person intubating to miss the trachea (NO ONE has a 100% success rate, period), that is myopic and shallow.  The focus here should be on the plethora of bad decisions that were made in the management of this patient and the lack of any real voice of leadership saying "no, this needs to stop immediately".


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## Carlos Danger (Mar 31, 2017)

Mike, no one is blaming anyone for not being an expert. I don't see what that has to do with this. 

The problem isn't lack of expertise, the problem is what passes for even basic competence in many cases.


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## FiremanMike (Mar 31, 2017)

Remi said:


> Mike, no one is blaming anyone for not being an expert. I don't see what that has to do with this.
> 
> The problem isn't lack of expertise, the problem is what passes for even basic competence in many cases.



I interpreted your response as placing the bulk of the blame on the person who missed the tube while dismissing the lack of CRM.  In light of your response, I reread the post I replied to and see how I could have misinterpreted that.


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## VentMonkey (Mar 31, 2017)

@FiremanMike as an EMS coordinator you offer us a completely fresh, and different approach. So I must ask, how would you go about reprimanding, or remediating such a sentinel event?

Do you feel emphasis on more CRM would make that big of an impact on the providers in your respective region, or service?

Does it make a strong enough case in your mind to rethink prehospital ETI for the providers you oversee?

Would it be reasonable to retrain all of the paramedics in your service (or any)---regardless of its size---the ins, and outs of the entire airway management approach (from proper basics, to difficult, failed, and crash airways)?

I think we can all stand to learn a bit more about where this could potentially lead us in each of our respective services should an unfortunate event like such take place.

Other than scolding, reprimanding, or the standard remediation techniques such as utilizing "Fred the Head", how would a person in your position A) explain this to their medical director, and most importantly B) do everything in their power to make sure this does not happen again?


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## Carlos Danger (Mar 31, 2017)

FiremanMike said:


> I interpreted your response as placing the bulk of the blame on the person who missed the tube while dismissing the lack of CRM.  In light of your response, I reread the post I replied to and see how I could have misinterpreted that.



I do think that the person who was leading the team, personally placed the tube (claiming to have seen it pass through the cords), and continues to insist that it is placed correctly bears the bulk of the blame. Should the others in the ambulance have recognized the error and spoken up, and do they share some responsibility for not having done so? Of course. Does the "system" that employs these folks and ostensibly assures their training and qualifications share some responsibility? Yes. But at the end of the day, I think the one who actually threw the ball that broke the window shoulders most of the responsibility. 

Is more focus on CRM the answer? I don't know. Maybe. But what if the intubator is alone in the ambulance with an EMT who doesn't know how to recognize an esophageal intubation? What if their partner is an RN whose never been involved in airway management? What if, like in this video, the intubator is 100% convinced that the ETT is placed, and offers other plausible (not that the ones in the video were) explanations for why the Sp02 is falling, and simply convinces the others that he's right? 

At the end of the day, people just need to know what they are doing. And protocols exist for exactly these reasons.


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## FiremanMike (Mar 31, 2017)

VentMonkey said:


> @FiremanMike as an EMS coordinator you offer us a completely fresh, and different approach. So I must ask, how would you go about reprimanding, or remediating such a sentinel event?



I address these issues through debriefing sessions that actually elicit understanding on the part of the learner.  I am an educator/trainer at heart and much prefer a positive approach to a negative one.  Personally, I find the PEARL method of debriefing elicits a significant amount of thought and discussion in a group setting and allows each person to make their own connections without putting them on the defensive.  I am only 1.5 years into this position currently, so I estimate it will take another 2-3 years to truly quantify the efficacy of this approach, but my short term results seem to be promising.



> Do you feel emphasis on more CRM would make that big of an impact on the providers in your respective region, or service



I really, really do.  I think it's time for EMS providers to disconnect from the paramilitary mindset and approach patient care and critical events as a team endevaor.  I am developing my own version of CRM for EMS and hope to have it available for lecture circuits within the next year or so.



> Does it make a strong enough case in your mind to rethink prehospital ETI for the providers you oversee?



Personally, no.  I think we currently have enough tools in place to ensure succesful intubation that truly poor outcomes from ETI should be outliers (admittedly, I have zero statistical evidence to back up that statement).  I have never really felt the isolated skill of ETI to be particularly difficult, it is the overall critical thinking and crisis management that goes along with the entire event.  I feel that if we continue to grow in our approach to developing medics with critical thinking abilities and, sorry to keep saying it, good CRM, prehospital ETI will remain a safe means for prehospital airway management.



> Would it be reasonable to retrain all of the paramedics in your service (or any) regardless of its size the ins, and outs of the entire airway management approach (from proper basics, to difficult, failed, and crash airways)?



Yes, and it might be time to really get serious about standardizing at least some portions of paramedic education and retraining.  When I speak to the medic students from our local programs, some get hours and days in the OR for live intubations, whereas others just need 50 succesful intubations on the airway head.  I was in the latter cohort, and suffered greatly in my first 1-2 years on the road with airway management.  It wasn't until I really took some personal accountability for it that it clicked for me.



> I think we can all stand to learn a bit more about where this could potentially lead us in each of our respective services should an unfortunate event like such take place.
> 
> Other than scolding, reprimanding, or the standard remediation techniques such as utilizing "Fred the Head", how would a person in your position A) explain this to their medical director, and most importantly B) do everything in their power to make sure this does not happen again?



Our last confirmed esophogeal intubation occurred on a cardiac arrest and was about a year ago.  From the medical director's perspective, he simply called and said "I need you to look into this run, our ED physician confirmed an esophogeal intubation after arrival."  In this case, I was able to review the chart as well as the captured audio from CodeStat.  For those that are unfamiliar with CodeStat, it captures all the data received by the LifePak as well as records audio from the incident.  It is entirely undiscoverable as a componant of QI and an INVALUABLE training tool for your crews. 

As I reviewed the CodeStat audio, we had a confirmed ETI with good waveform capnography.  At some point during the incident (as I recall, it was moving the patient from the bed to the autopulse), the ETT became dislodged and the waveform became a flat line.  The crew identified the loss of waveform capnography, discussed it briefly, and concluded that it was equipment failure on the part of the LifePak and disregarded further assessment of the efficacy of their tube.  Without CodeStat audio, this discussion and training event would have been difficult/impossible.  WITH CodeStat and a patient debriefing facilitator, the crew was able to understand how/why this error occurred (and hear/see themselves making it) without going on the defensive and make good connections.  After this training session, I shared my findings with the medical director and that was the end of the discussion.

As for whether these connections made a long term impact, again I think it's too early to tell.


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## EpiEMS (Mar 31, 2017)

Remi said:


> But what if the intubator is alone in the ambulance with an EMT who doesn't know how to recognize an esophageal intubation?



So this is one of the arguments for dual medic crews that has never really sat well with me. You only need a little bit of knowledge to be dangerous, I've been told, so in this case - a little bit of knowledge ("Hey, did you forget to put the capno-line on the tube?") *should *be all you need to keep the patient safe, one would hope?


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## VentMonkey (Mar 31, 2017)

@FiremanMike thanks for ths feedback.

@EpiEMS, again restructuring the entire respiratory, and airway modules through the national DOT, IMO, to include what I've beat to death seems the most practical approach rendering---in theory---crew configuration a non-issue.

Again, this is my take, and without further understandings be thrust upon all young paramedics-to-be it will now, and forever be treated as a "cool skill", which, as is proof with the catastrophic events in this thread topic just not damn good enough, nor does it give us the right as it stands now to call ourselves _proficient_ _airway management professionals_, and these 4 words alone should be synonymous with what we do; then again, so to should every "standard emergency" scenario we train for. 

These standard emergencies should all be second nature with proper education, and con-ed. We should not be allowed to think twice about our knowledge, and abilities with the clinical acumen of our education when didactic is all said and done, and we should be allowed to focus more on our "soft skills", where we clearly truly lack understanding also.

Until any of this changes, what have we done as a profession to prove our privileges? Is that not what _medically inclined professionals_ seek? Privileges to practice. Not our field, we're steeped in traditional "right aways", and egocentric self-entitlement. One, or two ambitiously driven providers just isn't enough to sustain such privileges; this is where I take it somewhat personal.


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## StCEMT (Mar 31, 2017)

Remi said:


> But what if the intubator is alone in the ambulance with an EMT who doesn't know how to recognize an esophageal intubation?



Having worked as both the B and P on an ALS truck, I don't think an EMT should be working in that role until they have been trained to assist with ALS equipment and their basic functions. Recognizing the signs of a successful intubation isn't all that hard. At the very least, an EMT knows how to listen to lung sounds, which is one of a few things that should be done with every intubation even if there is end tidal.


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## Harleyjon (Apr 27, 2017)

I am very new at this and have very little experience. I intubated a 1yo f, and a  66yo M (King airway). I was taught that you NEVER intubate without ETCO2 hooked up. I was unaware that its use is not universal. I learned something new today. After watching the video and reading alot of the posts (sorry, I read slow and did not slog through all of them) one thing stands out to me. For the sake of argument lets say that this service is one that does not utilize capnography. They have been taking care of this Pt for however long it has been, With the original setup there have been no problems maintaining decent SPO2 levels. The Pt thrashes about and dislodges the tube. The Pt is preoxygenated with a BVM presumably without problem and still maintaining good SPO2 (yes I know there is a delay). He is reintubated(is that a word?) and his SPO2 does nothing but drop continuously. As a member of the section of the human race that regularly attempts to utilize the theory of logical reasoning I would surmise that something is amiss. My first thought would (I hope) go to the fact that moments ago there was no difficulty preoxygenating the Pt. Why not extubate and use that method until I figure out what went wrong. Obviously I would need to monitor the Pt closely for aspiration  and maybe even reposition him on his side temporarily but hey he should get better oxygen than he is now. 
This may not be the thought process that other people would use and I may not even go there. I do believe though that I this type of thinking would be prefereable to "the tube is in, tell em the tube is in". I am simply trying to use this as a learning session because I dont have the expertise to criticize someone else. The most important thing I have been reminded is to ALWAYS use capnography (66yo M  ~18), listen to chest and abdominal sounds, and watch for color changes in mucus membranes and skin like that 1yo f going from grey to pink. Not to mention an occasional look at the SPO2 wouldn't hurt.


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## Carlos Danger (Apr 27, 2017)

Harleyjon said:


> I am very new at this and have very little experience. I intubated a 1yo f, and a  66yo M (King airway). I was taught that you NEVER intubate without ETCO2 hooked up. I was unaware that its use is not universal.



It has been the standard of care for quite a while now, and I think the vast majority of places probably have it, but I'm not surprised that there are a few places that don't, and I'm pretty sure there are places that have it and don't ensure it's consistent use to the extent that they should. 



Harleyjon said:


> For the sake of argument lets say that this service is one that does not utilize capnography. They have been taking care of this Pt for however long it has been, With the original setup there have been no problems maintaining decent SPO2 levels. The Pt thrashes about and dislodges the tube. The Pt is preoxygenated with a BVM presumably without problem and still maintaining good SPO2 (yes I know there is a delay). He is reintubated(is that a word?) and his SPO2 does nothing but drop continuously. As a member of the section of the human race that regularly attempts to utilize the theory of logical reasoning I would surmise that something is amiss.



Yeah, I think this is exactly what I found so disturbing about this scenario. Several tell-tale signs that the ETT was misplaced were rationalized away. It's one thing to be confused by conflicting information (such as you might have with a bronchospasm immediately following intubation) and make the wrong call; it's another to ignore several pieces of corresponding information because you don't want what they indicate to be happening. Makes you wonder if they would have simply ignored the lack of Etc02 confirmation, as well.


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## RocketMedic (Apr 29, 2017)

I think this all dovetails into the herd mentality people accept when someone "takes charge" and issues directives, regardless of their ability. Dunning-Kruger in action. It would not surprise me to find out the medic is a more passive/Type B personality and the RT was a take-charger. Or perhaps the crew was uncomfortable and unready for this patient and defaulted to the boldest member. 

@FiremanMike, complete agreement with you on CRM. I think the worst is that we mostly teach and train our students that asking out for help and advice is a sign of weakness and stupidity.


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