"Ambulance Attendants Sued"

[ffemt8978]

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

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

 

[Epi-do]

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

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

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

 

[VentMedic]

Wait, did she die?

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

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

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

ETI is NOT something to be taken lightly.

 

[VentMedic]

Time to review ETI and esophageal intubation:

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

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

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

Verification of Tube Placement

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

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

New Guidelines on Tracheal Tube Confirmation and Prevention of Dislodgment

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

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

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

 

[VentMedic]

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

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

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

 

[2easy4u]

Airway,airway,airway

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

 

[Aidey]

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

 

[daedalus]

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

Amen, EpiDo.

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

 

[VentMedic]

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

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

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

 

[daedalus]

Vent's Diaphragm displacement example

 

[Aidey]

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

And Daedalus.

Fail.


/shudders

 

[Fragger]

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

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

 

[Veneficus]

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

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

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

 

[medic417]

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

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

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

 

[medic417]

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

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

 

[enjoynz]

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

Cheers Enjoynz

 

[Fragger]

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

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

Cheers Enjoynz

 

[ffemt8978]

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

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

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

 

[medic417]

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

Cheers Enjoynz

Several posts have mentioned similiar thoughts.

 

[enjoynz]

Several posts have mentioned similiar thoughts.

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

Cheers Enjoynz