Unrecognized esophageal intubation

[Carlos Danger]

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

 

[GMCmedic]

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

 

[EpiEMS]

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

 

[DrParasite]

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)

 

[EpiEMS]

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?

 

[Eden]

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.

 

[VentMonkey]

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.

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

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.

 

[Eden]

O

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.

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.

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

 

[StCEMT]

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

 

[hometownmedic5]

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.

 

[TXmed]

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.

 

[NomadicMedic]

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.

 

[E tank]

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.

 

[StCEMT]

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).

 

[EpiEMS]

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."

 

[NomadicMedic]

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.

 

[E tank]

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.

 

[VentMonkey]

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...).

 

[StCEMT]

@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.

 

[EpiEMS]

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 ).