Unrecognized esophageal intubation

[E tank]

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.

 

[EpiEMS]

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

 

[E tank]

@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.

 

[Carlos Danger]

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.

 

[NomadicMedic]

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.

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

 

[E tank]

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.

 

[FiremanMike]

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.

 

[VentMonkey]

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.

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?

 

[EpiEMS]

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?)

 

[DrParasite]

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

 

[VentMonkey]

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.

@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
It's cool, Ep, don't beat around the bush, I won't.
2) Team dynamics that don't support making comments/asking questions (legacy of the paramilitary tradition?)
Oh, @FiremanMike is absolutely right, but again without proper EDUCATION CRM is only as good as you make it out to be.

Clearly we're severely lacking the humility (generally speaking) to be afforded the privilege of managing someone's airway with such advanced techniques, and without tried and true knowledge of the airway "Alphas and Omegas".

 

[Carlos Danger]

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.

 

[VentMonkey]

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

 

[NomadicMedic]

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

 

[TXmed]

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.

 

[RocketMedic]

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.

 

[zzyzx]

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.

 

[Carlos Danger]

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.

 

[FiremanMike]

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.

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".

 

[Carlos Danger]

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.