Unrecognized esophageal intubation

[FiremanMike]

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.

 

[VentMonkey]

@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?

 

[Carlos Danger]

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.

 

[FiremanMike]

@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.

 

[EpiEMS]

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?

 

[VentMonkey]

@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.

 

[StCEMT]

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.

 

[Harleyjon]

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.

 

[Carlos Danger]

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.

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.

 

[RocketMedic]

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.