YIKES! Gut Tubed in Rhode Island x 12

akflightmedic

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Maine indeed has AEMTs....cheaper by the dozen! The BIG skill, protocol change for this year regarding AEMTs is...wait for it....they are now allowed to give ODT Zofran!!! Woot Woot!!!
 

PotatoMedic

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Maine indeed has AEMTs....cheaper by the dozen! The BIG skill, protocol change for this year regarding AEMTs is...wait for it....they are now allowed to give ODT Zofran!!! Woot Woot!!!
Very risky! Gotta be careful about that QT prolongation. 🙄
 

DrParasite

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Very risky! Gotta be careful about that QT prolongation. 🙄
yeah, that's what I have always been told, which is why it is a paramedic only drug....

that being said, I have yet to find a single medic who has ever seen it in the field, and IM Zofran (or PO even) would make an awesome addition to the EMT drug skill set!!!! And as a former recipient of it, it's awesome and makes patients feel a lot better.
 

PotatoMedic

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yeah, that's what I have always been told, which is why it is a paramedic only drug....

that being said, I have yet to find a single medic who has ever seen it in the field, and IM Zofran (or PO even) would make an awesome addition to the EMT drug skill set!!!! And as a former recipient of it, it's awesome and makes patients feel a lot better.
I hope you know I was being sarcastic. Zofran at the bls level would be amazing.
 

Tigger

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Maine indeed has AEMTs....cheaper by the dozen! The BIG skill, protocol change for this year regarding AEMTs is...wait for it....they are now allowed to give ODT Zofran!!! Woot Woot!!!
My impression from visiting (parents live there) is that Paramedics are at least utilized through much of the state compared to RI and VT.

Zofran ODT is standing orders for Colorado EMTs, those with the IV endorsement add it IM and IV. I can't imagine going back to a world where my partner couldn't handle some nausea/vomiting, but so it goes I guess.

Interestingly, there is finally a push in Colorado to expand the number of AEMTs. There are some significant corollaries to what has/is happened in Rhode Island.

The IV endorsement came to be in Colorado to expand the rural EMTs scope of practice. In reality, the course is a near requirement to be a paid EMT and many employers see the value in having their EMTs be good "paramedic assistants." While their are rural providers who have the endorsement, it ended up being somewhat rare. It was a solution to a problem that didn't really exist either, as I think we all know that IVs aren't exactly lifesaving.

There is no "official" curriculum for the IV endorsement curriculum, which in addition to IV and IO access adds NS/LR boluses, Dextrose IV, and Narcan IV. There is no actual hour requirement. There is a recommendation for 10 "live sticks" but precious little additional clinical rotation guidelines. Some of these classes get run in eight hours.

See any similarities to Rhode Island? A class constructed to the "needs" of the state with apparently precious little oversight. These providers have invasive skills in their toolbox, but no idea how to properly utilize them. Obviously poor IV technique does not hold a candle to esophageal intubation. But some education groups in Colorado (Pikes Peak CC among others for those local), are no longer comfortable with signing off on EMTs to start IVs as there is no demonstrable standard for what IV training for EMTs should look like. There is however, a standard for NR AEMTs which of course includes IV initiation. As such, we are trying to encourage departments that want IV classes to instead look to a hybrid AEMT class that will at least meet a national standard for EMS education. Yes, it's more hours for (essentially) the same scope of practice, and that's ok. It's at least vetted.
 

Summit

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There is no "official" curriculum for the IV endorsement curriculum, which in addition to IV and IO access adds NS/LR boluses, Dextrose IV, and Narcan IV. There is no actual hour requirement. There is a recommendation for 10 "live sticks" but precious little additional clinical rotation guidelines. Some of these classes get run in eight hours.
Wow, I thought there were more standards. The class I took 15 years ago was 2 college credits and was 30+ hours of lecture and lab including vascular A&P, acid base balance, fluid/electrolyte balance, cell respiration, diffusion/osmosis, osmolality/osmolality, complications, conditions, indications, medications, complications, technique, practice on IV manakin arms, practice on classmates, then 10 successful live sticks minimum in the DG ED.

Sure, you can teach the psychomotor skill in 8 hours. Army includes IV in their 40 hour CLS course... and needle decompression as well. But skills only isn't what we want.

It should be noted that most RNs are not taught IV skills in school, although they get all the requisite educational theory. They may do them in clinical under the supervision of RN preceptors. RN schools decided that RN students practicing IVs on each other is too risky. IVs are generally learned as OJT after hire.

Medical Assistants start IVs too and this is mostly OJT, not program taught.

The reason why goes back to the simple fact: establishing peripheral venous access, though invasive, is very low risk. It is what you do with that access that is high risk and truly invasive.
 
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Tigger

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Wow, I thought there were more standards. The class I took 15 years ago was 2 college credits and was 30+ hours of lecture and lab including vascular A&P, acid base balance, fluid/electrolyte balance, cell respiration, diffusion/osmosis, osmolality/osmolality, complications, conditions, indications, medications, complications, technique, practice on IV manakin arms, practice on classmates, then 10 successful live sticks minimum in the DG ED.

The reason why goes back to the simple fact: establishing peripheral venous access, though invasive, is very low risk. It is what you do with that access that is high risk and truly invasive.
At my CC's program, that's about the curriculum we teach so we can offer it for credit. But not everyone does that of course.

I understand that it is relatively low risk but I think as healthcare moves forward we are going to have to move away from OJT education to a degree. That is not something I necessarily like, but with so many entities wanting more "proof" of procedures and policy, we won't have a choice.
 

Tigger

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There is a Colorado state IV Course Curriculum. Also TIL that IOs are included now.
I think the issue is that you do not actually have to follow this. There is no oversight from the state regarding these classes. If you're an education group, you can offer it.

As for IOs, my understanding is there is no more waiver for EMTs obtaining IO access in cardiac arrest.
 

SandpitMedic

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Ah, and now the mayor (retired FF) is also siding with the FF unions that they don’t need better training. At an EMS meeting last week the FF unions tripled down saying the study showing 12 deaths due to the gutted tubes was ... get this... “FAKE NEWS!”

They accused the physicians desiring more EMS training of “having an agenda.”

What a freaking joke in Rogue Island! Um, yeah, an agenda of having good EMS!

Again, bring on the class action lawsuits and negligence charges and burn that whole system down for a hard reset.

 

DrParasite

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I have a question (and it's a request for information only):
he had identified 11 patients with botched intubations that were not recognized by EMS first responders over about two and a half years. They all died.
What is the "accepted" margin of error in heathcare or in the hospitals for esophageal intubations? Is 1 per year an acceptable "margin or error"I mean, statewide, that's 12 in 2.5 years (another was found after the research was given to the state), and why didn't the ER's immediately identify the esophageal intubations and fix the issue? Yes, we should aim for 0, however what do the risk people say is an acceptable number before those skill should be taken away, because the risk is too great?

I will also agree this statement by the union: the physicians "don’t know what it is like to respond to emergencies because they work in hospitals, with bright lights and a lot of people helping them." it's a lot easier to perform when you have all the light and space you could want, and can move the patient to make things easier. HOWEVER, that is no excuse for not utilizing various methods to verify that you didn't intubate the stomach. putting a tube in the esophagus WILL happen; not recognizing it and not correcting its placement is an unforgivable error.
 

Summit

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@DrParasite the "accepted" margin for UNRECOGNIZED is zero. The study didn't quantify corrected situations, only unrecognized ones.

And as to the ER, the accounts from the original article are clear that the ERs tried to "fix" the issue, but you know very well that there isn't any fixing to be done when someone has been gut tubed for a 20 minutes.
 

Lo2w

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Funny enough when you try to google "eti error rates in hospital" it kicks back a whole page of EMS issues.

I know the RSIs I've seen in the ER, the doc is tubing with RT and RN at bedside, confirmed by auscultation and radiology is outside with the portable xray to visually confirm placement.
 

akflightmedic

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I am unsure if you are pro or con regarding the claim that no unrecognized intubations should ever occur.

All the tools, lights, and staff in the world still does not excuse or justify a failed intubation. Have I tubed the esophagus before? Absolutely...but when recognized by using the tools provided, I removed the tube and started over.

The fact that failed tubes made it thru transport before being caught is abysmal. Just thinking of the timing involved, of course the patients died. Let's say a generous 8 minutes from time patient drops until EMS arrives. Intubation within 3-5 minutes. Working the call, moving to the unit, transporting, moving patient inside and transferring care....seriously, we are easily a solid half hour of belly breathing if not more.

Why did no reassessments catch this? Every time they were moved, lung sounds rechecked? Capnography? Etc...failure all around and no justification for not observing a failed intubation.

And why are they transporting??? Entirely different discussion, but as backwards as Maine is, here we do not transport unless ROSC occurs. 20 minute codes is normal. The other week I worked one for about 35 minutes and that was only because he stayed in persistent fine vfib. Finally called the doc and informed him what was going on, he said up to you guys...if we agree to terminate, we terminate. Hung up phone, askedall crew if anyone objects, said we will do one more round then terminate. That is what we did.
 

DrParasite

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@DrParasite the "accepted" margin for UNRECOGNIZED is zero. The study didn't quantify corrected situations, only unrecognized ones.
not disagreeing with you, but that means if ANYONE in the hospital performs an unrecognized esophageal intubations, than that means EVERYONE loses the ability to intubate, hospital wide. that decision needs to be made at the agency or higher level as to what type of error is an acceptable risk. There are differences between a goal (what we are looking for, which is 0) and an acceptable risk (how many we will allow before we start taking action and removing said skill to prevent the issue from ever occuring).
I know the RSIs I've seen in the ER, the doc is tubing with RT and RN at bedside, confirmed by auscultation and radiology is outside with the portable xray to visually confirm placement.
Which is the advantage of intubating in the hospital... you have get an xray confirming placement moments later.... most of us don't have that ability in the field... and they have better toys to visualize that we don't have access to.

Most intubations are handled by anesthesia, so I did find these articles and studies:

I'm not saying the RI guys should get a pass on these epic screwups; but there are differences between a controlled or semi-controlled intubation and what prehospital providers often encounter. But these EMT-Cardiacs screwed up big time, and something needs to be done about it.
 

SandpitMedic

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DrParasite, are you playing devil's advocate here? I'm not sure what you're trying to get at.
Comparing the training of EMTs to that of ER physicians and anesthesia; that calculus just doesn't work out in my head... Maybe I just haven't had enough coffee.
I never needed a chest Xray to know if I was in or not, nor have others according to their posts...that's an ER thing because they have that capability and it is a nice check in the box... just saying.
 

SandpitMedic

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Also, I dont think it matters in this circumstance what ERs and hospitals do. Let's just simply compare them to other EMS systems, and we see there is a huge problem. Multiple problems based on their official responses.
 

Summit

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Post-intubation x-ray is NOT to confirm that the placement is tracheal vs esophageal. Hospitals use etCO2, auscultation, chest rise, and patient assessment for that. Just like the RI EMT Cardiacs should have.
 

DrParasite

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As was mentioned earlier by a more experienced provider than me when I mentioned verifying proper placement by ETCO2:
ETCO2 is an indicator of, not verification for endotracheal intubation. The only practical ways to "verify" placement is direct visualization of the upper esophagus and glottis via DL or a chest XR.

Breath sounds, ETCO2, "gastric auscultation" all fail and are only as good as the individuals being able to contextualize them to the whole picture. No substitute for training and experience and when things get technically difficult, those kinds of chops are not possible to have in a great many settings.
I'm not playing devil's advocate, but I'm trying to be realistic: if the procedure, drug, or tool is too risky, when the NNT (number needed to treat) isn't as beneficial as it needs to be to outweigh the risk, than it gets removed. basic risk management and how we can advance medicine and try new things (or take away stuff that doesn't work or help most people).

If we are going to look at intubation by EMS, there are plenty of studies that show that we, in general, suck at it. now, there are reasons for that (and I think many of them are location specific, but I digress), but if we consider medicine as a whole, and consider ourselves part of medicine, than we need to look at what others do, and what the standards of the medical community are when it comes to intubation. Last I checked, the only people who intubate are paramedics and anesthetist (and CRNA), with the occasional ER doc. but most don't. So we need to expand our sample circle, beyond what we do, to see what others in healthcare do.

and @Summit, I agree with you, the RI EMT-Cs should have used ETCO2 to confirm... I'd like to know why they didn't.
 

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