YIKES! Gut Tubed in Rhode Island x 12

SandpitMedic

Crowd pleaser
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ETCO2 is the metric.
I'd also like to see an official statement from the RI fire departments on why they don't utilize it or utilize it incorrectly if at all.
 

Peak

ED/Prehospital Registered Nurse
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An unrecognized gut tube in the hospital is a sentinel event, and for us requires a report to the state.

We gut tube people all of the time, especially during messy codes. We also recognize that about two breaths in. Then we pull the tube and start over.
 

E tank

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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....

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), .... 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.
I don't think this is a process problem, ie, we can solve our problems by looking at successful groups that intubate, emulate them, problem solved. There a false notion of passing a certain number threshold of intubations in order to arrive at competency. Pick a number. That's false because it's only valid for one type of situational/anatomic presentation.

So say 40 straight forward tubes= competency for easy intubations. Now 40 are needed for soiled airways, 40 for obese, no neck airways, 40 for obese, no neck soiled airways...and the list goes on and on and the multipliers become more and more complex.

The best services can intubate easy airways first try as well as any in-hospital intubator...The best services that can't intubate a difficult airway are lumped in with RI when RI can't intubate an easy one and there's no teasing out the difference when taking a 10,000 foot view of the issue of "pre-hospital intubation".

There are supraglottic airways now...the writing is on the wall...
 

Remi

Forum Deputy Chief
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I have a question (and it's a request for information only): What is the "accepted" margin of error in heathcare or in the hospitals for esophageal intubations?
Zero. The "accepted" incidence of unaddressed esophageal intubations is zero. Zero in the field, zero in the ED, zero in the OR. Zero.

We aren't talking about doing everything right and still failing to successfully manage a difficult airway that was beyond your capability due to lack of tools and experience, we are talking about making a choice not to use simple and reliable methods to ensure that the ETT ended up where it is supposed to be. Not doing so is malpractice, plain and simple. It is not a simple mistake. It borders on criminal negligence, IMHO.

that means if ANYONE in the hospital performs an unrecognized esophageal intubations, than that means EVERYONE loses the ability to intubate, hospital wide.
No, that is completely absurd. There is no logic whatsoever in that idea. However, what IS logical, and what you WOULD see if people in the hospital were routinely gut-tubing patients and not recognizing it, is a removal of intubation from the credentialing of the group that is guilty of the screwups.

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.
No, a chest x-pray is absolutely NOT used to rule out a gut tube. It takes long enough to get and read a portable CXR that you'd routinely see profound desaturation, regurgitation with aspiration, and a lot more post-intubation cardiac arrests if imaging were being relied on to tell the intubator whether or not the tube was in the right hole.

Post-intubation CXR's are useful for confirming the ETT tip in relation to the carina, as well as assessing all sorts of anatomical and clinical factors. Getting a chest x-ray on a patient who required intubation is like getting a BMP on a generally sick patient: it's cheap, it's quick, it's noninvasive, and it could very well tell you something important that you wouldn't otherwise know. If nothing else, it gives you a baseline to compare subsequent assessments to.

But the NUMBER ONE reason why CXR's are routinely done immediately post intubation is to COVER THE *** OF THE INTUBATOR. Precisely because there is no justifiable reason whatsoever for failing to recognize a tube in the goose, you WANT that photograph which objectively proves that you put the tube in the right place. That way, when a half hour later the staff dislodges the ETT when they are moving the patient from the ED stretcher to the ICU bed, you don't have to worry about anyone claiming that it was your fault because the tube was never properly placed to begin with.
 
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