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.
