Posted on 04/20/2008 8:05:56 AM PDT by Dysart
Not long after complaining of shortness of breath at her Quinlan home, Patricia Cannon was in a Hunt County ambulance heading north toward Greenville with a drug dripping into her veins capable of paralyzing every muscle in her body.
The drug, succinylcholine, was administered by a paramedic. The intent was for Cannon, thought to be suffering from a blood clot in the lung, to be immobilized while a breathing tube was placed in her windpipe.
But something happened along the way that prevented the tube from being inserted correctly. The job wasn't done until the ambulance delivered Cannon, 41, to the emergency room at Greenville's Presbyterian Hospital. By then, her condition had worsened considerably.
She was found to have suffered brain damage from an extensive period of insufficient oxygen. She died a week later after her family, told there was no hope, requested that she be removed from life support.
Cannon's death is one of several incidents involving Texas EMS providers that demonstrate the perils of a controversial procedure that can be used without restriction in the state even though it is heavily regulated elsewhere.
An examination by the Star-Telegram found that at least two people in Texas have died and another has become permanently disabled after being deprived of oxygen during the procedure, known as Rapid Sequence Intubation.
The incidents, detailed in court records stemming from lawsuits filed by the patients' families, show the harrowing downside of the procedure, which requires that endotracheal intubation, a difficult skill under any circumstances, be performed in the field on people who can no longer breathe on their own.
And the three incidents may indicate a much wider problem, according to some involved in EMS, because the majority of such cases remain unknown to outsiders, even the families of those affected.
"My gut feeling is that, for every one of these cases, there's probably a handful of others you never hear about," said Henry Wang, an assistant professor of emergency medicine at the University of Pittsburgh who has closely examined intubation by EMS personnel.
The situation also raises larger questions about EMS in Texas, illustrating what some believe is a state system that allows paramedics with minimal training to engage in increasingly invasive procedures.
"The elephant in the room is prehospital personnel have a difficult time managing airways," said Robert Simonson, director of emergency services at Methodist Dallas Medical Center and the medical director for CareFlite and six North Texas ground EMS providers. "And they get into particular problems when they paralyze patients. That is a very unforgiving thing."
A powerful procedure
Debate has been raging nationally for years over Rapid Sequence Intubation, or RSI, as the emergency medical procedure has found its way into use by EMS units.
The procedure calls for EMS personnel to induce paralysis with drugs before intubating patients whose airways otherwise would be difficult to manage because of gagging, clenched teeth, combativeness or other factors.
The most commonly used drug is succinylcholine, a short-acting paralytic that's also used when criminals are put to death by lethal injection.
RSI is considered a particularly valuable tool for air medical services, which typically deal with the most serious cases.
But while it has the potential to save lives, it can also be extremely risky. If the breathing tube is improperly inserted or becomes dislodged, the consequences can be disastrous. And because intubation can often be a challenge for paramedics, the stakes are high.
"I compare [RSI] to an M-16 -- extremely powerful in the hands of a master who's well-trained and gets a lot of practice, extremely dangerous in the hands of a beginner," said Wang. "Once you give the drugs, it is the point of no return. You must secure that airway."
The controversy has caused some states to limit the procedure, particularly for ground EMS.
Texas has followed a different path, allowing it to be used indiscriminately, even though it has backfired horribly in the hands of some of the state's providers.
The difference lies in that the states restricting RSI have statewide protocols that impose the same clinical standards on all EMS units, while Texas leaves such decisions to the physicians who serve as EMS medical directors.
Although Texas' approach to EMS, known as delegated practice, has long been considered a necessity because of the state's size and diversity, it may be put to the test by RSI.
"If you have a good medical director, somebody who's actively engaged and involved in EMS, you can kind of push the envelope," said Bryan Bledsoe, a Midlothian emergency physician and the author of several EMS textbooks. "The problem is a lot of these services have someone who just signs the chart."
Standard tools not used
In each of the cases examined by the Star-Telegram, records show that EMS personnel failed to use the rudimentary tools that are standard for checking whether breathing tubes are in the proper place.
And while the cases, all of which were settled out of court, generated thousands of pages of deposition testimony and other material on the public record, they never came to the attention of the Department of State Health Services, the agency that licenses EMS providers and paramedics in Texas.
Particularly compelling were the events surrounding Cannon's death in May 2000, just 11 days after she gave birth to her first child.
A lawsuit filed by Cannon's husband, Gary, against American Medical Response, the EMS provider for Hunt County, painted a troubling picture of a paramedic struggling to perform RSI in a moving ambulance.
Records and deposition testimony revealed that Cannon may have gone without oxygen for as long as 20 minutes and that the paramedic did not verify tube placement with any type of carbon dioxide monitoring device.
No action was taken against the paramedic by his superiors, even though it was the Hunt County EMS medical director himself who ultimately intubated Cannon correctly in the emergency room.
The same type of issues were raised as a result of a lawsuit filed against Air Evac Lifeteam by the children of Lu Allen, a volleyball coach at Graham High School who died in August 2003.
Allen's breathing tube was discovered in her esophagus when she arrived at a Wichita Falls hospital after being transported by helicopter from Graham, where she was struck by a pickup.
She was found to have suffered hypoxia, a lack of oxygen, and spent eight days on life support before her family asked that it be terminated.
Deposition testimony generated by the suit indicated that Allen, 58, received RSI while on the helicopter, which was staffed by both a nurse and a paramedic, yet no carbon dioxide monitoring devices were used.
"I'll say this flat out: There is no excuse for a misplaced tube," said William E. Gandy, an EMS educator in Tucson, Ariz., who is known nationally for his expertise in airway management. "We have the means to verify that a tube is in the right place. There's no excuse for not verifying."
While it is difficult to know how widespread such problems might be, many familiar with EMS issues say the incidents that reach the legal system are likely just the tip of the iceberg.
R. Jack Ayres, an Addison attorney who holds a paramedic's license and has long been involved in EMS at the state and local levels, said he knows of at least 50 cases in which botched intubations caused death or disability.
In some of those situations, the patient's family never suspected anything unusual because it was assumed that the outcome stemmed from the injuries or illness that caused the patient to be treated by EMS.
"The reality is the average family doesn't even know a problem occurred," he said.
Simonson said records he has reviewed at CareFlite show that the air medical service regularly has to "bail out" ground EMS crews that fail to intubate paralyzed patients.
"You sit and you look and you go, 'So we got there and the ground service paralyzed the patient and then couldn't get the patient intubated?'" he said.
Simonson said he has come to believe that RSI "needs to go away" when it comes to ground EMS. To that end, he has removed it from the protocols of all but two of the units under his direction because, he said, only those units had the necessary experience.
Wide leeway in Texas
Texas' EMS philosophy means that any provider can use RSI as long as its medical director gives the OK.
Although the system allows providers to attempt a cutting-edge procedure without dealing with a state bureaucracy, it also means the training for it is in the hands of physicians whose only requirement is that they be licensed to practice medicine in the state.
Ayres said RSI is a prime example of how the state has made medical directors "judge, jury and executioner."
State officials acknowledge that there is a risk in allowing RSI to be used without restriction, but they point out that making it off limits wouldn't be satisfactory either.
"If you do it by rule and prohibit it, then the potential is you decrease the ability for that procedure to save someone's life," said Ed Racht, an Austin emergency physician and chairman of the Governor's EMS and Trauma Advisory Council. "If you don't do that, the risk is you have systems with minimal medical oversight that are hurting people because they're not doing it properly.
"The question is, where's the balance? And, nationally, I don't think we really know where that is right now."
The attitude in Texas contrasts sharply to that in other states, including Pennsylvania, Georgia, Colorado and Kentucky. These states have statewide EMS protocols that prohibit the use of RSI by ground providers or allow its use only under tightly controlled conditions.
"Even in the nice, clean environment of an emergency department, it can be a challenging procedure," said Tim Price, state medical adviser for the Kentucky Board of EMS. "You can't just sort of willy-nilly give this over to [EMS] providers in the state."
Wang said it is "alarming" that Texas has no state regulations regarding RSI.
"If you are going to perform a technique as advanced as this, you should be able to demonstrate that you have the tools, resources and training to optimize its performance," he said. "And you should be able to back it up with clinical data."
Limited oversight
Intubation is a standard part of paramedic training in Texas, although some question whether it can be taught and practiced sufficiently well enough to ensure safety with RSI.
Anyone the state licenses as a paramedic or an EMT-intermediate can perform intubations.
Paramedics must complete at least 624 "clock hours" of prescribed course work after first becoming a basic EMT, which requires 140 hours. The EMT-intermediate level can be reached by completing at least 160 hours on top of the initial 140.
Becoming certified at either level also requires passing the National Registry exam, part of which is successfully demonstrating intubation on a manikin.
"You can become a paramedic in Texas with less than 700 contact hours, but it takes between 1,000 and 1,500 [to get a license] to cut hair," said Jay Cloud, an EMS instructor at San Jacinto College in Pasadena. "What's wrong with this picture?"
The bigger problem with intubations, according to many in EMS, is staying proficient, mainly because liability issues have made it increasingly difficult for most paramedics to work in hospital settings.
"Nobody is built like a manikin, and, unfortunately, that's where most of our training comes from," said Robert Knappage, EMS lieutenant in the Dallas suburb of Sachse.
The ability of the Department of State Health Services to monitor RSI and intubations is itself limited in several ways.
The agency's EMS/trauma registry does not collect the one piece of data that could show statistically whether a problem exists: the success or failure of an intubation.
EMS providers can lose their licenses if they do not report violations of the state's Health and Safety Code, but there is nothing spelled out as to what must be reported or when it must be done.
Moreover, there are no full-time investigators to scrutinize those matters that are reported.
The cumulative effect, some say, is a system that encourages providers to keep problems in-house and hides serious issues from public scrutiny.
"Presumably, if the public knew that the medics in Chicken Switch were intubating the esophagus 75 percent of the time, they would then go to their city leaders and raise hell about it," Ayres said. "But they don't have that option because they can't get the information."
DSHS officials realize that there are problems with EMS data collection and reporting regulations and are working to correct them, said Maxie Bishop, the agency's EMS director.
"As far as medical control and things that have happened out there, they don't always get reported to the state, and we know that," he said.
No monitoring
The issue of whether RSI should be practiced by ground EMS was underscored by the Cannon lawsuit, which charged that American Medical Response never retrained the paramedic who attempted to intubate Patricia Cannon even after the company, based in Greenwood Village, Colo., became aware of the facts of the case.
The paramedic, Jeffrey Dektor, stated in a deposition that he made two attempts to intubate Cannon, the second time with the ambulance stopped at a parking lot.
He testified that he believed his first attempt was successful but tried again with a larger tube when he noticed that Cannon's oxygen saturation levels continued to decline. During that attempt, he said, the tube became dislodged.
Asked why he didn't use any form of carbon dioxide monitoring, even though it would have been available on the ambulance, he replied: "I cannot state why I did not."
Twenty minutes passed from the time of Dektor's first attempt until Cannon was successfully intubated at Presbyterian Hospital, records show.
Robert Kowalski, who was the hospital's director of emergency medicine as well as Hunt County EMS medical director at the time, confirmed in his deposition that he was the physician who finally intubated Cannon.
He stated repeatedly during the deposition that the matter did not cause him any concern.
Kowalski, who now lives in Cadillac, Mich., said recently he doesn't remember the case well enough to discuss its details.
"It was not a paramedic we had problems with, I can tell you that, because I know the [paramedics] we had problems with, and he wasn't one of them," he said.
Dektor, who remains with Hunt County EMS and has the title "training coordinator," did not respond to phone messages from the Star-Telegram.
The settlement in the case resulted in a $500,000 payment to Gary Cannon and no admission of liability on the part of American Medical Response or other defendants.
The Allen incident involved EMS personnel attached to the Air Evac base in Wichita Falls. It occurred just four months after the company opened the base, its first in Texas.
Allen was intubated seven minutes before the helicopter landed at the United Regional Health Care center in Wichita Falls, according to records. The tube became dislodged before she was treated in the emergency room, the records indicate.
Both the flight nurse and the paramedic acknowledged in depositions that they did not use carbon dioxide monitoring, even though it was available.
The medical director for Air Evac's Wichita Falls base at the time was S. Addison Beeson, a Tulsa emergency physician. She did not respond to messages from the Star-Telegram.
Policies in area cities
Are paramedics allowed to use Rapid Sequence Intubation? Why or why not?
Yes
Fort Worth: A "core" of closely supervised paramedics that handles numerous calls every day makes it feasible for MedStar, the city's ambulance service, according to medical director John Griswell. Additionally, he said, paramedics must go through an intensive course before using paralytic drugs and perform two successful intubations on a manikin before every shift.
No
Arlington: Short transportation times and the inability to train a large number of paramedics are cited by Cynthia Simmons, the local medical director for the city's ambulance provider, American Medical Response.
Dallas: Paramedics in a large system don't have enough opportunities to sharpen their intubation skills, according to medical director Paul Pepe.
Either that or start importing them form the Third World. Comprendre?
Man, there are so many things to comment about in this article...but I do want to address your point made here.
While I agree with your first paragraph completely, the second paragraph I do not agree with.
An undetected ETT in the esophagus in a medical center setting is indeed malpractice considering the training involved for the providers involved and the equipment you mention. But I'm not certain that in an 'out in the field' setting that necessarily applies.
There are few things that can be as harrowing as trying to establish a patent airway in an emergency setting...it is often a very difficult thing to do. Conditions are rarely optimal, and often patients are already in extremis. If you have a lot of experience in this setting and are making this claim, more power to you...but to say that the problem can be resuced to 'near zero' is in my medical opinion suspect.
It would be nice if we could send highly trained anesthesiologists who are the most expert in performing intubations out on every ambulance run...but it ain't going to happen. To hold EMT's, who while trained, to the same malpractice standards as much more highly trained individuals while operating in some of the most demanding situations is just not right.
It sounds like you're thinking of a blind insertion airway, like the Combi-Tube or an oral obturator airway.
These are not endotracheal tubes, but esophageal airways. That is, the Combi-Tube and OOA are designed to go down the throat in the direction of the stomach. A pair of inflatable cuffs on the Combi-Tube (one down low near the stomach and another up high near the back of the throat) theoretically seal off the region of the trachea and allow air into the lungs. The OOA has a more involved system requiring a tight-sealing face mask, if I remember correctly (haven't seen one of those in ages). With the Combi-Tube, if you have by some insane miracle managed to stuff it into the trachea then you just switch over to the secondary tube and bag from there, it'll bypass the cuffs completely.
The endotracheal airways on the other hand, those require guided insertion. That is, we use this cool doohickey called a laryngoscope to lift the lower jaw up far enough for us to see the larynx, and then we do our damned best to send that tiny little tube screaming past it. In other words, the ET tubes are inserted in past the vocal cords and the inflatable cuff sits right above the lungs (ideally anyway, best laid plans of mice and medics...). And no, you don't want to go trying to rip THAT thing out after the cuff has been inflated :)
All things considered, if the patient needs (and is zonked out enough to tolerate) intubation then they're going to need an ET tube eventually. Might as well get it done right and get it done right now.
The Combi-Tubes might, possibly, be a useful stopgap if you can't get an ETT inserted or if you've got some EMT-Bs working the call in some state like Missouri (damn state wouldn't even let Bs use a glucometer when I was there, let alone play with the scope).
Avoiding paralytics in the emergency situation may make intubation more difficult, but allows the struggling patient to at least get some oxygen. That's better than being paralyzed and having oxygen go only into your stomach. If deep hypoxia occurs in an unparalyzed patient, the patient will stop struggling, and can be intubated then.
There's a saying in emergency medicine, “hypoxia is your friend.” It means that unparalyzed patients can be easily and quickly intubated once they become hypoxic enough to stop struggling. That saying is a justification for NOT paralyzing, and for allowing the patient to make whatever respiratory efforts they can. The caveat is that quick intubation is done if and only if deep hypoxia sets in, or when the patient can be brought to someone who really knows how to intubate.
I myself was trained in anesthesia, so I learned, without really reflecting on it, to intubate difficult airways as a matter of course. When I first heard the saying “hypoxia is your friend,” I thought it was completely insane. Why wait for deep hypoxia, when you can intubate, protect the airway, and keep the patient well oxygenated? I eventually learned that the answer is this: not everyone can intubate. It's not a hard skill, but it is a skill, and some people just can't do it. So, as a matter of routine, when devising protocols for providers to follow, I'd say the bare minimum to seriously consider routine chemical paralysis are these:
a trained anesthesiologist
working suction
an assortment of intubation blades
appropriate endotracheal tubes
and maybe a fiber-optic intubation kit, with someone who knows how to use it.
Most ambulances are missing one or more of these things (usually a trained anesthesiologist, but often working suction as well, and ambulances pretty much never have fiber-optic intubation kits, nor people who know how to use them), so paramedics / ambulance crews should NOT be paralyzing patients as a matter of course. It'll be easy enough to intubate the patient if they become sufficiently hypoxic, and if they're not hypoxic enough to easily intubate, they're really not hypoxic enough to paralyze in the field.
Just my opinion.
What you say is correct...but you should take this further to mention that Medicaid recipients often call for EMT responses for nothing other than convenience, i.e., they need a ride to the ER for some non-emergent problem. Unlike taking a cab, the ride in the Ambulance costs them nothing...so why not take the low-cost alternative to themselves even if the cost to the government and all the rest of us goes up?
Ambulance services are a MONEY LOSER for those that own them (hospitals or communities, it doesn't matter)...here in our town, the local hospital is trying to dump the service on the community, and I cannot say that I blame them as it has cost them a loss of between $500,000 to $1 million/yr.
I think what is wrong with that picture is that a lot of people want to go into the hair dressing business, enter a relatively non-stressful field with the option of being your own boss someday.
Contrast that against being an EMT, an extraordinarily high stress job that does not pay well considering the emotional and physical stress of the job, the long hours on uneven shifts never knowing what your next call is going to be like, and with very few prospects for running your own business.
Just my take on it.
Additionally, putting in a endotracheal tube is no simple matter even if the patient is unconscious, not flailing and there aren’t hysterical family members screaming in your ear, gang members trying to shoot you or tractor trailers whizzing by.
I have worked in medicine for nearly 20 years, and with all medical procedures, I have found that some people are naturally good at things, some people aren’t naturally good at some things but are smart and work hard to become good at it, some are smart and work hard but don’t get to be the best, and some people are either dumb, lazy or have poor judgement and never get to be good at a task like putting in IV’s or endotracheal tubes and they can cause you pain and hurt you.
The problem is, nearly every medical professional at some point makes mistakes.
Sometimes it is poor judgement.
Sometimes it is poor technique or poor training.
Sometimes it is laziness.
Often it is inexperience.
But sometimes, just sometimes, the person is having an off day. It happens. You aren’t as sharp because you aren’t feeling well and might not have slept more than a few hours, you have a lot going on in your personal life, someone called in sick and you are doing twice the work, whatever.
And you make a mistake.
I no longer work in direct patient care. But I was pretty good at what I did, and often when an IV needed inserting on a difficult patient, I would get called on to do it. I was pretty good at it.
One day, I was putting an IV in a patient to perform a test, and I missed. It just blew up on me. I rarely missed twice, so I buckled down and tried again, and missed again. The patient was very understanding, and I got a different setup to try again, and just couldn’t do it. I couldn’t get drawback on the blood. I tried and tried, to no avail. It was awful for the patient because I kept poking him, and emotionally, terrible for me.
After I had been digging around, something I was loathe to do but was desperate in this case, I realized I had left a stopcock in a off position. I had got so flustered after the two misses that blew up and changed equipment that I simply forgot to open it.
I told the patient immediately what I had done, and he forgave me. That was a simple error in a simple procedure. And I made more money and had less stress than EMT’s.
Owamba may be elected POTUS and has little training in anything, but he sure talks a great story.
Moral: If you intend to use "Sucs", you'd damned well better be fully ready to intubate at all costs. I don't know all the reasons behind this story. But I do know that the moment the paramedic pushed succinylcholine, he/she was duty-bound to secure that patient's airway, period, end of discussion.
Someone's head ought to roll for this.
You’re welcome.
Given the normal MSM accuracy in such matters, I figured I’d better ping an expert to find out the real deal.
Rapid sequence intubation should be done oNLY in an OR by an aneasthesiologist. Plain intubation in the field can be argued, I favor an LMA as I have seen too many EMT’s mess up an airway beyond retrieval with repeated attempts to intubate which wastes time and slows transport. Most pts can be adequately bagged, and an LMA is almost idiotproof.
Giving succ in a moving ambulance is stupid beyond belief.
Hopefully they would have secured the airway before they hit the road.
The hypoxic clenching patients in the ER might tend to disagree with you. ;'P
The problem here is not the intubation problems or the RSI, it is the failure to recognize that the tube is not in place, either initially or when it later became dislodged. The whole point of RSI is to put the patient down quickly, but BRIEFLY, while you intubate. The drugs should be chosen to wear off quickly so that if there is a problem with the intubation you can bag the patient until the drugs wear off, and at worst you are back to where you started within minutes.
These paramedics failed to recognize and address the problem of hypoxia, and that is a major failure. In addition to the clinical measures that should be used to verify tube placement, where the heck was the pulse oximetry? I don't know why any ambulance service would not be requiring its continuous use in all respiratory patients. It is the one thing that would have clearly let the paramedics know there was a problem with the tube. Maybe the patient didn't look blue or there was too much noise to properly assess breath sounds, and it seemed like the patient's chest was rising...but if that Pulse Ox is dropping, you have to know there is a problem.
That long time of UNRECOGNIZED hypoxia is the problem, not the actual intubation.
Just my 2 cents,
O2
What really gets me excited about RSIs now is a new tool called the McGrath laryngoscope. Have you heard of it? It's a digital camera with the lens at the end of the blade. The thing is AMAZING. I first saw it in action when we were having trouble securing the airway of a patient in CCU who was in severe respiratory distress and the ED MD could not, for some reason, visualize the vocal cords with a standard laryngoscope. We were getting ready to do an emergency cric on the patient when the anesthesiologist shows up at the last second, whips out a McGrath laryngoscope, and slips a 7.5 down just as neat as you please. He totally saved the day!
He showed me how the McGrath works. He says it had saved a lot of patients from getting "criked" since he started using it. My hospital evidently saw its potential benefits, too. Now our ED, OR, and CCU each have McGraths as standard equipment in our difficult airway kits and it has become the tool of choice, with only a few exceptions where the blades are not long enough.
And here's the real kicker: the guy who invented it wasn't even in the medical profession. McGrath was an engineering student in the UK, and IIRC his capstone project was to invent something. He looked for an opportunity to invent something that would benefit people, and somehow decided to try and improve intubation techniques.
Mr. McGrath came to America last year to assess the effectiveness of his invention, and he actually visited my hospital a few months back. We showed him the statistics r/t before and after getting his laryngoscope. The contrast was stunning. The MDs and anesthesiologists also presented the areas where the McGrath was not effective (longer airways and hyper-morbidly obese patients. He took notes. A few months later, we got new McGrath blades that incorporated his revisions to accomodate the problem patients.
A friend of mine who is an anesthesiologist told me that Mr. McGrath was totally blown away about the effectiveness of his brainchild. She said that McGrath was one of the most self-effacing, humble, genuinely nice people she has ever met. I don't think that McGrath will ever realize how many lives will be saved by his invention. I think there's a special place in heaven for the guy.
But I digress from the subject.
From my particular point of view as an Emergency RN, I have found that even a bad airway is better than no airway at all. At least it's a start. And if a patient is in cardiopulmonary arrest in the field, then an emergency airway should be obtained. LMAs are good, but the rationale that intubation is preferable if it can be done safely is, IMO, a sound one.
There is variation among regions regarding the skill of medics. I think that it would be a good thing to assess the training and skill of each ALS medic and to provide enhanced training for those medics who do not demonstrate proficiency in securing an emergent ETT in field conditions. Maybe providing the McGrath would improve things. Anyway, that's my long-winded response. Have a great day, Doc. Cheers! /Gunner
I’m sorry I misspoke I think RSI should only be done in a fully equipped hospital, not in the field. If you dont have a good airway in the field, I think paralyzing the pt has a lot more potential for making things worse than better.
In a hosp with ED personnel and back up from anesthesia it is a different story. I did not mean to exclude the ED from acceptable places for RSI. I also think the LMA is a good thing. It is brainless enough even I can use it with success!
Have a great week!
The “near-zero” percentage I was referencing was a tube being left in the esophagus. These days with pulse oximetry , capnography in the field, in addition to good post procedure technique (auscultation, etc.) leaving an esophageal placed tube - even in a noisy accident scene - should not occur.
With a properly equipped and trained paramedic crew this still should be a very rare occurrence. I know with a bloody field of view or disturbed anatomy secondary to trauma, or if your intubating a trapped person, etc. intubation can be nearly impossible at times, so I am not knocking the medics.
Hello, Mom MD! No apology is necessary. I completely agree with your positions r/t the risks of paralyzing in the field. As I stated in a previous post, if EMS paralyzes a patient in the field, they had better be ready to secure that airway or face the severest consequences, including civil trial for gross negligence and even criminal prosecution for manslaughter.
with modern day CO2 detectors, listening isnt even necessary. And if you have a pulse oximeter, which most EMS should, there is no excuse for not recognizing esophageal intubation. But my main point was that I do not think RSI or use of paralytics is a field procedure for EMS. Period.
We will just have to agree to disagree. This is an issue where informed people of good will could disagree.
That Mcgrath laryngoscope is so amazing and interesting! I never heard of it...you are a wealth of info!!! thanks :)
Hello again, Mom MD. I wish to respectfully weigh in on the subject of capnometry, if I may.
Current ACLS/TNCC guidelines call for a rapid, three-step methodology for verifying proper ETT placement. First is auscultation at the epigastum for gurgling; second is auscultation at bilateral upper chest at mid-clavicular lines for air movement; third is observation of the CO2 detector for yellow vs. purple.
It may seem redundant, but I have personally caught esophageal intubation in this manner at step one before the capnometer turned purple. It may seem time-consuming at first, but in this case it saved a few seconds. And in a crash, a few seconds can make the difference.
However, I do agree that the capnometer is a valuable tool for verification of ETT placement.
Thank you for your kind indulgence. Have a blessed Sunday!
/Gunner
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