Skip to comments.High-risk EMS procedure gets a low level of oversight
Posted on 04/20/2008 8:05:56 AM PDT by Dysart
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Graham High volleyball coach Lu Allen, center, was struck by a pickup, and she received RSI while being flown to a hospital. Her breathing tube was later discovered in her esophagus.
Jeff Stanard, 34, suffered a brain injury because of lack of oxygen. A dislodged intubation tube may have gone unnoticed for as long as eight minutes, according to records and testimony.
Definitive pre-hospital airway control with an ET tube, if indicated, save many more lives than the relatively rare complications highlighted in the article.
An undetected ET tube in the esophagus is malpractice and unnecessary with modern equipment. Proper training and careful selection of paramedic candidates will reduce that problem to near zero.
Starting an IV is not a potentially deadly procedure. It can save a life, but in itself will probably not result in injury or death.
Still, EMT's who do not regularly start IV's will have high failure rates - lines that are found not working upon arrival at the ER.
An important part of quality assurance in a well run EMS system is knowing how your experience level, your successes and failures, compares to others in the system.
Could you give a reference to the modern equipment - I remember reading something about a tube that if it went into the esophagus, you just inflated the ballon that blocked the esophagus and proceeded with respiration/resuscitation.
"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 protocols under which these providers practice are designed not just to save lives, but to limit liability and protect the EMS personnel as well.
There are very good reasons for the apparent slavish obedience to protocols and procedures found in EMS.
That is one type of tube. Their are several proprietary hybrid tubes.
I was thinking of devices which attach to the ET tube to detect CO2 (present in exhaled air), pulse oximetry, and other capnography equipment. That is in addition to using good technique, auscutation of breath sounds, observing for increasing abdominal distention, fogging of the tube, skin color, etc.
I have to ask a question of the writer of this article, “If they hadn’t tried to insert the tube, would the patient have been able to breathe on their own? Would they have gotten sufficient oxygen or would they still have suffered brain damage?” They were unable to breathe before the medics attempted to insert the airway so it seems to me they were doomed to oxygen starvation either way.
Seems to me the risk are outweighed by the consequences of not intubating. Also, there are but a handful of cases described here, no numbers are given but much speculation on how many cases go unreported with no proof that any go unreported. Typical liberal type scare tactics.
Only 700 hours is ridiculous. I spent a day a month with the anesthesiologist in the OR doing intubations when I was in a low call volume setting.
But, before anyone starts slamming medics doing intubations. Try watching an average physician (not an ER doc or anesthesiologist) try to intubate a patient in a hospital it is more often horrific than a smooth procedure.
Most often advanced EMS providers are too restricted by their protocols and people die because of it.
“And this screams out for remedy:”
In many parts of the country, the practice of prehospital medicine amounts to little more than human experimentation. EMS medics make very little income when compared to their othther public service counterparts. Most medics only have a high school education.
Medicare and Medicaid (roughly 60% of EMS patients) are paying less and less for EMS services, while the demand for same is increasing at a rate of 8-10% per year. Many have argued that stricter training standards and systems of accountability are the answer, and would produce higher incomes for the medics. However, there is no “new money” in the form of EMS reimbursement that will make this a reality. Thus, there is a nation-wide shortage of qualified medics because thay can earn more by flipping burgers at McDonalds.
Not likely with the good samaritan laws in most states.
My point exactly.
I don’t even see “why” he would had have to be intubated.
Every patient who has an airway has a chance of survival. EVERY patient without an airway will die 100% of the time. The decision to attempt non-surgical airway (ET) intubation must be considered in light of this reality. However attempting intubation in a moving vehicle, without benefit of proper assistance, suction, lighting,positioning is extremely difficult even for a trained MD, CRNA or ER provider. In addition the contents of the stomach is unknown with the very real possibility of regurgitation and aspiration. Placing and leaving a tube in the esophagus should be an easily recognized complication as others have stated here. I was taught long before today’s sophisticated monitors to listen to the stomach and watch for chest rising before taping the tube down. That only takes a pair of ears and eyes a few seconds. Endotracheal intubation is an art that takes a long time and hundreds of cases to master. RSI(crash intubation) is an all or nothing form of this which should only be used by experienced clinicians or by others only when there is no other means of ventilating the patient(pending death).
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