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Things you shouldn't say to the ER doctor when you bring in a patient

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So, after a less than stellar performance by a crew the other day I was reflecting on what happened and wanted to share (as much as HIPAA allows) to help others not make the same mistakes. Feel free to make this go both ways as it can be educational for EMS/RNs/MDs/DOs. The purpose is NOT to bash but to learn from others mistakes. Think of it as an unofficial M&M conference.

Paramedic "I'm not sure if the tube is in right."

60s y/o male who coded in front of family. FD first responders did CPR for a minute and got a pulse back. Upon EMS arrival, pt was still unconscious and they were able to drop a tube. 15 minutes out from the hospital the pt goes into arrest again. Asystole upon arrival at the ER. We hear a whooshing sound when we are bagging. At this point the paramedic makes the above comment. Take a look and the balloon is sitting in the back of the throat. Pt pronounced shortly after arrival.

Take home point: If you are not sure the tube is good, make it good or get it out. NEVER have a questionable tube.
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Posted · Report post

Running these high energy calls can be stressful and chaotic but there is so much emphasis put on tube confirmation, reconfirmation there is no reason for this to happen. Do they have etco2? Maybe I'm obsessed with this but my tube is my baby. If I worked that hard to get it in, you can guarantee it I will be anal about keeping it in, and keeping it in the right place.
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Most of the services around here have ETCo2, I'm not sure if they do but if they do, I do not think they were using it. I agree that these things can be chaotic, but that is no excuse. That is why you are trained to do this. I also agree about the tube. When you tube someone, it is your tube, your lifeline. You do not let go until it has been secured. Someone else can listen to the initial lung sounds to confirm placement. I had a resident the other day who let go of the tube before it was secured to grab her stethoscope. I cringed and grabbed the tube. We talked about it afterwards. The scary part about the original call was that they had secured the tube with one of the Tomas holders.
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My process for tube confirmation:
[list=1]
[*]Watch the tube pass through the cords
[*]Look at the measurement on the tube and compare it to the teeth, not the lips.
[*]Watch for chest rise and fall
[*]Watch for fogging in the tube during exhalation
[*]Listen to the lungs
[*]etCO[sub]2[/sub] Capnography
[*]SPO[sub]2[/sub]
[/list]
Even so, I have arrived in the ER and realise there was a problem with the tube. In this case the seal had leaked and blowby was occurring. Being able to hear subtle changes in airway sounds from the tube is pretty much impossible while in transit, but even during a code I will often find a few seconds to check the tube placement on a regular basis, even just to check the measurement and if it fogs up.
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Posted · Report post

I wouldn't exactly describe these airway sound changes as subtle.
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[quote name='ERDoc' timestamp='1355592889' post='291599']
I wouldn't exactly describe these airway sound changes as subtle.
[/quote]

Every tube I have heard leaking was pretty obvious.
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The only way I can describe it was it sounded like when you blow into a dogs mouth/nose. Same tone and volume.
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[quote name='ERDoc' timestamp='1355593530' post='291602']
The only way I can describe it was it sounded like when you blow into a dogs mouth/nose. Same tone and volume.
[/quote]

You do this frequently?
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[quote name='DFIB' timestamp='1355594067' post='291604']
You do this frequently?
[/quote]

This isn't about me. :whistle:
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[quote name='ERDoc' timestamp='1355592889' post='291599']
I wouldn't exactly describe these airway sound changes as subtle.
[/quote]

No, a fully dislodged tube would be quite easy to hear even when travelling down the road with a sound environment in the 90+ db range. I was thinking of things less obvious.

I suppose that is one significant detriment to being perfect at placing tubes...I've never heard what one sounds like when there are complications so I'd never know what to listen for. :D Edited by Arctickat
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No reason for a medic to ever bring a patient in with an improperly placed tube. To many checks and balances that should be in place to help catch a displaced tube as soon as it occurs.

Can't believe the idiots statement to you doc. Sounds like a confession if incompetence on his/her part. I suggest you contact his/her service and suggest a major airway refresher course.
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Needless to say, the county medical director is a partner in my group and a good friend. It has been sent for review.
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Please just don't allow the knee jerk reaction to remove intubation because of this one medics failure.
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Wow. Did he really say that?

Just... wow.

To be a fly on the wall in that meeting. And so many questions.

Is this guy normally that incompetent? Is the department? Was he just having a bad day? Or is this a recurrent problem with him?
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I wish I had the answers to those questions. We a fairly large city with a huge cachement area so we get lots of providers I don't recognize. I normally don't complain about things that the field crews do. I was on the other side for almost 10 years so I know what goes on but this one felt like it needed to be referred.
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[quote name='ERDoc' timestamp='1355584144' post='291590']
So, after a less than stellar performance by a crew the other day I was reflecting on what happened and wanted to share (as much as HIPAA allows) to help others not make the same mistakes. Feel free to make this go both ways as it can be educational for EMS/RNs/MDs/DOs. The purpose is NOT to bash but to learn from others mistakes. Think of it as an unofficial M&M conference.

Paramedic "I'm not sure if the tube is in right."

60s y/o male who coded in front of family. FD first responders did CPR for a minute and got a pulse back. Upon EMS arrival, pt was still unconscious and they were able to drop a tube. 15 minutes out from the hospital the pt goes into arrest again. Asystole upon arrival at the ER. We hear a whooshing sound when we are bagging. At this point the paramedic makes the above comment. Take a look and the balloon is sitting in the back of the throat. Pt pronounced shortly after arrival.

Take home point: If you are not sure the tube is good, make it good or get it out. NEVER have a questionable tube.
[/quote]

Probably a stupid question but could improper tube placement cause the asystole or was that caused by other underlying problems? Obviously it could impact respirations.

This applies to more than just tubes. If your going to do anything - do it properly and don't half-ass it.
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Yes. An improperly placed tube could contribute directly (or indirectly) to this patient going into cardiac arrest. Whether that is what happened here is up for ERDoc to expand upon.
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I can't say for sure but my feeling is it did affect the short term outsome. The guy had stage 4 cancer (don't remember the primary). The pt had ROSC and hypoxia would obviously work against that.
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I wouldn't be able to sleep at night even with the suspicion that one of my interventions with so many failsafes may have killed a patient. We're human, we makes mistakes and I understand that, but this isn't just a mistake, it's complete ignorance to the basic standards of intubation. And to admit that you think you effed up without trying everything in your power to correct the mistake is unbelievable.
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If you are questioning the tube, and you cannot confirm it just pull it out. What's wrong with bagging? So many medics have this ego about ET tubes its pretty sick.
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Bought a patient into resus and was met by the Consultant Emergency Physician as part of the resus team. At this particular hospital all the staff wore different coloured scrubs so you could tell everybody by everybody else.

"So, are you the nurse?"

That did not go down well :D
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