rogue medic

When the police have kept me from patients, I have been far enough away that I couldn't really tell what the condition of the patient was. I never tried announcing an individual name on the radio, but the orders came down form the highest ranking LEO on scene and that person was not talking to me. Announcing that police were not allowing access to the patient produced a response of "OK, you are available."

The "proper" ways were not working. The tube did not migrate. I was able to continually confirm that because of the waveform capnography. This was an unusual situation, the patient had consumed a large amount of some extremely slippery substance. Nothing was sticking. Why do you believe that tube migration is a problem, rather than these being cases of misplacement? When "I saw the tube go through the vocal cords," is followed by "it must have become dislodged," why does anyone believe that the tube was ever in the trachea? I am not claiming that tubes never become dislodged, but that the rate of tracheal intubation followed by dislodgement, is wildly exaggerated. The tube was never in the trachea. The medic has been trained to say "I saw the tube go through the vocal cords," because if the medic does not state that, the testing body will punish the medic for a critical failure. This is teaching bad airway management. It teaches the student to say that the student sees something the student doesn't see. It is rare for a properly managed tube to leave the trachea. Even with the parts of my tube separating and nothing sticking, my tube was never dislodged. "Winged Migration" was not a movie about endotracheal tubes. The true dislodged tube is rare. The research I quoted showed that in an excellent system the rate of unrecognized esophageal tubes was 0.3 % and decreased with the addition of capnography. Other systems claim to have equal success at intubating, just an extremely high rate of dislodged tubes. Some people believe that. The word for that is gullible.

If police are telling you to not transport, there is not much that you can do. If you insist and they arrest you, then nobody is transported until later on. Distractions can certainly contribute to a bad assessment. Many people are not good at assessing children. What actually happened? I don't know. I have never been present at a scene described by the news media, where the reporting was completely accurate. The politics of this became more important than the reality, whatever that was. The people I know from Hatzolah would not let the race of a patient interfere with patient care. The child is still dead, the animosities are greater because of the instigators.

I think that DustDevil got the sarcasm that I am not as pretty as my life-like "photo not available" picture.

Dwayne, I don't believe I ever stated that VentMedic claimed it was the only method of confirming placement. I disagreed with her claim that it is an effective part of assessing placement. It is a very ineffective means of assessing placement. It does not contribute to assessment. It misleads people into keeping tubes in place that should be pulled. People think that what they see is what is happening. People see what they want to believe. Why is it that so many people state that they saw the tube go through the cords, when the tube is actually in the esophagus? I am critical of cord visualization and strongly encourage waveform capnography. VentMedic is critical of waveform capnography in the prehospital setting and feels that visualizing the tube going through the vocal cords is an important component of tube placement confirmation, unless I misunderstand her position. Neither of us was suggesting that these be the only method of confirmation. One is supported by plenty of research, especially in the prehospital setting. The other is not. How do you come to the conclusion that cord visualization has a place in assessment and capnography does not? Perhaps you can explain where I am not getting VentMedic's argument.

Congratulations. Don't worry about the screen name. A good medic never stops being a basic EMT. You always have that to fall back on. Get to know your medical director as well as you can. The medical director will let you know when you are being too much of a nuisance. The really good ones can almost always make time for you.

The you here is a generic you - any EMS provider presented with this situation. I am not recommending choosing patients. You have 2 patients. I am making the point that choosing is wrong. You have 2 patients. You may have a boss tell you that you only have a responsibility to the patient you were called for. Is it written somewhere on the side of the ambulance that the 911 writing is not just for information, but that you must call 911 to be transported? You may not flag down an ambulance? I was under the impression that this took place in Atlantic City, which is still in New Jersey, at least it was the last time I was there. You guys = anyone trying to come up with an idea why you can pretend that you do not have 2 patients. Acting as if you are Solomon and will split the baby to determine who the mother is. These are just distractions from the reality of - you have 2 patients. Nothing personally directed at anyone. Just a "what are you thinking?" kind of comment. You cannot choose unless you have some other provider to transfer care to, or you end up with a refusal. EMS initiated refusals do happen in NJ, but NJ OEMS will pull your card if they find out. Dwayne, you complimented me twice. Boy are you going to lose credibility with everyone else. You just like me, because of my picture. Well, I am not that pretty in person. :oops: I appreciate the kind comments. I was not even noticing a Florida connection to the forum. My bad.

Disconnecting stuff that you don't understand is bad patient care regardless of where it takes place. Ask before you disconnect. Also, it might be a good idea to ask before you cut a capnography cable that is not disposable. But, I'm sure there is a good reason for the ED staff to be destroying EMS equipment. Maybe, it just demonstrates that a person was acting without thinking. What licensed signature? They just start pulling on things. Good thing I haven't seen them do this to a PICC line, yet. If you don't know what it is, ask. If you want it removed, don't panic and start grabbing things you don't understand, ask someone to remove it. Please explain what you are talking about. What argument? What standards? It looks as if you clipped part of a comment and did not get all of it. I was just answering the who part of your question: Since I put your quote in front of my answer, I thought you might see the connection. And your point is that I have a bad memory? :roll: Really, I sell rose tinted glasses for people who believe that "seeing the tube go through the cords" is a dependable assessment. If I were selling something, I would have some way for you to order it. I might even identify a particular product. I do not sell anything. I do not advertise anything. I have links to tinyURL, dictionary.com, and Epocrates. I do not receive any money from them. These are there to make it easier for people to find information. If someone goes to one of these sites and purchases something, I do not receive anything for it. I have never plugged any of these on my blog, other than to provide access to them on the side bar. I have links to several blogs. Many of them do not have any kind of advertising. The blogs that do have advertising are probably not making any significant money from the ads. Certainly not when you break it down per hour devoted to keeping the blogs going. The links are there to provide ideas for interesting and informative reading. I also link to the web sites of these people and organizations. They do not endorse my blog. They do not pay me. They are there to make it easy for readers to find reputable information. EMT City might have links to some, or all, of them somewhere. * Dr. Bryan Bledsoe * EMS House of DeFrance * EMS1.com * EMStock * EMSunites.com * National Association of EMS Educators * National Association of EMS Physicians * National Association of EMTs * National Association of State EMS Officials * National EMS Museum Foundation * Prehospital Emergency Care * SLAM - Street Level Airway Management My blog is Rogue Medic. I am not hiding or selling anything. If you want to come and read and laugh at me, go ahead. If you want to come and disagree, you are welcome, also. If you want to come and agree, I have to warn you that VentMedic is watching and will be taking names. :shock: Actually, I do sell one thing - ideas. Those ideas are free. Some might say that they aren't even worth that much. Oh, well. Ad hominem attacks generally indicate that the critic has no other way of making a point, no valid argument. VentMedic does not have any research that shows that a medic, or nurse, or doctor, claiming to "see the tube go through the cords" is an effective way to determine tube placement. This is just wishful thinking on VentMedic's part.

We can't take unrelated patients because of HIPAA? Patients who may be separated by only a curtain in the ED. That is assuming that they are not in hallway beds with no curtains available. You have two patients. Which one you have been dispatched for is unimportant. You are the person representing yourself as the trained care provider. Why do you now panic and claim to be incapable of handling 2 patients? We don't know how serious the pediatric patient, with hemorrhaging from a head injury, really is until we assess the patient. At the hospital they determined the kid only needed stitches. We don't know how bad the auto/pedestrian patient lying in the road was. No mention is made of the patient arguing or yelling in pain or having any pain. We don't know. Y'all just made that stuff up. What good reason is there to not transport both patients? What if the next due ambulance is half an hour away? Do you wait with both of your patients on scene? Do you not assess both of your patients in the mean time, because of misunderstanding of HIPAA? Do you leave one of your patients on scene and tell them wait there for another ambulance. What if they don't wait? What if there actually is something that you missed in your assessment, because of all of the bystanders fighting and the patient does not go to the hospital - after all the trained professionals refused to take the patient, how bad could it be? Maybe, the auto/ped has a fracture that sets wrong. No liability, there? Maybe, the kid develops an infection from the fence that he ran into. No liability, there? Or Dr. Brabson receives a call about the EMTs refusing to transport a patient. Is he going to be unhappy with patients for confusing his EMTs? Is NJ so backward that you are not allowed to be a patient, unless you call 911, first? Is any other state? You have 2 patients and you can't figure out how to transport both? As long as they are not interfering with the care of the other patient, put them in the truck, take your thumbs out of your orifices, and stop wasting everyones time. Aren't people from The Swamp State always complaining about people causing ambulances to be unavailable because of minor injuries. Here you have the EMTs causing 2 ambulances to be tied up, instead of just one. You guys are probably whining more than both of the patients did. If you can't deal with this there are exciting jobs in the fast food industry.

Why would anyone not use the most effective tube confirmation device available? Look at the RSI cases from Texas. They did not assess carbon dioxide by any means. Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9. Prehospital use of succinylcholine: a 20-year review. Wayne MA, Friedland E. RESULTS: Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations. A large number of patients in a system that appears to do an excellent job. They added capnography and the esophageal tube rate went down. This is not a bunch of yokels being given a toy to play with. These are medics, who are very good at what they do. They do not turn up their noses at something that will help them to assess placement better. Capnography is not a substitute for competence. Incompetent medics do not belong in EMS. The medical directors, who allow them to treat patients need to be eliminated. Bad medical oversight just allows bad medics to kill patients. Adapting the type of ALS to accommodate bad medics is just allowing the incompetence to continue. If you can't afford ALS, BLS works. Incompetent medics are not better than good basic EMTs. The only time I have seen it used in the ED was when I provided it. Not many EDs seem to have anything other than the plastic covered litmus paper color change devices, CO2-wise. My comment was that the ED personnel would not go to the ICU and start pulling off equipment that they are unfamiliar with. If you don't know what something is, you ask. You do not disconnect things you do not understand. If ED personnel go to the ICU and start disconnecting things, because they are in the way, they should not expect to be treated as professionals. What equipment do you have that does not have the possibility of failure? The tube can fail, the bag can fail, the oxygen can fail, the stretcher can fail, the ambulance can fail, . . . . Everything can fail. All of these have happened to me and I have adapted, as I have adapted to capnography problems. Capnography is just one assessment tool, but it is the most effective one. Anyone relying on only one assessment does not belong in EMS. You seem to keep trying to justify the untrained and under-supervised medic. These need to be eliminated before they kill and/or injure people. Anything else is just plain dangerous. National Registry keeps making it easier for people to get medic cards, regardless of their incompetence. For them visualizing the tube going through the cords is a mandatory statement. How many people have they helped to kill with that requirement? They also teach that you treat the rhythm, not the patient. It is a tool that can fail. Just as I do not start CPR, because there is a flat line (or artifact) on the ECG of a patient with a pulse, I do not make the capnography the only assessment. But I have already stated this a few times. You can keep making the same comments and you will keep getting the same responses. I never wrote that capnography is, or should be, the only assessment. I wrote that it is the most reliable, the most effective. Claiming that I stated anything else is misleading. Relying on seeing the tube pass through the cords" is not a mistake I make. I assess the patient for signs that the tube is in the esophagus (epigastric sounds with each breath, lack of chest rise, significant belly rise, . . . ) and pull the tube quickly if that appears to be the case. Again, you misrepresent what I wrote to claim that I am inconsistent. Capnography should not be the only assessment. Using a bougie has absolutely nothing to do with not using capnography. Using the bougie does rely on feel. Using the standard excuse for esophageal tubes - "I saw it go through the cords" as anything more than a hint of where the tube might be, is wrong. Visualization is even less reliable than the bougie. Having a lot of tools is important. Understanding their use, and their potentially to mislead is also important. Discouraging people from using tools that can improve their assessment of the airway is bad medicine. Almost every esophageal tube is accompanied by the statement "I saw it go through the cords." Is there any less reliable means of assessing tube placement? I do not remember when I started using capnography. The first several times I saw it used was when working in an ICU. On the ambulance it has been extremely helpful. Several tubes, that were not as secure as I would have liked, were left in place due to the ability to continuously demonstrate good gas exchange. As I wrote before, I have had a false positive with capnography for longer than the 6 breaths that are supposed to be the maximum. A bystander had been doing mouth-to-mouth for a while. The waveform did not change significantly. The rest of the assessment was ambiguous, but did not agree with the capnography, so the tube was pulled. The patient was reintubated successfully. I should have pulled the tube a few breaths earlier, but I did let the capnography mislead me. This was a very large patient with a very distended belly making assessment difficult. Breath sound/stomach sound, chest rise/belly rise. In spite of all of the air in his belly, he never vomited. I have talked with Dr. Baruch Krauss of Boston Children's Hospital. He attends a lot of conferences and is always looking to hear how capnography can be used better, how capnography malfunctions, and anything else that affects the use of capnography. His name is on about half of the capnography literature. He also has written a lot of the literature on pediatric sedation, pediatric PSA, and pediatric analgesia. These two are related. Capnography is used some places for any heavy sedation. It gives a clear, objective, assessment of ventilation. That does not mean that you ignore other assessment skills. Who sold me on capnography? The research. The research is very clear about the value of capnography.

This is not to be encouraged. Capnography is there to assist with assessment of airway management. It is only one part of the full airway assessment, but it is the most reliable part. If I must choose between a tube that is placed with the cuff above the cords and an esophageal tube, that is an easy choice. If the tube is not through the cords and does not stay in place, capnography will let me know this more reliably and more quickly than any other method of assessment. The goal of airway management is ventilation, not intubation. An LMA is an acceptable means of securing an airway. Anyone repeatedly attempting intubation, instead of securing an alternative airway is not providing patient care, but protocol care. Even if the tube is haphazardly secured, the capnography will let you know, better than any other method of assessment, if things change. Since capnography is the most sensible part of airway assessment, the use of capnography must be what keeps you from collecting those nickels. Who's paying these nickels out, anyway? I am not a fan of gadgets, but capnography is the one gadget that is most important to EMS. Oximetry is rarely an assessment that is significant. The one true benefit of oximetry is recognizing covert hypoxia, which is not so common. Capnography does not make the person better at intubation, but better at assessing the placement of the tube. The person who lacks intubation and assessment skills should not be treating patients by ALS means. If the incompetent are allowed to treat patients, then the medical director is the problem. I think the research is quite clear on the value of capnography. Capnography is a diagnostic adjunct that is far more useful than a "National Registry mandatory phrase," such as "I saw the tube go through the cords." The one thing I do not want to hear is the recitation of a NR mantra when the patient needs an airway. The tubes that are in the esophagus are almost always accompanied by that NR monkey phrase. Yes, we need to have medics much better educated. NR's teach to the test is the opposite of education. Seeing the cords is nice on all of the easy tubes. What do you do when you can't visualize the cords? What do you do with your higher grade Cormack-Lehane views? Should you not use a bougie, since it is incompatible with seeing the tube go through the cords? I have no problem with using crutches to manage the airway. LMA, King LT, CombiTube, BVM, . . . , are all crutches. Other crutches that I think are important to use are Bimanual Laryngoscopy, the bougie, placing the tube above the arytenoid cartilage (much easier to recognize in a difficult airway than any of the other structures), using suction, looking for bubbles in the liquid in the airway that is coming out faster than suction can manage, surgical cricothyrotomy, RSI, . . . . Crutches allow me to deliver better care, they are not an alternative to it. If I want to know where the tube is, capnography is the most important assessment, but it is not the only assessment. When I arrive at the ED and they pull the capnography tubing that they do not like, they are only demonstrating profound ignorance. The ED personnel would not do that in the ICU, but they are removing equally valuable equipment. Someone should not be using any equipment unless properly trained. If your people are not properly trained in capnography, the problem is not the capnography, but the person who allows this to happen and the medical director who doesn't stop it.

One reason for the patients with unrecognized esophageal tubes is often the mistaken belief that the medic, nurse, or doctor, is so good that they don't need it. This is the most important EMS device available. Look at the cases from the Star-Telegram article. Nobody checked end tidal CO2 by any method. These killers are not people to copy. Waveform capnography is the most important prehospital assessment of tube placement. It is far more important than the little piece of litmus paper used in colorimetry (color change CO2 assessment) or the hand held capnometry (number measurement without a waveform). Capnography is not perfect. I have had a false positive that lasted much longer than 6 breaths with minimal change in pattern or numbers. This was a patient with a very distended belly following aggressive mouth-to-mouth prior to EMS arrival. Although capnography is not perfect it is far more reliable than "I saw it go through the vocal cords." This is the lie that accompanies almost every esophageal tube. Whether it is a doctor, a nurse, or a medic telling the lie, it is a lie. The "Wandering Tube Foundation" has plenty of members who swear the tube was in the trachea. You can recognize them when tube placement is checked and they call out to other members - "WTF!" Any magician will tell you "seeing is deceiving." Proper tube management and use of capnography will prevent this self-deception. Not using capnography, instead relying on inferior assessments, when capnography is available is just bad patient care. Capnography is just a part of competent airway assessment. Absence of sounds over the belly is probably the next most important assessment. Too many people want to hear the sounds over the lungs and waste time that could be spent ventilating the patient. The sooner you realize that the tube is in the wrong place, the sooner you can correct the problem. Listening over the lungs delays this. How many gurgling breaths over the stomach does it take to know that the tube is in the wrong place vs listening over the lungs again and again and again because you "just know you saw it go through the cords." The EDD is not something that I have used, but it has good research to back it up. SLAM recommends its use. Improvement in patient condition is also an important assessment. Chest rise, amount of belly rise, mucus membrane color changes, heart rate, . . . . Obviously, you should have training on the use of capnography, if you are going to use it on patients. That is a no brainer, but having capnography and not using it is just bad medicine. You have the ability to accurately document that the tube is not in the esophagus, but you don't? Why would anyone do that? Capnography will also let you know when there has been an important change in the patient's condition much sooner than any other assessment. Through compressions and artifact capnography will quickly pick up on a change in cardiac output. What else does? Capnography can be very helpful in assessing for capture with a transcutaneous pacer, when there is so much muscle spasm that you cannot tell if it is a pulse or a muscle twitch from the pacer. Differentiating between CHF and pneumonia, so that the protocol monkeys can be discouraged from giving Lasix to pneumonia. Not that they should be giving it to anyone who doesn't have peripheral edema, but some doctors are a bit slow on changing their protocols to follow the research. Differentiating between CHF and COPD exacerbations, so the same protocol monkeys are not following the wrong protocol. When moving a patient with a tube that is hard to keep in place, capnography is the most important tool you can have. As long as your waveform does not change, assuming you have a good waveform, you know the tube is still where you want it to be. At the hospital, the waveform is more reliable than direct visualization by the emergency physician. And waveform capnography is cheaper than a lawyer. :-)