Prehospital Intubations and Mortality - comment from 30 ff/pm

In the comments to Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective I, 30 ff/pm wrote:

Like most studies done by someone who wants their name in a publication, this one is throws out some numbers as if they mean something.

To compare 4 diff. types of airway management and give the impression that there is a "relation with mortality" without giving at least a head nod to the INJURY is asinine.

I do not know what the motivations of the researchers[1] was, but it is good that they are publishing the results of their study, even though it makes them look really bad.

I would rather have them publicly face their problem, than cover it up and ignore it.

The type of injury should not matter. With a large enough sample size, there should be a wide enough variation in injuries, that the result falls into the category of normal distribution. A few really tough tubes should not make a big difference in this sample size.

The question is, Do they recognize what the problem is?

Sadly, I think we agree that the medical directors probably do not recognize that this is a problem of oversight, not so much a problem of bad medics. The medics were probably just doing what they were trained to do.

If they did 2 successful crics, what did they use for a tube? A Bic pen? If they used an ETT that pt IS TUBED, just not orally. That is NOT a failed intubation.

I will agree that this is successful airway management, if the crichothyrotomy truly was necessary. 1% is on the high side for crichothyrotomy rate, but this is such a small sample size that the numbers are well within the expected normal distribution of crichothyrotomies.

The term should be not a successful orotracheal intubation. You are correct, but it is not an important problem in my opinion. Their lack of understanding of airway management is a much greater problem.

Where we part ways in thought is your hairspltting "control" issues.

We never have control of the airway. Even a properly placed endotracheal tube does not mean control. Control suggests that something does what you want it to do.

We manage airways, i.e., we control them.

The airway may not do exactly what I want it to do - that's why I have a laryngoscope in my hand in the 1st place - but with a tube in place it sure as hell is easier to manage than without it and that is control as far as airways go.

with a tube in place it sure as hell is easier to manage than without it and that is control as far as airways go.

For the 12% of these patients with unrecognized esophageal intubations, the airway was not managed.

How is that control?

Control suggests something that has been accomplished, something that can be considered completed, something that can be checked off. This subconscious, or even conscious, approach to airway management is part of the problem. If you are managing the airway you are constantly reassessing it and looking to maintain oxygenation and, much more importantly, ventilation. Airway management is never a task that has been completed. Airway management is a process that requires perpetual vigilance. Control suggests just the opposite.

This is like the approach to success. Success is a way of doing things, not an easily definable goal. The goal is continually changing as one is presented with different complications.

If we look at intubation as control, once the tube is in, if we saw what we think was the tube going through the cords, how aggressive are we in looking for evidence that we were wrong?

There is one thing that is pretty consistent with unrecognized esophageal intubations. The medic/nurse/doctor thought the tube was in the trachea. They thought the airway was controlled.

They had stopped looking for evidence that the tube was in the wrong place.

They had become complacent with their assumed control.

What I want to know is how the hell did 8 friggin' people live with a tubed gut??

Those had to be tubes that got dislodged at the ED door or bedside moving the pt.

How the hell did 8 friggin' people live with a tubed gut??

They were probably breathing adequately on their own around the misplaced tube. Where is the evidence that all of these patients needed to be intubated? That all of these patients needed to have their airways controlled?

Where is the evidence that the tube suddenly migrated to the esophagus at the ED?

I am under the impression that endotracheal tubes are not any more migratory than coconuts. Besides, good airway management (unlike airway control) involves continual assessment of tube placement. Unrecognized esophageal endotracheal tubes should not happen with good airway management.

These GI medics were only controlling access to the esophagus, and probably not even doing that well. It isn't as if they were aware of what was going on with the airway. Control implies that there is no longer a need to remain aware of what is going on.

They certainly were not demonstrating any awareness of what was going on with the airway.

No. I believe these are the same as other groups of patients, who survived in spite of being esophageally intubated. They were spontaneously breathing. They were breathing around the tube. It isn't as if the tube was blocking the trachea, since it was not in the trachea even a little bit. They were overcoming some of the medics' best efforts to kill them.

With this group of medics, there is no reason to give them the benefit of the doubt about tube placement. They should have had waveform capnography, but even without waveform capnography there should be a much lower unrecognized esophageal intubation rate

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.[2]

12% vs. 0.3%.

Six (0.36%) unrecognized esophageal intubations were discovered in the emergency department or at autopsy. Only one (0.06%) of these occurred since the addition of capnography and a tube aspiration device in 1990. In this patient, a zero reading on the capnograph was ignored and not verified by a tube aspiration device or by removing the tube and re-intubating the patient.

That is the kind of problem that continues to exist even in places that use waveform capnography - and there is no acceptable excuse for not using waveform capnography.

The problem is that the tube is in the mouth. The medic/nurse/doctor thinks the tube is in the right place, for whatever reason, then the medic/nurse/doctor ignores all evidence to the contrary.

Maybe the tube was in originally, but came out en route. We have no way of knowing because the medics have no way of showing evidence of where the tube was. If we have a series of printouts of a good waveforms, we know that the tube was either in the trachea or above the cords, but resting with the tip of the tube in the top of the trachea. Without waveform capnography, we have the medic's word vs. the word of the unrecognized esophageal tube.

Is the medic telling a lie, or is the tube telling a lie?

We are very good at deceiving ourselves about what we want to believe. That is why we need to continually be looking for evidence that the tube is in the wrong place. That is why we should avoid using words that lead to airway complacency. that is why we should avoid using the word control. We should also avoid this fixation with, I saw the tube go through the cords. that is more self-deception. The only justification for it is to satisfy people who are incompetent at teaching and incompetent at assessment.


^ 1 Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed - indexed for MEDLINE]

PubMed states that the full text article is free at the journal site, but it is not. This seems to have been posted on all of the Anesthesia & Analgesia abstracts at PubMed.

^ 2 Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed - indexed for MEDLINE]


1 comment:

Adam Thompson, EMT-P said...

They were probably breathing adequately on their own around the misplaced tube. Where is the evidence that all of these patients needed to be intubated? That all of these patients needed to have their airways controlled?

An astute observation. I'm a believer in less is more. I think that most of these patients probably have breathing problems not airway problems. I bet they would rather breath on their own if they had the choice.