Troubling rumor about Riverside County, CA

[thegreypilgrim]

I've heard some rumblings about REMS pulling adult ET from their scope. Airway management will be limited to use of Combitube or King airway (whichever is used in Riverside). Anyone else heard this?

 

[foxfire]

That had has been traveling down the grapevine in my area. Don't know if it is going to go anywhere at this point.
I can see why to a certain degree they would give consideration to pulling it from scope of practise.

 

[DesertMedic66]

yeah i have heard that rumor also. i heard the info passed down from a fire chief. he said that its due to "Faulty paperwork". we already took out peds so adult seemed to be comming soon as well.

 

[thegreypilgrim]

I heard what happened was there were 3 independent incidences of esophageally intubated patients without any secondary-confirmation devices used. Documentation was also substandard from what I gather.

 

[DesertMedic66]

i heard this rumor start up in 2009 so its been around for a while and still has happened. but it could change.

 

[usalsfyre]

I heard what happened was there were 3 independent incidences of esophageally intubated patients without any secondary-confirmation devices used. Documentation was also substandard from what I gather.

If this is the case, I don't find this troubling at all, and support it 100%. Missed intubations are entirely excusable. Unrecognized esophogeal intubation is entirely inexcusable in the age of readily available waveform capnography. If it's there and you choose not to use it, your too effin stupid to wield a poteintial murder weapon (also known as a laryngoscope).

 

[socalmedic]

i can confirm the ramblings, there is a possibility that this will happen. my source is Dr. Chua Medical Director for AMR Riverside, also a lecturer at NCTI riverside. this was brought to my attention when Dr Chua was brought 2 esophageal intubations back to back and one the following week, while he was the attending physician. note that all ambulances have waveform capnography. this was in 2009 so if nothing has happened by now i doubt it will, however the rumors are correct.

 

[DrankTheKoolaid]

re

Looking at the Riverside EMS website it shows both AMR and Fire as the providers. Sure would be nice if they would actually break it down to try to pinpoint the problem areas and increase education. Instead of removing a valuable tool from the medics toolbox.

 

[18G]

3 cases do not warrant taking a skill out of an entire EMS system. Deal with the three people involved.

 

[Aidey]

I think that we are moving quickly towards a time where waveform capnography will be required for ET intubation. It is unofficially the policy here, it isn't in writing yet, but our MD has said "you will use it, or else".

Although, we had a rather scary incident here where an esophageal intubation was confirmed by waveform capnography, and the medics in charge refused to pull the tube. The medic who did the intubation declared it was a good tube and the machine must be broken.

 

[usalsfyre]

3 cases do not warrant taking a skill out of an entire EMS system. Deal with the three people involved.

It's not three cases over a year (although even that is three too many) it's thre cases in TWO WEEKS! If that's not indicative of a system wide issue, what is?

 

[JPINFV]

Although, we had a rather scary incident here where an esophageal intubation was confirmed by waveform capnography, and the medics in charge refused to pull the tube. The medic who did the intubation declared it was a good tube and the machine must be broken.

[sarcasm] I thought treating the patient not the machine was one of the marching songs of EMS. [/sarcasm]

 

[usalsfyre]

I think that we are moving quickly towards a time where waveform capnography will be required for ET intubation. It is unofficially the policy here, it isn't in writing yet, but our MD has said "you will use it, or else".

It's been our policy for at least the three years I've been here, and was in place when I started. We don't generally fire people for clinical issues. They will can you quick fast and in a hurry for not using capnography when delivering PPV artificial airway or not.

Although, we had a rather scary incident here where an esophageal intubation was confirmed by waveform capnography, and the medics in charge refused to pull the tube. The medic who did the intubation declared it was a good tube and the machine must be broken.

This guy needs to be gone. If there's any doubt pull the tube and reintubate. If your still not sure, maintain the airway via BLS.

 

[WolfmanHarris]

If we leave aside the emotions and the feelings of inadequacy that go with having a skill potentially pulled it starts becoming quite clear that maybe it's time for this to happen.

How many studies have been published that show increased complications, increased mortality and high failure rates and yet we still look at those, poo-poo and say "Well that's not my system." At this point the evidence is mounting, it is your system and every system at least on at least some level.

How can we tout evidence based medicine when it supports new and exciting directions for EMS, yet fight tooth and nail when EBM is clearly telling us that an intervention we use is harming patients.

Frankly I'm not a huge fan of EMS losing ETT as an option, but I can at least understand entirely where this is coming from. Any prudent medical director, faced with repeated, uncorrected esophageal intubation in their system, will look at those cases, look at the mounting body of evidence against prehospital ETT and say, enough is enough.

 

[Aidey]

I don't disagree the guy needs to be gone, unfortunately I've yet to hear what the resolution of the situation is going to be, and it has been 6+ months. I highly doubt the guy is going to be fired or even demoted from being a medic. I anticipate remedial training, if that. Since the FD put capnography in service after the incident, they will probably argue that training was good enough.

Part of the problem is that at the time, the FD didn't have capnography, so the capnography being used was the ambulance's. I'm sure the union will argue that the medic couldn't be expected to use it because it wasn't his equipment or some crap. The ambulance medic was the one who recognized the missed tube and suggested it be pulled, and reported it to the MD at the hospital. Under the county protocol the first medic on scene is in charge until they hand over care, if they ride in to the hospital the ambulance medic has no standing to over rule the FD medic.

 

[usalsfyre]

I don't disagree the guy needs to be gone, unfortunately I've yet to hear what the resolution of the situation is going to be, and it has been 6+ months. I highly doubt the guy is going to be fired or even demoted from being a medic. I anticipate remedial training, if that. Since the FD put capnography in service after the incident, they will probably argue that training was good enough.

Part of the problem is that at the time, the FD didn't have capnography, so the capnography being used was the ambulance's. I'm sure the union will argue that the medic couldn't be expected to use it because it wasn't his equipment or some crap. The ambulance medic was the one who recognized the missed tube and suggested it be pulled, and reported it to the MD at the hospital. Under the county protocol the first medic on scene is in charge until they hand over care, if they ride in to the hospital the ambulance medic has no standing to over rule the FD medic.

Holy crap. So even if he's obviously a flaming moron you can't boot him off the truck and undo the damage he's done?!?!

This is why I hate unions, esp the IAFF. Not because I get a warm fuzzy feeling about management, it's because they'll stick up for a guy who esentially tried (or succeeded) to murder a patient because he was too proud to admit he might have screwed up. I'm sure he was "a good brother" though. Makes me freaking sick.

 

[usafmedic45]

It's not three cases over a year (although even that is three too many) it's thre cases in TWO WEEKS! If that's not indicative of a system wide issue, what is?

LOL My dear usalfyre....give that some thought and you'll see why knee jerk reactions are a bad thing. You're probably overlooking a lot of factors in that. One of those "if you see yourself as a hammer, all the world looks like nails" sort of things. It's a huge problem in my other career which is injury prevention research.

Besides, it's not necessary to pull something when simpler measures will suffice. If those are put in place, then I would support removing intubation as an option. Remember, the goal is to establish and maintain an airway, not to insert an ETT. That's one of the things I have the hardest time conveying to EMS providers when I speak on airway management at conferences. The problem is that so many of us (like the guy who insisted that the "machine was wrong") view our ability to place an ETT as a reflection of the size of our penis. It's better to view your ability to deliver the patient alive to the ED through whatever it takes (within your skill set) to showcase how "well endowed" you actually are, so to speak.

 

[usalsfyre]

LOL My dear usalfyre....give that some thought and you'll see why knee jerk reactions are a bad thing. Besides, it's not necessary to pull something when simpler measures will suffice.

If those are put in place, then I would support removing intubation as an option. Remember, the goal is to establish and maintain an airway, not to insert an ETT. That's one of the things I have the hardest time conveying to EMS providers when I speak on airway management at conferences.

I do see the thought process of "a bad week", and not going with a knee jerk reaction to a couple of events. However are EMS providers living under rocks to not know the danger associated with the number of times we move a patient, let alone the difficulties that EMS often has placing the airway in the first place? With this knowledge why would anyone NOT use waveform capnography if it's available?

The second part of your post is the reason I've seen the two airway disasters I've witnessed. I'm a huge proponent of prehospital intubation, and airway management overall. I think it's criminal that all medics aren't afforded surgical airways in thier scope, as when one is needed nothing else will do. That said, unless the system (education and equipment) and the provider (time and putting ego aside) are willing to invest in the ability to put a piece of plastic between the vocal cords, they don't need to be doing it.

Edited to add: Sorry for getting on the d@mm soapbox, I'm pretty sure you agree with me on that point. I'm just burning out on seeing poor airway management defended by "well it's harder in the field". Like the patient cares.

 

[usafmedic45]

However are EMS providers living under rocks to not know the danger associated with the number of times we move a patient, let alone the difficulties that EMS often has placing the airway in the first place?

You read this forum, so do you really have to ask how many of our colleagues are functioning with their heads buried in the sand? The truly terrifying aspect of that is that even the dumbest person on this forum is still more proactive than those who choose not to seek out sites like this where they might learn something.

With this knowledge why would anyone NOT use waveform capnography if it's available?

Ego.

I'm a huge proponent of prehospital intubation, and airway management overall.

Shoot me a PM and we will discuss this further.

I think it's criminal that all medics aren't afforded surgical airways in thier scope, as when one is needed nothing else will do

True...I agree with you on that. Actually, I'd be more comfortable with surgical airways being the fall back for the few cases where non-visualized airways will not work than with letting some EMS providers continue to intubate.

Sorry for getting on the d@mm soapbox, I'm pretty sure you agree with me on that point

Not a problem at all. I do agree with you completely.

I'm just burning out on seeing poor airway management defended by "well it's harder in the field". Like the patient cares.

Yeah....same here. I think that's a piss poor excuse and quite frankly, it should be a reason to know, stay current on, and utilize every trick in the book, not to give a pass to someone who screwed something up because of their ego, their lack of practice or plain old apathy.

 

[socalmedic]

3 cases do not warrant taking a skill out of an entire EMS system. Deal with the three people involved.

it wasnt the 3 cases, it was 3 cases in IIRC 6 days GOING TO THE MEDICAL DIRECTOR. The county had around 14 missed intubation that year. ETCO should be used however I do not believe it is required yet. I have not heard too much lately about missed intubations which makes me think the problem is fixed. I know two of the medics had a 1 year suspension of their licenses.