Another malpractice case

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1. Eyeballs taped
2. Mask securely on face with that awful black S&M strappy thing
3. Dexamethasone
4. Prop/sux/tube?

Sux/tube/Prop?

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The brief also mentions there was no pre-op evaluation done. That alone pretty much closes the door on this case...
Maybe the case was stat, for some reason. That would explain the lack of NGT, too.

Letting lawyers and laypeople judge professional decisions, without even passing through a specialty panel first, is crazy.
 
Maybe the case was stat, for some reason. That would explain the lack of NGT, too.

Letting lawyers and laypeople judge professional decisions, without even passing through a specialty panel first, is crazy.

Yeah there’s a lot of unknowns - no preop, no NGT, and there’s a mention of letting the patient have PO clears that morning. That doesn’t sound like someone you are worrried about an emergent SBO.
 
Yeah there’s a lot of unknowns - no preop, no NGT, and there’s a mention of letting the patient have PO clears that morning. That doesn’t sound like someone you are worrried about an emergent SBO.
This is why these discussions should first take place in a medical court (possibly with a panel from a different state), not in an emotionally charged civil court with an easily influenced jury.

Mr. President, where is our federal malpractice reform?
 
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what exactly is considered standard of care for a sbo?
I will admit we get a lot of sbo's and I don't always place one prior to induction. Is there literature on ngt decreasing risk of aspiration? I also have a habit of not entering my pre op note on an emergent case until it is underway, though I have evaluated the patient prior to them having anesthesia.
 
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Just a thought about a hypothetical case but could occur to one of us. 60 yr old man with NASH cirrhosis 400 pounder admitted for melena. Pt planned for EGD later but suddenly drops pressure with hematochezia. You are paged and rush in but in front of you pt has large hematemesis and aspirates with sats dropping to 70s. You decide RSI with miller/etomidate/suc. Grade 4 view with miller, shift to glideoscope but camera covered with blood can't get a look. You stat page trauma, stats are 50 and pt bradys and codes. Another look with miller and fiber optic unsuccessful due to blood and secretions in post pharynx. You attempt cric but with coagulapathy , neck size , the surgical airway is a disaster . Trauma arrives 5 -10 minutes later from trauma bay and place cric but ROSC can't be achieved. What would be your legal liability ?
 
Just a thought about a hypothetical case but could occur to one of us. 60 yr old man with NASH cirrhosis 400 pounder admitted for melena. Pt planned for EGD later but suddenly drops pressure with hematochezia. You are paged and rush in but in front of you pt has large hematemesis and aspirates with sats dropping to 70s. You decide RSI with miller/etomidate/suc. Grade 4 view with miller, shift to glideoscope but camera covered with blood can't get a look. You stat page trauma, stats are 50 and pt bradys and codes. Another look with miller and fiber optic unsuccessful due to blood and secretions in post pharynx. You attempt cric but with coagulapathy , neck size , the surgical airway is a disaster . Trauma arrives 5 -10 minutes later from trauma bay and place cric but ROSC can't be achieved. What would be your legal liability ?
One should have induced with ketamine and maintained spontaneous respirations. The other thing is the Supreme+OGT I mentioned above and the tricks in the video. An intubating LMA may have worked, too. Or a combitube. All these should be easily accessible in a good code cart and a good intensivist's armamentarium.

I don't understand why ketamine is not standard of care for most emergent inductions in the ICU. It maintains spontaneous ventilation beautifully. It's one of my goto drugs for difficult airways. Let's not mention all the difficult airway devices that are seldom found in the code cart. Plus the ridiculous setup in most ICU rooms, where it takes forever to get to the head of the bed, instead of the bed being at least 3-4 feet from any wall, with clearly marked emergency zones and pathways that cannot be occupied by equipment. Plus all the useless people who love to aggregate for every emergency and occupy precious space.
 
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One should have induced with ketamine and maintained spontaneous respirations. The other thing is the Supreme+OGT I mentioned above and the tricks in the video. An intubating LMA may have worked, too. Or a combitube. All these should be easily accessible in a good code cart and a good intensivist's armamentarium.

I don't understand why ketamine is not standard of care for most emergent inductions in the ICU. It maintains spontaneous ventilation beautifully. It's one of my goto drugs for difficult airways. Let's not mention all the difficult airway devices that are seldom found in the code cart. Plus the ridiculous setup in most ICU rooms, where it takes forever to get to the head of the bed, instead of the bed being at least 3-4 feet from any wall, with clearly marked emergency zones and pathways that cannot be occupied by equipment.
That's a cool video. I am learning more intubation tricks as my career progresses but still don't have the hang of the two ET tube suction method. Early in my fellowship I was using the modified RSI i.e versed/etomidate/bag to sats 99% /roc tube. I kept sats up but I had a patient aspirate big time. Now I use the pure RSI preoxygenate/etomidate /sux /tube. If I see secretions in post pharynx I will just get the tube through the cords /inflate the balloon and then suction afterwards. Luckily no one aspirated but that's probably the sux kicking in. I have been lucky that although there have been secretions in the pharynx I was able to visualize the glottis every time.
 
I don't understand why ketamine is not standard of care for most emergent inductions in the ICU. It maintains spontaneous ventilation beautifully. It's one of my goto drugs for difficult airways.
I recall proposing a similar line of thinking not so long ago and being shouted down. There's a time and a place for everything.

I really really like the non paralysed intubation in ICU emerg setting.
 
I recall proposing a similar line of thinking not so long ago and being shouted down. There's a time and a place for everything.

I really really like the non paralysed intubation in ICU emerg setting.
The problem is full stomach (e.g. SBO). They can throw up and aspirate (but a good NGT may decrease the risks significantly). Textbook is to do at least an awake look if the airway looks difficult, then RSI. But I think non-paralyzed intubation is a safe alternative for the clearly NPO ICU patient, e.g. the one that has been on BiPAP for hours, or the one who fails extubation etc. Learn to do a gastric ultrasound, to get a better idea what you're facing. It's all a matter of risks vs benefits and, in a malpractice suit, all experts are so brave at being Monday morning quarterbacks.

The key with ketamine is to be slow with the laryngoscope, be generous with the ketamine, stop if the patient reacts, give more ketamine, try again (almost like an awake intubation). When you know you have or can easily get a view, push the muscle relaxant (if really needed) and intubate (caveat: I have seen lost views after muscle relaxation). If really difficult airway, don't be afraid to spray a bit of benzocaine on the way in, to decrease the need for higher doses of ketamine and risk of apnea (caveat: decreased airway protective reflexes). Not to minimize aspiration risk, including its medico-legal consequences, but I think more people get seriously hurt from the impossibility to both ventilate and intubate, than from aspiration pneumonia secondary to intubation attempts. I would not RSI a 400 pounder without a quasi-awake look, unless the latter is impossible.

Also, glycopyrrolate (0.3-0.4 mg) upon arrival is a great friend (especially to your videolaryngoscope), if the patient is not already tachy.

If the patient's mental status is so altered they will tolerate an awake look, just go for it. Don't forget to push some atropine before stimulating; awake laryngoscopy can induce life-threatening bradycardia.
 
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The problem is full stomach (e.g. SBO). They can throw up and aspirate (but a good NGT may decrease the risks significantly). Textbook is to do at least an awake look if the airway looks difficult, then RSI. But I think non-paralyzed intubation is a safe alternative for the clearly NPO ICU patient, e.g. the one that has been on BiPAP for hours, or the one who fails extubation etc. Learn to do a gastric ultrasound, to get a better idea what you're facing. It's all a matter of risks vs benefits and, in a malpractice suit, all experts are so brave at being Monday morning quarterbacks.

The key with ketamine is to be slow with the laryngoscope, be generous with the ketamine, stop if the patient reacts, give more ketamine, try again (almost like an awake intubation). When you know you have or can easily get a view, push the muscle relaxant (if really needed) and intubate (caveat: I have seen lost views after muscle relaxation). If really difficult airway, don't be afraid to spray a bit of benzocaine on the way in, to decrease the need for higher doses of ketamine and risk of apnea (caveat: decreased airway protective reflexes). Not to minimize aspiration risk, including its medico-legal consequences, but I think more people get seriously hurt from the impossibility to both ventilate and intubate, than from aspiration pneumonia secondary to intubation attempts. I would not RSI a 400 pounder without a quasi-awake look, unless the latter is impossible.

Also, glycopyrrolate (0.3-0.4 mg) upon arrival is a great friend (especially to your videolaryngoscope), if the patient is not already tachy.

If the patient's mental status is so altered they will tolerate an awake look, just go for it. Don't forget to push some atropine before stimulating; awake laryngoscopy can induce life-threatening bradycardia.
Ketamine gets too much of a bad rap because of the theoretical risk of cardiovascular collapse due to catecholamine depletion.
 
Ketamine gets too much of a bad rap because of the theoretical risk of cardiovascular collapse due to catecholamine depletion.
If that's the case, the patient will become hypotensive even with etomidate. I haven't done enough ketamine inductions (it's a pain to get it in the ICU), but I would be surprised if it's that significant at the dose one needs to induce a sick patient. Also, in the ICU, I always have a norepi stick if I suspect the patient may crash upon induction, regardless of the induction drug used, and I push that norepi before the induction drug.
 
This is why these discussions should first take place in a medical court (possibly with a panel from a different state), not in an emotionally charged civil court with an easily influenced jury.

Mr. President, where is our federal malpractice reform?

Tom price just resigned so probably no where in sight.

Just a thought about a hypothetical case but could occur to one of us. 60 yr old man with NASH cirrhosis 400 pounder admitted for melena. Pt planned for EGD later but suddenly drops pressure with hematochezia. You are paged and rush in but in front of you pt has large hematemesis and aspirates with sats dropping to 70s. You decide RSI with miller/etomidate/suc. Grade 4 view with miller, shift to glideoscope but camera covered with blood can't get a look. You stat page trauma, stats are 50 and pt bradys and codes. Another look with miller and fiber optic unsuccessful due to blood and secretions in post pharynx. You attempt cric but with coagulapathy , neck size , the surgical airway is a disaster . Trauma arrives 5 -10 minutes later from trauma bay and place cric but ROSC can't be achieved. What would be your legal liability ?

A good technique ive heard about is just to shove the tube in and inflate balloon. If it's in airway good, if not it decreased reflux hopefully. And if in esophagus w balloon up. Shove the next tube in and hopefully in trachea !
 
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