Case gone wrong ... wouldn't this be easy to find?

[DD214_DOC]

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I'm an MSIV currently doing a forensic path rotation. We had a case come in that I find a bit profound.

19 yo F rushed to surgery due to an ectopic pregnancy. Pt put under and intubated. Surgery proceeds.

Obviously, patient dies during surgery. No major complications reported by surgeon. Autopsy was completely unremarkable except for the ET tube being in the esophagus. This was ruled to be the mechanism related to her death.

Really, HOW could this happen? I know accidentally intubating the esophagus isn't that uncommon, but how hard is it to really figure out you've done that? Even if you skipped checking to make sure there are sounds in both lung fields, would the monitoring equipment not have shown signs of hypoxia?

 

[SleepIsGood]

I'm an MSIV currently doing a forensic path rotation. We had a case come in that I find a bit profound.

19 yo F rushed to surgery due to an ectopic pregnancy. Pt put under and intubated. Surgery proceeds.

Obviously, patient dies during surgery. No major complications reported by surgeon. Autopsy was completely unremarkable except for the ET tube being in the esophagus. This was ruled to be the mechanism related to her death.

Really, HOW could this happen? I know accidentally intubating the esophagus isn't that uncommon, but how hard is it to really figure out you've done that? Even if you skipped checking to make sure there are sounds in both lung fields, would the monitoring equipment not have shown signs of hypoxia?

Hard to say what's the issue. Sure, there is a Pulse Oximeter and a Capnogram. Capnogram will usually tell the anesthesiologist if you are in the trachea. Of course, if the patient 'desats' that may also suggest that you are not in the trachea (provided she has 'good' lungs).

Now you have here in the morgue. If the ET tube is in the esophagus in the morgue its hard to say that IS the reason she died. Patients can get 'handled' a lot when they are brought down to the morgue. It's conceivable that the tube may have migrated into the esophagus upon transport.

I know as part of our training, most anesthesiologists listen to breath sounds and look at the capnogram. Also there are various techniques employed by physicians to detect endotracheal intubation.

On the contrary, if a CRNA (nurse) was providing anesthsia, I'm not so sure they are apprised of all the techniques to confirm Endotracheal intubation.

Food for though.

 

[mhause]

I have not a clue how that could be missed, could be some anesthesiologist used to "supervising" not sure that they could confirm an airway after supervising for a long time.

Truthfully IF that is the cause then it was an absolutely inexcusable error no matter the provider, there are just two many ways ways to confirm placement, last I checked capnogram was standard of care and any fool can read it.

 

[Bertelman]

Like Sleep says, there is a fair chance that tube moved during transport and handling in the morgue. I tape my tubes fairly securely, but I also know to handle it appropriately during patient transport if the tube remains. If I am taking a patient to the floor intubated, I throw on extra tape. In the standard case that I do, though, I would not be at all surprised if 50% of my tubes were dislodged at some point during multiple transports from untrained personnel.

I find it hard to be believe that an ET tube in the wrong pipe would be an unrecognized cause of death in this country. I'm not saying tubing the goose doesn't happen, but it most certainly should be recognized before that hits the morgue.

 

[Planktonmd]

I have not a clue how that could be missed, could be some anesthesiologist used to "supervising" not sure that they could confirm an airway after supervising for a long time.

Are you sure you are a medical student?
Usually medical students don't come on a physician's forum and insult physicians.
I think hiding your education and pretending to be something you are not might indicate that you are not very proud of who you are.
It's OK to be a nurse.

 

[Planktonmd]

Question to our pathology friend:
If a patient died of esophageal intubation and as a result of hypoxia, are there any other signs you would be looking for during the autopsy to confirm hypoxia as the cause of death??

 

[fastosprintini]

you should talk to the crna who did the case prior to coming here....
fasto

 

[jwk]

On the contrary, if a CRNA (nurse) was providing anesthsia, I'm not so sure they are apprised of all the techniques to confirm Endotracheal intubation.

You guys know I'm usually on your side, but this comment is absolutely assinine. Seriously.

 

[Planktonmd]

You guys know I'm usually on your side, but this comment is absolutely assinine. Seriously.

I agree, it was not necessary.

 

[kmurp]

"On the contrary, if a CRNA (nurse) was providing anesthsia, I'm not so sure they are apprised of all the techniques to confirm Endotracheal intubation."

You are joking right?

 

[Tee Cell]

I am confused. If the pt died in surg, why would the et tube be left in place anyway. It just seems like a wierd thing to keep in till the last minute- during the autopsy of all things.

 

[Planktonmd]

I am confused. If the pt died in surg, why would the et tube be left in place anyway. It just seems like a wierd thing to keep in till the last minute- during the autopsy of all things.

When a patient dies in the OR the ETT is usually left in place if the case was anticipated to go to the medical examiner.

 

[Planktonmd]

Unrecognized esophageal intubation as a cause of death is extremely unlikely if pulse oximetry and capnometry were being used correctly.

http:/depts.washington.edu/asaccp/ASA/Newsletters/asa61_6_18_20.shtml

If the patient was already in cardiac arrest at the time of intubation then ETCo2 and SPO2 are not very helpful to confirm intubation of the trachea.
It is conceivable that the patient arrested because of massive hemorrhage (ruptured ectopic) then was intubated but this does not seem to be the case here.

 

[Bertelman]

Absolutely.

A scenario I can think of is they were originally overconfident that the ETT was in the trachea. Then they didn't pay attention to the monitors until the alarms went off. By this time, they were well behind the eight ball. They encountered trouble with reintubation/ventilation. Soon enough, a code was called. Now there was no CO to confirm intubation/ventilation with monitors. And at the end of the day, the ETT was still in the esophagus.

Or something like this...

If that's the case, this shouldn't have been such a mystery presented to the pathologist to determine a cause of death.

Furthermore, if they're ventilating the stomach while the surgeons muck around in the peritoneum, I find it hard to believe a surgeon would not have asked for more "relaxation".

 

[Arch Guillotti]

It's OK to be a nurse.

Murse actually.

 

[ProRealDoc]

I'm an MSIV currently doing a forensic path rotation. We had a case come in that I find a bit profound.

19 yo F rushed to surgery due to an ectopic pregnancy. Pt put under and intubated. Surgery proceeds.

Obviously, patient dies during surgery. No major complications reported by surgeon. Autopsy was completely unremarkable except for the ET tube being in the esophagus. This was ruled to be the mechanism related to her death.

Really, HOW could this happen? I know accidentally intubating the esophagus isn't that uncommon, but how hard is it to really figure out you've done that? Even if you skipped checking to make sure there are sounds in both lung fields, would the monitoring equipment not have shown signs of hypoxia?

These kinds of mistakes should not happen in this day and age. Whoever provided the anesthesia for this case better be ready to pay. For the newbies, always, always, always take your time when managing the airway. Don't rush through this crucial part of your anesthetic. I have seen people intubate patients as if they are in a race to get the tube in just to prove who knows what. That's foolish. You will burn yourself and hurt the patient badly.

 

[Licoricestick]

I'm an MSIV currently doing a forensic path rotation. We had a case come in that I find a bit profound.

19 yo F rushed to surgery due to an ectopic pregnancy. Pt put under and intubated. Surgery proceeds.

Obviously, patient dies during surgery. No major complications reported by surgeon. Autopsy was completely unremarkable except for the ET tube being in the esophagus. This was ruled to be the mechanism related to her death.

Really, HOW could this happen? I know accidentally intubating the esophagus isn't that uncommon, but how hard is it to really figure out you've done that? Even if you skipped checking to make sure there are sounds in both lung fields, would the monitoring equipment not have shown signs of hypoxia?

I'm assuming that when you say "autopsy completely unremarkable..." that you mean the macroscopic examination only and that you are using a bit of poetic license (I would have thought the presence/absence of ectopic etc would be relevant). If she died of hypoxic brain injury then histopath findings should concur with this (although I don't know how long finalisation of an autopsy takes where you are - it takes about a year for a coroner's case autopsy final report to be issued where I work).

Secondly - autopsies (like most medical investigations) should be done in the clinical context. In other words, the information from the anaesthetic record and report of the anaesthetist would be taken into account so there should be more information than just "no major complications reported by surgeon".

Yes there are multiple ways of confirming the ETT is actually in the trachea, but if unrecognised oesophageal intubation actually occured in this case then, like most medical errors, it would most likely represent the "swiss cheese" scenario. In other words a number of different things have to happen for the final outcome (death) to occur. So the tube went down the oesophagus (compounded by RSI setting and possibly influenced by the degree of difficulty of the intubation and experience of the laryngoscopist), then maybe there was CO2 return on the capnograph initially (see http://www.capnography.com/new/index.php?option=com_content&view=article&id=117&Itemid=61), maybe the SpO2 trace was a crappy trace and kept giving different readings, add in someone who wasn't paying quite as much attention as they should along with it likely being a middle of the night case (ectopics rarely seem to need to be done in hours), maybe the patient developed hypoxia induced bradycardia just as the surgeons were inflating the peritoneum so the anaesthetist gave atropine thinking it was vagal and then didn't get the cardiovascular responses that you normally see with hypoxia.... Who knows exactly what happened, but it's rarely as simple as "tube in wrong hole".

And before someone says that I'm defending unrecognised oesophageal intubation... I'm NOT. I am saying that the OP/med student's understanding of the events that would have led to the patient being in a morgue are likely more complicated that he thinks... so don't insult when you don't understand.

"It's not a crime to put the tube in the oesophagus, but it is a crime to not recognise it."

 

[poresofkohn]

You guys know I'm usually on your side, but this comment is absolutely assinine. Seriously.

>
I think he was trying to smoke out a troll......

 

[mocdoc]

If this is real, if the patient actually died due to an esophageal intubation, and it was not detected the only rational conclusion I can come to is that someone did not believe their monitor. If they were not using capnography, then it is time for the nurse AND anesthesiologist to start writing checks.

I have seen nurses do this most commonly, especially when misled by another confirmatory sign, such as transmitted gastric breath sounds. . . something MUST be wrong with the capnograph . . . I had a few good breaths of end tidal co2 and then it went away. . . there are sounds in the chest, so I must be okay.

Much more likely is a difficult airway, and they could not get the tube into the trachea. If this was the case, the anesthesiologist should have cut the neck, rather than let the patient die.

I have seen unrecognized esophageal intubations, where the anesthesiologist pushed the drugs and left, the nurse tubed the goose, and then went to work on another IV.

I walked in, the nurse ran out . . . I intubated with a second tube, before extubating the esophagus, and the nurse refused to believe that he put the tube in the esophagus, because he "saw" it go in.

Regardless of level of training, it is this type of attitude that leads nurses and physicians down these deadly paths. How many times have we seen surgeons demand really stupid things because they don't fully understand the circumstances?

If all you have is the tube in the goose, look for confirmatory signs of hypoxia, hypercarbia, and asphyxiation. But you are almost a doc . . . and should know this by now. Develop a differential diagnosis, do your work.
I say >90% chance the tube slipped into the esophagus AFTER the patient was dead. Rule out exsanguination, allergic reaction, MH, etc. Now that I think about it, I hope you are a troll, not almost a doc.

 

[DD214_DOC]

But you are almost a doc . . . and should know this by now. Develop a differential diagnosis, do your work.
I say >90% chance the tube slipped into the esophagus AFTER the patient was dead. Rule out exsanguination, allergic reaction, MH, etc. Now that I think about it, I hope you are a troll, not almost a doc.

I do know these things, that is why I found it pretty unbelievable. I was asking because the only thing I could think of is the anesthesiologist/CRNA just completely ignored the monitors. The question wasn't, "How else could she have died", the question was, "How could someone **** that up?"

This is second-hand information. The case came through a couple days before I started, so I only have what I was told (which is above). I would assume other possibilities were ruled out before deciding on the ultimate cause.

Thanks for the insults though.

 

[SleepIsGood]

You guys know I'm usually on your side, but this comment is absolutely assinine. Seriously.

The point is this.

Like many people have stated on here it's almost impossible to not recognize esophageal intubation in AMERICA these days in the OPERATING room.

If there is any question, I think a board certified anesthesiologist would have picked it up. I can think of THREE different confirmatory tests NOT utilizing monitors (etco2, pulse ox) to validate esophageal intubation.

I strongly believe that anesthesiologists go through more 'advanced' airway training etc inorder to recognize this.

Nurses are not as facile with these tests, nor is it my responsibility to apprise them of these techniques. One can not go zip through nursing school and then CRNA school and have knowledge of all these extra techniques. That's why med school is 4 years long and residency is 4 years long.

Just calling it as it is.

 

[Monty Python]

I can think of THREE different confirmatory tests NOT utilizing monitors (etco2, pulse ox) to validate esophageal intubation.

.

From my days on the street, I can think of:

balloting the ETT cuff at the suprasternal notch while feeling for the bouncing pressure transmitted to the pilot cuff.


putting both hands on the lateral portions of the rib cage and feeling for equal chest excursion while someone else bags.

Oh, you said in the goose:

inserting an NG through the ETT and suctioning bile

rapidly injecting 60 cc air while listening over the stomach

the squeeze-bulb thingy

 

[maceo]

I'm an MSIV currently doing a forensic path rotation. We had a case come in that I find a bit profound.

19 yo F rushed to surgery due to an ectopic pregnancy. Pt put under and intubated. Surgery proceeds.

Obviously, patient dies during surgery. No major complications reported by surgeon. Autopsy was completely unremarkable except for the ET tube being in the esophagus. This was ruled to be the mechanism related to her death.

Really, HOW could this happen? I know accidentally intubating the esophagus isn't that uncommon, but how hard is it to really figure out you've done that? Even if you skipped checking to make sure there are sounds in both lung fields, would the monitoring equipment not have shown signs of hypoxia?

go find theh anesthesia record and it will tell you what happened.

if there is confirmed co2 on the capnogram for several hours with a spo2 of 100 percent then the patient died it is unlikely due to misplaced ett.
ectopic pregnancy cases are high risk.. death is usually due to i guess exsaguination and sepsis and DIC but usually not intraop

 

[Impromptu]

Capnography is one of the greatest safety advances made in the field of anesthesiology.

Regarding checking to make sure the tube is in the right place, during my first anesthesiology rotation as an MSIV, I thought that listening for breath sounds in 4 points after intubation was something they had medical students do, but not something done in "real" practice. It sure seemed like a waste of time to wait for each breath then move to the next spot, until I actually found a patient that I could hear perfectly fine on the one side, but barely audible on the other. The resident and attending confirmed my finding, we pulled the tube back just a little bit, and suddenly breath sounds were loud and clear on both sides.

 

[anon-y-mouse]

I'm an MSIV currently doing a forensic path rotation. We had a case come in that I find a bit profound.

19 yo F rushed to surgery due to an ectopic pregnancy. Pt put under and intubated. Surgery proceeds.

Obviously, patient dies during surgery. No major complications reported by surgeon. Autopsy was completely unremarkable except for the ET tube being in the esophagus. This was ruled to be the mechanism related to her death.

Really, HOW could this happen? I know accidentally intubating the esophagus isn't that uncommon, but how hard is it to really figure out you've done that? Even if you skipped checking to make sure there are sounds in both lung fields, would the monitoring equipment not have shown signs of hypoxia?

I'm also MSIV, and I'm assuming you haven't done an anesthesiology rotation yet... because at least in my experience intubating, you're scared ****less that you tubed the goose until you get that sweet sweet end-tidal CO2 on the capnograph. This was pretty much reflexive, and ridiculously basic... it's highly highly highly unlikely that someone didn't look at the end-tidal CO2... that's what you do when you intubate someone to confirm!

Also, something that people haven't mentioned yet: because of the awesomely important practice of preoxygenating everyone (which I hope is also done in the private practice world!!), O2 sat may not start to drop for 8-10 minutes. of course, then they will. then I'd try to mask ventilate like crazy, then reintubate.

there's something else to this story. tubed goose seems like more of an 80's phenomenon (less advanced monitoring, etc.), at least according to the closed claims database. and the first thing i learned on the rotation was 'look at the goddamn monitor'.

 

[deleted59964]

go find theh anesthesia record and it will tell you what happened.

if there is confirmed co2 on the capnogram for several hours with a spo2 of 100 percent then the patient died it is unlikely due to misplaced ett.

except if you reposition the patient, trip on the tubing etc. etc.

 

[kmurp]

"I have seen unrecognized esophageal intubations, where the anesthesiologist pushed the drugs and left, the nurse tubed the goose, and then went to work on another IV.



Really? What kind of facility is this? This seems like a description of a rather poor standard of care by the anesthesiologist.

 

[doctor712]

Capnography is one of the greatest safety advances made in the field of anesthesiology.

Regarding checking to make sure the tube is in the right place, during my first anesthesiology rotation as an MSIV, I thought that listening for breath sounds in 4 points after intubation was something they had medical students do, but not something done in "real" practice. It sure seemed like a waste of time to wait for each breath then move to the next spot, until I actually found a patient that I could hear perfectly fine on the one side, but barely audible on the other. The resident and attending confirmed my finding, we pulled the tube back just a little bit, and suddenly breath sounds were loud and clear on both sides.

I'm not an MSIV just yet, but I can say that of the 200 hours I've spent shadowing Anesthesia, only ONE doctor, at P&S Peds Anesthesia, had his residents check EVERY patient's bilat breath sounds after intubating. I learned the reason to do this on day one, when he demonstrated what you wouldn't hear or see if you but the tube into the esophagus. When I then went to five different hospitals, following this experience, not a SINGLE resident/attending/private practice anesthesiologist has checked for breath sounds. I once asked a doc, "Why don't you check for breath sounds?" And I was scoffed at. The old eyeroll. So, I stopped asking and realized that even at these well-known research institutions, it's just not frequently done when you have the monitor. That's just my lowly observation though.

D712

 

[drccw]

I agree that capnography is important to verify ETCO2 and endotracheal intubation but when I was in academic I would stress to the residents and students what I think is the gold standard: visualization of the OET between the vocal cords. Whever I intubate I spend an extra two seconds to verify that I see the tube between the cords-> if I see that then I dont even look for ETCO2 because I know that the OET is in the right place...

it's funny though because I've had a fair number of both students and residents who I would ask if they saw teh tube between the cords to which they reply yes; only to not see ETCO2.... it's important to spend those two seconds to verify....

there are many occasions in which we intubate without capnography- I've done it in an elevator with ongoing CPR- all I had was a MAC 3 and a tube... so it's important to be able to see the tube between the cords...

and of course we all know the situations when a proper endotracheal intubation will not yield ETCO2 (remember, it's dependent on both ventilation and perfusion)....

 

[anon-y-mouse]

and of course we all know the situations when a proper endotracheal intubation will not yield ETCO2 (remember, it's dependent on both ventilation and perfusion)....

Can you please elaborate?

 

[psychbender]

Can you please elaborate?

Prolonged arrest...no cellular metabolism means no CO2.

Other causes could include PE, severe pulmonary stenosis, kinked/obstructed tube, tetralogy of Fallot, etc.

 

[jwk]

I agree that capnography is important to verify ETCO2 and endotracheal intubation but when I was in academic I would stress to the residents and students what I think is the gold standard: visualization of the OET between the vocal cords. Whever I intubate I spend an extra two seconds to verify that I see the tube between the cords-> if I see that then I dont even look for ETCO2 because I know that the OET is in the right place...

it's funny though because I've had a fair number of both students and residents who I would ask if they saw teh tube between the cords to which they reply yes; only to not see ETCO2.... it's important to spend those two seconds to verify....

there are many occasions in which we intubate without capnography- I've done it in an elevator with ongoing CPR- all I had was a MAC 3 and a tube... so it's important to be able to see the tube between the cords...

and of course we all know the situations when a proper endotracheal intubation will not yield ETCO2 (remember, it's dependent on both ventilation and perfusion)....

Sorry, beg to differ. Watching the tube go between the cords is not the gold standard. It certainly gives me a warm fuzzy feeling to see it, but that is not the way you CONFIRM placement. Do you actually chart "I watched the tube go between the cords" or do you check a box or write "BBS=", ETCO2+ or something similar? And don't you place ET tubes from time to time when you can't see the cords?

We've all intubated without the benefit of ETCO2 indicators - electronic or chemical. Neither were even available when I started in anesthesia 30+ years ago. And with due respect to those who think otherwise, not listening to breath sounds is absolutely foolhardy. The reason anesthesia has become so much safer over the years is because we have monitors that will CONFIRM what we THINK we know.

 

[jwk]

The point is this.

Like many people have stated on here it's almost impossible to not recognize esophageal intubation in AMERICA these days in the OPERATING room.

If there is any question, I think a board certified anesthesiologist would have picked it up. I can think of THREE different confirmatory tests NOT utilizing monitors (etco2, pulse ox) to validate esophageal intubation.

I strongly believe that anesthesiologists go through more 'advanced' airway training etc inorder to recognize this.

Nurses are not as facile with these tests, nor is it my responsibility to apprise them of these techniques. One can not go zip through nursing school and then CRNA school and have knowledge of all these extra techniques. That's why med school is 4 years long and residency is 4 years long.

Just calling it as it is.

There are most certainly differences between anesthesiologists and CRNA's and AA's. Possessing some mysterious MD-only technique for determining correct tube placement is not one of them. Seriously.

And I can assure you - board certified anesthesiologist do indeed screw up and have unrecognized esophageal intubations in the US, even today. It shouldn't happen anywhere - but it does.

 

[dfk]

The point is this.

Like many people have stated on here it's almost impossible to not recognize esophageal intubation in AMERICA these days in the OPERATING room.

If there is any question, I think a board certified anesthesiologist would have picked it up. I can think of THREE different confirmatory tests NOT utilizing monitors (etco2, pulse ox) to validate esophageal intubation.

I strongly believe that anesthesiologists go through more 'advanced' airway training etc inorder to recognize this.

Nurses are not as facile with these tests, nor is it my responsibility to apprise them of these techniques. One can not go zip through nursing school and then CRNA school and have knowledge of all these extra techniques. That's why med school is 4 years long and residency is 4 years long.

Just calling it as it is.

i wasn't aware all these "extra techniques" are taught in med school. kudos to that 👍

 

[Planktonmd]

i wasn't aware that advanced airway management/techniques are taught in med school. kudos to that 👍

You think that verifying that the tube went into the trachea is "advanced airway management/techniques" ???

 

[Planktonmd]

i wasn't aware all these "extra techniques" are taught in med school. kudos to that 👍

You think that verifying that the tube went into the trachea is "advanced airway management/techniques" ???

😕
Why did you change your initial post?

 

[dfk]

😕
Why did you change your initial post?

Nurses are not as facile with these tests, nor is it my responsibility to apprise them of these techniques. One can not go zip through nursing school and then CRNA school and have knowledge of all these extra techniques. That's why med school is 4 years long and residency is 4 years long.

Just calling it as it is.

plankton, i liked the second wording better. in any event, sleep mentioned having knowledge of all these extra techniques, of which CRNAs can't seem to possess. but goes on to allude the learning of all these things in med school AND residency. IMO, residency, not med school, is where one gets all the knowledge of all these extra techniques.
i was merely commenting on that.

 

[Bertelman]

plankton, i liked the second wording better. in any event, sleep mentioned having knowledge of all these extra techniques, of which CRNAs can't seem to possess. but goes on to allude the learning of all these things in med school AND residency. IMO, residency, not med school, is where one gets all the knowledge of all these extra techniques.
i was merely commenting on that.

We may learn the specifics of the extra techniques in residency, but the FOUNDATION of why those tests are confirmatory is well-established in medical school. Thus, when my attending tells me why X confirms or produces Y, I'm not filing a new piece of info in my brain. I'm simply recalling info I already knew, but had not yet applied to anesthesia.

 

[Southpaw]

IMO, residency, not med school, is where one gets all the knowledge of all these extra techniques.
i was merely commenting on that.

No offense, but how do you know? Attendings who have been out of medical school for 10 years have lost complete touch with what a medical student should and should not know. I see it everyday. If you've never been been to med school, you can't possibly grasp what we learn or what we don't.

Also, if you read Miller and then listen to a discussion that touches on your reading, you understand both your reading and the discussion better and your learning is accentuated.

Likewise, if you go to medical school, it forms a solid foundation which allows everything you apply and learn during residency to make so much more sense and you're the better for it. In short, learning the what without the why leaves knowledge gaps. Others have no gaps, and patients are best served by these people.

 

[SleepIsGood]

No offense, but how do you know? Attendings who have been out of medical school for 10 years have lost complete touch with what a medical student should and should not know. I see it everyday. If you've never been been to med school, you can't possibly grasp what we learn or what we don't.

Also, if you read Miller and then listen to a discussion that touches on your reading, you understand both your reading and the discussion better and your learning is accentuated.

Likewise, if you go to medical school, it forms a solid foundation which allows everything you apply and learn during residency to make so much more sense and you're the better for it. In short, learning the what without the why leaves knowledge gaps. Others have no gaps, and patients are best served by these people.

exactly what i wanted to say. I hope DFK can read that.

 

[drccw]

Sorry, beg to differ. Watching the tube go between the cords is not the gold standard. It certainly gives me a warm fuzzy feeling to see it, but that is not the way you CONFIRM placement. Do you actually chart "I watched the tube go between the cords" or do you check a box or write "BBS=", ETCO2+ or something similar? And don't you place ET tubes from time to time when you can't see the cords?

We've all intubated without the benefit of ETCO2 indicators - electronic or chemical. Neither were even available when I started in anesthesia 30+ years ago. And with due respect to those who think otherwise, not listening to breath sounds is absolutely foolhardy. The reason anesthesia has become so much safer over the years is because we have monitors that will CONFIRM what we THINK we know.

Dont get me wrong, I'm not downplaying the importance of ETCO2... especially in those I cant see shizat.. (had one of those today; bougie to the rescue)

What I am trying to say is that residents and students are relying too much on ETCO2. I want them to tell me that they see the tube between the cords. It's a two second pause after intubation and the plastic tube should be between those beautiful little cords. If they see that, then they should be able to confidently say the tube is between the cords. And I agree, thinking you see the tube pass through cords is one of the eye's and mind's cruel tricks... that's why two seconds to look again and verify..

What I have seen instead is residents and students turning immediately to the monitor to verify ETCO2. They do not develop clinical accumen if they do that. We need to be clinicians, not merely intubating technicians. Or my favorite question after induction upon initiation of BMV- are you moving air-> probably 60% of residents and and 90% of students would turn to the monitor to look for ETCO2. I want to see them looking at the chest, watching the mask so they get the sense of what it looks like to properly bag mask a patient..same thing happens on emergence. "are they moving air?" On goes the mask to look for ETCO2.

I see the same behavior when I supervising nurses. They turn to the monitors for everything. I think we need to be better clinicians. Of course I understand the role of ETCO2.

 

[SleepIsGood]

Sorry, beg to differ. Watching the tube go between the cords is not the gold standard. It certainly gives me a warm fuzzy feeling to see it, but that is not the way you CONFIRM placement. Do you actually chart "I watched the tube go between the cords" or do you check a box or write "BBS=", ETCO2+ or something similar? And don't you place ET tubes from time to time when you can't see the cords?

We've all intubated without the benefit of ETCO2 indicators - electronic or chemical. Neither were even available when I started in anesthesia 30+ years ago. And with due respect to those who think otherwise, not listening to breath sounds is absolutely foolhardy. The reason anesthesia has become so much safer over the years is because we have monitors that will CONFIRM what we THINK we know.

JWK

I know you are an AA and perhaps your training is different. But I would agree with DRCCW.

The gold standard is to "visaulize the tube going through the cords'. Yes, people get the tube into the trachea on a 'bad view' and really dont see the tube going in at times. Those should be the exception. The situations you describe are the ones when someone gets 'lucky'. You write, "b/l bs equal, +etco2" etc to support your conclusion that the trachea is intubated.

Also, goign to what DrCCW stated, it's all about physical exam. As PHYSICIANS that is drilled into our heads since medical school. There's no fancy set of equipment like a capnogram that can eliminate completely the need to be a clinician. We're not technicians. Capnography is simply a tool to help confirm. As I alluded to earlier there are other 'tools' that we have that are not equipment that rely on physical examination.

 

[dfk]

No offense, but how do you know? Attendings who have been out of medical school for 10 years have lost complete touch with what a medical student should and should not know. I see it everyday. If you've never been been to med school, you can't possibly grasp what we learn or what we don't.

Also, if you read Miller and then listen to a discussion that touches on your reading, you understand both your reading and the discussion better and your learning is accentuated.

Likewise, if you go to medical school, it forms a solid foundation which allows everything you apply and learn during residency to make so much more sense and you're the better for it. In short, learning the what without the why leaves knowledge gaps. Others have no gaps, and patients are best served by these people.

dude, you're missing it. how do i know? granted, i haven't personally walked the halls, but i've worked and chatted and golfed and drank with MANY residents of several ilk(s)?.. i'm not saying, by any means, i know all.. but what i can tell you is we're not talking about attendings that have been in practice for 10 yrs. the point is what the residents are learning and being taught.
i have read miller, and yea, i get it. just b/c i don't have "MD" after my doesn't mean i can't comprehend and correlate miller's words.
i don't disagree med school and residency provide more than CRNA training, but man.. CRNAs ain't dumb.
i think the point was missed along the way.

 

[dfk]

exactly what i wanted to say. I hope DFK can read that.

sorry. i can't read. i'm a murse.

 

[flashgordon]

No, we do not think CRNAs are stupid. But since we function on different levels, it does not mean our professions are the same. WTF- It's as if you guys are insulted when we say CRNA does NOT equal MD. I've had enough of this pissing contest BS. Let's work as a TEAM .

 

[proman]

I would argue the gold standard for verifying tube placement is fiberoptic bronch. At least for the boards. Anytime I have a question on where the tip of the tube is I get a FOB (easy at my place).

As for relying too much on the monitors, we have a peds attending who will turn the monitors off during induction. Teaches you quickly to look at the patient.

 

[drccw]

I
As for relying too much on the monitors, we have a peds attending who will turn the monitors off during induction. Teaches you quickly to look at the patient.

Turning off the monitors for inductions was one of my favorite things to do... Even the CA-3s who were getting ready for the real world would get really uncomfrtable

 

[dfk]

No, we do not think CRNAs are stupid. But since we function on different levels, it does not mean our professions are the same. WTF- It's as if you guys are insulted when we say CRNA does NOT equal MD. I've had enough of this pissing contest BS. Let's work as a TEAM .

i don't disagree with your words at all here. currently in an ACT, and don't mind ONE bit!

 

[SleepIsGood]

I would argue the gold standard for verifying tube placement is fiberoptic bronch. At least for the boards. Anytime I have a question on where the tip of the tube is I get a FOB (easy at my place).

As for relying too much on the monitors, we have a peds attending who will turn the monitors off during induction. Teaches you quickly to look at the patient.

WOW...that's an awesome little trick. I should try that on the CA1s coming in. That will definitely teach them to use physical exam. Great idea!

 

[proman]

WOW...that's an awesome little trick. I should try that on the CA1s coming in. That will definitely teach them to use physical exam. Great idea!

Today I did a mask induction on a 3 y/o girl with Trisomy 21, tet s/p repair for redo RV to PA conduit. No way would she allow us to place any monitors prior to induction. Essentially did an induction without monitors until she was asleep. You must be comfortable at doing this.

Give the CA1s a few months before traumatizing them with the experience though!