EM Malpractice: Airway Disaster

[thegenius]

Kind of sad these threads turn into arguments over midlevels and med students.

Here Here. Usually the same people who participate in it too.

---

Members don't see this ad.

 

[MedicineZ0Z]

Here Here. Usually the same people who participate in it too.

This whole thing started when a PA decided to say they're better than doctors. A common theme in the past few years of healthcare.

 

[Rendar5]

Let’s not devolve into “He started it... :’( ::sniffle::” arguments

 

[Rendar5]

I am EM boarded out of residency x 18 yrs. Worked in Level 1 trauma/crash/take everything, 60K community flagship hospital with every specialty imaginable, Middle of nowhere Ers where they were just difficult to staff. You name it, I have or would be comfortable working there.

I believe I have had 3-5 intubation in my life where gas had to come and help me when I could not get it. I probably would have eventually gotten most but they were available.

I don't think many EM docs sees that many difficult airways in their careers. If they are having trouble regularly intubating someone, it likely has to do with the tuber.

Anyhow..... Carry on with the APC vs FM pillowfight.

Agree that difficult an airway is a very rare. If you have to do more than 1-2 crics in an entire career you are really unlucky. 7 years Post residency only had 1 case I couldn’t get and 1 I never even bothered to try on (850 lb obtunded guy, no exaggeration. Crna who showed up when anaesthesia was called at 2am took one look and woke up the attending anaesthesiologist who got it but almost **** his pants in doing so per his words)

 

[MedicineZ0Z]

Agree that difficult an airway is a very rare. If you have to do more than 1-2 crics in an entire career you are really unlucky. 7 years Post residency only had 1 case I couldn’t get and 1 I never even bothered to try on (850 lb obtunded guy, no exaggeration. Crna who showed up when anaesthesia was called at 2am took one look and woke up the attending anaesthesiologist who got it but almost **** his pants in doing so per his words)

how did he get it lol

 

[Rendar5]

how did he get it lol

Ramped up “awake” (as awake as an obtunded guy can be) fiberoptic intubation with the anaesthesiologist practically standing on top of the bed with beads of sweat dripping down.

 

[TooMuchResearch]

I mean that's pretty rare, and truthfully alot of the time Bob doesn't do to well.

Let's be honest - do you really think someone who intubates <10x a year as an attending and got likely <50 tubes as a resident is suddenly gonna be successfully tubing 300lb angioedema patients in the boonies? prob not.

Sort of off topic, but you know what grinds my gears?
In the big house, where I have very rapid access to surgeons, ORs, and any help I may need, I also have flexible fiber optic scopes to help intubate angioedema Bob.

In my rural centers where I'm the only doc in the hospital and it's faster to transport to the big house than it is to muster an OR team (including a surgeon who might not be comfortable and no on call ENT, no MDA but a CRNA at home), I have an old generation glidescope and DL...no fancy scopes/toys.

 

[TooMuchResearch]

The airways were more difficult in residency. Part of that was acuity, but much of it was lack of experience.


Even the routine difficult (and not the once per blue moon truly difficult obese no neck can't ventilate oh man there's so much blood why didn't I sink an NG first why god why) ones are much easier with the magic of repetition and reflection.

 

[thegenius]

Glidescope has made intubating so easy. It's like playing a video game, Super Mario Brothers Airway Game.

Dada da tada da...beep beep beep babadada beep tada babadada....
Left Left Right Right Up Down Up Down B A Start

 

[BoardingDoc]

Glidescope has made intubating so easy. It's like playing a video game, Super Mario Brothers Airway Game.

Dada da tada da...beep beep beep babadada beep tada babadada....
Left Left Right Right Up Down Up Down B A Start

I think you mean up up down down left right left right B A start.

Filthy casual.

 

[thegenius]

I think you mean up up down down left right left right B A start.

Filthy casual.

 

[coffeebythelake]

Interesting case about an EM doc and a respiratory arrest gone wrong. Attempted nasal intubation in a hallway bed with no meds, hospital banned docs from using paralytic, finally got a King airway in place. Transferred to another hospital, lawsuit ended up being more about the transfer than the management.

Case 6: Respiratory Arrest – medmalreviewer

King airway is for peri-hospital airway management, mostly for EMTs out in the field. It was made for simple ease in less experienced hands. It isn't part of the ASA difficult airway management algorithm. Why would they even use this here in the ED? If you can't DL or VL, then place a SGA with gastric port. Success rate is fairly high. You can intubate through the new generation SGA's., either blindly or with FB guidance. Aspiration risk remains low. (When I say SGA I mean devices based on LMAs)

Obviously maintaining oxygenation/ventilation is paramount, but after you've established that it seems careless to transfer the patient without establishing more definitive control of the airway. Is this a standalone ED? Is there anesthesiology in house?

NOTABLY, there is NO mention of whether they were able to mask ventilate the patient before the airway was placed.

As others have mentioned, hospital banning use of paralytics is institutional malpractice

 

[TooMuchResearch]

King airway is for peri-hospital airway management, mostly for EMTs out in the field. It was made for simple ease in less experienced hands. It isn't part of the ASA difficult airway management algorithm. Why would they even use this here in the ED? If you can't DL or VL, then place a SGA with gastric port. Success rate is fairly high. You can intubate through the new generation SGA's., either blindly or with FB guidance. Aspiration risk remains low. (When I say SGA I mean devices based on LMAs)

Obviously maintaining oxygenation/ventilation is paramount, but after you've established that it seems careless to transfer the patient without establishing more definitive control of the airway. Is this a standalone ED? Is there anesthesiology in house?

NOTABLY, there is NO mention of whether they were able to mask ventilate the patient before the airway was placed.

As others have mentioned, hospital banning use of paralytics is institutional malpractice

Have you ever worked in a place that only had Kings or ETTs? I have. We stock some form of LMA now.