Freestanding ED physicians sued after suspected loss of airway

[deleted500612]

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- Previously healthy 40 y/o F undergoes cosmetic facial plastic surgery
- 8 days later shows up to a freestanding ED with unilateral facial and neck swelling (hematoma vs abscess?), dysphagia, intermittent altered mental status, and concern for impending respiratory and circulatory compromise
- ED was staffed by an EM doc as well as an FM doc
- They requested transfer to a facility with access to higher level care and decided to sedate and intubate the patient pending transfer
- After inducing with etomidate, succ and midaz the EM doc was unable to secure the airway after multiple attempts, eventually a paramedic at the ED intubates the patient using a glidescope. Pt was then paralyzed with rocuronium and put on a vent
- Some time later when the patient was being moved to a stretcher for transfer, the sedation/paralytic had worn off enough that the stimulation aroused the pt to start bucking the tube
- Pt quickly becomes hypoxic and dusky in coloration, sedation/paralytics are re-administered
- Pt continues to deteriorate, going into PEA arrest. CPR is performed for 20 minutes unsuccessfully
- Was at some point ascertained that the ETT had become dislodged during the bed transfer, though it is unclear due to lack of documentation when exactly it was noticed or if/when there was any attempt made to reintubate the patient throughout the course of CPR or if this was something noticed after the patient was declared deceased.

Couple discussion points I wanted to touch on here:

1.) Why was an emergency medicine physician unable to intubate the patient to the point where he had to get a paramedic to do it for him? This seems like a red flag for the EM doc's overall competency level in airway management.

2.) Absence of any documentation that they rechecked the airway or made any attempt to re-intubate when the pt began to crash after bed transfer is a critical error. Just open your wallet and bend over.

3.) The plaintiff's expert witness (a dual boarded EM/FM physician) claims that one of the negligent acts was not having performed a CXR to confirm proper depth of ETT placement. Although it's one of many tools available to assess ETT placement, I have a hard time buying the claim that a CXR is absolutely essential to the extent that it would be *negligent* to not immediately order a CXR to confirm placement of an ETT in every case if you've already used direct/indirect video visualization, capnography, auscultation and tube depth measurement to assess the airway. Maybe that's just my anesthesia bias, but I don't have experience with ED intubations so maybe someone else can chime in if the standard of practice there is just completely different for some reason.

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[deleted59964]

4) are you a lawyer?

 

[chocomorsel]

There are incompetent people in every field.
I agree with all your points. But maybe we need EMs input.

 

[dchz]

Why would you not put this in the EM forum?

No you don't need to get a CXR to confirm tube placement. But the tube dislodging and no sedation is negligence. Whether they can prove that in a court of law is up to the lawyers and the law.

 

[deleted500612]

Why would you not put this in the EM forum?

No you don't need to get a CXR to confirm tube placement. But the tube dislodging and no sedation is negligence. Whether they can prove that in a court of law is up to the lawyers and the law.

I mean sure it could go in the EM forum too, but it's a loss of airway lawsuit that has a lot of obvious cross-relevance and implications to anesthesia practice the same way a cardiologist might be interested in the particulars of a lawsuit over mismanagement of MI in the ED, or an endocrinologist regarding mismanagement of DKA etc. It's still possible to have a productive and relevant discussion of the merits of an interesting airway lawsuit despite it not being an anesthesiologist at the head of the bed.

 

[Arch Guillotti]

4) are you a lawyer?

He’s been lurking on here for 7 years waiting for a shot.

 

[s109442]

Bye bye

 

[Mman]

I mean sure it could go in the EM forum too, but it's a loss of airway lawsuit that has a lot of obvious cross-relevance and implications to anesthesia practice the same way a cardiologist might be interested in the particulars of a lawsuit over mismanagement of MI in the ED, or an endocrinologist regarding mismanagement of DKA etc. It's still possible to have a productive and relevant discussion of the merits of an interesting airway lawsuit despite it not being an anesthesiologist at the head of the bed.

The thing is, this is not your normal loss of airway situation applicable to anesthesia. This isn't that could not intubate, could not ventilate scenario after we gave paralytic. This is a patient that they eventually muscled a tube into and secured the tube and paralyzed the patient. At some point later the patient coded and had the tube dislodge, but was that the chicken or the egg?

The legal questions for this case are not really up my alley. I do not know what ED standards for sedation/paralytic of an intubated patient are. I do not know how closely they are monitoring those airways during transfers/transports. I know in the OR that when we are moving a patient, say from the OR table to the ICU bed to transport them, the person at the head of the bed holding the patient and the tube is qualified to put the tube back in if it falls out and if it was a difficult intubation they will be holding on awful tight. I suspect in the ED that it is more often the RN and maybe RT and some aides that are moving the patient around and the attending probably has other things to be doing and probably isn't even in the room.

So while we obviously handle airways, this isn't really a similar situation. IMHO this is more applicable to how an ICU would manage an intubated patient.

 

[kidthor]

How did that altered, respiratory compromised patient manage their way into a freestanding ED? Weird.

 

[coffeebythelake]

How did that altered, respiratory compromised patient manage their way into a freestanding ED? Weird.

Definitely mistake #1 in this series of events.

 

[chocomorsel]

How did that altered, respiratory compromised patient manage their way into a freestanding ED? Weird.

I wonder if these free standing EDs are in socialized economies. I mean, most people aren’t that smart to know which ED to go to. One in a hospital or a free standing one. All they see is ER and they think, hey I am having an emergency.
Or, I am having a bad cold and can’t see my doctor for three days.

 

[Mman]

How did that altered, respiratory compromised patient manage their way into a freestanding ED? Weird.

what exactly is a freestanding ED? I plead ignorance. There is no such thing in my state and I have never seen such a thing in my career. Is it like a glorified urgent care? The only EDs I have ever seen are part of a hospital that can admit you. Now it might be a podunk hospital with a family medicine doc in the ED....

 

[Arch Guillotti]

Is it like a glorified urgent care?

I think so. I think originally many were owned by physicians but I am not sure how they are turning out in the long run.

 

[NITRAS]

what exactly is a freestanding ED? I plead ignorance. There is no such thing in my state and I have never seen such a thing in my career. Is it like a glorified urgent care? The only EDs I have ever seen are part of a hospital that can admit you. Now it might be a podunk hospital with a family medicine doc in the ED....

We got a bunch. We get a handful of transfers, at least several a week. I’m actually happier with those ED docs than some Of the local hospitals.. .

I think the patients tend to be higher on the Social ladder and get more “complete” work ups. Before all this COVID business, got a young guy who came in with fever and headache. Had CT, LP, lab work up, IVF tons of antibiotics, a couple of Dilaudid. All the work up negative and wanted to admit for severe sepsis. “Dude, I won’t say no, but he’s got a cold. “

 

[nycitygas]

I think so. I think originally many were owned by physicians but I am not sure how they are turning out in the long run.

When I moved to Texas several years ago, they were everywhere. Since then, it seems like 90% have shut down.

I went to one by accident thinking it was an urgent care (had never heard of free standing Ed). Ended up paying close to 1k out of pocket because everything was out of network. I had a decent PPO plan and was told at the front desk that they accepted my insurance without a problem haha

 

[deleted126335]

We have them in our area. They are staffed by ED physicians as opposed to urgent cares which are staffed by NPs.
Generally located close to competing health care system's hospitals in relatively well insured areas designed to skim the cream- STEMIs, Neuro interventional, any well insured patient- particularly one who needs admission.

 

[Man o War]

what exactly is a freestanding ED? I plead ignorance. There is no such thing in my state and I have never seen such a thing in my career. Is it like a glorified urgent care? The only EDs I have ever seen are part of a hospital that can admit you. Now it might be a podunk hospital with a family medicine doc in the ED....

We have a bunch here. Plopped in strategic locations by the big health systems in town. Their purpose is to capture patients and get them into their system. Cheaper than opening a full hospital, and they just transfer the patients to the mothership when needed

 

[chocomorsel]

We got a bunch. We get a handful of transfers, at least several a week. I’m actually happier with those ED docs than some Of the local hospitals.. .

I think the patients tend to be higher on the Social ladder and get more “complete” work ups. Before all this COVID business, got a young guy who came in with fever and headache. Had CT, LP, lab work up, IVF tons of antibiotics, a couple of Dilaudid. All the work up negative and wanted to admit for severe sepsis. “Dude, I won’t say no, but he’s got a cold. “

That’s because they make a lot of money from all those procedures and tests. Many unnecessary.
They probably don’t see people without insurance.

 

[chocomorsel]

When I moved to Texas several years ago, they were everywhere. Since then, it seems like 90% have shut down.

I went to one by accident thinking it was an urgent care (had never heard of free standing Ed). Ended up paying close to 1k out of pocket because everything was out of network. I had a decent PPO plan and was told at the front desk that they accepted my insurance without a problem haha

I still see them all over DFW and Houston.

 

[ShockIndex]

That’s because they make a lot of money from all those procedures and tests. Many unnecessary.
They probably don’t see people without insurance.

Free standing EDs come in 2 flavors : hospital owned and independent. Those that are hospital owned fall under the same CMS rules and regulations as the medical center or hospital EDs, and must comply with all CMS Conditions of Participation which includes EMTALA. Independent shops operate under state regulations which are often similar to EMTALA.

The real money in free standing EDs is not so much the testing and procedures but the much higher facility fees that they generate. For example, the facility fees were the driver of the 1000% increase in billing in this study of urgent cares that converted to free standing EDs.

The Impact of Conversion From an Urgent Care Center to a Freestanding Emergency Department on Patient Population, Conditions Managed, and Reimbursement - PubMed

After three UCCs converted to FSEDs, patient volume decreased and reimbursement per visit increased, despite no change in patient characteristics and little change in conditions managed. These case studies suggest that some FSEDs are similar to UCCs in patient mix and conditions treated.

pubmed.ncbi.nlm.nih.gov

As for the case, I have 1 question - did they document a capnography waveform after this paramedic put a tube god knows where?

 

[Robotic Wis-Hipple]

As for the case, I have 1 question - did they document a capnography waveform after this paramedic put a tube god knows where?

This. This is why continuous end tidal capnography should be standard. Even without capnography the vent should have been wailing with low tidal volume/pressure alarms if the tube got dislodged during transfer. What’s to say tube wasn’t goosed from the start?

 

[chocomorsel]

This. This is why continuous end tidal capnography should be standard. Even without capnography the vent should have been wailing with low tidal volume/pressure alarms if the tube got dislodged during transfer. What’s to say tube wasn’t goosed from the start?

Because the OP states that she was placed on the Vent and the ventilator would have shown something wrong. And then, “some time later” transferring was attempted. And her color changed to dusky. If she had been goosed her color wouldn’t have come back to normal then to dusky again after a difficult intubation.

When you goose someone, how long does it take you to figure it out even without ETCO2? Sats don’t take long to drop, and color changes even faster. She wasn’t sitting around goosed waiting for transport with normal color.

 

[Katheudontas parateroumen]

What are your thoughts about how they went about this intubation? With impending airway comprise stated with AMS and progressive swelling, no time for an awake fiber optic. I wonder if they had a fiber optic in hand at these facilities. Induction of etomidate/sux/midaz seems reasonable. I’m kinda surprised paramedic got it after 4th try with glidescope over the EM doc but who knows. I wonder what they tried to sedate the patient with as it doesn’t state in the article. Do they even have stuff like propofol drips, fentanyl drips etc? Should they even have privy to that type of sedation? This is not in their usual scope of care I believe? This doesn’t look good for freestanding EDs for true emergencies like this.

 

[Mman]

I wonder what they tried to sedate the patient with as it doesn’t state in the article. Do they even have stuff like propofol drips, fentanyl drips etc? Should they even have privy to that type of sedation? This is not in their usual scope of care I believe? This doesn’t look good for freestanding EDs for true emergencies like this.

It states they gave the patient rocuronium. Doesn't really matter what they gave for sedation as it would appear the paralytic wore off enough to allow them to buck. If they had given enough paralytic, even if the patient was wide awake and unsedated they would not have been able to buck on the tube.

 

[ShockIndex]

Because the OP states that she was placed on the Vent and the ventilator would have shown something wrong. And then, “some time later” transferring was attempted. And her color changed to dusky. If she had been goosed her color wouldn’t have come back to normal then to dusky again after a difficult intubation.

When you goose someone, how long does it take you to figure it out even without ETCO2? Sats don’t take long to drop, and color changes even faster. She wasn’t sitting around goosed waiting for transport with normal color.

I’m aware of cases where people were goosed with sedation only or very sub therapeutic doses of sux that went unrecognized for several minutes as the patient was able to breath around the tube enough to support life. In one case, it went unrecognized for about 15 minutes despite sats in the mid 80s% until a large dose of vec was pushed to facilitate keeping the patient still for a CT scan. Of course, nobody with any airway or resuscitation skills was present in the scanner when the vec was given via verbal order.

 

[chocomorsel]

I’m aware of cases where people were goosed with sedation only or very sub therapeutic doses of sux that went unrecognized for several minutes as the patient was able to breath around the tube enough to support life. In one case, it went unrecognized for about 15 minutes despite sats in the mid 80s% until a large dose of vec was pushed to facilitate keeping the patient still for a CT scan. Of course, nobody with any airway or resuscitation skills was present in the scanner when the vec was given via verbal order.

Ok. I will give you that.
Except in this case patient had facial and neck edema and impending respiratory failure from obstruction. Very unlikely she would survive that long without a properly placed ETT.
Of course I don’t claim to know how much later transport was initiated.

 

[chocomorsel]

What are your thoughts about how they went about this intubation? With impending airway comprise stated with AMS and progressive swelling, no time for an awake fiber optic. I wonder if they had a fiber optic in hand at these facilities. Induction of etomidate/sux/midaz seems reasonable. I’m kinda surprised paramedic got it after 4th try with glidescope over the EM doc but who knows. I wonder what they tried to sedate the patient with as it doesn’t state in the article. Do they even have stuff like propofol drips, fentanyl drips etc? Should they even have privy to that type of sedation? This is not in their usual scope of care I believe? This doesn’t look good for freestanding EDs for true emergencies like this.

They are EM docs. They are well within their scope to induce, intubated and paralyze and sedate thereafter.
Of course having poorer skills than a paramedic is concerning.
Ketamine and prececedex comes in handy in these situations.
But patients like this, gotta sedate quite deep because they are panicking and uncooperative with an awake tube.

 

[ShockIndex]

This. This is why continuous end tidal capnography should be standard. Even without capnography the vent should have been wailing with low tidal volume/pressure alarms if the tube got dislodged during transfer. What’s to say tube wasn’t goosed from the start?

I’d say in EM that some form of CO2 detection is standard of care. Colorimetric CO2 detection immediately after tube placement allows one limp across the standard of care threshold, however continuous waveform capnography is a best practice whenever it is available (which should be every ED in America). However, I have no confidence in doctors who like to place tubes without understanding the value of continuous waveform capnography in critically ill patients which is far too many EPs that I encounter.

 

[24GaugeEJ]

What are your thoughts about how they went about this intubation? With impending airway comprise stated with AMS and progressive swelling, no time for an awake fiber optic. I wonder if they had a fiber optic in hand at these facilities. Induction of etomidate/sux/midaz seems reasonable. I’m kinda surprised paramedic got it after 4th try with glidescope over the EM doc but who knows. I wonder what they tried to sedate the patient with as it doesn’t state in the article. Do they even have stuff like propofol drips, fentanyl drips etc? Should they even have privy to that type of sedation? This is not in their usual scope of care I believe? This doesn’t look good for freestanding EDs for true emergencies like this.

I worked as a medic for several years prior to medical school, both for a municipal 911 service and in an ED. The ED I worked at had an annual census of about 100k, and was in a non-academic hospital. We did not have a fiberoptic in the department and I seriously doubt any of the docs had done one recently, or would be very comfortable doing one given the appropriate circumstances. In my limited experience this just isn’t done very often in the emergency department setting.

I’ve had other medic friends who have had to intubate patients in smaller and freestanding EDs staffed by FM or older ED trained docs. Circumstances aren’t always ideal, unfortunately - particularly in smaller facilities or out in bfe where there just aren’t specialists around 24/7. My guess is the medic got the tube in, but it wasn’t deep enough and/or secured properly, and was dislodged during movement from the hospital bed to the medic’s cot. The docs are rarely around to help out transferring/transporting patients because they’re attending to other patients and the nurses/techs are accustomed to doing this. This whole situation sounds awful for everyone involved.

 

[Robotic Wis-Hipple]

Because the OP states that she was placed on the Vent and the ventilator would have shown something wrong. And then, “some time later” transferring was attempted. And her color changed to dusky. If she had been goosed her color wouldn’t have come back to normal then to dusky again after a difficult intubation.

When you goose someone, how long does it take you to figure it out even without ETCO2? Sats don’t take long to drop, and color changes even faster. She wasn’t sitting around goosed waiting for transport with normal color.

Ok, I agree. But my post was more to illustrate that it’s possible the tube was never in the trachea. Why is there no time given for induction/intubation but there is for the PEA? I’ll admit to not reading the full blacked out disposition initially and seeing that Vec was given so my point was that it’s plausible that Etomidate/sux was given, difficult 4x intubation attempted before “success“ followed by induction dose and sux wearing off, patient moving during transfer and a save face “tube dislodged during patient transfer” claim put in. But I agree, if vec was given and the Pt was on a vent for awhile sure, dislodgement is far more likely.

If anything this again demonstrates that the devil is in the details and the timestamps matter a lot here.

Also, (now that I’ve read the full disposition and not just the post cliff notes), if the ED physicians actually saw expanding neck swelling in front of them I might argue decompression would’ve been the better course (especially if no FOB in the freestanding ED). With that said “approximately one week later” from surgery is a bit strange for a venous bleed and probably indicates abscess rather than hematoma but again, the devil is in the details.

 

[Southpaw]

With that said “approximately one week later” from surgery is a bit strange for a venous bleed and probably indicates abscess rather than hematoma but again, the devil is in the details.

likely a clot/scab broke off and bleeding ensued, similar to a post-tonsillectomy bleed.

 

[BLADEMDA]

I’ve seen a patient maintain a saturation of 88 percent after an esophageal intubation. The ER physician then pushed paralytic VEcuronium and the patient coded. By the time I arrived on the scene (6 minutes later) I quickly reintubated the patient. The ETT was in the esophagus. Despite my successful ETT placement the patient was brought back from cardiac arrest only to be declared brain dead a few days later.
The documentation stated the ETT became dislodged at some point and anesthesia reintubated successfully.

This is just one case of many I could post about but won’t do so. All I can say is the real world isn’t like the TV shows and difficult airways deserve the most qualified person readily available.

 

[vector2]

I’d say in EM that some form of CO2 detection is standard of care. Colorimetric CO2 detection immediately after tube placement allows one limp across the standard of care threshold, however continuous waveform capnography is a best practice whenever it is available (which should be every ED in America). However, I have no confidence in doctors who like to place tubes without understanding the value of continuous waveform capnography in critically ill patients which is far too many EPs that I encounter.

I think it's crazy that more EDs don't use continuous capno for trauma codes and medical codes which are BIBEMS. Watched a multiple GSW activation today down in the bay. Asystolic, comes in with lucas machine going. Intubated by the ED relatively quickly with positive color change. Pulse ox and NIBP not picking up. Proceeds to a wayyyy too long a period where blood isn't going in the pt, and when it finally did it was through an IO. Finally gets clamshelled, cordis jammed in heart and connected to infuser, internal massage. Cardiac activity never comes back.

Throughout this process I'm glancing at the colorimeter which the RT hasn't bothered to take off the ETT. It was a nice yellow when the pt first gets tubed, and progressively over the first golden minutes when the pt failed to get resuscitated it transitioned to a solid purple throughout the respiratory cycle. This is not the first time that the ED+trauma surgeon for whatever reason failed to prioritize getting blood into the pt ASAP, and I wonder if the lack of cardiac output were made more obvious capnographically before thoracotomy or d*cking around with REBOAs, then gaining access and giving blood to temporize first might become more of a priority?

 

[emergentmd]

EM doc here who trained at one of the busiest ED/trauma center in the country, worked in Level 1 trauma, busy community level 2s, rural Ers, FSERs.

Airways are missed even by the best ER docs as they are missed by Anesthesiologist although I would never argue that Er docs are better. If we could have Anes in the Er 24/dy, most ER docvs would love it. But this is not economically/physically possible so we do the best we can.

FSERs quality of care is somewhere between busy Community ERs (virtually All EM boarded) and Rural ERs (Good percentage of non ER docs). As there are no EM boarded requirements (I wish this was not the case), any doc with a license can open a FSER. This creates a quality of care issues where a FP doc can open an ER without the experience to work in a place without coverage.

I have no clue what happened in this case but I suspect that this was not an ABEM doc. The FSERs I worked/owned, I would put up our ER doc up against Level 1 Trauma docs b/c most of our docs have worked at these sites. But this is not the case with many FSERs.

This could be as simple as an EM doc with extensive experience who missed an intubation or as bad an an unqualified FP doc who never intubated someone since residency.

 

[Robotic Wis-Hipple]

EM doc here who trained at one of the busiest ED/trauma center in the country, worked in Level 1 trauma, busy community level 2s, rural Ers, FSERs.

Airways are missed even by the best ER docs as they are missed by Anesthesiologist although I would never argue that Er docs are better. If we could have Anes in the Er 24/dy, most ER docvs would love it. But this is not economically/physically possible so we do the best we can.

FSERs quality of care is somewhere between busy Community ERs (virtually All EM boarded) and Rural ERs (Good percentage of non ER docs). As there are no EM boarded requirements (I wish this was not the case), any doc with a license can open a FSER. This creates a quality of care issues where a FP doc can open an ER without the experience to work in a place without coverage.

I have no clue what happened in this case but I suspect that this was not an ABEM doc. The FSERs I worked/owned, I would put up our ER doc up against Level 1 Trauma docs b/c most of our docs have worked at these sites. But this is not the case with many FSERs.

This could be as simple as an EM doc with extensive experience who missed an intubation or as bad an an unqualified FP doc who never intubated someone since residency.

Good post. But I don’t think anyone was bashing ED airway skills here. On paper that’s a bad airway that anyone could’ve struggled with regardless of center and airway equipment at the ready.

And we anesthesiologists have had our own share of these types of things from docs that have had skill atrophy working in 9-3p surgery centers.

 

[MoMoGesiologist]

I think it's crazy that more EDs don't use continuous capno for trauma codes and medical codes which are BIBEMS. Watched a multiple GSW activation today down in the bay. Asystolic, comes in with lucas machine going. Intubated by the ED relatively quickly with positive color change. Pulse ox and NIBP not picking up. Proceeds to a wayyyy too long a period where blood isn't going in the pt, and when it finally did it was through an IO. Finally gets clamshelled, cordis jammed in heart and connected to infuser, internal massage. Cardiac activity never comes back.

Throughout this process I'm glancing at the colorimeter which the RT hasn't bothered to take off the ETT. It was a nice yellow when the pt first gets tubed, and progressively over the first golden minutes when the pt failed to get resuscitated it transitioned to a solid purple throughout the respiratory cycle. This is not the first time that the ED+trauma surgeon for whatever reason failed to prioritize getting blood into the pt ASAP, and I wonder if the lack of cardiac output were made more obvious capnographically before thoracotomy or d*cking around with REBOAs, then gaining access and giving blood to temporize first might become more of a priority?

When I see the EtCO2 start to drop in the OR, I know it’s time to panic.

 

[BLADEMDA]

This case is as much about failed ventilation as it is failed intubation. Confirming the ETT placement is critical. Breath sounds are inadequate for confirmation imho. You need definitive confirmation and correct ETT depth. If the intubation was indeed successful and known to be difficult then the prudent thing to do is make certain that tube doesn’t come out. Once the saturation’s of this particular patient started to deteriorate incorrect ETT placement should have been very high on the short differential list of causes especially in an inadequately sedated patient.

Before any of you think that I haven’t been in these scenarios with a live patient you are mistaken. I fully realize the consequences of failed ventilation and failed intubation in a patient. I would like to think we are held to a higher standard than an ER physician in terms of the airway so I am cautious about applying our standards to a free standing ER facility staffed by a physician of unknown specialty or experience.

 

[chocomorsel]

I’ve seen a patient maintain a saturation of 88 percent after an esophageal intubation. The ER physician then pushed paralytic VEcuronium and the patient coded. By the time I arrived on the scene (6 minutes later) I quickly reintubated the patient. The ETT was in the esophagus. Despite my successful ETT placement the patient was brought back from cardiac arrest only to be declared brain dead a few days later.
The documentation stated the ETT became dislodged at some point and anesthesia reintubated successfully.

This is just one case of many I could post about but won’t do so. All I can say is the real world isn’t like the TV shows and difficult airways deserve the most qualified person readily available.

Ok. If you arrived to the bedside six minutes later how did you “see” it before arrival? How could you be sure it wasn’t in, maybe shallowly and moved?

 

[emergentmd]

Good post. But I don’t think anyone was bashing ED airway skills here. On paper that’s a bad airway that anyone could’ve struggled with regardless of center and airway equipment at the ready.

And we anesthesiologists have had our own share of these types of things from docs that have had skill atrophy working in 9-3p surgery centers.

Didn't take it as a slight. There are many docs who works in the er that I would never let touch me. But that goes with all specialities.

 

[ShockIndex]

It is not a violation of the standard of care to intubate the esophagus. That has happened to everyone posting in this thread at sometime in their career. It is a violation to not recognize it in a timely manner and allow your patient to be permanently damaged by it. The never event is not recognizing it.

In other words, if you patient dies or suffers anoxic brain injury because of a tube that you put in the esophagus, just tell your insurance to start writing the check. That goes for paramedics up to anesthesiologists.

The extension of that argument is that if your patient dies or is injured by a tube that has “walked” prepare to face an uphill battle in you defense if you were not using capno. I see far, far too many case of patients dying (or worse) from misplaced tubes and everyone swears that is was initially placed properly...despite no documentation of capnography anywhere in the chart.

 

[dannyboy1]

The extension of that argument is that if your patient dies or is injured by a tube that has “walked” prepare to face an uphill battle in you defense if you were not using capno. I see far, far too many case of patients dying (or worse) from misplaced tubes and everyone swears that is was initially placed properly...despite no documentation of capnography anywhere in the chart.

That’s why a CXR would have been perfect for this case. No better documentation then that.

 

[vector2]

That’s why a CXR would have been perfect for this case. No better documentation then that.

Agreed. When called to an offsite location, putting an attestation in the chart that I saw the tube go through the cords, saw the colorimeter turn yellow, and heard bilateral BS is one thing. But it doesnt rise to the documentary evidence level of a timestamped picture in PACS showing the ETT in the right place and at the right depth to minimize the chance of inadvertent extubation.

 

[Mman]

Agreed. When called to an offsite location, putting an attestation in the chart that I saw the tube go through the cords, saw the colorimeter turn yellow, and heard bilateral BS is one thing. But it doesnt rise to the documentary evidence level of a timestamped picture in PACS showing the ETT in the right place and at the right depth to minimize the chance of inadvertent extubation.

a portable AP CXR can miss an esophageal intubation a not insignificant portion of the time

 

[MirrorTodd]

I think we'd be hard pressed to find a medical textbook stating that cxr is any sort of gold standard for confirming tracheal intubation....but I have been wrong many times before.

 

[vector2]

a portable AP CXR can miss an esophageal intubation a not insignificant portion of the time

I know, but I'm talking about what I'm doing personally from a medicolegal standpoint when asked to intubate away from the OR. I already know the tube is through the cords well before the portable arrives, but from a documentary standpoint the CXR read by a 3rd party radiologist (which will 100% of the time demonstrate tube in trachea if I'm doing the intubation) is good to have in the chart if fingers start getting pointed after I've walked away from the ED.

 

[coffeebythelake]

Verification of Endotracheal Tube Placement

Verification of Endotracheal Tube Placement

www.acep.org

 

[Mman]

I know, but I'm talking about what I'm doing personally from a medicolegal standpoint when asked to intubate away from the OR. I already know the tube is through the cords well before the portable arrives, but from a documentary standpoint the CXR read by a 3rd party radiologist (which will 100% of the time demonstrate tube in trachea if I'm doing the intubation) is good to have in the chart if fingers start getting pointed after I've walked away from the ED.

do you stand by and wait for the CXR to be shot and read by a radiologist before you walk away?

 

[vector2]

do you stand by and wait for the CXR to be shot and read by a radiologist before you walk away?

The tech is always on standby in the ED so I make sure it's been shot before leaving. I don't need to wait for an official radiologist read before walking away- I just need to make sure the image is going into PACS so the radiologist can eventually confirm what I already know.

 

[ShockIndex]

do you stand by and wait for the CXR to be shot and read by a radiologist before you walk away?

I generally stand by the bedside for every patient that I tube in the ED and ICU until after the CXR. Not because the CXR gives me much reassurance that the tube is in the trachea, but because the immediate peri-intubation period is exceedingly high risk for critically ill patients. If something bad is going to happen, the first 10 min on PPV is often when it happens. I stay at the bedside to use the room’s computer to input my orders or at least stay in visual contact with the monitor and vent.

Are there times that I’m running between rooms - absolutely. However, my attention is always focused on data streams from the bedside and the patient-vent interface.

People who drop the mic and walk away after a difficult intubation are dangerous.

 

[deleted697535]

When I see the EtCO2 start to drop in the OR, I know it’s time to panic.

I never really thought about it til now but yes that is probably also my time to panic monitor also!
Low sats, low HR, low BP, who cares we gotta drug for that...
Low Co2, if its really real is not going to end well