EM doc here...interesting case, tragic. So, the first thing I find odd is that there are 2 docs that seem to be described as equally involved in this pt's care. Most FSEDs, that I've seen at least, have one clinical doc on shift so this must be either a really busy FSED, right around shift change? or perhaps the "EM trained" doc was the owner and just happened to be there? I can't tell. Anyway, if the primary physician was the FM doc and he didn't have all the additional requisite training and experience dealing with these types of situations, then that might explain things. I find it very odd that the "EM trained" (ABEM?..doesn't say) failed to intubate (Or was it the FM doc?), yet the paramedic successfully intubated. That really just..never happens in my experience. Not to slight medics, some of which can be skilled with endotracheal intubation in the field, but I've never seen a medic take over an airway in real world practice because an EP failed to intubate. Most of them here use Kings or combitubes. In fact, most ABEM docs are going to be trained to cric as the ultimate back up and if they haven't done one in a live pt, they should have done several on cadavers and simulations as part of their training. An EM trained doc is going to be much more aggressive about performing a cric, barring that there weren't anatomical/post surgical issues that prevented it from being done. Usually they have already thought about it in advance and mentally made the decision that it's a viable surgical option.
Also, what kind of airway equipment was readily available at the FSED? Theoretically, it should mimic most ED's, in which case: LMAs, bougies, bronch, OPAs, NPAs, blades, fiberoptic laryngoscopes, cric kit, etc..
As far as the case... Yikes. I would imagine zooming in on her neck and the hairs standing up on the back of my neck. Danger Will Robinson! Danger! The first question I have...was she truly decompensating where intubation was absolutely indicated prior to transport? Anyone with common sense would have to know this has a very high probability of turning South very quickly. Therefore, a reasonable EP would want all of their backup devices available. This one screams awake FOI. I can't rationalize why someone would paralyze this patient and use standard RSI. It also would be a good idea to ask the medic for a combitube or King Laryngeal tube to have on hand for a worst case scenario. Better to do awake FOI, take a peek and paralyze at the cords. However, if she's breathing on her own and not in extremis and there wasn't a sudden clinical change, I'd have been very tempted to fly her to the closest tertiary care center where her surgeon has hospital privileges without touching that neck. Really weird that someone like this chose to present to an FSED of all places?
Anyway, I'm surmising that they might have been short a few backup airway devices.
The CXR as standard of care? Eh..I guess. Yes, we probably order a ton more of these in the ED than you guys do in the OR after intubation. It is rather routine to get a confirmatory CXR in the ED. Do we really need it to know we're in the right place? Not really, but it's just how most of us were trained. The majority of the time, I'm looking to see if I need to pull the tube back and I want to examine the chest and lungs for any other valuable/relevant information that would influence my care of the pt. It's not simply to measure ETT to carina. Personally, I intubate just a tad deep because they whip the pt off to CT or elsewhere and I'm paranoid of the tube getting dislodged. I wouldn't think to transfer a pt without getting one after intubation, but that's me. I think he was giving roc to prolong the paralysis. ED RNs are not the best at sedating patients quickly and correctly titrating for an accurate RASS, etc.. so many times we'll give a longer acting paralytic to keep them still while we're running the other tests for fear they'll wake up and grab the tube. Roc just happens to be the 2nd most readily available paralytic in most EDs.
It sounds like the pt wasn't sedated well enough post intubation (common in real world) and they forgot to push more paralytics to keep them still (important for transport). No confirmation CXR...I know this is debated on this thread but I'd have to argue from EM perspective, this is very common and probably standard of care. I'd honestly have to fault them for not performing one. Failure to identify tube dislodgment and to correct it in a timely manner proved fatal.
Easy to nit pick these types of cases, but it's always important to keep in mind that it could happen to anyone. Thanks for sharing!