Interesting.

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They're all certified badasses until they need a captain of the ship.....

And CO2 color change? No end-tidal? Did they not even have a vent? Sounds like a panic tube and BVM. Wonder if this was a total spinal and not just too much prop.
 
That CRNA had not intubated a patient in 5 years.....wtf.

No wonder he/she didn't recognize an esophageal intubation.
 
The co-defendant CRNA testified at his deposition that he was responsible for providing anesthesia to the patient, but that the insured was the “captain of the ship.”

Damn right under the bus
 
how often do situations like this happen to real anesthesiologists?
 
breastfeeding-cartoon.gif
 
Chloroform4Life said:
That CRNA had not intubated a patient in 5 years.....wtf.

No wonder he/she didn't recognize an esophageal intubation.
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I find that hard to believe. Even if you are doing eyes all day every day, aren't there some patients, that you just intubate? Sick heart patients, poorly controlled HTN. Those vitrectomy patients aren't exactly the healthiest, compliant patients.
And when one intubates and thinks the tube is in the right place, but the sats remain in the crapper, and are unsure about lung sounds/color change don't you just remove and give it a second go?
I also like to listen to my own lung sounds. Learned the hard way.
I don't get it.
 
Anesthesia skills need to stay polished and active or they erode and become flabby. Even if you were an olympic athlete the fact is without exercise and a poor diet you could end up like this guy:

funny-fat-guy-pictures.jpg
 
That looks like a fun patient to take care of. Guess I should have done derm. HAHA. You don't have to worry about the fatties trying to croak on you.
 
chocomorsel said:
That looks like a fun patient to take care of. Guess I should have done derm. HAHA. You don't have to worry about the fatties trying to croak on you.
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I do several patients like this every week for EGDs. That'll put hair on your chest........
 
chocomorsel said:
I also like to listen to my own lung sounds. Learned the hard way.
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The only reason I listen to breath sounds is for quality (wheezing or rhonchi), not to confirm the tube is in the trachea. CO2 or direct visualization are the only ways I rule out esophageal intubation.
 
Two points (pet peeves of mine:
1. Often providers listen for BS on the chest (near the sternum) on both sides-BS need to be auscultated in the axilla! A goosed tube sounds great when listening at the costo-sternal borders

2. CO2 color change is glorified litmus paper-gastric air can change the color to yellow as well. This place needs capnography (time to join the 21st century!)
 
I can tell by the feel of the bag.

There is also the Cosham test. Apply negative pressure with a bulb attached to the ET tube. It reinflates if tube is in the trachea. Stays flat if tube is in esophagus.

ETCO2 trace trumps all. So does visual confirmation of tube in larynx.
 
Tuohy said:
Two points (pet peeves of mine:
1. Often providers listen for BS on the chest (near the sternum) on both sides-BS need to be auscultated in the axilla! A goosed tube sounds great when listening at the costo-sternal borders

2. CO2 color change is glorified litmus paper-gastric air can change the color to yellow as well. This place needs capnography (time to join the 21st century!)
Click to expand...

Great point on number two, particularly for residents.

Particularly if patients are being mask ventilated prior to intubation, you can get a color change. It has to be a sustained color change. I also once went a code where there was NO color change aka "please do better chest compressions, sir". So that little calorimeter is deceiving.
 
Mman said:
The only reason I listen to breath sounds is for quality (wheezing or rhonchi), not to confirm the tube is in the trachea. CO2 or direct visualization are the only ways I rule out esophageal intubation.
Click to expand...

I am going to have to redevelop habits when I start supervising. I rarely listen to breath sounds. I quickly glance at the tube depth marker as it passes the cords when intubating for measuring depth. Can tell by bag compliance if it's in if questionable. Not sure I would trust a resident or nurse though. A lot of things I do because I know my limitations but I'm not sure about others.
 
Tuohy said:
Two points (pet peeves of mine:
1. Often providers listen for BS on the chest (near the sternum) on both sides-BS need to be auscultated in the axilla! A goosed tube sounds great when listening at the costo-sternal borders

2. CO2 color change is glorified litmus paper-gastric air can change the color to yellow as well. This place needs capnography (time to join the 21st century!)
Click to expand...
Unless gastric air has co2 from bmv, gastric air shouldn't have an acidic ph. Gastric fluid is acidic, but hydrogen ions are not volatile enough to change the litmus paper.
 
Wiscoblue said:
ETCO2 trace trumps all. So does visual confirmation of tube in larynx.
Click to expand...
All the tubes are always "visualized thru the cords". They somehow manage to "slip out". I have heard this story so many times. If I had a dime...

Never trust stories of the tube being visualized when you are not doing the laryngoscopy yourself.

Video laryngoscopy is good for this. Everyone gets to watch.
 
urge said:
All the tubes are always "visualized thru the cords". They somehow manage to "slip out". I have heard this story so many times. If I had a dime...

Never trust stories of the tube being visualized when you are not doing the laryngoscopy yourself.

Video laryngoscopy is good for this. Everyone gets to watch.
Click to expand...

I agree. 95% of esophageal intubations had somebody see the tube go through the cords. If I don't see end tidal CO2 on capnography, seeing it with a video laryngscope for myself or a quick bronch are the only ways I believe it's in.
 
Noyac said:
I can't tell if you are being serious or not.

What's funny about it is that the pt is fat and complaining of swallowing problems which obviously he or she doesn't have difficulty with since they are fat.

Thats funny.
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They just have a slow metabolism, it's genetic
 
BLADEMDA said:
Lastly, call 911 immediately when a potentially life-threatening situation arises."

That's hilarious; when SHTF I'm supposed to call 911?
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The only reason to call 911 is when a paramedic can provide skills or equipment that are necessary and not available. It should happen exactly NEVER in an OR!

(Except when the skill is the humility to consider an esophageal tube in your differential...)
 
I don't think this one story about one bad crna makes much difference. there are any number of equally bad anesthesiologists out there. anyway, what surprises me is that they moved to intubate so quickly because the guy didn't even have the skills to manually ventilate to maintain sats. if the paramedic was easily able to intubate, that means the airway probably wasn't too bad and at least ventilateable +/- oral airway; sounds like a stupid rush to intubate that cost the pt his life.
 
leaverus said:
I don't think this one story about one bad crna makes much difference. there are any number of equally bad anesthesiologists out there. anyway, what surprises me is that they moved to intubate so quickly because the guy didn't even have the skills to manually ventilate to maintain sats. if the paramedic was easily able to intubate, that means the airway probably wasn't too bad and at least ventilateable +/- oral airway; sounds like a stupid rush to intubate that cost the pt his life.
Click to expand...

Swiss cheese model. There were any number of instances and opportunities that could have been used to easily avoid danger. Overtime they got to a fork in the road to rectify the situation they took the wrong road.

I will say that bad anesthesiologists exist, but I have never seen one that hasn't intubated in 5 years or needed to have EMS bail him out unless it was an emergent transfer, as I'm assuming this was.
 
Ignatius J said:
I will say that bad anesthesiologists exist, but I have never seen one that hasn't intubated in 5 years or needed to have EMS bail him out unless it was an emergent transfer, as I'm assuming this was.
Click to expand...

yeah I get that, but that was part of my point - not intubating in 5 years doesn't matter as long as you can get o2 into the pt's lungs however you can. i'm surprised this guy's skills had deteriorated (if he ever had them) to the point he couldn't even mask ventilate; while it's plausible this particular pt was one of those truly impossible to ventilate types, those are so rare I kinda doubt it.
 
Psai said:
They just have a slow metabolism, it's genetic
Click to expand...
I don't know if you guys do the same HLC modules that we so, but I recently did the "bariatric sensitivity" one. This was almost verbatim one of the quiz questions:
T/F (the answer was of course true)-
"Many physicians believe that obesity is the cause of their patient's medical problems"
Intimating that physicians are INSENSITIVE and/or factually INCORRECT for believing this. I couldn't believe someone thought this was an appropriate suggestion! Any physician that doesn't counsel their obese patients on weight loss is negligent, in my opinion.
 
PressureSupport said:
The only reason to call 911 is when a paramedic can provide skills or equipment that are necessary and not available. It should happen exactly NEVER in an OR!

(Except when the skill is the humility to consider an esophageal tube in your differential...)
Click to expand...

Need to transfer to actual hospital at some point.
 
Noyac said:
I can't tell if you are being serious or not.

What's funny about it is that the pt is fat and complaining of swallowing problems which obviously he or she doesn't have difficulty with since they are fat.

Thats funny.
Click to expand...
Dead serious; too many 16 hour days in a row...I do get it now and it IS funny. Forgive my obtuseness.
 
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