Supra-Glottic Airways Taste Like Failure.

In 2007 Elaine Bromiley went in to the hospital for an elective sinus surgery. Thirteen days later she died.  If you are unfamiliar with the case, there is a reenactment video of what happened in the OR here. Be forewarned, it is not an easy video to watch.

Recently we discussed the case at work. Providers expressed their disbelief over the events. “I don’t get it. How could that have happened?” was asked. Before doing quality assurance (QA) in EMS for several years I know I could tell you the answer, it is glaringly obvious to anyone with or without any medical knowledge – THEY ARE INCOMPETENT IDIOTS! For good measure I might also throw in some pseudo-intellectual comment about how the definition of insanity is doing the same thing over and over and expecting different results. For the coup de grace I would add they should lose their license to practice medicine.

Doing QA is hard. Sure you can just read reports and dole out sanctions for protocol violations like some sort of EMS SVU. “In the EMS justice system, QA based offenses are considered especially heinous. In the agency, the dedicated QA officers who investigate these vicious felonies are members of an elite squad known as the Special Victims Unit. These are their stories.” Chung-chung. It won’t make your system better or safer, but you can do it. It happens all the time.

To do QA right requires you to either have natural talents in things like emotional intelligence (I don’t) or to learn about yourself and come to some unpleasant realizations, things like you are wrong a lot. Even worse, after doing QA for some time you might come to find the root cause of some of the problems in the agency also involves you. The notion that second ago you were sure the providers were morons and now you are contemplating that you are perhaps a causative factor in the incident can be a bitter pill to swallow.

Growth is hard and to be honest not all that fun. It kind of sucks, actually.

Going back to the Elaine Bromiley case it is easy to be the judge, jury and executioner when we view the events that occurred with the benefit of hindsight.

The thing is if you were to present the scenario in the Bromiley case to anyone of the people that were there in there that day in the form of a question, “your patient is circling the drain, the 02 sats are in the shitter, should you keep trying to intubate?”I guarantee every single person would say “hell no!” But the truth is the people in the OR that day may never have even considered there were other choices. There probably was no choice presented in their minds. The only solution they could think of was “get the tube.” Or maybe they did have choice but the best solution from their perspective was to “get the tube.” Perhaps they though in another five seconds that tube would go through the cords and the disaster would be averted, certainly better to spend another five seconds in the airway than to cut the neck and scar this woman, right?

Wrong.

But they could not know that. Only with hindsight can we tell them that it would not be just another 5 seconds to get the tube. If we had the foresight to say you are never going to get the tube I assure you no one would still be mucking around in a person’s airway when their spo2 is south of 40%.

It is easy to watch the Bromiley video and believe your inner monologue, “IDIOTS.” It is harder to look at things from the provider’s perspective. It takes self-restraint to not jump to conclusion. It is very hard to look at things from their perspective and try and understand what they thought was going on then and why they made the choices they did that day. I think this is referred to as empathy.

hindsight

From the outside perspective watching a fixation error unfold is a baffling ordeal, it boggles the mind how people could do what they are doing.

Fixation errors are very real. I made one once. After you experience one the world is different. You will be left with lingering doubts about your skill as a clinician. Are you a shit paramedic? How the hell did that happen in the first place? From the calm of your kitchen typing away on your computer it seems almost impossible to understand what occurred that day. You know the facts, you know what happened, but the why of it is much more elusive. Like some half remembered drunken evening you have bits and pieces of went on. What led you astray that night was not just one thing, and you know this. You know the holes of the Swiss cheese lined up just right to set the trap and you took the bait. Hook, line and sinker.

Given enough time, you can begin to understand exactly what did happen. Given enough time, you can be okay with a lot of things. You can begin to understand how others can get lulled down the same shitty path. There are few things in life as seductive as just taking one more “quick look” in your patient’s airway when you know at that moment that an ET tube is the solution to all your problems.

I think there is another component to the issue of fixation. Failure. There is a subtle sense of failure when you place a supra-glottic airway after you could not get the ET tube in, especially in a patient you paralyzed.  But you do it. You put that supra-glottic device in, because that is what is needed, that is what is right and correct and should happen, has to happen, but it still stings. It still feels like failure.

But the goal was never intubation, was it? The goal was managing the airway. Or was it? It seems when every cardiac arrest is tried by a jury of our peers the burning question is “did you get the tube?” or “Who got the tube?”

Of course, talking about this is probably going to be frowned upon be some. We are supposed to be bigger than this when it comes to ego and our own biases and patients.

On the other hand, preventable medical errors may be the third leading cause of death in the USA. Maybe it is time we start looking at some human related factors.

Let’s have the uncomfortable talk about how our cognitive biases, ego, and sense of pride might be playing in to killing a bunch of people. If you do not think this is a huge problem in EMS, I would refer you to the post about the ET tube petition. Right next to ET tubes on the NASEMSO document was a call for the removal of PEEP. Now, the thing is there is not a ton of evidence about EMS ET tubes, and what evidence there is paints the practice in a questionable light, but PEEP on the other hand seems to be pretty soundly based in science and evidence. Out of the save intubation crowd there was virtually no science or data or evidence given, only anecdote and an appeal to emotions.

Where was the petition to keep PEEP? There wasn’t one.

  • Number of people who signed the petition to keep intubation in the paramedic scope: 26,476.
  • Number of people who signed the petition to keep PEEP in the paramedic scope: What petition?

You can ask yourself why no one cared about the PEEP issue but I suspect you know the answer, you have known it all along. We, as an industry, have some weird emotional attachment to intubation; it has somehow become an integral part of our identity as a paramedic. This is not to say that intubation does not have a place in EMS, I think it does, but I think it might be time to start the conversation about why we are so god damned emotionally invested in intubation. Myself included.

How did our value as a paramedic come to rely on a 30cm piece of plastic tubing? How does self-worth hinge on shoe-horning a two dollar piece of plastic several inches in to a patient? I do not know.

 

 

 

Why I am Not Signing The Petition About Intubation.

So I do not have to post a lengthy comment every time the petition pops up on my feed.
If you have not seen it, here it is

Where do I begin? First, NASEMSO is not coming for our ET tubes. This was literally them publishing comments they received. The comment came from one person in an area where paramedics need additional training to be able to intubate. Agencies often solicit public comments when implementing policy change and when they do this some of comments are from people that should not comment on policies. The fact that 9000+ people could not be bothered to understand what was going on here or ask for further clarification speaks volumes about our industry.

Secondly, many people think EMS should in fact stop intubating. A petition is not going to change the minds of the shot callers. They look at things like evidence and training and standards and outcomes. A bunch of whiny rhetoric about the heroics we perform is not going to sway them in the least.

petitionThey deal in cold hard facts, not appeals to emotions. 

This petition just makes us look silly. “Allow Paramedics to continue to save lives with endotracheal intubation!” is a real stretch to say the least. While I think an ET tube is the gold standard, I do not see much in the way of life and death between it and a supra-glottic airway. Ventilation matters, not our ego.

The petition states the reason why ET tubes are on the chopping block is because we receive less training than anesthesiologists. That is wild speculation and, I don’t even know where that came from. If you are a paramedic and are not sure why people are considering that maybe we should not be intubating I would like to introduce you to the Dunning-Kruger Effect.

The petition should be calling for intubation education reform. Want to “Save The Tubes?” Then start writing NASEMSO about how we need more education on things like apneic oxygenation, peri-arrest intubation, ARDS, PEEP, etc. Show the people that write the educational guidelines that we want to be safe and educated and trained well and competent. Show them that we can demonstrate humility and are capable of using critical thinking and accepting feedback. Or keep getting mad over a non-issue and saying what heroes we are. 

When Only Outlaws will Intubate…

Get on the band wagon!!! The NASEMSO is coming for your laryngoscopes and ET tubes!

If you are on social media and in EMS you have no doubt seen the posts today. They are coming for your tubes. Soon intubating will be outlawed and only outlaws will intubate. And it is out fault because we suck at intubating, or we haven’t trained enough, perhaps our QA programs have failed, and our education is inadequate. We are getting what we deserve.

Except that is either nonsense or speculation, or some of both at this point.

First, states can do whatever they want and the national scope of practice is not a law, it is not binding and to be honest, whatever, you should have gotten your critical care cert by now. If you want to complain about EMS education and training and have not done it yet, well…let’s just say that if you complain that we aren’t taken seriously but haven’t taken a board certification exam that you could have…get off your ass. Or don’t. I don’t know. Do whatever you want.

The part about removing intubation is under the “comments received for exclusion of practice” section…right next to the comment about removing PEEP. I am not respiratory guru but I think some of the ARDS patients I transfer are going to be unhappy with removing PEEP.  Does anyone think NASEMSO is going to remove PEEP? I do not think so. This may be the EMS equivalent of Yahoo Answers or it could be the real deal. I made a comment on the 2015 AHA/ILCOR guidelines asking them to remove epi from adult cardiac arrests and it is still in the algorithm. When organizations intend to change policy they solicit comments from the public. Not everyone in the public, how do I put this…think of how bright the average person out there is, now realize 49% of people are not as bright as them, but they do have internet access. Or risk losing all your faith in the human race and get on Yahoo Answers or read the comments below a YouTube video.

Who made these comments about removing intubation? No one knows? What is going to happen with the comments? Also unknown.

Which brings me to the bigger issue here; everyone is jumping to conclusions about this. We don’t know who said it and we do not know why they said it. Could it be that EMS is bad at intubating? It is certainly possible. But there are tons of other reasons as well that could exist. Perhaps it is a lack of evidence that ET tubes actually change many outcomes? It certainly seems problematic that one comment has caused mass condemnation in EMS.

Maybe it is time to think about ET intubation is simply a risky procedure and unless you are dropping 40+ tubes a year it is extremely dangerous. Perhaps the risk is simply too great when presented with the logistical challenge of getting all the paramedics in the country 40 tubes per year. Perhaps we have been too cavalier with the whole thing and we need to own up to we simply were allowed to do an unsafe act and we need to rectify that? It does not mean we are failures.

No reason or logic was given for the comment, but that did not stop folks from piling on with comments about how EMS is a failure and doomed, and this is what we deserve, and that they are leaving EMS and other rhetoric. If an anonymous comment is all it takes to push you out of EMS, it might be time to question your commitment to it in the first place.

problem solving

Don’t get me wrong, I think intubation is a good skill to have and just like everyone else in EMS I am an above average intubator*.  I want to hang on to it because I think it is beneficial to some patients, but if I am putting patients at an unjustifyable risk, then I am okay with taking it away. There certainly is marked room for improvement in EMS education, QA and training. But before we know the facts here (if there are any at all because it may just be a nameless commentator) we should probably not condemn all of EMS. The sky is not falling; you do not need to start stock piling high capacity bougies and semi-automatic capnography monitors.

Perhaps this is the time to show that we are professionals, ask for more information, take feedback well and improve where needed.  Blaming does not fix errors.

* Dunning-Kruger

Dave’s Subs

If you are interested in learning about Just Culture I highly recommend the book Dave’s Subs by David Marx.

Dave’s Subs is an easy to read book about applying the Just Culture principals to your workplace and is not nearly as dry as some other works that exist on Just Culture.

Before I read this book I was looking for EMS or at the very least medically related Just Culture Books and education. The reality is that Just Culture principals can be applied universally across any industry.
daves subs

How to do QA Without Being an Asshole.

This is a  rambling, poorly organized blog post about EMS QA that started out as an answer to a question posted on facebook and turned in to a collection of random thoughts on the subject. People often find themselves assuming the role of QA with little to no training on the subject. I know myself and many others have learned quite a few lessons the hard way. Continue reading “How to do QA Without Being an Asshole.”

EMS, PTSD and Russian Video Games: Could Playing Tetris Save Your Life?

You just ran a really bad call, should you take 20 minutes to play some Tetris or Candy Crush?

While more research on a larger scale is needed, it certainly seems plausible that playing video games after a bad call could reduce the amount of flashbacks, a cardinal symptom of PTSD,  that occur.

No research has been published specifically on first responders regarding video games and PTSD. When members of the general public are exposed to traumatic events, playing video games after the event is associated with a lowered number of flashbacks and intrusive memories compared to those in the control group that did not.

The journal Molecular Psychiatry released a studyon March 28th 2017, Preventing intrusive memories after trauma via a brief intervention involving Tetris computer game play in the emergency department: a proof-of-concept randomized controlled trial.[1] The study was comprised of 71 people over the age of 18 that went to the emergency room at John Radcliffe Hospital, in Oxford, UK within 6 hours of experiencing or witnessing a motor vehicle accident that met DSM-IV PTSD criterion A1 for traumatic events. This is described as “experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury.”

Participants were randomized, half of them were asked to briefly explain what the worst moments of the accident were and were then instructed to play Tetris for 20 minutes in the ER. The other half of the participants spent an equivalent amount of time writing down all the things they had done in the ER, but did not have the memory cues and did not get to play video games.

The study looked at number of intrusive memories that happened in the 7 days following the accidents. The group that had played Tetris in the ER had significantly less intrusive memories than the control group.

The authors of the study hypothesize that playing Tetris immediately after the exposure to traumatic events causes a competition in the brain between the game with high visuospatial needs and consolidation of the memories, resulting in less intrusive memories.

The authors also stated that it does not have to be Tetris, “but any task with high visuospatial demands is likely to be useful within the procedure (e.g. games such as Candy Crush, drawing).”

This recent study builds on the 2009 study, Can Playing the Computer Game “Tetris” Reduce the Build-Up of Flashbacks for Trauma? A Proposal from Cognitive Science.[2]  where 40 participants watched a 12 minute film with scenes of injuries and death.   Following a short break after the film half of the participants sat quietly for 10 minutes and half of them played Tetris for 10 minutes.  Participants who played Tetris had significantly lower rates of flashbacks over the next 7 days.

2009 tetris
Flashback frequency over one week. From Holmes, et al. 2009.

While further research is needed it might be reasonable to play 20 minutes of Tetris or Candy Crush as soon as possible after completing a bad call. It seems there is at the very least a theoretical benefit and playing video games for 20 to 30 minutes is not likely to be harmful.
Standard disclaimer: I am not a psychologist, psychiatrist, counselor, etc. I had one semester of psychology in college. This blog is not a substitute for seeking care or treatment from a mental health professional. I probably have no idea what I am talking about.

 

  1. Iyadurai L, Blackwell SE, Meiser-stedman R, et al. Preventing intrusive memories after trauma via a brief intervention involving Tetris computer game play in the emergency department: a proof-of-concept randomized controlled trial. Mol Psychiatry. 2017;
  2. Holmes EA, James EL, Coode-bate T, Deeprose C. Can playing the computer game “Tetris” reduce the build-up of flashbacks for trauma? A proposal from cognitive science. PLoS ONE. 2009;4(1):e4153.

 

Red Badge of Courage: Has PTSD Jumped The Shark in EMS?

I have no doubt this piece will be misunderstood, it will be polarizing and it will make people angry.

PTSD is not something to be proud of, it is not something to brag about, it is not an excuse to act like an asshole and it is not a thing to rally around and sell paracord bracelets or challenge coins about.

With frequent pictures of ghost surrounded, sobbing angel-winged  EMS providers and numerous gofundme sites for nonsense* like horse therapy for EMS providers with PTSD…Are we trivializing those who are really injured?

PTSD is no more glamorous than a work related back injury. It should be treated like any other work place injury, not some sacred cow that is above reproach. It is a very real thing, that is not up for debate. People are exposed to things working in EMS  that may cause a mental or physical injury.  I am asking all of us to really take a look at how we view these injuries and examine how we are portraying them.
Continue reading “Red Badge of Courage: Has PTSD Jumped The Shark in EMS?”

Resuscitation: What the @$#! do we know?

Maybe you have been in EMS long enough to remember the good old days of the early 2000’s. I sometimes long for the days where we knew that epinephrine, fluids, airway management and antiarrhythmic medications were lifesaving interventions.

These days I have no idea if the interventions I  perform during resuscitation attempts are  the right thing or not. what the bleep to we know

Should we give epinephrine in cardiac arrest? I don’t know.
What is the optimal ventilation ratio in cardiac arrest? I don’t know.
Are mechanical CPR devices in cardiac arrest beneficial? I don’t know.
Is there a reason to use anti arrhythmic medications in cardiac arrest? I don’t know. Continue reading “Resuscitation: What the @$#! do we know?”

My Baby Looks Hot Tonight: An Open Letter About Light Bondage and The NREMT

Dear NREMT,

I like you, I really do. I think you do some good stuff for EMS. But man, as a friend, I feel the time has come to speak up.  You have become like that friend we all have that is still hung up on that one girl that dumped him eighteen months ago.  He still thinks there is a chance; she has moved on and is now engaged to an investment banker named Brent that she met on Match.com. It’s over man, move on, stop looking at their Facebook photos of their vacation. 

The time has come to remove seated spinal immobilization testing from the EMT psychomotor exam.  Continue reading “My Baby Looks Hot Tonight: An Open Letter About Light Bondage and The NREMT”