EMS Artifact

Harsh post title, but after reading the following article in the Boston Globe, I think it might be too kind.

Rhode Island EMS crews brought patients to the hospital with misplaced breathing tubes: None of them survived

Go ahead and read the entire article. It’s long but worth reading. If you’re in EMS, you should be shaking your head, or maybe banging it against your desk, when you’re done. I’ll post a few excerpts with my commentary.

Spoiler Alert;

It won’t be a positive commentary.

In the summer of 2018, Dr. Nick Asselin was doing research on cardiac arrests in Rhode Island when he made a horrifying discovery.

Hospital records showed patients had been arriving by ambulance with misplaced breathing tubes, sending air into their stomachs instead of their lungs, essentially suffocating them. At first, he said, there were four cases, then seven. More trickled in.

By the time Asselin presented his findings to a state panel in mid-March, he’d identified 11 patients with so-called esophageal intubations that had gone unrecognized by EMS providers over the previous 2 ½ years. All 11 had died.

11 patients killed by incompetence with arrogance on top. There is, as I was taught many years ago, no disgrace in missing an intubation. We’ve all done it from time to time. The disgrace is in not recognizing it, not using technology that has been available to EMS for close to 25 years, and not following in a clearly spelled out protocol provided by the state EMS regulators.

Here is the pertinent section of the Rhode Island Statewide EMS Protocols, section 7.03, Step # 10.

Confirm proper placement of the ETT utilizing standard methods (presence of breath sounds, absence of gastric sounds) and quantitative waveform capnography (a colorimetric EtCO2 device may be used for initial confirmation of placement if waveform capnography is not immediately available).

Straightforward. It’s done thousands of times a day across the nation and in Canada too. It’s done even more in hospital operating rooms. In fact, that’s where first encountered End Tidal Carbon Dioxide monitoring. In a hospital operating room when I was a paramedic student back in 1990.  It was sometime in the early 2000s when ETCO2 spread to EMS, but a few years previously, “colormetric ETCO2” was introduced and used by most EMS systems.

Although apparently not in Rhode Island, at least not consistently.

So, here is where the arrogance starts to pile on top of the stupidity.

Jason M. Rhodes, the state Health Department’s EMS chief, recommended a way to tackle the problem that aligned with national standards: restricting the practice of placing those tubes to paramedics, the most highly trained EMS providers. Rhode Island is the only state in New England, and among a minority nationally, that allows non-paramedics to intubate patients.

But a coalition of Rhode Island’s EMS practitioners, municipal fire chiefs and a city mayor pushed back. They said the “ET tube,” as it’s known, saves lives. Taking it away, as one fire chief put it, “would be a sin.” A lobbyist for the firefighters union lambasted the doctors for not consulting more of its members before proposing such changes, saying, “We’re the experts … not the doctors!”

In the end, the board didn’t restrict the practice to paramedics, instead requiring that all providers — paramedics and EMTs alike — consider less invasive measures before inserting a breathing tube.

The emphasis is mine, not in the original article.

First, the fire chief is wrong. Ironically, there is some study evidence that use of ET Tubes in the field decreases survival. It’s not clear why that is, but placing the ET Tube in the esophagus instead of the trachea and not realizing it clearly does not help.

Then, there is the lobbyist for the firefighters union. Really? YOU know more about medicine than the doctors? I’ve known some very sharp fire service EMS providers, but not one of them has ever stated that he’s an expert and a doctor isn’t.

I’ll grant that many emergency medicine doctors who don’t have a role in EMS systems still don’t know enough about EMS.Still, this clown saying that EMT Cardiacs, a provider level that I thought went out in the 1990s, know more than doctors is ridiculous. Oh, and arrogant.

Consider, but not actually attempt.

Moving on,

Until recently, Rhode Island was the only state in New England where 911 call takers were not trained to provide guidance over the phone on how to perform CPR. That changed this year after The Public’s Radio and ProPublica reported on the deaths of a 6-month-old baby in Warwick and a 45-year-old woman in Cumberland after 911 call takers failed to give CPR instructions to the family or other bystanders.

Rhode Island now has a new 911 center director, and by late winter, all 911 call takers are expected to be trained in emergency medical dispatch, which includes providing CPR guidance over the phone.

So, not just EMS, but apparently EMS dispatch is years, no decades, behind the national standard for 9-1-1 call takers.

By the way, and I ask this question of students a lot, who decides medical “standard of care?”

That’s sort of at trick question and the answers I get are some variation of “doctors”, “medical committees” or something else that sounds like an organized process.

Here’s the answer I got from a paramedic/lawyer friend with extensive experience in EMS litigation.

“Juries.”

Standard of Care comes from litigation when a medical case, including EMS, goes really bad and someone sues someone.

Who wants to be “that guy” whose actions caused a new “standard of care?”

Not me.

There’s a description of how this epidemic of misplaced ET Tubes was discovered. I won’t quote it here, but again read the entire article, especially if you’re in EMS.

You can, and should, read about fire chiefs, fire union officials, and politicians doing the damnedest to impede progress in improving medical care in Rhode Island.

As we used to joke about the fire department in Sorta Big City “150 years of tradition, unimpeded by progress.” If you think I’m kidding, you didn’t witness the battle to get all fire fighter to wear their SCBA packs when they went into a burning building.

But I digress.

There is a lot of “rice bowl protecting” going on among the opponents to improving care and patient outcomes. It seems like the fire lobby is worried about private ambulance services trying to horn in on their sinecures.

A couple of more quotes to set up my closing comments,

At 6:03 a.m., Kerry Duarte’s 911 call was patched through to the dispatcher at the Pawtucket Fire Department. Within eight minutes, an EMS crew had arrived at the Goff Avenue apartment and began CPR, according to hospital records provided by the family to The Public’s Radio and ProPublica. Paula Duarte had no pulse and her heart rhythm was asystolic, or flatline.

The EMS crew continued CPR for 11 minutes before one of the crew members — a licensed EMT-Cardiac — performed what he later described in his run report as a “successful intubation.” The placement of the tube was “confirmed 3 times … by 3 different personnel,” according to a copy of the report attached to the hospital record.

and,

he doctor removed Duarte’s endotracheal tube and reintubated her. Then she was given more CPR and more medication. At 7:02 a.m., she was pronounced dead.

It’s impossible to know whether Duarte could have survived if she’d been properly intubated. Duarte had been unconscious for about 30 minutes before the ambulance arrived, the EMS report said.

and,

But unlike the 11 other patients who arrived at hospital emergency rooms with misplaced breathing tubes, Duarte’s case was reported to the state Health Department, triggering a formal investigation.

A month after Duarte died, the state Health Department issued a stern warning to state emergency medical service providers. The notice referenced the 11 other cases, saying they represented an “unacceptable high rate” for such errors. It reiterated that providers should try other means before inserting a breathing tube.

finally,

The department’s investigation into Duarte’s case found that the EMT-Cardiac who intubated her, Wesley J. Meyer, “never attempted” to use a device to monitor the patient’s exhaled carbon dioxide levels, according to a consent order he signed in September. The state’s protocols require that the device be used.

Meyer wouldn’t answer questions about the case, telling a reporter who came to his door, “I don’t want to talk about this.”

While the state said that Meyer engaged in “unprofessional conduct,” it noted that those breaches were “tempered” by the fact that Meyer had already taken steps to “retrain himself on the relevant subject matter,” and that his past performance in EMS is “unblemished.”

Meyer’s EMT license was placed on two years’ probation; his 30-day license suspension was “stayed,” meaning he can continue to practice uninterrupted, according to a state Health Department spokeswoman.

To recap, an EMT-Cardiac places an ET Tube in the esophagus of a young lady in cardiac arrest. He fails to follow the protocol regarding tube confirmation. Then, either through laziness, stupidity, or some other motive, he writes an inaccurate report.

The state agency responsible for oversight lets him slide because he did some self remediation. He gets not even a slap on the wrist. No suspension of his EMT certification, not required remediation under supervision of a neutral party, nothing. Nothing at all. Unless you count two years of unsupervised “double secret probation” and a 30 day suspension of his certification, which was “stayed.”

In my daily work doing Quality Improvement reviews for fire based EMS systems not in Rhode Island, I emphasize education and fight against any sort of punitive action for medical mistakes. Which is how I was educated and trained for over 30 years. Medical mistakes happen, that’s just inevitable. What’s important is that you acknowledge those mistakes, learn from them, and make sure that you don’t make them again.

Denying that you screwed up, having your fire chief, mayor, or some other pinhead puff out his chest and claim the doctors are trying to stop providers from “saving lives”, is none of the above. It’s protecting yourself with complete disregard for the well being of patents.

I have to wonder if this article will lead any of the survivors of those 11 victims to contact lawyers?

Discovery, as the saying goes, would be interesting.