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Fatal Mistakes in Prehospital Medicine
“Primum non nocere.”
The admonition “First, do no harm,” has been a maxim of medical care since the days of Hippocrates. The phrase reminds physicians and other healthcare providers to first consider the potential harm an intervention might do. In some cases, it may be preferable to do nothing rather than risk that potential harm.
With the limited tools available for the provision of BLS care, often the greatest harm is caused by not acting, but the decision-making process is far more complex for ALS providers. Not only can we act with everything in the BLS arsenal, but we have a broader array of tools, skills and knowledge to provide lifesaving care and, potentially, harm.
And few tools in the prehospital care arsenal have as great a potential to cause harm as the laryngoscope, the syringe and the ink pen.
Inappropriate AMA Refusals
One may think the greatest risk of obtaining an AMA (against medical advice) refusal is to the EMS provider, but one study showed no significant difference in hospitalizations or deaths in comparing patient-initiated refusals versus provider-initiated refusals.1 In other words, patients are just as likely to suffer adverse outcomes when we refuse to transport as they are when they refuse transport against our advice.
Refusal of care, both patient-initiated and provider-initiated, is an area fraught with legal liability for EMS providers. Inappropriate AMA refusals may result in disastrous consequences for the patient and the provider.
The first step in obtaining a legally defensible AMA refusal is determining if the patient is competent to refuse care in the first place. Traditionally, EMTs have documented the patient’s level of alertness (awake, alert and oriented to person, place, time and event) as a means to demonstrate the patient was competent to refuse care, but this practice leaves much to be desired, both ethically and legally.
A signature on a refusal form accompanied by the magic phrase “AAOx4” does precious little to shield the provider from legal liability. While it is relatively easy to justify taking a patient to the hospital, leaving them at home requires a good deal more assessment and thorough documentation. Before you obtain a patient refusal, you must first perform and document a thorough patient assessment, including the patient’s present mental capacity, of which their level of alertness is but a small part.
What most EMTs fail to realize is the shorthand “AAOx4” is a conclusion. A lawyer would phrase it as a conclusion based upon facts not in evidence, and if you don’t include those facts in your documentation, the jury doesn’t get to hear them. It is better to document the facts, and let those reading your report—including jurors—draw the obvious conclusions.
Determining present mental capacity hinges on the following elements: memory and recall, orientation, and cognitive ability. By taking five minutes to have the patient answer a few questions and perform a simple mental exercise, and documenting the patient’s answers to those questions, you can adequately demonstrate that the patient was indeed competent to refuse care—or reveal a patient at risk of further deterioration that a cursory examination of their orientation may have missed.
Memory: Ask the patient to memorize four simple words—horse, apple, car and television—and tell him he will be asked to recall those words later in the exam. Have him repeat the words aloud to you, and tell him to remember them.
Orientation: Rather than document the conclusion “AAOx4,” instead document the questions you asked, and the answers the patient provided. Leave the conclusion to the person reading your report.
When asked if he knew where he was, patient correctly stated he was on his front porch at 1283 Sycamore Lane. When asked for his demographic information, patient was able to correctly state his name, birth date and social security number without prompting. When asked for the time, patient stated, “Ah, heck if I know,” looked at his watch for reference, and then stated the correct time as “12:53 p.m.” When asked if he remembered the events preceding the call to 9-1-1, the patient stated he fell off a ladder while helping his neighbor clean rain gutters, and his spouse called 9-1-1 at the request of his neighbor. Spouse and neighbor confirm this was the correct sequence of events. When asked to identify those present, patient correctly identified his spouse “Mary,” his neighbor “Hank,” and the police officer present as, “Some cop, I don’t believe I caught his name in all the excitement.”
Cognitive ability: Ask the patient to do a simple mental exercise, such as calculating the value of a coin combination or repeating the Serial Sevens:
When asked if patient could calculate the value of three quarters, two dimes, two nickels and six pennies, patient correctly stated, “One dollar and eleven cents.”
When asked to count backwards from 100 by sevens, patient was able to reach 51 without error, and was told by EMTs that was sufficient.
Recall: When asked to recall a series of words provided five minutes earlier—“horse, apple, car and television”—patient was able to correctly recall the words, but repeated them out of sequence.
A perfect score isn’t essential, but the more correct answers, the more weight your report will carry in court. Five extra minutes on scene to do these exercises, and five extra minutes of documentation, will go a long way toward protecting your patients and yourself.
Remember, your patient care record may be the last thing a jury sees before reaching a verdict based upon your actions. If your report contains factual information from which the jury can conclude your patient had the present mental capacity to understand what he was doing, you will be far ahead.
Misplaced Endotracheal Tubes
Endotracheal intubation has been considered a cornerstone of the paramedic skill set for years, but recent research has questioned both the efficacy of prehospital endotracheal intubation2 as well as our ability to provide it.3–6 Not only that, but the effectiveness of CPAP and the various supraglottic airways, coupled with the AHA’s de-emphasis of endotracheal intubation in resuscitation, have resulted in ever-dwindling opportunities to practice the skill. Paramedics today intubate significantly fewer patients than they did even 10 years ago. For some patients, such as those with CHF or acute pulmonary edema, the insertion of an endotracheal tube—even if properly placed—can make the patient’s clinical course much stormier.
Still, when it is indicated, few procedures can be as lifesaving as endotracheal intubation. Done improperly, however, few procedures can be as lethal. When performing endotracheal intubation, consider the following tips to ensure you not only get the tube in the proper hole, but that it stays there once inserted.
BURP maneuver: Often, particularly among those patients with anatomical abnormalities, obesity and cervical fixation, direct visualization of the vocal cords through direct laryngoscopy may prove difficult. Traditionally, cricoid pressure, or Sellick’s maneuver, has been utilized to facilitate a better laryngoscopic view. However, in these cases external laryngeal manipulation (ELM) or the BURP maneuver (Backwards, Upward, Rightward Pressure) may provide better visualization of the glottis,7 often improving the laryngoscopic view by one grade or more.8
To perform the BURP maneuver, have an assistant press the patient’s thyroid cartilage back toward the spine, upward cranially and angled toward the patient’s right ear. Coach your assistant in the degree of pressure he or she provides to obtain the best view.
Adequate preoxygenation: Hypoxic episodes can have adverse effects on the patient, even if corrected with rapid reoxygenation after the tube is secured. It is vital that every patient we intubate be adequately preoxygenated, saturation maintained during the intubation attempt and reoxygenated afterward.9
Current recommendations for preoxygenation prior to ETI are to give at least eight vital capacity breaths of 100% oxygen via BVM or to apply a non-rebreather mask at 15 lpm for four minutes. Unfortunately, the non-rebreather mask, even with a good mask seal, provides only 60–70% oxygen rather than the greater than 90% commonly believed.10
To maximize preoxygenation and maintain oxygen saturation during your intubation attempt, add a nasal cannula at 15 lpm to your preoxygenation technique, and keep it in place until the tube is secured. The nasal cannula creates a reservoir of 100% oxygen in the nasopharynx, making your non-rebreather mask far more effective, and by creating an artificial pressure gradient, can maintain your patient’s oxygen saturation at 98% for up to 100 minutes—even while apneic.10
Unfortunately, a myth persists that an intubation attempt must take no longer than 30 seconds. This is not based upon science, but it is perpetuated in many textbooks and by NREMT skill standards. In the authors’ opinions this “rule” alone has probably resulted in a substantial number of missed and misplaced tubes. A patient with 98% oxygen saturation and no serious underlying pulmonary complications will not desaturate for many minutes, affording ample time for a controlled intubation to be accomplished.10
Confirm placement with multiple methods: Direct visualization of the tube passing between the vocal cords has long been considered the best method of confirming tube placement. Unfortunately, given the high numbers of misplaced prehospital endotracheal tubes in the literature, it is apparent that a great many paramedics are not sure what vocal cords actually look like. As such, it is prudent to confirm tube placement with multiple methods.
Every confirmation technique has its limitations. Every method can yield false positives or false negatives. Even waveform capnography, the current gold standard for objective confirmation of tube placement, cannot detect a right mainstem intubation, and colorimetric CO2 detection may not detect CO2 in low perfusion states.
Even so, exhaled CO2 remains one of our most reliable confirmation parameters, and when used in conjunction with other methods, has proven extremely effective at preventing unrecognized esophageal intubation.
When you tube someone, always confirm placement with at least two clinical exam methods and at least one mechanical device—one that measures exhaled CO2 in some way. Further, reconfirm placement after every significant movement of your patient. Once in place does not mean always in place.
An unrecognized esophageal intubation with an endotracheal tube is the unforgivable sin in medicine. It is medically and legally indefensible.
Medication Errors
Every paramedic has memorized the Five Rights of Medication Administration—right patient, right route, right dose, right time and right medication. However, not all indications, precautions and contraindications for medications can be so easily classified. While we could devote an entire series of articles to medication errors, let’s look at a couple of common EMS medications and how their administration can have disastrous consequences for some patients, even when seemingly clearly indicated.
Adenosine for SVT: Adenosine has long been one of our mainstays for treating supraventricular tachycardia. While its effects can be rather dramatic—bradycardias, asystole—they are also very short-lived, making adenosine one of the safer antiarrhythmics in the drug box. Recent research has even caused the American Heart Association to give adenosine its official blessing for use in ventricular tachycardia as well.
However, some patients can suffer disastrously adverse effects from adenosine administration. Patients with accessory conduction pathways, like Kent fibers in Wolff-Parkinson-White syndrome, and James fibers in its lesser known cousin, Lown-Ganong-Levine syndrome, have been known to suffer adverse effects when given adenosine.
Adenosine and other AV-node blocking drugs, like beta blockers and calcium channel blockers, slow conduction only through the patient’s normal conduction system, thus promoting conduction through the abnormal pathways. The result can be an even faster tachycardia, or even ventricular fibrillation.11
When your patient has WPW tachycardia, use procainamide, amiodarone or synchronized cardioversion instead. If you’re unsure of the history or diagnosis of WPW, keep in mind that heart rates over 250 in adults almost always involve an accessory conduction pathway. Avoid the use of adenosine in these patients.
Naloxone for narcotic overdose: If a habitual narcotic user is stuporous and lethargic but still breathing effectively, it is a dose, not an overdose. The indication for naloxone in opiate overdose is to reverse respiratory depression. Titrate your naloxone administration to restoration of respiratory effort and avoid using it to wake the patient, or ruin their “high.” Naloxone administration can have disastrous consequences for habitual users, including seizures, vomiting, profound hypertension and flash pulmonary edema.12, 13 To mitigate the risk of inducing these side effects, use small doses and titrate to restoration of respiratory drive as your dosing endpoint.
Good habits can prevent fatal mistakes in medical care. Since the American Society of Anesthesia issued guidelines for advanced airway care that included use of waveform capnography, claims involving misplaced endotracheal tubes have dropped dramatically. Careful attention to basics and common sense go a long way in preventing fatal mistakes. And above all, keep learning. What we thought we knew yesterday may well be wrong today, just like the “30 second rule.”
References
1. Pringle RP, Carden DL, Xiao F, Graham DD. Outcome of patients not transported after calling 9-1-1. The Journal of Emergency Medicine, 2005 May; 28(4): 449–454.
2. Wang He, Yealy DM. Out-of-hospital endotracheal intubation: where are we? Ann Emerg Med, 2006; 47: 532–541.
3. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med, 2001 Jan; 37(1): 32–7.
4. Jemmett ME, Kendal KM, Fourre MW, Burton JH. Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting. Acad Emerg Med, 2003 Sep; 10(9): 961–5.
5. Wirtz DD, Ortiz C, Newman DH, Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehosp Emerg Care, 2007 Apr–Jun; 11(2): 213–8.
6. Colwell CB, Cusick JM, Hawkes AP, et al. A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region. Prehosp Emerg Care, 2009 Jul–Sep; 13(3): 304–10.
7. Takahata O, Kubota M, Mamiya K, et al. The efficacy of the “BURP” maneuver during a difficult laryngoscopy. Anesthesia & Analgesia, Feb 1997; 84(2): 419–421.
8. Benumof JL, Cooper SD. Quantitative improvement in laryngoscopic view by optimal external laryngeal manipulation. Journal of Clinical Anesthesia, 1996 Mar; 8(2): 136–40.
9. Weingart SD. Preoxygenation, reoxygenation and delayed sequence intubation in the emergency department. J Emerg Med, 2010 Apr.
10. Levitan R. NO DESAT! (Nasal Oxygen During Efforts Securing A Tube). Emergency Physicians Monthly, www.epmonthly.com/archives/features/no-desat-/.
11. Gupta AK, Shah CP, Maheshwari A, Thakur RK, Hayes OW, Lokhandwala YY. Adenosine induced ventricular fibrillation in Wolff-Parkinson-White syndrome. Pacing and Clinical Electrophysiology, 2002 Apr; 25(4 Pt. 1): 477–80.
12. Flacke JW, Flacke WE, Williams GD. Acute pulmonary edema following naloxone reversal of high-dose morphine anesthesia. Anesthesiology, Oct 1977; 47(4): 376–7.
13. Howland MA. “Opioid antagonists.” In Goldfrank LR, Flomenbaum NE, Lewin NA, Weisman RS Goldfrank’s Toxicologic Emergencies, 6th ed. Appleton & Lange, 1998, pp. 996.
Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the Louisiana Association of Nationally Registered EMTs. He is a frequent EMS conference speaker and the author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.
William E. (Gene) Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate’s degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and urban settings and in the offshore oil industry. He has testified in court as an expert witness in a number of cases involving EMS providers and lectures on medical/legal aspects of EMS. He lives in Tucson, AZ.
