Monday, June 2, 2008

Blood Ran Cold

I never want to have that feeling again. That cold rush of fear that runs up and down my spine, instantaneous and unexpected at the utterance of just a few words. Normal one second, the next I am sweating and anxious, shifting my weight from foot to foot and staring intently at the scene ahead.

My patient is dead. He is spread out on the cot, naked and surrounded by nurses and doctors performing CPR, looking over my cardiac strips, pushing drugs, yelling out commands. The scene is organized chaos, but my focus is set upon just one person there, at the head of the stretcher.

Its the doctor saying that my tube is in the esophagus.

The feeling of fear and shame was so intense, so immediate and powerful that I still remember it with utmost clarity today. Surely any paramedic who has been in a similar position can sympathize. I was taken by surprise, having run this cardiac arrest for more than thirty minutes to the best of my ability, exhausted from the effort and glad to turn over care to the emergency department, only to hear this.

The doctor ordered an intubation kit and the nurses scrambled to comply. I caught a few eyebrow-cocked glances from those in the room. An unrecognized esophageal intubation is probably one of the worst things a paramedic could possibly do, and there I was, helpless in front of my jury, waiting for the verdict from a white-coat at my patient's head. My god I didn't know what to do. My blood ran cold and I just stood there, my mouth half open and staring at the scene as it unfolded. What the hell do you mean my tube isn't in??

The doctor put the laryngoscope in the patient's mouth and almost immediately made the claim again. "Yup," he said, "It's in the stomach." I remember the words exactly.

He asked for another tube with an outstretched hand and a nurse quickly complied. With my tube still in it's place, the doctor directed his new tube slowly, deliberately. It bent upward. He tried again, and again. Each time the tube would contort out of place and resist forward motion. He tried moving the blade around, lifting higher and harder. No luck.

I stared at my monitor printout. It listed the end-tidal CO2, which showed readings in the high teens and twenties for the entire trip. I remember listening to the lung sounds and hearing them clearly. Positive in both lungs, negative over the epigastrium. I SAW the tube pass through the cords, and it fogged up with my first few squeezes of the BVM. The patient's stomach remained perfectly flat for thirty minutes of bagging through that tube, and I re-checked the position at least three times on the way into the ER. God dammit, I was sure about that tube.

...But the doctor continued to insist that it wasn't in. He went back with his laryngoscope and dug harder, peering into the mouth from only a few inches away, squinting his eyes and contorting his face. The tube continued to bend on each of his attempts.

A nurse tapped me on the shoulder and I almost jumped. I was so focused on the events at hand, I didn't pay attention to anything else going on in the room. Now it was the doctor getting the half-cocked looks, and the nurse tapping on my shoulder whispered in my ear. "Don't worry about it," she said, "thats a good tube."

It was. It took the doctor a few more tries before he gave up, pronounced the patient dead, and signed my paperwork acknowledging that I had a good tube. He never said a word to me about it and carried on with whatever else he had to do.

Exhausted, relieved, and trembling, I found a quiet corner to write my run form. Its amazing how quickly things can turn around on you with this job.


Anonymous said...

OMG, that had to have been horrible. I've got a few intubations left to do yet on my paramedic clinicals; a misplaced tube is among my greatest fears.

brendan said...

Idiocy like that should be punishable by an immediate headbutt to the face.

CJH said...

Goddamn doctors!!!

At least you had the waveform to prove that your tube was in. And that dumbass doc shouldn't have said anything without an X-ray.

Must've been a docling.

RevMedic said...

Can you print out waveforms? I can and do, and if there is any question, I wave the strip as my personal Bullshit flag and tell them "In your face, bitch!"
OK, maybe not that drastic, but the waveform strip is your proof of a good tube and positive ventilations. Good job in believing in yourself.

Anonymous said...

that doctor sounds like a god damn idiot...

Anonymous said...

I wonder if its the same Doc that sheepishly gave me an apology last month after blowing up at me over a nonintubated code.

Anonymous said...

not uncommon to be blamed for this. as usual, ambos are blamed for everything that goes wrong in hospitals

crazyrn2be said...

I think he owes you an apology and were it me, I would have told him so.

FF_EMT said...

Nice work. The doc certainly owes you an apology. He has everything at his finger tips, numerous people to help, and a nice controlled environment...You, on the other hand, don't have all of those advantages and still manage to get the tube. Every time I see a medic in the ER get crap for something like that, it irks me to no end because the "doctors" don't have a clue what it's like out in the field. They have all the comforts and protection of their ER.
A few months ago, I saw a dr. get pissed off at a paramedic asking "why did I not know this patient wasn't intubated?" The medic, who clearly worked his butt off said that the information was in the patch. Still the doc didn't cut the medic any slack. I lost a lot of respect that day for the particular doctor. Wonder if it's the same one...
Sorry to ramble, but I get pretty heated when the doctors disrespect EMS as they sometimes do.

Anonymous said...

If I didn't know any better, I would have said you wrote that about me and my 3rd tube after I got hired. I knew I was in, but being new I didn't stand up for it. It wasn't until the doc finally admitted later to me in private that my tube was in all along and he made a mistake....although it made me feel good he admitted he was wrong, it did nothing to make the other staff not look at me like I didn't know what I was doing on the next code.

The one thing I learned about being a medic, hospitals/docs, etc will have no problem placing blame on pre-hospital providers. Don't be an idiot about it, but be vocal and this scenario, ask the doc to put the blade in and let you see before they pull it--especially when you had capnography reading. But don't let them tell you you were wrong when you know you were right--- There will be plenty of other times you'll be wrong in your career and you'll suspect/know it. ;)