I haven't been on here in forever, but I had to vent about this!!!
Today I was involved with a rapid sequence intubation of a COPD'er whose CO2 was 136 (I know, impressive right??) The doctor rushes into the room, the patient is lethargic but alert and his eyes are wide open. The MD immediately runs to the head of the bed laryngoscope and tube in hand..... I am taking over this patient from another nurse, and I immediately ask if the patient has received any sedatives at all? His response is "No" :uhoh3: Another nurse runs to the pyxis and grabs out a RSI kit (has succs, etomidate, etc in it) The nurse runs back into the room and is holding up the bag of meds "Are you going to order RSI meds????"
We stand back in sheer shock and disbelief as the doctor rams the laryngoscope down the patients throat as he is wide awake now and GAGGING!!!! He does not answer the nurse and continues to try to tube the patient, the patient is choking, gagging and fighting the tube as best he can. He desats to the 70s and finally the doctor stops. :smackingf
We ask AGAIN "Doc, what do you want to give this patient to sedate him??" As we're bagging the patient back up to the 90s, he states "I want to try it again" And starts attempting intubation AGAIN, with the patient choking and gagging.... One nurse walking out of the room, mumbling something like "this is BS" Finally, the doctor gets the tube in place, hands it to RT to get on the vent, I start bagging and the MD immediately starts heading for the door........
At this point I'm LIVID, I'm bagging the patient and I cannot even ventilate him because he is choking on the tube and the patient starts grabbing at it "Doc, we gotta knock this guy down, quick, this isn't right" The MD states "We got the airway, that's what's important" :confused: Is this seriously happening I'm thinking??? This is someones grandfather, someones father, Would you want this done to your family member????
"DOC, it doesn't matter if he has an airway, I CANNOT ventilate him, he's choking! And he's gonna pull this thing out!" He finally mumbles "Fine, I'll order some propofol...."
He orders a measly 30mg bolus for a patient of 113kg and tells me to start slow with the drip because he's worried about his pressure (which is 160s systolic at this point)....... Get my bolus given, throw the gtt up at 20 mcg's, and titrate it all the way up to 50mcg's, (while monitoring his pressure of course) until FINALLY this poor man is sedated....
This seriously ripped my heart out of my chest....... Would I want my mother treated in this manner???? As I'm titrating the gtt and the poor guy is still choking on the tube, I tell him "I'm going to get you comfortable as quickly as I can"
Is there any excuse for this??? Is there any reason at all that there could be no meds given prior to the intubation? Nothing?? This seriously ruined my day....
Yeah I can see the sadness here, some sedation would have been nice. But even awake you should have been able to ventilate him if the ET was correctly placed. You generally don't choke on a tube when it's in your trachea.
I have had patients I have been unable to ventilate d/t the need for sedation. You can't bag against a cough, they are coughing, gagging, freaking out, it isn't pretty. As they turn bluer and bluer...so it ends in one of two ways: I give sedation and the world is right again, or they pass out from hypoxia and I eventually can bag them back to baseline. Not fun.
I cannot imagine any legitimate reason for this to have occurred. My guess is that this is not inconsistent with the antics of this particular MD. I think some follow up is called for. I can understand fear of retaliation, but surely there is *someone* safe you can report the incident to?
Yeah I can see the sadness here, some sedation would have been nice. But even awake you should have been able to ventilate him if the ET was correctly placed. You generally don't choke on a tube when it's in your trachea.
Having a foreign object stuck down your throat is uncomfortable. It is not uncommon for a patient to fight ventilation due to coughing and a suffication feeling of breathing through a very small tube. If the care providers don't understand this, the patient suffers. This is also why ventilators cost up to $90k for patient comfort but sometimes it just takes the proper sedation to make a $10 BVM more effective.
Patients must be kept comfortable before, during and after intubation. Sometimes people, including doctors, are just taught a skill and not always the whole treatment process. I also would rather have a critical care medicine physician managing the intubation process who understands more about the consequences of stress and aspiration that occurs during intubation. ED physicians and hospitalists are sometimes not well versed in the proper preparation and follow through of the whole intubation process.
Specializes in Flight, ER, Transport, ICU/Critical Care.
It sounds like there was not an immediate and emergent need and perhaps there was "time" for some pharmacological interventions.
I can understand your reaction and frustration.
I have intubated without RSI meds. Most patients were somewhat obtunded and now, it was not pretty - but, it was essential to KEEPING SOMEONE ALIVE. But, yes, I have one time I orally intubated a trauma patient via force, standby suction and prayer - and it was not something I will ever forget. It was 100% vital at that very moment - even so, it haunts me from time to time. I have also intubated many via the nasal route - so, there are often several options.
When I started in EMS - RSI was not done in the field - so field intubation usually just waited till the patient "coded" or became totally unresponsive. Not a great situation. Thankfully, I now have more "tools" in my toolbox.
I can however, think of situations where I may not do a full "sequence" of drugs - if I need a crash airway - sure, I'll do what I can to and ensure that the patient is as comfortable as possible. However, there is a protocol option for just pushing a paralytic alone if I have to have that airway NOW - it is used very rarely.
RSI meds and the process is fairly straightforward.
Assess.
Prepare (to intubate and have a rescue or two - King airway - quick trach kit) Plan A, B, C, D ....
Sedate.
Pre-oxygenate.
Analgesia.
Paralytic.
Pre-oxygenate - assure good BVM compliance.
Most experienced, capable places ETT via DL.
Confirm tube, secure.
Set ventilator -
Repeat medications - 1. Sedation for anxiety (versed, diprivan, ativan) 2. Analgesia for pain (fentanyl, dilaudid) and 3. Paralytic comes last.
Keep in mind that any time a paralytic is given - something else has to be given to keep the patient comfortable. I run into a lot of folks that think that a paralytic is all that is needed for ventilated patients. Folks - when you see this - remember - THAT IS TORTURE. Simple TORTURE. Sure, the patient can't move - but, most are fully aware and yet have to just lie there - TRAPPED. Imagine the horror.
Always advocate for your patient. I think this case may warrant review and discussion and may present a "learning" opportunity. At the very least I'd ask the MD to help me understand what was happening so that I can learn. I try to turn FU'ed situations into non-threatening opportunities to learn - so maybe that would be an angle to go with - just an idea.
From what I read that was poor way to intubate someone. The CO2 level being that high will probably keep the patient from remembering a lot of it though, so that is at least one good thing. I am surprised that the patient didn't have ST changes and/or an MI during all this.
FYI: Patients will cough, gag, and buck anytime you place a tube in the trachea if they aren't paralyzed or deeply sedated enough. It has nothing to do with being in the right spot or not.
Yeah I can see the sadness here, some sedation would have been nice. But even awake you should have been able to ventilate him if the ET was correctly placed. You generally don't choke on a tube when it's in your trachea.
It's a foreign body. Yes, any patient who isn't obtunded or sedated with choke on it and be difficult to ventilate.
OP, I think you should have filled out a QRR form and report the incident. I'm sure there is some kind of a policy for this procedure, and he most definitely didn't follow it. Document and report, so that idiot of a doctor wont do it to another poor unfortunate soul
This makes me sick & furious! Write his sorry butt up! Unless they are totally unresponsive, and death will occur....no excuse. While I am at it..... I will also have a fit if they are not sedated....along with the paralytic...inhumane!
Although this sounds like just poor airway management, there are acceptable ways to intubate someone without changing their LOC. Just assuming it's appropriate to RSI everyone is a good way to get into a nightmare airway/have an unneeded death. At 113kgs you can bet I'm doing a good airway assessment and considering doing it awake if I have time.
This makes me sick & furious! Write his sorry butt up! Unless they are totally unresponsive, and death will occur....no excuse. While I am at it..... I will also have a fit if they are not sedated....along with the paralytic...inhumane!
Sedation and paralytics are an awesome way to kill someone who's a poor candidate, just so you can be "humane".
Sedation and paralytics are an awesome way to kill someone who's a poor candidate, just so you can be "humane".
I think the message in that post was it is inhumane to give paralytics only without sedation which is sometimes done. Some don't give enough sedation or forget as long as the patient is not moving. There are a few situations where giving just the paralytic might be necessary but very, very few.
Although this sounds like just poor airway management, there are acceptable ways to intubate someone without changing their LOC. Just assuming it's appropriate to RSI everyone is a good way to get into a nightmare airway/have an unneeded death. At 113kgs you can bet I'm doing a good airway assessment and considering doing it awake if I have time.
Grabbing an RSI kit does not necessarily mean you are going to paralyze the patient. We stock several different meds to facilitate intubation and may rarely use the paralytic. Some of these meds can not be stocked in the regular intubation tray or cart.
:uhoh3: Another nurse runs to the pyxis and grabs out a RSI kit (has succs, etomidate, etc in it) The nurse runs back into the room and is holding up the bag of meds "Are you going to order RSI meds????" 
As we're bagging the patient back up to the 90s, he states "I want to try it again" And starts attempting intubation AGAIN, with the patient choking and gagging.... One nurse walking out of the room, mumbling something like "this is BS" Finally, the doctor gets the tube in place, hands it to RT to get on the vent, I start bagging and the MD immediately starts heading for the door........ 
kessadawn, BSN, RN
300 Posts
That doc should be written up, he a danger to his patients! Who wants to render a guess at the damage caused to that man's airway by that maverick?