Re: Can EMS treat and release?

[Guest guest]

Ah Larry, it seems you slaughtered the sacred cow here by actually

saying you saw a doctor do something wong !! How could you? To

answer your question Mr Kellow, yes I have reported a doctor for

this ONCE. There was so much flack from the entire medical community

you wouldn't believe. How dare a " lowly " paramedic dare to question

the medical decision of an actual walking on water Doctor? You want

to know why complaints aren't filed? I'm pretty sure that others

have run into this same situationand don't want to go through it

again. Since then, whenever I do an intubation, I document

EVERYTHING precisely, how the intubation was accomplished, how

placement was confirmed, how many times it was checked, condition of

patient, O2 saturation, the whole nine yards. That way if I get a

tube puller that kills somebody my backside is covered. You see,

it's perfectly alright for a doctor to berate or belittle anybody

else in the medical field, but don't let anybody dare to say

anything about a doctor, no matter how incompetent he/she may be.

Ok, I'll climb down and let somebody else have the soapbox.

>

> " ...albeit rarely and limited to a very few... " , assigns neither

facts,

> proof nor motives. Just another anecdotal (war story) report. Did

you turn

> them in? File a complaint? Are you able to testify under oath that

this

> happened? With whom? And, when? When did you file your complaint?

And if

> not - why not? Names, dates, patients & witnesses - please.

>

> To defame an entire medical specialty over something that you've

not

> substantiated or validated by fact is not only unconscionable, but

> irresponsible. It's like saying that, " paramedics are killing

people every

> day because they're idiots " . Barring any evidence to support your

> statements, your remarks are both ill-founded and ridiculous.

>

> Oh - and by the way, " sadly, it does occur " . Prove me wrong in the

absence

> of evidence. The burden of proof is yours.

>

> Bob Kellow

>

> Re: Re: Can EMS treat and release?

>

>

> > Dr. Mahon-

> >

> > As a RN with 22 years of ER/ICU experience and a Prehospital

Provider

> (either EMT Paramedic or Certified Flight RN) since 1976, I have

seen occur

> (albeit rarely and limited to a very few) situations where

physicians have

> removed patent ETTs (verified by Capnography, laryngoscopic

visualization,

> auscultation) on a backboard with headblocks in use and tube

controlled with

> a " Tube Tamer " or similar device.

> >

> > One extremely unfortunate episode resulted in failed

intubation with

> death to the patient and another with prolonged cerebral hypoxia

and brain

> damage.

> >

> > Yes, that behavior is egregious, and sadly, it does occur.

> >

> > L.A. , RN LP

> > Houston Texas

> >

> >

> >

> > " A prudent man foresees the difficulties ahead and prepares for

them; the

> simpleton goes blindly on and suffers the consequences. "

Proverbs 22:3

> >

> >

> > __________________________________________________

> >

[Guest guest]

I am feeling alot of anger and frujstration in some voices about ER doc's. I

have been in EMS now for just short of 21 yrs and I will have too tell you that

over all I have not encountered some of the things so many of you all seem to

have. I will admit there are some in my area that I like more than others but we

really seem to have a pretty good set of doc's in the area.

I guess what I am trying to say is that there are good and bad in all lines of

work and to genearalize ER docs as so many of you are doing is not any more

appropriate than them bashing Parmedics in general. And again there are goods

and bads amongst us as well. Look around can you say that all of your coworkers

are ones that you would be ok with working on your family. Not that they are BAD

but that do they ALL meet your standards.

As far as the billing ability I happen to know of services that STRONGLY

DISCOURAGE the use of flight for transport when it is totally appropriate

because of there ability to bill for the 911 call and then get the transfer to

where the patient should have gone in the first place. Granted it is company

policy not individual medic policy BUT is this and MANY other similar practices

any different than what you describe the " ER DOC " doing.And this is a not just

our area but is all over.

My two cents thrown in for what it is worth.

Joe wrote:

Ah Larry, it seems you slaughtered the sacred cow here by actually

saying you saw a doctor do something wong !! How could you? To

answer your question Mr Kellow, yes I have reported a doctor for

this ONCE. There was so much flack from the entire medical community

you wouldn't believe. How dare a " lowly " paramedic dare to question

the medical decision of an actual walking on water Doctor? You want

to know why complaints aren't filed? I'm pretty sure that others

have run into this same situationand don't want to go through it

again. Since then, whenever I do an intubation, I document

EVERYTHING precisely, how the intubation was accomplished, how

placement was confirmed, how many times it was checked, condition of

patient, O2 saturation, the whole nine yards. That way if I get a

tube puller that kills somebody my backside is covered. You see,

it's perfectly alright for a doctor to berate or belittle anybody

else in the medical field, but don't let anybody dare to say

anything about a doctor, no matter how incompetent he/she may be.

Ok, I'll climb down and let somebody else have the soapbox.

>

> " ...albeit rarely and limited to a very few... " , assigns neither

facts,

> proof nor motives. Just another anecdotal (war story) report. Did

you turn

> them in? File a complaint? Are you able to testify under oath that

this

> happened? With whom? And, when? When did you file your complaint?

And if

> not - why not? Names, dates, patients & witnesses - please.

>

> To defame an entire medical specialty over something that you've

not

> substantiated or validated by fact is not only unconscionable, but

> irresponsible. It's like saying that, " paramedics are killing

people every

> day because they're idiots " . Barring any evidence to support your

> statements, your remarks are both ill-founded and ridiculous.

>

> Oh - and by the way, " sadly, it does occur " . Prove me wrong in the

absence

> of evidence. The burden of proof is yours.

>

> Bob Kellow

>

> Re: Re: Can EMS treat and release?

>

>

> > Dr. Mahon-

> >

> > As a RN with 22 years of ER/ICU experience and a Prehospital

Provider

> (either EMT Paramedic or Certified Flight RN) since 1976, I have

seen occur

> (albeit rarely and limited to a very few) situations where

physicians have

> removed patent ETTs (verified by Capnography, laryngoscopic

visualization,

> auscultation) on a backboard with headblocks in use and tube

controlled with

> a " Tube Tamer " or similar device.

> >

> > One extremely unfortunate episode resulted in failed

intubation with

> death to the patient and another with prolonged cerebral hypoxia

and brain

> damage.

> >

> > Yes, that behavior is egregious, and sadly, it does occur.

> >

> > L.A. , RN LP

> > Houston Texas

> >

> >

> >

> > " A prudent man foresees the difficulties ahead and prepares for

them; the

> simpleton goes blindly on and suffers the consequences. "

Proverbs 22:3

> >

> >

> > __________________________________________________

> >

[Guest guest]

Is there no other way to confirm tube placement besides pulling it and

reintubating? I thought capnography was now the accepted standard of care? At

the very least, ascultation would seem to be a less drastic measure.

-Wes Ogilvie, MPA, JD, EMT-B

Austin, Texas

In a message dated 6/9/2006 1:25:28 AM Central Daylight Time,

kirkmahon@... writes:

Mr ,

I have pulled many tubes that were documented to have all of the

characteristics you describe. Why do you think I did it? For billing?

You must be smoking crack if you think that. It is because I was unsure,

despite all the charting that the tube was good and it is my ethical duty to

the patient to confirm or replace it. Your assertions are suspect.

Kirk D. Mahon, MD, ABEM

6106 Keller Springs Rd

Dallas, TX 75248

[Guest guest]

Kirk,

If capnography confirms that there is CO2 being exhaled, why would you

question that? If you don't have capnography but have capnometry, and it's

positive for CO2, wouldn't that show that the tube was in place? Can't you

determine whether or not a tube is in the right place without pulling it? Do

you

know how to verify tube placement with a bulb syringe? With a bougie? Can

you take a look with the laryngoscope and verify tube placement? How about

oxymetry? If you have good readings on all those, why would you question the

tube placement? Because you can't hear breath sounds? Not a good indicator.

Because the tube doesn't fog? Not a good indicator.

If you can't verify tube placement with a bougie, then I rest my case. Of

course, there are fiberoptic means, and lots of other toys that you may or may

not have, but if you put the bougie in and feel it bumping along the rings,

and it holds up at the level of the carina, then the tube is in.

Of course, if you have none of these toys, then I guess you're on your own.

Gene

>

> Mr ,

>

> I have pulled many tubes that were documented to have all of the

> characteristics you describe. Why do you think I did it? For billing?

> You must be smoking crack if you think that. It is because I was unsure,

> despite all the charting that the tube was good and it is my ethical duty to

> the patient to confirm or replace it. Your assertions are suspect.

>

> Kirk D. Mahon, MD, ABEM

>

> 6106 Keller Springs Rd

> Dallas, TX 75248

>

>

>

[Guest guest]

Mr ,

I have pulled many tubes that were documented to have all of the

characteristics you describe. Why do you think I did it? For billing?

You must be smoking crack if you think that. It is because I was unsure,

despite all the charting that the tube was good and it is my ethical duty to

the patient to confirm or replace it. Your assertions are suspect.

Kirk D. Mahon, MD, ABEM

6106 Keller Springs Rd

Dallas, TX 75248

[Guest guest]

Kirk, Gene, et al...

One thing missed here in this discussion is the detail that most ED docs are

either salaried hospital employees or hourly independent contractors, and

thus have very little incentive to 'churn the billing' by doing excess

procedures. We get paid the same if we see 1 patient per shift or 50 patients

per

shift.

Yes, I've had the coding/billing folks hassle me about write ups that 'only

need one more detail to go to the next level', but I can not think of a time

in an over 15 year career as an attending when I changed a tube just for

billing....even when I was billing for what I did. And if I had done it as a

student or a resident, it would have had severe repercussions!

I can think of a number of tubes that were changed because I could not

verify placement by capno, ascultation, pulseox, etc...and yes, I am familiar

with

the bougie techniques as well...I've used them multiple times either to help

get the ETs down or to change out a tube with a leaking cuff...or

occasionally to change out a too small tube for one that ventilates the patient

better

(say in a 300 pound male that the P placed a #6 tube 'because that was all he

could fit').

While the Toomey ('turkey baster') syringe is a neat trick, I've also seen

it fail to identify an esophageal intubation after several minutes of gastric

inflation due to BVM and poor head positioning...resulting in a very red

faced medic....fortunately for the crews involved, that was a situation where

the

patient was not salvagable from the time of first contact, so there was no

repercussions beyond some retraining of all involved.

ck

S. Krin, DO FAAFP

[Guest guest]

Wes,

Of the two, capnography is much more likely to be accurate than breath

sounds and provides a dynamic real time perception of is the airway in

place.

C

Re: Re: Can EMS treat and release?

Is there no other way to confirm tube placement besides pulling it and

reintubating? I thought capnography was now the accepted standard of

care? At

the very least, ascultation would seem to be a less drastic measure.

-Wes Ogilvie, MPA, JD, EMT-B

Austin, Texas

In a message dated 6/9/2006 1:25:28 AM Central Daylight Time,

kirkmahon (AT) hotmail (DOT) <mailto:kirkmahon%40hotmail.com> com writes:

Mr ,

I have pulled many tubes that were documented to have all of the

characteristics you describe. Why do you think I did it? For billing?

You must be smoking crack if you think that. It is because I was unsure,

despite all the charting that the tube was good and it is my ethical

duty to

the patient to confirm or replace it. Your assertions are suspect.

Kirk D. Mahon, MD, ABEM

6106 Keller Springs Rd

Dallas, TX 75248

[Guest guest]

In a message dated 09-Jun-06 12:09:37 Central Daylight Time,

kirkmahon@... writes:

Seems like we agree on a lot Gene in relation to our views of airway, not

ethics. You clearly have had some awful experiences.....I remain charmed I

guess to avoid that muck...

From what says, he and I have also avoided the problem in the past...

S. Krin, DO FAAFP

[Guest guest]

In a message dated 09-Jun-06 13:06:24 Central Daylight Time,

L@... writes:

A very similar, totally stupid incident happened to me a couple of shifts

ago in the Dallas area. 58 y/o male respiratory failure when we got to him,

nasal ET with good confirmation via waveform Capnography and clinical

assessment. Pts bradycardia deteriorated into arrest. On arrival at the ER

the (usually pretty good young doc) proceeded to complain about and take the

nasal out because he just couldn't believe that we could get him nasally

tubed in arrest so the tube must not be in (he couldn't grasp the part about

the guy was awake when we tubed him), he attempted to visualize but using a

Mac 2 blade and the fact that the guy had no neck was unable. Even after we

showed him the Capnograph he still proceeded with extubation. At this point

the 6 of us left the room as to not be a part of the situation. This ER

sees 60,000+ per year so it is not a lack of patient experiences.

Lee

sometimes we all have spells where we get tunnel vision to the point where

we are " Stuck on Stupid. " I have seen that before, but not, I'll admit, with a

good airway as you describe.

I'd have gotten out a bougie (or at least a large Mac blade) to try to

verify it...but then, I'm quite comfortable with nasotrach intubation of

breathing

patients...

ck

S. Krin, DO FAAFP

[Guest guest]

Would an x-ray be used for tube confirmation? I have seen that done before,

not a lot but a few times.

[Guest guest]

You can, but a properly formed capnograph waveform is only seen in

properly tubed patients. There are variations of it to indicate a

patient who sedation is wearing off, a tube too deep, or too shallow,

etc. X-rays are okay but with the availability of capnography to

confirm airways, it would be foolhardy not to use it.

RE: Re: Can EMS treat and release?

Would an x-ray be used for tube confirmation? I have seen that done

before,

not a lot but a few times.

[Guest guest]

Gene says: "

If capnography confirms that there is CO2 being exhaled, why would you

question that? If you don't have capnography but have capnometry, and it's

positive for CO2, wouldn't that show that the tube was in place?   Can't

you determine whether or not a tube is in the right place without pulling

it? Do you know how to verify tube placement with a bulb syringe? With a

bougie? Can you take a look with the laryngoscope and verify tube

placement? How about oxymetry? If you have good readings on all those,

why would you question the tube placement? Because you can't hear breath

sounds? Not a good indicator. Because the tube doesn't fog? Not a good

indicator.Â

Yes, I agree. I wouldn't pull any tube that I thought even might be in

place in a perfusing (delivering CO2 and O2) patient but would serially

examine and use ALL the methods plus the condition of the patient.

Capnometry becomes less useful in an arressted patient. And yes, just

looking with a scope and seeing it would also suffice. REMEMBER, my main

point is we DO NOT just PULL the tube. If an airway is accomplishing its

goal, I am not going to be quick to replace it immediately. If BVM is

accomplishing its goal well, without gastric distention, I would continue

that as well and cover other immediate issues before ETT. I believe too

much emphasis is in general put on " the tube " rather than " the airway " or

" ventilation/oxygentaion. "

Seems like we agree on a lot Gene in relation to our views of airway, not

ethics. You clearly have had some awful experiences.....I remain charmed I

guess to avoid that muck...

Kirk D. Mahon, MD, ABEM

6106 Keller Springs Rd

Dallas, TX 75248

[Guest guest]

A very similar, totally stupid incident happened to me a couple of shifts

ago in the Dallas area. 58 y/o male respiratory failure when we got to him,

nasal ET with good confirmation via waveform Capnography and clinical

assessment. Pts bradycardia deteriorated into arrest. On arrival at the ER

the (usually pretty good young doc) proceeded to complain about and take the

nasal out because he just couldn't believe that we could get him nasally

tubed in arrest so the tube must not be in (he couldn't grasp the part about

the guy was awake when we tubed him), he attempted to visualize but using a

Mac 2 blade and the fact that the guy had no neck was unable. Even after we

showed him the Capnograph he still proceeded with extubation. At this point

the 6 of us left the room as to not be a part of the situation. This ER

sees 60,000+ per year so it is not a lack of patient experiences.

Lee

Re: Re: Can EMS treat and release?

In a message dated 09-Jun-06 12:09:37 Central Daylight Time,

kirkmahon@... writes:

Seems like we agree on a lot Gene in relation to our views of airway, not

ethics. You clearly have had some awful experiences.....I remain charmed I

guess to avoid that muck...

From what says, he and I have also avoided the problem in the past...

S. Krin, DO FAAFP

[Guest guest]

HOORAY! There's something we agree on.

Just to even things up, I'll now attack the lawyers. Every month the Texas

Bar Journal reports on disbarrments, suspensions, and reprimands. This

month's Journal lists:

One judge publicly reprimanded;

Four resignations in lieu of disciplinary action;

One disbarrment;

Eleven suspensions;

Four public reprimands.

Most of these actions involve, in some way, failures to properly represent a

client, and there is a strong undercurrent of substance abuse, particularly

alcohol, in these cases.

There. Everybody feel better now?

And just for the record, I have seen 5 doctors in the last year for various

conditions, and they are all top notch, top of the game. I have known and

been friends with many, many physicians over the years, and bad conduct is

certainly the exception rather than the rule.

Perhaps when you consider the length of time I've been involved with the

medical profession, those few cases I reported do not reflect so badly on the

profession after all. I have represented many physicians over the years, and

many are still my friends.

There are idiots in every profession.

Gene G.

>

> Gene says: "

>

> If capnography confirms that there is CO2 being exhaled, why would you

> question that?  If you don't have capnography but have capnometry, and it's

> positive for CO2, wouldn't that show that the tube was in place?    Can't

> you determine whether or not a tube is in the right place without pulling

> it?  Do you know how to verify tube placement with a bulb syringe?  With a

> bougie?  Can you take a look with the laryngoscope and verify tube

> placement?  How about oxymetry?  If you have good readings on all those,

> why would you question the tube placement?  Because you can't hear breath

> sounds?  Not a good indicator.  Because the tube doesn't fog?  Not a good

> indicator.Â

>

> Yes, I agree.  I wouldn't pull any tube that I thought even might be in

> place in a perfusing (delivering CO2 and O2) patient  but would serially

> examine and use ALL the methods plus the condition of the patient. 

> Capnometry becomes less useful in an arressted patient.  And yes, just

> looking with a scope and seeing it would also suffice.  REMEMBER, my main

> point is we DO NOT just PULL the tube.  If an airway is accomplishing its

> goal, I am not going to be quick to replace it immediately.  If BVM is

> accomplishing its goal well, without gastric distention, I would continue

> that as well and cover other immediate issues before ETT.  I believe too

> much emphasis is in general put on " the tube " rather than " the airway " or

> " ventilation/oxygentaion. "

>

> Seems like we agree on  a lot Gene in relation to our views of airway, not

> ethics.  You clearly have had some awful experiences.....I remain charmed I

> guess to avoid that muck...

>

> Kirk D. Mahon, MD, ABEM

>

> 6106 Keller Springs Rd

> Dallas, TX 75248

>

>

>

>

>

>

>