Drowning

[Garyb3985]

Sunday my partner and I assisted another crew on a 20 month old that was found in a pool.The parents said the kid "was only under for a minute"(they were in the house so they don't really know).When we got there the other crew was loading the Pt .The kid was pulseless, apenic, fixed ,dialated,asystole. One of the other crew tubed the Pt and he said it was good however you could hear breath sounds ,very wet breath sounds over the abdomin and lungs. We pulled the tube and tried again ,with the same results.We all listned and decided that it was good. Abdomin was not disteding at all. I tried an IO (18 ga was all that was in the box)and the needle bent.I sraightined it out and tried again,but it bent worse this time.

We gave Epi. down the tube.At the ER I had to leave caues we got another call.When we got backthey were still working the kid.


Later on we called back and the nurse said that just as they were about to call it.the kid started breathing on its own and had a good pulse,and they flew the kid out.

The next day I got a call from my EMS corrdinator and she ask how the call went and I told her. She told me that the tube was NOT good ,and wondered why I didn't get the IO.

I think if I had a 15 ga it would not have bent,and for the tube I don't know I thought it was good and so did every one else .The only thing I can think is that it may have disloged when moving the Pt from rig or to the bed from the cot.


Comments?????
Questions?????
Suggestions???

[RyanEMVFD]

If there's water in the lungs, that would account for the wet sounds. Did the person tubing visualize the cords?

I don't know all the details, I wasn't there but usually a pedi code feels like a cluster @#$% anyhow. The fact that they flew the pt out is at least a good sign so far.

Does your unit stock 15 ga IOs? If so someone should have checked the truck out and realized y'all were out of 15s. Also IOs aren't something that is usually practiced on a regular basis like intubation or bandaging and splinting.

Hopefully, if there is a next time, next time it would go better.

[Garyb3985]

Yes he said he saw the cords both times.Yes we do stock 15's but that truck obviously didn't get checked.

The prognosis dosen't look good ,but kids seem to be able to take Drownings better,however I personaly don't think we did that poor kid any favors. :bang:

[DaSharkie]

How does the EMS coordinator know that the tube was not good? Did the ED replace it? Was it good when it was placed but became dislodged? Just wondering hwo she knows? Were X-Rays done of child to verify tube placement when they got ot the ED?

If the EMS coordinator is going to rip you and your crew for your "failed" intubation, then look them right in the eye and tell them to get you to the standard of care and get wave form capnography on every truck. This is the only way to truly verify and continually monitor an ET. It also is a great thing to have in litigation since you can print out the tracing and keep it with the PCR.

More than one doctor has had to eat their words after ripping into a Paramedic and telling them their tube was not "good." Paramedic shows them the code summary with the waveform on it and they changed their tune.

Placing a C-Collar is good to maintain placement.

Visualizing the tube through the cords, misting of the tube, verifying breath and gastric sounds, confirmation device, and the wave form capnography will go a long way in CYA and verification. Add in SpO2 and you have your patient and your *** well covered.

[CB-EMT]

Tell the Coordinator to get her *** on the truck, SHE can run the next Pedi code since she's obviously perfect.

Those who can't do, teach.

Those who can't teach, supervise.

[Garyb3985]

E.R. Doc must have called and complained to her ,cause I was with a stupervisor and he never got a call.Again today I got the 3 rd degree from her about the call, how it went and what I thought bout it. And agin I told her that the call went wonderful considering. She told me I wasn't in trouble or anything,I kind of think we are going on a "wich hunt"for this guy! If we had a pedi bulb check if we had other means of checking tube ,if we,if we if we........Buy the wat the kid is still alive 4 days later must have done something right! !

[celestialdaisy]

Well, congrats on helping him get this far!

[SMOKN65]

I am new to this forum. I am a medic in california. We just had a head on collision killing two people, one was a 13 month old child. We flew the infant to the local trauma center, and later was transporting the infatnt to the local airport to be flown to Davis. Enroute the infant started to Brady down to 60 CPR was started and epi and atropine were given, then the baby went into V-tach. Earlier from the Traffic Collision i had stuck 2 IO's into the kid, now we had another line (done in the hospital). We checked dope and none applied. We ran the code and after 5 min we got the baby back. We had to go back to the hospital. If i didn't mention i am still a new medic. I have never been so scared. We got the baby back so the grandparents could say goodbye. We found the baby was herniating so bad. We did notice blood from the nose and ears. This is Kinda Cathardic. Smokn65

[SMOKN65]

Does anyone know of a refresher course anywhere in the USA. I am willing to travel. I would like to do a refesher course instead of all the CE's. I know National Registry states that these are accepted, but I can't find any, and I have looked on the internet. :wow:

[firechic]

I agree 100%with all the items DaSharkie mentioned earlier. I also verify tube placement after EVERY movement of the patient.
Patient to backboard (for lifting) = verify tube placement
Patient to stretcher = VERIFY
Stretcher to MICU = VERIFY
Once patient is inside MICU = VERIFY
Once at the hospital & stretcher taken out of MICU = VERIFY
Inside the hospital, just before transferring to the bed = VERIFY

This is not as cumbersome as it sounds and it has saved my @ss on more than one occasion. If something goes wrong, they always try to point a finger at the medic for some reason.

Just my $1.50
;)

[hageremtp]

And always use a tube holder with a C-Collar...............

[volparamedic]

It is much easier for someone to critique than to work the call. Always...Always recheck your tubes!!! Child's airway is much smaller and easier to displace tubes not to mention if you have the wrong size tube you can have leak causing air to escape. I found that they are now recommending smaller amounts of volume to patients that previously thought to be good. I know lines are preferable but the save's I had had with ET drugs came out with no complications from the use of absorbtion through the lungs. If you cannot get the tube in anything but the esophagus then if possible leave that tube and you know where not to go! Don't you have protocol for NG tubes in drownings? If you can't get a tube at least you can protect the airway by empting the stomach.

To have a save in any problem/situation you must first fix what the underlying cause is!!

Karen Gadd EMT-P

[firechic]

And always use a tube holder with a C-Collar...............


OOPS! Forgot to mention that - it's so automatic that when I'm actually thinking about it - I forget :rolleyes:
Thanks for remembering. :bow:

[IAMedic]

You can check your tube placement after each move, you can use tube holders and C-Collars, but let's be realistic people...tubes can become displaced. Using these techniques will likely decrease your chances of it happening, but I have still had it happen to me.

As far as your efforts, sounds like you did the best you could with the materials you had. I agree that a 15 ga IO would have been better, but all you had to work with was a 18 ga, so don't let that bother ya.

It's too bad there has to be somebody to blame when there isn't a good outcome, which is probably going to be the case here. Everyone wants to play the blame game. I wish life was so cut and dry, but it's not and we all do the best we can.

[smurfe]

You can check your tube placement after each move, you can use tube holders and C-Collars, but let's be realistic people...tubes can become displaced. Using these techniques will likely decrease your chances of it happening, but I have still had it happen to me.

As far as your efforts, sounds like you did the best you could with the materials you had. I agree that a 15 ga IO would have been better, but all you had to work with was a 18 ga, so don't let that bother ya.

It's too bad there has to be somebody to blame when there isn't a good outcome, which is probably going to be the case here. Everyone wants to play the blame game. I wish life was so cut and dry, but it's not and we all do the best we can.

I have to agree with Brad here but I will say that the only times I have lost tubes, I attribute it to my own self for not properly securing the tube. Take the extra minute to assure it is properly secured.

Smurfe :beer:

[firechic]

I agree with IAMedic and smurfe: tubes can still become displaced.
That is why you consistently and constantly check placement. Once you catch it, then you can correct it.

[SMOKN65]

The other day I had a 2 month old sids patient. We intubated this baby 4 times. Every time we intubated we heard sounds over the epigastric. We came to the conclusion this was because the tube was uncuffed. We found later the tube was good. We were unable to put a collar on the chilld because no collar would fit a two month old. On the Truama code i had 1 shift later, we intubated the baby in the field and we were still unable to put a collar on the infant. We did put her on a pediboard.The second child we constantly checked the tube, and we went off the acronym DOPE. I dont know if your familiar with it but it runs through my mind when a child is in my care. Displacement, Obstruction, Pneumo, Equipment failure. I know you guys know this but in reading the posts i thought I would mention it. Now why your EMS Lady got involved I dont know why. Has she ever been in the field? Also are you feeling guilty. Cause we used 15g IOs for the trauma pt and I thought both were bad. Later I found that 1 IO was good and one was bad. They bent and I got aspirtation on the bad one. I don't have a clue, but damit I did the best I could with what God gave me. I would rest on that and dont beat your self up, cause you wont last too long if that is the case. I dont mean to offend.

[Garyb3985]

I agree with everyone about continusly checking tube placement,I do several times on "my" calls. This was another crews call,and my partner and I had to go on another call as soon as I steped out of the rig .Believe me I know to well the CYA game.

Well the dreaded a$$ chewing came this week from the EMS cordniator and the PMD and It was exactly what I expected , a "witch hunt" for one of the medics on the rig we assisted.

And apearantly we are going to have a protcol change,our PMD has been reading lotsa studies about NOT intubating peds unless we have a long transport time. Anyone else heard of this? Any way I was praised for going for the IO and being "agressive".


Anyway Pt. update they Dc'ed the vent last wednesday The 20th and the kid made it through the night and died the following day.And what really sucks about this wholr thing is that they couldn't use any organs because the kid didn't die within 2 hours or the vent being pulled

[RyanEMVFD]

I noticed that in PALS, NRP and PEPP regarding the intubation. Actually what they are teaching is to only intubate if needed, but regarding the long transport, put in a NG tube.

[SMOKN65]

Wouldnt a drowning child consitute intubation. Clearly they cant protect there own airway. That would classify a need.

[Garyb3985]

Apperantly recient studdies have shown that good BVM ventalations W? 100% O2 is better cause pedi tubes are uncuffed and can dislodge VERY easy,and gettin good ventalation with a BVM is better that getting none with a bad tube.