Today I got a chance to read few blogs, which is something that I don’t often get to do.  I read this post by Roguemedic which was a reaction to this original post from a blog I had never seen before.  My heart truly goes out to this guy and the reason is that I have had a similar experience.  Thankfully it did not lead to any sort of state investigation of my certification.  Actually I maintained the upper hand throughout my interaction with the doctor.  But I found myself reliving this horrible event in my mind so I thought I would post the story here and lay it to rest.

I had been a paramedic for about six months, I think.  This was many years ago at my first job in Texas.  We often did back-up 911 runs for a little suburb town of Dallas called Mesquite.  We got a run for shortness of breath and we were there in just a few minutes.  Our patient was a man in his 50’s who was struggling to breathe and had cyanosis around the lips.  His fingers were also turning blue.  Believe it or not, he was wearing three nasal cannulas.  One was in his nose, and two were positioned in his mouth and he was breathing all of it in.  He said in short two-word sentences, “This is…bad…I have never…had it…this bad…you are…going to…have to…use one of…those tubes…”  I put a pulse ox on him and got a reading of 45.  His fingers were warm and had good circulation.  To this day I have not had an accurate reading that low on a conscious man.  His wife said that they got every O2 bottle in the house together and that he was getting 18 liters and it still wasn’t enough.  His nebulizer was still humming from his third or fourth treatment as well.

This was before anyone let me get anywhere near RSI or sedation facilitated intubation.  I had been shown nasal intubation once in school, but that had been a while ago, and I had only tried once on a manikin.  The procedure was allowed by our protocols, but not many had ever tried it.  This was back in the days when we usually let people go down and tubed them after the fact.  My partner had never even heard of it, which was obvious by his confusion at me getting the airway kit out.  “What are you going to do, tube him while he is talking to you?!?”

I explained to the patient, “Look, I don’t want to wait until you go down to put that tube in you.  It might be too late by then.  There is a way to get it in your nose.  I would like to try that,” I was lubing the tube as I talked, “I am not very familiar with this procedure, and I am not going to lie, it’s gonna hurt.  But if I get it in you will be able to breathe.  If I miss, you will have a bloody nose and I will go back to plan B.”

Without wasting a second he nodded his consent and leaned his head back to expose his nose.

I was completely unfamiliar with this procedure, and was trying to remember things I had read about it.  Nothing I could remember guided me towards what size to use.  I thought that surely a 7.0 could not fit.  (Now I know better, but back then this was fringe stuff.)  So I picked something I thought would fit in his nose.  It has been a long time ago, but I think it was either a 5.5 or a 6.0.  I lubricated it and said, “Sorry man, this is going to hurt,” and went to town.  It went down easier than I thought it would.  My partner whose eyes were wide as saucers started to bag the patient.  Instantly the color came back to his face and his pulse ox came up to the mid 90’s.

I was feeling like a bad ass.  This was a TV moment.  Just like that show “E.R.”.  The new paramedic is presented with a difficult, non-typical case.  Our hero pulls some book knowledge out of his ass, tries something unorthodox and saves the day!  I was feeling better than the patient.  I was on cloud nine.  So I said, “Hey man, how are you feeling?”

He said, “A lot better.”

Oops.

For all of you non-medical types out there, if someone is intubated properly he cannot speak because the tube has been placed beyond his vocal cords.  He was obviously not intubated properly and my heart began to sink.  Then I thought, “Wait! Wait just a minute!  Who cares?  He’s not blue any more.  His pulse ox came up.  And he is no longer dying.  We still win.  I’ll just have to explain this to the ER when I get there.  I’m not re-fixing anything that isn’t broken.”

I took out a blade and had a look down his throat just to see what had happened.  As I had suspected, the tube was too short.  The end of the tube was hanging directly over the glottic opening.  But air was going in, and it was coming out.  The patient was better.  I started to feel more confident about what had happened.  I said, “Sir, that tube is not quite in the right place, but you know what?  You are getting better.  So I am going to leave it alone until we get to the hospital.  Does it make you want to gag or vomit?”  He indicated no.  “Okay then, we are just going to let it go.”

We took our time getting out of the house.  We had no backup, so we had to get him to the truck and protect the tube by ourselves.  I had my partner bag so that I could start and IV and put the monitor on.  Then I took the bag myself and said, “Alright, lets go.”

“Code 1 or code 3?”

I was feeling better about this all the time, “You know what?  Let’s not get crazy.  I got his airway, so give us a really nice code 1 and warn me about the bumps.”

We drove slowly to the hospital.  His wife was riding up front with us.  She knew we had saved his life and was going to great lengths to thank us.  Despite my protesting, the patient would every so often say something nice around the tube.  I tried to get him to quit, but he was so happy and relieved that he couldn’t stop himself.  I was really feeling good about this run.

Upon arrival at the ER, things changed.  I had called in report and a bunch of staff was waiting at the doorway.  I have always been confident in my skills.  Even confident enough to point out my own mistakes without shame.  “Listen up, I have to tell on myself.  I attempted nasal intubation, and it isn’t in the right place.  It did not go down his trachea.  However, the tube is hanging right above the glottis and that was enough to get him ventilated and his sats have come from the 40’s to the 90’s.”

I was only about halfway through my speech when the doctors and nurses started rolling their eyes at me and he was already barking orders for extubation prep.  Even though I was new, I stood my ground.  “Doc, that’s a mistake.  I know that this doesn’t look pretty, but it worked.  You need to have a plan before you pull this thing out.  I’m telling you he looked like crap.  He was blue and wearing three cannulas.”  He looked at me like I was insane, pushed me out of the way and started extubating.  I gave my last plea, “Doc, don’t let this be an ego thing.  Listen to me.  He was in bad shape before we did that procedure.”

But they didn’t listen.  He pulled it out, threw it on the floor, told the nurse to put him on a cannula and walked out of the room.  It wasn’t long before the patient started to gasp for air.  His sats fell.  He started to flail his arms.  I was shocked.  I said, “Look, this has gone far enough.  Look at him.  We have got to ventilate him or…”

While I was talking he went into full arrest.

Now, I know you have probably heard a lot of medics talk big about telling a doctor off.  I did.  I will admit it was not my most professional moment.  But I went off and I am not particularly proud of it.  I was horrified that this doctor and this nursing team had killed someone because of their bloated ego and inability to use reason.  “You useless mother fucker!”  I told you it was not my most professional moment.  “You just fucking killed a man.  You better fix your fuckup pretty god damn quick!”

I was horrified.  And I was pulling no punches.  Not only had I saved this guy, but I had grown to like him and his family trusted me.  I felt as though he was dying because I was not strong enough to stop the staff from doing what they did.  I felt that somehow it was my fault.  “You sons of bitches killed this man!”

I backed up while they worked.  The doctor finally got him orally intubated and they worked him for about 30 minutes.  It was no use.  He was in asystole the whole time.  It looked like they were about to cease efforts.  I wanted to get my last shot in.  I walked around the bed to the doctor and stood right beside him and to this day I can remember what I whispered in his ear, “You just killed this man.  You killed him just as sure as you had put a gun to his head and pulled the trigger yourself.  I hope you think about that every night before you go to sleep for the rest of your life.  Fuck you.”

He hurriedly walked out of the room and they gave up.  He was dead.

I went out to talk to the family.  I wanted to tell them what had happened.  But it was not my place.  They were grieving.  My anger was no reason to complicate their grief.  So I told them that he had died while the hospital was trying to regain his airway.  I gave her no details.  I simply said that I did everything I could do.  I told her that if she ever had any questions about what happened to please call me and I gave her our dispatch line.  She never called and I never saw her again.  I still feel sick just thinking about this.  The curse I had wished upon that doctor backfired and sometimes wakes me up to this day.  What if I had just intubated him correctly to begin with?  What if I had somehow convinced the staff to respect me and stop?  What if I had done more?  What if?  What if?  What if?

I will never know.

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