Over the years I have come to understand that there are a few phrases that should make you STOP and THINK before you do anything else. I picked this up while flying around in different areas of the country where I saw that some areas have great and aggressive thinkers/doers, while others seem to be predisposed to questionable decision making.
These questionable decisions are sometimes the result of trying to make a decision under duress. They are human… Sometimes it is a “right answer, wrong math” kind of situation. Sometimes we can be caught up in our own “stuff” and miss these subtle cues that we need to stop and think deeper about a problem.
Keeping a calm/cool head once you arrive to these situations is key. Support the team that was there before you. Keeping cool allows you to focus on and catch some of those subtle cues and have the wherewithal to hit the pause button when you hear/see certain things.
Here is one phrase that I learned to make a hard stop and reevaluate things whenever I heard it:
“We are getting ready to re-paralyze them for you.”
Usually heard during the chaos just after intubating a patient in extremis. The ED’s or EMS folk are well intended with what they are trying to do. They see a patient they just intubated writhing all over the place and they want to stop it. In some cases they think this is helpful for us (and on the surface it is) and they believe they are saving us a step. But there is a better approach to the post intubation patient.
Develop the Situation:
1.) What were they intubated with and how long ago? (etomidate and sux offer zero pain control).
2.) When was the last time they got anything for PAIN (sedation with propofol alone is not enough for transport).
3.) Are the IV’s patent? (This one got me once).
4.) Is there an immediate danger of the patient extubating themselves or messing up another intervention (e.g. reaching for the excruciatingly painful tourniquet)?
5.) Is the tube confirmed? (don’t be shocked to see at least one or two tubes in the gut).
Why Does It Matter?
Will we not accomplish the goal of safety and ease of mechanical ventilation of the intubated patient if we just re-paralyze them for the transport? Yes. But there is a much better way to go about it.
In 2015, I attended the Critical Care Transport Medicine Conference (CCTMC). I listened to Dr. Michael Abernethy introduce the topic of PISA, post intubation sedation and analgesia, and the concept of pain control first in the intubated patient. Dr. Weingart of EMCRIT has also made several episodes about the topic as well:
EMCrit 21 – A Bad Sedation Package Leaves your Patient Trapped in a Nightmare
EMCrit 115 – A New Paradigm for Post-Intubation Pain, Agitation, and Delirium (PAD)
EMCrit 84 – The Post-Intubation Package
The logic is hard to argue with.
These patients are writhing in pain because there is a rigid piece of plastic in the back of their throat. There is a constant pain stimulation and their brain is screaming to remove that stimulation. Your first action may be to sedate them to the degree that they stop moving, but this only fixes half of the problem. They are still in pain, they just do not have an outwardly physical way to let you know. You see tachycardia and hypertension on the monitor, which can cloud your clinical picture (depending on what their primary problem is). In practice, a sound pain control strategy before using large doses of sedation medication is both more comfortable for the patient and actually allows for easier management of them during transport. Long acting paralytics can do the same thing, but the problem of being in pain and aware is still present… leaving the patient trapped in that nightmare is barbaric.
Eric made a podcast about this issue of long-term paralysis in transport a few years ago on Episode 71 of the Flight BridgeEd Podcast:
A Flight Story
I saw this once in an ED with a patient suffering from an ICH. When we walked in the room, she was intubated, writhing on the bed, fighting her restraints. She was hypertensive, for which the sending facility had maxed out her nicardipine drip, and they had already began pushing second line agents (labetalol if memory serves). They also were in the process of pulling up a repeat dose of rocuronium to “paralyze her for the transport.” The ever present propofol drip was up on the IV tree as well.
At first we were on board with what was happening since the presentation matched her clinical problem (we never were really on board with re-paralyzing the patient, and were sure we would be packaged and out the door before things got that far). Hypertension goes with head bleeds like jelly goes with peanut butter. The writhing on the bed and pulling against the restraints looks a lot like someone who is posturing. But something about this made us stop and think…
When asked if there had been any pain meds administered post intubation, we were met with a predictable “no, we have her on propofol.” Propofol, if you recall, has no analgesic properties. She was intubated via RSI with etomidate and succinylcholine, both of which also provide no analgesia. Looking at the patient and seeing that she was dramatically over breathing the ventilator prompted us to start thinking about this problem differently. She received a 100mcg fentanyl bolus (and a bolus of ketamine as well) and in short time we find ourselves in a different struggle. She is now profoundly hypotensive… This patient departed soon with a levophed drip, no cardene, a sniff of propofol, and small boluses of fentanyl for continued pain control. She did stabilize in flight, but the overall outcome is unknown.
What Happened?
The sending staff is not stupid, they were well intended, but they were overwhelmed. The human factor comes in to play and what sometimes happens is that clinicians will end up chasing the numbers on the monitor. There is a degree of confirmation and anchoring bias that is blinding the decision makers. We can become so hyperfocused on “the problem” that we can forget to manage the whole patient. A procedure like intubation adds a level of complexity to the patient care episode that we have to account for in our overarching management strategy. Often times you will find yourself having to manage two or three different “problems” with respect to how each intervention to control an element of one problem will influence elements of the other problems…
Eric and Ashley talk about this in a little bit different context on Episode 154, The Second Fracture.
Close Out
Throughout your career you will experience similar episodes and learn that there are certain things that are said that should cause you to STOP and THINK deeper about what is going on. In some cases, you will miss the call during the first episode, but it will be a lesson that will stick with you for the duration of your career. For me, whenever I hear someone say “we are about to re-paralyze them” I want to stop and make sure everything else that can be done to prevent that has been done.
Scott Weingart, MD FCCM. EMCrit 115 – A New Paradigm for Post-Intubation Pain, Agitation, and Delirium (PAD). EMCrit Blog. Published on January 13, 2014.
Scott Weingart, MD FCCM. EMCrit 84 – The Post-Intubation Package. EMCrit Blog. Published on October 16, 2012.
Scott Weingart, MD FCCM. EMCrit 21 – A Bad Sedation Package Leaves your Patient Trapped in a Nightmare. EMCrit Blog. Published on February 26, 2010
