Intubation: A Lesson in Helplessness
 Med
League offers analysis of medical records for pain and suffering.
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Critically
ill patients are frequently intubated and attached to ventilators.
Intubation is a lesson in helplessness, and constitutes
an element of damages in personal injury and medical malpractice
cases. When I am asked to evaluate medical records for evidence
of pain and suffering, I often
see the patient’s care included a stay in the critical
care unit on a ventilator. First, why is it necessary to
be intubated? Endotracheal tubes are inserted to gain control
of a severely injured patient when the patient’s behavior
prevents the diagnostic testing needed to determine injuries.
In addition, adult respiratory distress syndrome can result
from crushing chest injuries, severe head injuries, or sepsis.
Anesthesiologists typically rapidly administer medications
to paralyze the diaphragm and sedate the patient in order
to slide the endotracheal tube into the lungs. There are
multiple opportunities for liability associated with management
of the intubated patient. For example, harm to the patient
occurs if improper intubation technique results in inadequate
ventilation of the lungs and the resultant decrease in oxygenation.
The
medical, nursing, and respiratory therapy team work together
to oversee the multiple needs of the ventilated patient.
The physicians look for ways to prevent ventilator–associated
pneumonia, one of the quality indicators singled out by
patient safety organizations. This hospital-acquired condition
can kill. Physicians also look for signs the patient is
ready to be weaned off the ventilator.
Critical
care nurses are responsible for protecting the airway -
preventing the patient from pulling on and removing the
endotracheal tube. Although there is a trend away from the
use of restraints in health care, preventing the patient
from harming himself or others by careful use of wrist restraints,
is an exception. The unplanned self-extubation can result
in loss of an airway, and death, particularly if the patient
has received paralyzing agents and cannot breathe on his
own. Nurses are also responsible for suctioning the endotracheal
tube to prevent the buildup of secretions that can block
the airway. Failure to frequently suction when indicated
can be a deviation
from the standard of care. Mucous plugs can block airways
and kill.
Respiratory
therapists function within the realm of minding the machine
- the ventilator - and providing patient treatments. Along
with the nurses, they are responsible for checking that
alarms are properly set on the machines. An alarm signals
that the airway is occluded or the patient has stopped breathing.
Alarms that are turned off and fail to detect an emergency,
can kill.
The
impact on the patient
What is it like to lose one’s voice, to lay
flat on one’s back, and be unable to communicate needs?
Consider that the patient’s hands are tied to her
sides, and she is unable to speak due to the presence of
the tube in her mouth. She cannot write notes or call for
assistance. She is constantly exposed to the hissing sound
of the ventilator, and sounds from alarms on IV pumps, cardiac
monitors and ventilators. The suction catheter threaded
through the endotracheal tube stimulates the cough and gag
reflexes, and leaves her gasping for air at times. Suctioning
is associated with its own set of hazards, including a drop
in oxygen level, increased intracranial pressure, irregular
heartbeat, mucosal injury, infection and death. These hazards
exist whether or not the nose/throat or the tracheostomy
tube is the entry site for the suction catheter.
Many
people are sedated while on a ventilator; the trend is to
use the minimum amount of sedation needed. The patient may
be awake and aware even while receiving low doses of sedation.
The medical community recommends turning the sedation off
onceevery 24-hours, and allowing patients to wake up in
order to evaluate their behavior and level of awareness.
This is particularly useful when patients have sustained
head injuries. But the patient wakes up to the sights, sounds
and sensations of being on a ventilator. Nurses notes frequently
describe the patient as anxious or agitated during the periods
of awareness.
There
is no general agreement within the medical profession as
to the precise number of days a patient can have an endotracheal
tube in place before a tracheostomy should be performed.
Weaning efforts usually occur before a decision is reached
to perform a tracheostomy. The patient who becomes acutely
short of breath and anxious during weaning is a candidate
for a tracheostomy.
| Implications
for attorneys
1.Plaintiff
attorneys should question their clients about
what, if anything, they remember about being
on a ventilator in the critical care unit. Note
also that some medications, such as Versed,
eliminate the memory of the experience. A major
head injury can also wipe out awareness and
memory. Did the patient experience a sense of
helplessness, fear or frustration? Does the
patient remember being suctioned?
2.
The defense counsel should be aware of this
element of damages, and focus on factors that
eliminate memory of the dependency period.
3.
Both sides on the case should have a legal nurse
consultant or expert look at the medical records
for evidence of conscious suffering. The reviewer
will look for chart entries of gagging and coughing
during suctioning, withdrawal from the noxious
sensation of suctioning, and incidents of self-extubation.
4. Tracheostomies leave scars on the neck, which
can be pronounced in those prone to keloid formation—wide,
rippled scars. |
|
The
need for a tracheostomy
Why do patients need tracheostomies? Here is why:
long-term mechanical ventilator use, symptom relief, improvement
in patent wellbeing, facilitation of activities of daily
living, optimization of long term function, airway obstruction,
chronic aspiration, an acute neural insult, progressive
neuromuscular decline, high
quadriplegia, and an unstable or obstructed airway.
Tracheostomies are usually performed in the operating room,
but can be done in the critical care unit when the patient
is too unstable to move into the OR. The skin over the neck
is cut and dissected down to the trachea, which is then
opened to permit the entrance of the tracheostomy tube.
Maintaining the airway is crucial during this time. Liability
is associated with performing the tracheostomy too low and
too close to major blood vessels and in removing the endotracheal
tube before the tracheostomy is secure.
Decannulation
There is no consensus as to when a tracheostomy
tube can be safely removed. Stelfox [1] found these factors
influence removal of the tube: level of consciousness, ability
to tolerate tracheostomy tube capping, cough effectiveness,
and secretions. There is little in the way of evidence-based
recommendations for removal of the tube, including the timing
of and process of removal. The clinicians Stelfox surveyed
believed the best candidates for decannulation were those
who were:
•
Alert and interactive
• Had a strong cough
• Required minimal supplemental oxygen
• Had scant thin secretions
Choate
[2] studied the rate of re-cannulation, and found that 4.8%
of 823 decannulation decisions resulted in a need to re-insert
the tracheostomy tube. The failure rate was highest (60%)
within 24-hours after the tube was removed. The clinical
manifestations of a decannulation failure include a change
in vital signs, increased effort to breathe, increased pulse
rate, and changes on a chest x-ray indicating accumulation
of secretions. Liability is associated with failure to re-intubate
a patient who cannot breathe on her own. Ventilators and
tracheotomies are unpleasant but essential aspects of keeping
a patient alive. Managed correctly, they save lives. Managed
incorrectly, they can kill.
References
1. Stelfox, H, Determinants of the tracheostomy decannulation:
an international survey, Critical Care, January
1, 2008
2. Choate, K, Tracheostomy and decannulation failure rate
following critical illness: a prospective descriptive study,
Australian Critical Care, January 1, 2009
Med
League offers analysis of medical records for pain and suffering.
Contact us to obtain a sample report and more information.
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