Georgia Tagalos was rushed into the emergency department of St. James Hospital and Health Centers at Olympia Fields, IL, after suffering an asthma attack. The 49-year-old patient arrived at 1:45 p.m., gasping for air and unable to speak. Her oxygen saturation level was 89 percent.
The attending emergency physician told his resident to “go see the lady in bed 3,” who “may need to be intubated” at 1:52 p.m. The resident attempted to intubate Mrs. Tagalos and failed. One, two, three, four, five more tries to intubate were unsuccessful. Mrs. Tagalos' oxygen saturation level dropped from 50 to 49 to 45 to 40 before it fell to 0 at 2:10 p.m., and Mrs. Tagalos had no pulse.
The attending emergency physician then asked a trauma surgery resident to perform a cricothyrotomy. A tube was placed through the patient's throat in 10 seconds, and her vital signs returned to normal. But Mrs. Tagalos was brain dead due to hypoxia.
Intubation failures in the ED are increasingly rare. An analysis of data from 30 EDs participating in the National Emergency Airway Registry Pilot Project (NEAR II) from 1998 to 2001 showed that7,712 patients underwent emergency intubation, failing only in 2.7 percent (207). (J Emerg Med 2002;23:131.) A more recent study of 17,583 emergency intubations at 13 EDs in the United States, Canada, and Australia found that the first-attempt intubation success rate was 83 percent. (Ann Emerg Med 2015;65:363.)
Guidelines dictate in these rare cases that EPs use another method like cricothyrotomy to secure an airway. The EP in this case continued intubation efforts for another 10 minutes after the first attempt failed. This was a tragedy that could have been prevented with better training in airway management, said Christopher Hurley, the attorney representing Mrs. Tagalos' son, who won a $4.7 million judgment against the doctor, resident, nurse, and hospital.
“Their hearts were in the right place, but their training wasn't there,” said Mr. Hurley, a managing partner of Hurley, McKenna & Mertz P.C. “Ultimately, we came to the conclusion that we'd like to be part of the solution rather than part of the problem.”
Difficult Airway Course
Mr. Hurley decided to donate $50,000 to the NorthShore University HealthSystem Foundation to bring the necessary training to hospitals in the Chicago area. He had come across the Manual of Emergency Airway Management by Ron Walls, MD, during the trial and learned about Dr. Walls' “Difficult Airway Course: Emergency,” a CME program that teaches airway algorithms and provides hands-on training in different emergency airway scenarios through medical simulations. It was exactly what Mr. Hurley was hoping to give back.
Ernest Wang, MD, the Alvin H. Baum Family Fund Chair of Simulation and Innovation of the Grainger Center for Simulation and Innovation at Evanston Hospital, helped bring the course to the center for 30 physicians who participated for free in this workshop that normally costs more than $1,200 per person.
Dr. Wang is no stranger to difficult airway simulation training. The Grainger Center runs the Emergent Procedures Simulation Skills Lab twice a year for the Illinois College of Emergency Physicians. He himself is a veteran of the Difficult Airway Course, which he said offers a unique framework to help emergency physicians think through the steps of airway management.
“It helps you anticipate where there is going to be a difficult airway, and it helps you anticipate when there are going to be difficulties with other aspects of pre-intubation, how to use a bag-valve mask, how to anticipate when there are going to be problems with that, how do you address it,” Dr. Wang said. “It takes all these aspects and makes it logical and more systematic so you have a better chance of success.”
Practice Begets Confidence
Another challenge is that emergency medicine residents lack familiarity with alternative techniques like cricothyrotomy, beginning with their having too little exposure to the procedure. Only 139 emergency cricothyrotomies were performed in the 12,564 trauma patients admitted over a 10-year period at a Level I trauma center with EM and surgery residencies. (Acad Emerg Med 1998;5:247.) Chang, et al., found that surgical residents may become proficient in cricothyrotomies in the OR, but EM residents may never see or perform one during their training.
Emergency physicians have no choice but to rely on intubation, the technique with which they are familiar, which further exacerbates the issue. EPs opted to use rapid sequence intubation (RSI) in 49 percent of the 207 patients in whom initial intubation had failed and cricothyrotomy in only 21 percent of the cases in the NEAR II study. The widespread use and extremely high success rate of RSI have most likely led to a loss of familiarity with alternative techniques even if there were opportunities to learn them.
The Difficult Airway Course gave EPs who might not had had the training or the means to obtain the training a chance to make up for that skill gap or brush up on their skills over two days. They practiced what they knew well and what they didn't over and over in simulations. They also learned new skills such as video laryngoscopy, fiber optics, and endoscopy. Participants left with new knowledge and tools like a book, cards, or an app to help them reinforce that knowledge.
“All these things help you with your skills, then with your self-confidence,” Dr. Wang said. “Everyone left the course feeling much more confident that they would be able to successfully manage a difficult airway; they may not have had that same confidence at the beginning.”
A Unique Collaboration
Collaboration between doctors and lawyers, especially a personal injury trial attorney like Mr. Hurley, are uncommon. He represented hospitals and institutions before he switched to helping plaintiffs so he has seen both sides, and he said he understands malpractice lawsuits have sown hostility and resentment in medical professionals toward attorneys. The “big issue I see is doctors are always skeptical and somewhat suspicious of lawyers,” Mr. Hurley said. “Maybe in some cases, it's deserved, but I felt that in a situation like this, sharing our joint experience and disseminating this information would be good for everybody.”
This collaboration with Evanston Hospital serves as a bridge between the two professions. Mr. Hurley spoke about the reasons he wanted to get involved at a lunch where he was honored with a plaque from the hospital. Dr. Wang, who was present, said Mr. Hurley became emotional during his speech, and the physicians present felt how genuine he was.
“Everyone who was there really appreciated it. This is a unique collaboration. Sometimes in tragedies, unique collaborations are born,” Dr. Wang said. “I hope this will be something that will carry on. It was refreshing. I can't say enough good things about it.”