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From death we learn – Victorian coroners finding on failed intubation


Some of the most powerful lessons I find are from the coroners websites and inquest findings.

Here is a 2012 finding from the Victorian coroner

Coroners Court Victoria Finding into death of Ruben Chand

Lesson : Confirm tracheal intubation using objective methods – capnography or real time bedside USS .
Failure to intubate happens all the time. But failure to oxygenate should never be a sin of omission.
In the words of one of the ICU consultants involved in the inquest, Oxygenation is the key not intubation.

Nasal Cannula Oxygenation may have helped in this case, even with unrecognised oesophageal intubation. It may also not have helped by masking effects of incorrect tube placement and delaying correction.

These coroners findings and similar ones are a matter of public record and appear on official websites for general digestion.
They are never pleasant or positive things to read for all parties and I take no joy nor smugness from discussing them here.
But I hope to honour the tragedy

This is not about assigning blame. It is about learning from the past, making things safer.
This case could have happened to any of us.

I truly believe from death we can learn and become better at what we do.
This is the responsibility we take on in our jobs providing emergency care no matter where.
This is the discipline.

5 Comments Post a comment
  1. Always instructive to read Coronial reports or closed-claims. No gloating over individual’s misfortunes – but learn from mistakes and address faults, whether at systems level or training/equipment level.

    Would checklists have helped?

    Still waiting for the Coroner’s report on the Kerang train crash…that’ll be interesting.

    January 7, 2013
  2. Jimmy D #

    OK Minh, et., al., a little thought experiment here, if you don’t mind. Don’t take it too seriously, just think about the possibilities, and even how failures of techniques can lead to success.

    Did you guys in Australia ever see the Esophageal Obturator Airway (precursor to the Combitube?)? One of those could be effectively created quickly if an intubation attempt resulted in an esophageal intubation.

    If working with minimal equipment is a fact of life (as is esophageal placement of a tracheal tube), it would be an interesting idea to capitalize on the esophageal intubation by immediate mask ventilation with the tube (still) resting in the esophagus. Why? Because that tube in the esophagus acts like a big oral airway, thus assisting mask ventilation. To make this work, the tracheal tube would need to be capped at the top (with a stopper), and folded so that it fit within the confines of the face mask.

    I have provided sedation for upper GI endoscopies enough to know that the GI endoscope acts like an oral airway (decrease SpO2 in those cases represent “central” or CNS causes of apnea, not apnea from airway obstruction). A tracheal tube in the esophagus may provide an opportunity to assist mask ventilation, if it can be “tweaked” quickly and efficiently to assist in this capacity. And you don’t have any other SGA’s.

    January 9, 2013
    • ok thats a bit from left field!
      I think the issue was the lAck of recognition of the esophageal intubation early enough

      January 9, 2013
  3. Jimmy D #

    I know it’s from left field!

    January 10, 2013

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