It's a warm spring evening in Wheat Ridge, CO, and I'm en route to the nearest trauma center with Bob, a middle-aged male. Bob moans but does not wake as I flick the side of his face and yell his name in his ear. He was c-spined by the local fire department after being partially ejected through the side window of his Celica. As I systematically move through my secondary assessment, I recognize that Bob has begun to dangerously hypoventilate, and I admit to myself a fact I'd been avoiding since I arrived on scene: Bob needs to be intubated.
Inserting a 7.5 ET tube in Bob's right nare, I feel a sense of relief as I advance the tube in time with Bob's respirations and see the telltale fog gather inside the plastic. The presence of bilateral lung sounds, absence of epigastric noise and normal-looking capnography waves all further confirm my assessment that the tube is in the correct place. At the emergency department, the respiratory therapist checks the tube placement and announces that the tube is good. I return to my ambulance, relieved and pleased that I performed my skills well.
I was mistaken. Ten minutes after I left Bob's bedside, a nurse returned to the room with his x-ray and startling news. The ET tube did not appear to be in the trachea. The physician, who was busy cauterizing a wound on the patient's scalp, set down his cauterizing tool and rushed to the light screen to examine the x-ray. Moments later, the diagnosis confirmed, my nasal tube was removed and the patient was orally intubated. During the procedure, the hot cauterizing tool, still lying on the bed, rolled under Bob's shoulder, creating a significant burn.
This is what James Reason, in his book Human Error, refers to as an evolving disaster. His theory is that errors don't just happen--they evolve. Systems of checks and balances often discover a single error before it becomes problematic. But while a single error can be significant by itself, our most critical mistakes often occur when one error leads to another in a compounding manner.
When I heard about the episode with Bob, I returned to the ED in disbelief. My initial reaction was to defend myself. The capnography wave, the breath sounds--how could the tube possibly have been bad? Could it have been dislodged after I left? My ego wanted to defend my care. I wanted to immediately turf the error onto someone else. Sure, mistakes like these happen, but that's little consolation when the mistake is yours.
The physician and I reviewed the x-ray together, and he patiently pointed out the obvious radiopaque line that showed the tip of the ET tube sitting at the tracheal opening, the inflated balloon precariously sealing the opening.
"Didn't the tube seem awkwardly shallow for a nasal tube?" he asked.
"Well…yes," I hesitantly agreed. I was used to seeing the tube much deeper after a nasal intubation.
"Did you orally observe the tube after intubation?" he continued.
Again, I admitted that due to the patient's active gag reflex at the time of intubation, I hadn't gone back and attempted to orally visualize the tube, a technique that probably would have been possible as Bob's level of responsiveness waned.
As the conversation continued, I recognized that I had made an error. The intubation would need to be recorded as a hyperpharyngeal tube placement. The tube was indeed ventilating Bob, but its location placed him in danger of losing the airway with the slightest movement of his head. In retrospect, the spinal immobilization was probably the only factor that had allowed the tube to remain in place for as long as it had.
Even worse, my error had begun a cascade of events that led the patient to suffer an additional injury. While Bob's burn was not causally related to the misplaced tube, it was the precarious airway that set off the unfortunate chain of events. The sting of the failed intubation seemed intensified because of the role it played in this secondary injury.