I don’t think anyone but another ER nurse can understand the feeling you get in the pit of your stomach when that EMS radio goes off and the report is of someone involved in an accident who meets the general description of one of your children.
I had just such a scare in late April 2010. The radio went off a little after midnight and EMS was transporting two young people who had been involved in a motor vehicle crash on I-20 westbound. We had at least a 20 minute ETA, as they were being brought from out of town to our trauma center.
I knew my daughter, Megan, and son, Aaron, were supposed to be on their way home from a Texas Rangers game in Arlington and would be traveling that route.
I immediately called my daughter’s cell phone, thinking she would be the passenger in the vehicle and my son Aaron would be driving. Megan answered the phone on the first ring.
“So, where are you?” I asked, trying my best to be casual.
“We’re on the way home. Just passed the sign for Lake Leon. Why?”
“I was just worried about you and wanted to see if you’re going to stop by here on your way home.”
“Mom,” she said laughing, “did you just have a wreck come in or something? I can always tell when you have something bad come in. You worry too much.”
“Yeah, as a matter of fact they are coming in now and I always worry that it’s going to be one of you. Where’s Aaron?”
“He’s asleep, right here beside me.”
“Because you shouldn’t be talking on the phone while you are driving.”
“Mom, chill! I’m on hands-free, and besides, you called me, remember?”
“OK, I gotta go. You! Get off the phone! Be careful, and stop here when you get home. I love you. No texting and driving! Why is Aaron letting you drive anyway?”
“He and Trent had beer at the game and I’m the DD.”
“Well, I can’t really fault that logic. Be careful. Wake Aaron up so he can keep you awake. I don’t want you falling asleep at the wheel. Don’t be texting and driving, and don’t be talking on the phone!”
“Duh, you called me. Love you. See you in the morning and quit being such a worry wart. I’m a very good driver.”
“OK, Rain Man. Call me when you get home.”
It was less than two weeks later when I was awakened from my daytime sleep after a 12 hour shift by something. I don’t really know what. It was only about 1 p.m. and I usually didn’t get up before 4 p.m. Megan had just left a short while before to head back to school in San Angelo. I remembered hearing her singing in the shower and then hearing her and David talking downstairs before she left.
I’d poked my head in her room that morning before I went to bed and she told me she didn’t have any finals until the end of the week, but had to go back that afternoon to take care of Kaitlyn.
She was an afterschool “nanny” to Kaitlyn, who was in first grade, and picked her up after school and took her to her activities and so on until her mom got off work.
I remember telling her what a disaster area her room was, and that it was going to take her all summer to clean it up.
She said, “Just wait till I bring all my stuff from the dorm this weekend, it’s going to be a lot worse.”
“Oh my God,” I said, “I don’t think it can get any worse.”
She seemed unconcerned. Yawned and stretched and said, “Don’t forget Wednesday.” We had an appointment to go to see her senior pictures at Great Expectations Photography in San Angelo.
She said, “Wait till you see them, they are awesome.”
I asked her what time the appointment was and she said 3 p.m. I told her I would be there with my checkbook, as always, and she laughed.
“Look on the bright side, Mom. I haven’t overdrawn my checking account at all this month.”
“Yeah, and that’s only because I took the overdraft protection off so you would have to keep up with it.”
“Well, even so, it’s not overdrawn.”
“Excellent, I’m so proud. Now get up and start working on this room if you can find it under all these clothes.”
“I’ll do it when I get back. We stayed up late last night watching videos of us during our high school years so I’m tired, but we had so much fun. I’m gonna sleep in and leave at noon.”
“OK, I’m going to bed. Good luck on your finals.”
Megan was a sophomore in college but had left high school a year early to get a head start on her career. She was planning to walk the stage with her class of 2010 even though she had been in college for three semesters.
I took a shower and got dressed for work even though I didn’t have to be there for several more hours. I really don’t know why I did that. I went downstairs and started checking the fridge for a snack when my cell phone rang. I didn’t keep it in my room because I would be awakened by annoying sales calls. I always kept it in the charger by the couch. I felt a sudden alarm when it rang like I already knew what was coming. I answered the phone.
“Is this Mrs. Gilbreath?”
“Do you have a daughter, Megan?”
“Yes, who is this?”
“This is Officer Meadows, with the Texas Highway Patrol. I’m sorry, ma’am, but your daughter has been involved in an accident on Highway 277.”
“Is she alright? Can I talk to her?”
“No, ma’am, I’m afraid you can’t. She’s being loaded onto the helicopter now and they are taking her to Regent’s hospital.”
I remember my heart doing a complete flip in my chest and I started to panic. “No! Are you sure it’s Megan?” I ran outside with the phone to my ear and saw Megan’s car sitting in the driveway. “It can’t be her, her car is right here. It must be someone else.”
“Ma’am, your daughter was driving a green Chevy pickup at the time of the accident.” The officer seemed sure.
“Oh my God, I need to find my husband and we will be there as soon as we can. Is she awake? Is she talking? Can you tell me any more about her condition?” In the back of my mind I was processing the fact that she was in David’s pickup.
“No, I’m sorry, I can’t, but I will meet you at the hospital to try and fill in the details.”
The accident occurred at 1400 in the afternoon. She was not drinking or doing drugs. She had her seatbelt on. She missed a turn and overcorrected, causing her accident.
She was driving her dad’s pickup because it was finals week and she needed to bring all of her belongings back from the dorm. She was unused to driving a pickup, as she normally drove a car with a wide wheel base that’s low to the ground. Both her inexperience in the vehicle and her speed probably were contributing factors.
As a result of the accident she sustained serious injuries, including a broken leg and a closed head injury. She was conscious at the scene but confused and lethargic. Her injuries, while serious, were not life threatening.
When the air ambulance personnel arrived at the scene they determined that in order to safely transport her to the hospital they needed to sedate and paralyze her, and perform a procedure—endotracheal intubation.
This procedure is intended to protect the airway and allow them to maintain the patient while in transport. This decision was based on the fact that when they inserted a nasopharyngeal airway she reached up and pulled it out and became agitated. She did not have airway compromise at this time, nor had she had any airway compromise during a prolonged extrication.
They documented that she was “combative.” Megan was 5 foot 4 inches and weighed 120. The paramedic on board was 6 foot and weighed at least 200. At her most combative I think the straps on the backboard would have sufficed. Also, pain medication or sedation alone should be considered as opposed to a paralytic.
The procedure was performed due to Megan’s confusion and movement at the scene. She was breathing adequately on her own prior to this procedure. Intubation was performed as a means of restraint more so than an adjunct to her breathing.
The team performed the procedure incorrectly and placed the tube not in her trachea or windpipe but in her esophagus, the tube leading to the stomach. While this is not that uncommon, it is very uncommon, and very deadly, to leave the situation uncorrected.
They failed to recognize this and failed to respond to her deteriorating condition prior to and during the flight by removing the tube and either replacing it correctly or using alternative equipment that should have been available to them.
The consequences of these errors and failure to respond with appropriate management resulted in Megan’s death a few minutes into the flight. While they attempted to support her heart with CPR, they failed to provide oxygen as they never removed the misplaced tube, causing all air to enter the stomach and not the lungs.
The paramedic and RN paramedic on the crew did not have Megan on a cardiac monitor or pulse oximetry at the time she was intubated. They did not use end-tidal CO2 or capnography, even though both were available to them and were required by their protocols.
They later claimed the capnography monitor was inoperable, but the record shows they never hooked it up and their preflight check indicated it was working that morning.
A paramedic, who was one of the first responders, and his EMT-Basic student both told the helicopter crew that the tube was not in place when they saw immediate abdominal distention and cyanosis that had not been present prior to the intubation.
The RN paramedic informed them this was normal and he knew the tube was in place as he had visualized it passing through the cords.
Megan was brain dead on her arrival at the medical center after over 30 minutes with no oxygen to her brain. The team at the trauma center immediately recognized the tube was misplaced due to Megan’s distended abdomen and her lack of breathe sounds. They replaced the tube correctly and were able to revive Megan’s heart and lungs to a point where she sustained a pulse and blood pressure. They could not, however, reverse the damage to the brain caused by lack of oxygen for this extended period.
We are so thankful they were able to maintain her vital signs in order for Megan to become an organ donor. This is something she had expressed to us and to her friends that she wanted to do in the event she was ever in an accident.
Megan was a bright and beautiful 18-year-old college student, with a brilliant future and many hopes and dreams. It is our hope that by making this medical incident public, you and the emergency medical personnel in the field will be aware that the goal of intubation is to provide oxygenation to the brain. You must be diligent in reassessing all patients requiring intubation to ensure proper placement.
There are alternatives to intubation that require less skill and provide adequate oxygenation, such as laryngeal mask airways and the Combitube, and I recommend strongly that the personnel in the field consider these alternatives rather than intubation in order to prevent this horrible outcome from happening in the future.
Unless you are in a position where you intubate every day, please don’t intubate my child today. Use your head and don’t ever be too arrogant to listen to other medics on the scene. If there is any doubt in your mind, or the mind of anyone else on the scene, as to whether that tube is in place, pull it out and bag-valve mask until you figure out your next move.
Please consider all alternatives prior to using paralytics, which will not allow the patient the opportunity to fight for their own life. If paralytics must be used to protect the patient and crew, make sure your skills are adequate to perform the task and that you are able to adequately assess the patient’s airway immediately following the procedure and at all times thereafter.
It has been over two years since Megan’s death and the situation was reported to the State Department of Health, which oversees the paramedic certification, and to the State Board of Nursing in regards to the RN paramedic. Both departments did a very thorough investigation. Both paramedics in this case had their license suspended, and the RN paramedic has since surrendered his nursing license.
It has been an incredibly long two and a half years, and anyone who tells you that time will ease your pain is either lying or simply has no idea. The fact that I am a nurse may help me to understand the physiology of death but we are never really prepared for the loss of any child, let alone our own child.
It does, however, give me a very different perspective in terms of how I deal with others experiencing a loss. I think I have become more in tune with the feelings of those experiencing a sudden loss.
It was just too difficult for me to continue to work full-time in the trauma center after Megan’s death. I did continue to charge the unit full-time for about six months, but eventually transferred to another position where I still get to spend a lot of time in the emergency department but I’m not “locked-in,” so to speak, and can work in other areas of the hospital as well.
The lawsuit has been settled, but my family and I will never be the same.
We have set up a scholarship fund—the Megan Gilbreath Memorial Scholarship—which has given a scholarship each year to a student pursuing a career in nursing. We hope to continue that each year and have done so with the help of generous donations from friends and family.
In loving memory of Megan Dianna Gilbreath, December 21, 1991 to May 3, 2010.
Judy Gilbreath, RN, CEN, is an emergency room nurse.