Submental Intubation [video]

Holy moly... Never realized submental intubation was actually a procedure that really is performed. Check out this video (or watch below) showing a submental intubation being performed.

First, an incision is created right below the jawline slightly off from midline. Dissection is bluntly carried right to the floor of the mouth under the tongue. The endotracheal tube is than grasped and pulled through this opening resulting in a submental intubation.

Seems quick and elegant with minimal bleeding... but I have some big issues with this procedure. There are multiple avoidable risks associated with this approach including:

1) Permanent lip paralysis. The nerve that innervates the lower lip crosses right through this region.
2) Chronic submandibular sialadenitis. The duct that carries spit from the submandibular gland (one of the major glands that produce spit) to the mouth can potentally be injured resulting in stenosis and chronic salivary gland inflammation if not infection.
3) Permanent numbness of the bottom of the mouth. The nerve that provides sensation to the region under the tongue crosses right through this area.
4) Permanent tongue paralysis. The nerve that allows for tongue movement crosses through this area.

Rather than a submental intubation, why not perform a tracheostomy or cricothyroidotomy. With either of these alternative procedures, the risks are minimal (there is no risk of nerve damage).

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Unhappy with Your Appointment Day/Time with your Doctor?

A common complaint for patients is how long it may take to get in to see a medical specialist. A new patient appointment may be 1-2 weeks away when an earlier appointment may be desired.

What to do?

Of course, one can call around to every single specialist office in the region to see who has the next earliest appointment.

Other options which may work just as well include the following:

• Do NOT limit yourself to a specific day of the week and time. Always use the phrase "the very next available appointment whenever that may be."

• Ask your regular doctor to call and make an appointment for you. Be aware that if you resort to this option, you will have to accept whatever day/time you are given. Do not use this option if you will most likely end up changing the appointment to suit your schedule, otherwise risk being given an appointment far into the future.

• Although in theory, there are appointment wait lists you can put yourself into, it only works if the medical office checks it regularly... which typically does not happen. What works better is to call everyday! On a daily basis, there are ALWAYS cancellations that occur. In my office daily, there are usually 1-2 new patient appointment cancellations and double that in established patient appointment cancellations. Such cancellations usually are called in by 10AM for that afternoon or 4PM for next day cancellations. So call around that time to see if any appointment slots have opened up that you can slip into. This is why medical offices beg patients to always call if you are not going to show up and even charge a fee if you fail to inform in advance. It is to help other patients who desperately want to be seen and who could have been scheduled into your appointment slot that ended up being wasted.

Based on a study by ZocDoc, here are other appointment related trivia:

• Tuesday is the most popular day for doctor appointments; it's also the day with the most last-minute openings.
• For pediatricians, the most popular day for doctor appointments is Monday
• The most popular appointment of the week is Friday at 10AM, followed closely by Friday at 2PM.
• Thursday has the longest wait time.

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Problem with Medical Protocols (and Lawsuits Because of Them)

Over the past decade working in hospitals, I've seen the proliferation of "established procedures and protocols" for literally everything under the sun...

• Chest Pain Protocol
• Discharge Protocol
• Pneumonia Protocol
• Stroke Protocol
etc, etc, etc

Protocols are essentially standing orders that are supposed to be implemented whenever a given medical situation occurs. It is supposed to follow best evidence-based practices and make it easy for healthcare personnel know what to do without thinking to hard (akin to a checklist a pilot performs before flying to ensure they did not forget something).

The problem with protocols are that it can be made so detailed as to become worthlessly bloated. To use an analogy, take the protocol, "Going Shopping Protocol."

Protocol A (Simple):
1) Make grocery list
2) Drive to supermarket
3) Pickup and purchase items on grocery list
4) Come back home

Protocol B (Detailed):
1) Pickup #2 pencil
2) Sharpen pencil to appropriate point using pencil sharpener model 15-231
3) Test pencil to ensure proper writing ability
4) Obtain 3x4 inch index card
5) Write shopping item #1 on index card using pencil (from steps #1-3)
etc, etc, etc

Now when dealing with something as complex as medicine, protocols can be a godsend or hopeless depending on how it is written and who uses it.

And, that's where protocols become problematic.

Make a protocol too detailed, and it becomes bloated to the point of being useless, especially when dealing with time-sensitive medical problems.

Take for example something as simple as "Chest Pain Protocol." Orders for EKG, aspirin, IV fluids, sublingual nitroglycerin, and morphine seem obvious (assumption being heart attack), but what if we are dealing with a 10 years old child who got punched in the stomach by a bully? What about a stabbing into the chest?

Does that mean there needs to be multiple branch-points explicitly addressed in the protocol to handle every single possible scenario of chest pain under the sun at any age for every possible scenario?

Clearly, the answer is "NO"!

So protocols are made with several assumptions:

1)  A general level of medical competence of healthcare professionals
2 ) Healthcare professionals are already familiar with a given protocol and knows when to appropriately activate it
3) Protocols are deliberately made to be not too specific as it is understood that there is variability in the care of patients. Protocols can not and should not be applied cookie cutter to every patient as there are nuances that the protocol leaves to the judgement of the doctor.

Unfortunately, by making protocols to generalized, it does open up the possibility of lawsuits.

Take an ongoing case in Georgia where the medical director of an emergency room is being sued for professional negligence in the death of a woman from a heart attack... because of a chest pain protocol he wrote. Note that this medical director NEVER provided any direct medical care, did not have an established patient-physician relationship, and was not even in the hospital when the woman came into the ER. [link]

So is the solution to avoid having any protocols in place to avoid lawsuits? Sorry... NOT having a protocol in place can also be subject to a lawsuit. In 2000, a hospital was sued for either failing to follow established anesthesia procedures or protocols or failing to have any established procedures or protocols in place. [link]

So what to do?

Well, getting sued is a risk that is inherent to the medical field, especially whenever there is a bad outcome.

As such, the default action taken by physicians and hospital administrators are to minimize or spread the risk. How?

• Have as many different physicians write-up a given protocol that is signed off by everybody (spreading the risk)
• Avoid positions of responsibility (default scapegoat for lawsuits)
• Involve many physicians in the care of a patient (spreading or transferring the risk)
• Have protocols, but do not depend on them (clinical judgement trumps protocol).
• Have MANY documented training sessions on how protocols are to be used and discuss weaknesses and strengths of them

References:
UPSON COUNTY HOSP., INC. v. HEAD 540 S.E.2d 626 (2000) 246 Ga. App. 386 UPSON COUNTY HOSPITAL, INC. v. HEAD. No. A00A1601. Court of Appeals of Georgia. October 13, 2000.

Gaulden v. Green, No. A12A1872 (Ga. Ct. App. Oct. 30, 2012)

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Surgical Time-Out, circa Year 2050

In the year 2050, surgical time-outs have reached a new level of safety to ensure the utmost care and risk reduction for patients.

Unlike the primitive time-outs performed in the the first decade of the 21st century (2000-2012) which involved one designated individual to confirm prior to incision (Basic9), the patient name, surgical site, performing surgeon, allergies, antibiotic administration, positioning, x-ray name confirmation, fire hazards, and fall risk, significant additional safety checklists have been implemented to create a new state-of-the-art culture of safety both in and out of the operating room.

In 2015, surgical time-outs extended to also include electrical and air quality checks (Environ2) along with separate mandatory time-outs of the Basic9 before, during, and at conclusion of surgery.  To ensure minimal air contaminants as well as maintain the highest performance of all electrical equipment in the operating room, the Environ2 requires a separate electrical and environmental engineer to certify all equipment and confirm air quality at a level of no more than one contaminant part per trillion to the 10th power in 35 separate locations within the operating theater. The Environ2 checks are double-confirmed by the circulating nurse who has been granted broad powers to cancel surgery for any reason without consequence if there are any concerns with the operating room environment that may increase infection risk for the patient as well as sub-optimal performance of any and all equipment used to perform the surgery.

In 2020, the Total5 was added to Basic9 and Environ2 which truly heralded the onset of state-of-the-art surgical time-outs. Total5, developed jointly by the Harvard School of Public Health and National Institute of Medicine, involves a comprehensive time-out of any and all individuals entering into the operating room in the knowledge that surgical outcomes are affected by personnel movement into and out of the operating room whether from contaminants on the skin or clothing of staff to infections that they may or may not be harboring. In rare cases, given the recent terrorist attacks both biological as well as chemical, the Total5 would additionally eliminate such threats.

As such, Total5 involves for each and every staff member that enters the operating room to undergo "individual time-outs":

1) Geiger counter check

2) Body pat-down by TSA (whose duties have tremendously expanded from initial airport security)

3) Metal detector check

4) Chemical check (specifically looking for arsenic, mercury, formaldehyde, etc as well as drug screen)

5) Biohazard check (routine organisms include MRSA, VRSA, C dif, HIV, hepatitis, etc as well as more exotic organisms like Ebola, Swine Flu, Anthrax, etc).

A separate consent must be in the chart for each and every individual who is present for the patient's surgery with their Total5 report.

The Basic9, Environ2, and Total5 surgical time-outs collectively have ensured a 360 degree safety net for the patient.

But... it is not until now in the year 2050 that the surgical time-out has reached a penultimate state with the expansion of the Total5 to Total10. In addition to the original Total5 for surgical staff, 5 additional time-out checks of surgical staff is now required. Continuing with #6...

6) Retina scan (to confirm staff identity)

7) Fingerprint scan (to double-check staff identity)

8) Malpractice insurance check (if positive, consent must be in chart to ensure patient was aware of any malpractice committed by any surgical personnel doctor or nurse)

9) EKG to ensure peak cardiac health of staff member

10) EEG to ensure a rested mind at peak performance of staff member

As with the Total5, Total10 report for each staff member must be included in the patient consent in the patient's chart.

There was some confusion whether each staff member can undergo just one Total10 per day, but with new regulation acknowledging possibility of patient infection contaminating personnel as well as staff member fatigue that may progress throughout the day, a Total10 MUST be performed before each and every surgical case.

For any further questions on surgical time-outs, please contact your local hospital JCAHO executive liaison.

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