Doctors: EMTs should carry breathing aid


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By Robyn Shelton | Sentinel Medical Writer
Posted March 22, 2005


Orange County doctors are pushing for all paramedics in Florida to use a device that checks whether patients with breathing troubles are getting the oxygen they need.

They say making more of these devices available will increase patients' chances for survival.

The equipment continuously detects the carbon dioxide exhaled when someone is breathing properly. It is used to check a procedure called intubation, which involves putting a tube down the person's throat so air can be pumped into the lungs.

Sometimes, the tubes can be placed in the wrong spot, such as the esophagus, or they can fall out of the correct location while a patient is being moved.

The carbon-dioxide devices have been mandatory in Orange County since 2001 but remain optional in nearby communities and statewide. Officials credit the technology with reducing the number of intubated patients brought into Orlando Regional Medical Center with misplaced tubes.

In a 1997 study, an alarming 25 percent of intubated patients arriving at ORMC had tubes in the wrong position. A new ORMC study found a 9 percent rate overall but noted that every patient who was monitored with the carbon-dioxide device arrived with the breathing tubes in the right spot.

Because 11 counties bring patients to ORMC, those outside Orange may not be using the equipment. It's the lack of uniformity that has local physicians pushing for a statewide requirement.

"This is a problem that we've been looking at for years," said Dr. George Ralls, medical director of Orange County Emergency Medical Services. "I think everybody knows that the rate [of misplaced tubes] is unacceptably high, and here we have a study that shows an intervention that is successful."

Never an easy procedure

The issue is not limited to Florida. Research done elsewhere since the early 1980s has found rates of misplaced tubes in 0.4 percent to 10 percent of cases.

Doctors say intubation is not an easy procedure in the best of circumstances. And it's even tougher for paramedics, who often work in stressful conditions on patients who have injuries that make it harder to identify anatomical structures in the throat.

In addition, intubation is just one method used to help patients breathe, and Orange County's 900 paramedics may intubate only one or two patients a year, which limits their experience with the procedure.

Mistakes happen

Dr. Salvatore Silvestri, also medical director of Orange County EMS, said mistakes are going to occur, and that's not the problem.

"The problem is when it's not recognized," said Silvestri, the lead author of the study that was posted recently at the online site of the medical journal Annals of Emergency Medicine. "We expect to have 100 percent recognition" of misplaced tubes.

In the study, Silvestri and his colleagues tracked every intubated patient who arrived at ORMC during a 10-month period in 2002.

Of the 153 patients, doctors determined breathing tubes were in the proper position for 139 and misplaced in 14 people. All of the mispositioned tubes occurred in patients who did not have continuous carbon-dioxide monitoring.

Despite having misplaced tubes, five of those patients were breathing on their own by the time they arrived at ORMC. But overall, nine of the 14 died at the hospital; two with brain damage were discharged to long-term-care facilities; and three went home without neurological complications.

Silvestri said it's not fair to blame the patients' outcomes on the misplaced tubes, because their deaths or brain injuries might have been the result of the initial condition or accident that they suffered.

Danger signs

Others are blunt about the danger in that situation.

"If it's not recognized, you're sealing the patient's coffin -- it's that bad," said William F. Toon, a paramedic and battalion chief in Johnson County, Kan., where the carbon-dioxide monitors have been required for years.

These monitors provide continuous, highly sensitive readings that immediately alert a paramedic when oxygen is not reaching the patient's lungs. The equipment is used already in operating rooms so the anesthesiologist can be certain a patient is getting enough oxygen.

The state is considering making the devices mandatory for all Florida paramedics, but cost is an issue.

Sophisticated monitoring systems can run as much as $30,000 apiece. Though the technology is widespread in hospital operating rooms, it is fairly new to the emergency medical community.

"Even though this technology has been around for a long time, it's not necessarily been available in a rugged machine that you can set out in the middle of a freeway," said Scott McDermid, deputy director of Emergency Medical Services for the Florida Department of Health.

He expects more EMS systems to adopt the new technology as they become more familiar with it. In the past two years, the state already has given more than $205,000 in grants to EMS agencies so they can buy the equipment.

Toon from Kansas said it's money well-spent. His EMS system invested more than $750,000 to upgrade its technology.

"It's still cheaper than what it would cost to settle a lawsuit [if someone sued over a misplaced tube]," he said. "And the bottom line is we're supposed to do no harm."

Robyn Shelton can be reached

at rshelton@orlandosentinel.com

or 407-420-5487.