Paramedic Intubation Errors: Isolated Events Or Symptoms Of Larger Problems?

Abstract

Paramedics provide life-saving emergency medical care to patients in the outof-hospital setting, but only selected emergency interventions have proved to be safe or effective. Endotracheal intubation (the insertion of an emergency breathing tube into the trachea) is an important and high-profile procedure performed by paramedics. In our study population, we found that errors occurred in 22 percent of intubation attempts, with a frequency of up to 40 percent in selected ambulance systems. These findings indicate frequent errors associated with this life-saving technique. These events might be emblematic of larger issues in the structure and delivery of out-of-hospital emergency care. (EMS) to patients suffering life-threatening conditions such as cardiac arrest, respiratory failure, and major trauma. Paramedics often must perform endotracheal intubation (ETI), the insertion of a breathing tube into the trachea (windpipe), on these critically ill patients. Intubation is regarded as one of the most important EMS procedures and has been the standard of care in the United States for more than twenty years. 1 ETI is a complex procedure. Considerable skill is required to maneuver the breathing tube into the correct position. An improperly placed tube (for example, in the esophagus) can deprive the patient of oxygen and rapidly lead to death. Physician trainees in anesthesiology, critical care medicine, and emergency medicine spend many hours in controlled settings learning and practicing this difficult procedure. In contrast, paramedics undergo only a fraction of the training in ETI that physicians receive. Furthermore, paramedics perform ETI in uncontrolled, stress-

Part 14: Pediatric Advanced Life Support

“…[45][46][47][48][49][50][51][52] In the prehospital setting it is reasonable to ventilate and oxygenate infants and children with a bag-mask device, especially if transport time is short (Class IIa, LOE B). Bag-mask ventilation requires training and periodic retraining in selecting a correct mask size, maintaining an open airway, providing a tight seal between mask and face, providing ventilation, and assessing effectiveness of ventilation (see Part 13, "Pediatric Basic Life Support").…”

The impact of prehospital resuscitation research on in-hospital care

“…[58][59][60][61] Carbon dioxide measurement was seen as a viable method to definitively confirm correct endotracheal tube placement after intubation and is now a mainstay of prehospital airway management. However, its usefulness has extended beyond a simple dichotomous check of endotracheal tube placement.…”

Patient safety in emergency medical services: executive summary and recommendations from the Niagara Summit

“…Despite the substantial body of research on the safety of paramedic intubation, [4][5][6][7][8][9][10][11][12][13] there was skepticism among participants that intubation failure contributes to a significant proportion of adverse outcomes. Unfortunately, our current data are unable to resolve this issue.…”

“…Wang and colleagues used a populationbased data set in an effort to identify the shortcomings of documentation with respect to intubation and our subsequent inability to comment on adverse events related to advanced airway techniques. 13,14 What remains lacking is a common set of definitions and reporting on intubation attempts, successes, and failures. Sixty-two percent of participants rated intubation as an important issue, and 68% felt that it was feasible to address.…”