Emergency Medicine

Paramedic errors in lifesaving endotracheal intubation may be a symptom of larger emergency medical system problems

Paramedics must be able to perform endotracheal intubation (ETI), the insertion of a breathing tube into the trachea (windpipe) of critically ill patients, to maintain the flow of oxygen to the brain and other vital organs. An improperly placed tube (for example, in the esophagus) can deprive the patient of oxygen and rapidly lead to death. Yet, paramedic intubation errors occur in 22 percent of intubation attempts, according to a study supported in part by the Agency for Healthcare Research and Quality (HS13628).

ETI is a complex procedure that requires considerable skill to maneuver the breathing tube into the correct position. However, paramedics undergo only a fraction of the training in this procedure that physicians do. In addition, paramedics perform ETI in uncontrolled, stressful, and chaotic out-of-hospital settings, such as the floor of a cramped bathroom or in a mangled car after an automobile crash. Also, prehospital patients are often critically ill and injured, and it is often impossible to identify basic airway structures. Finally, most paramedics do not perform this procedure frequently. Given these factors, there is great potential for adverse outcomes and errors during ETI, explains Henry E. Wang, M.D., of the University of Pittsburgh School of Medicine.

Dr. Wang and colleagues analyzed data collected from forms prepared by rescuers in 42 advanced life support emergency medical services in Pennsylvania on 1,953 patient encounters involving ETI. The researchers identified ETI errors such as breathing tube misplacement or dislodgment from the trachea, multiple attempts to perform ETI (four or more efforts to expose the vocal cords), or failed ETI. Overall, errors occurred in 22 percent of intubation attempts and up to 40 percent of the time in selected ambulance systems. ETI errors were not associated with system configuration (ground vs. air medical), personnel patterns (all career vs. mixed career/volunteer), the number of paramedic-level rescuers, mean response or transport times, or population characteristics. The researchers suggest that these errors may be a symptom of larger problems with delivery of out-of-hospital emergency medical care, which has not changed since its conception over 25 years ago.

More details are in "Paramedic intubation errors: Isolated events or symptoms of larger problems?", by Dr. Wang, Judith R. Lave, Ph.D., Carl A. Sirio, M.D., and Donald M. Yealy, M.D., in the March 2006 Health Affairs 25(2), pp. 501-509.

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