Emergency Medical ServicesMisplaced endotracheal tubes by paramedics in an urban emergency medical services system*
Introduction
Placement of endotracheal tubes (ETTs) in the field by paramedics is a well-accepted out-of-hospital procedure used to obtain definitive airway control. Several studies have reported the incidence of unrecognized, misplaced endotracheal intubations in the field to be low, typically 1% to 5%1, 2, 3, 4, 5 (Table 1).In the majority of these studies, verification of tube placement was performed in the field. It was our clinical impression before conducting our study that the incidence of patients with misplaced ETTs on arrival to our emergency department was substantially higher than that reported in the literature. To our knowledge, no study had investigated the actual incidence of misplaced ETTs on patient arrival to an ED.
The literature has addressed the utility of confirmatory devices to verify ETT position.6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 Although well accepted as the standard of care by anesthesiologists in the operating room,10 the role of end-tidal carbon dioxide (ETCO2) devices has not gained universal acceptance in the out-of-hospital setting.6, 7, 8, 9 The purpose of our study was to determine the incidence of unrecognized misplaced ETTs that had been inserted in the field, in an emergency medical services (EMS) community in which ETCO2 monitoring was not consistently used.
Section snippets
Materials and methods
This study was conducted at an urban, Level I trauma center teaching hospital between May 1, 1997, and December 31, 1997. Our purpose was to assess the incidence of unrecognized, misplaced ETTs inserted by paramedics in an urban, decentralized EMS system. The institutional review committee determined that patient consent was unnecessary because of the observational and quality assurance nature of the project.
The county EMS system used a 2-tiered response with multiple providers (Table 2).
Results
The study patients included the 108 intubated patients who were brought by paramedics to the ED during the 8-month study period. On 2 occasions, study forms were completed the next day after review of the ED patient log by the research nurse revealed the absence of completed study forms. Direct laryngoscopy was used to evaluate 63% (68/108) of the tubes. In 43% (35/81) of the cases, tubes were deemed to be endotracheally placed by virtue of the presence of bilateral breath sounds, appropriate
Discussion
The incidence of unrecognized, misplaced endotracheal intubations in the present study is alarming, and substantially higher than in previously reported series. We believe there may be several explanations for this discrepancy. All of the previously published series1, 2, 3, 4, 5 were conducted in EMS systems directed by academic EMS directors with tightly controlled oversight of paramedic training and practice. Evaluation occurred in the field with researchers present during the procedures.
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Address for reprints: Jay L. Falk, MD, Department of Emergency Medicine, Orlando Regional Medical Center, 86 West Underwood, Suite 200, Orlando, FL 32806; 407-237-6324, fax 407-649-3083; E-mail [email protected].