The Dark Side of Airway Management

While many agree that endotracheal intubation (ETI) is the “gold standard” when discussing airway management, very real concerns about its actual benefit in EMS persist to this day. Those concerns include the training required to attain mastery level; the requirements to maintain that level; recognition of failed ETI attempts and misplaced tubes; and, ultimately, the question of whether there is a benefit to EMS patients even when the technique is performed flawlessly.¹ Clearly these concerns are magnified when discussing a needle cricothyroidotomy or other surgical airway techniques.

While other authors have discussed the complications and pitfalls of ETI, this article reviews EMS litigation cases where those complications and pitfalls were the focal point.

Estate of Elderly Asthmatic Patient v. Very Large City EMS (VLC) 2003

A paramedic ambulance in a very large city is dispatched for a patient experiencing “difficulty breathing.” Upon arrival the crew finds a 75-year-old black female who has been complaining of shortness of breath for more than 12 hours.

She has a 40-year history of reactive airway disease and is an avid cigarette smoker. She is on multiple medications for the RAD and also hypertension. The patient lives on the sixth floor and the building’s elevator is out of service.

As per the PCR, she takes an albuterol (Proventil) rescue inhaler and montelukast (Singulair) for the RAD, and an ACE inhibitor, as well as furosemide (Lasix) and potassium supplements for the HTN. As the crew places her on high-flow oxygen, her vital signs and a physical are obtained. Her BP is 120/60, HR 120, pupils are equal and responding to light. Her lung sounds demonstrate profound wheezes that do not clear with coughing. The patient is also exhibiting cyanosis in the lips and mucous membranes in the mouth.

Under standing orders, the paramedics administer Albuterol Sulfate 0.083% (one unit dose of 3 ml) by nebulizer at a flow rate that delivers the solution over 5 to 15 minutes.

After this intervention the patient is no better. The crew repeats the nebulizer treatment and documents “there still is no change in the patient status, except that her breathing is a bit shallower.

Once again, the crew elects to try a third dose of albuterol. They have now been on the scene for 45 minutes. The location is 10 blocks from the receiving hospital. Once the third dose of albuterol has been inhaled, they administer ipratropium bromide 0.02% (one unit dose of 2.5 ml) by nebulizer.

All of this is within the VLC paramedics’ standing orders. However, the crew missed the following note in black, bold letters in the protocols: Under no circumstances should you delay transport to administer additional nebulizer treatments.

By this point, the patient is not responding positively to the treatment provided by the paramedics and is, in fact, getting worse. The paramedics decide to put the patient on a stair chair and begin to carry her down the six flights of stairs. After nine minutes they reach the first floor and realize the patient is no longer breathing but has a pulse at 110/min.

The paramedics take her out of the chair, put her on the floor and begin ventilating her with a BVM and supplemental oxygen. They decide to perform endotracheal intubation. A 7.5 mm ET tube is placed and the paramedic performing the intubation states that he saw “it got through the cords.” (Note: no lung sounds were auscultated as per the paramedic documentation, nor were they documented in the narrative of the PCR. The check off box that said “auscultated lung sounds” was not checked at all.)

The patient is transported with no end tidal CO₂ detection or waveform capnography. This is due to the fact that the committee that oversaw VLC ALS at the time had yet to mandate the presence of these devices on their ambulances.