Nearly a dozen patients died at Rhode Island hospitals in the past three years after being improperly intubated by EMS crews, according to an investigative report from ProPublica.
Nick Asselin, DO, an assistant professor of emergency medicine at Providence, R.I.-based Brown University, identified the pattern of deaths while conducting research on cardiac arrests in summer 2018.
He discovered 11 instances in which patients died after being brought to Rhode Island emergency departments with misplaced breathing tubes over the past 2 and a half years. The medical error, called esophageal intubation, causes air to travel into patients' stomachs rather than lungs.
In every case, the patients died at the hospital. While it's impossible to know whether correct breathing tube placement would've saved these patients, many received immediate CPR and had heart rhythms that may have responded to defibrillator shocks, ProPublica noted.
None of the errors were documented on EMS reports or reported to state health officials, suggesting that EMS crews failed to recognize the mistakes. Hospitals are required to report safety events that occur within their facilities, but mistakes that occur outside of the hospital — like unrecognized esophageal intubations — fall on ambulance services to report, according to Joseph Wendelken, a spokesperson for the Rhode Island Department of Health.
Dr. Asselin presented his findings to the state's Ambulance Service Coordinating Advisory Board in March 2018. In response, the board issued a new requirement that all EMS providers must consider less aggressive measures before intubation.
To view the full report, click here.