PITTSBURGH RESEARCH Paramedic intubation procedures studied

The use of breathing tubes by paramedics was pioneered in Pittsburgh.
SCRIPPS HOWARD
PITTSBURGH -- In the 1970s, Pittsburgh paramedics began inserting plastic breathing tubes down the throats of trauma patients -- a procedure previously performed only in hospitals -- to help keep them alive until they could reach a hospital.
It made so much sense that today virtually every U.S. city has paramedics who intubate critically injured patients. The problem is that it doesn't seem to be working as intended.
Researchers at the University of Pittsburgh School of Medicine who reviewed thousands of cases from across Pennsylvania found that patients with traumatic brain injuries who are intubated in the field are four times more likely to die than those who are intubated in the hospital.
What's more, those patients who survive after being intubated at the accident scene are more likely to suffer neurologic damage than those intubated in the hospital, the researchers report in this month's issue of the Annals of Emergency Medicine.
It's too soon to say that paramedics should stop intubations, emergency medical specialists say, but it's becoming clear that researchers need to figure out what's going wrong.
"Up until five years ago, people thought this was a good idea," said Dr. Donald Yealy, Pitt's vice chairman of emergency medicine and one of the study's authors. But then several studies began to show that the intubated patients fared poorly.
Studying the conclusions
The study, led by Dr. Henry Wang, is by far the largest of these studies, so its conclusions are difficult to dismiss, according to Drs. Brian Zink and Ronald Maio, emergency medicine physicians at the University of Michigan who wrote an accompanying editorial.
"Patients with severe traumatic brain injury already have the deck stacked against them," they wrote. "If current out-of-hospital airway standards are dealing these patients a bum hand, we need to reshuffle the cards and take a fresh look."
Still, the findings are puzzling. After all, placing an endotracheal tube down a patient's throat has long been considered the definitive method for keeping a patient's airway open. If a patient has stopped breathing or is having difficulty breathing, the tube provides a means of pumping air into the lungs. And if the patient is still breathing, the tube keeps him from choking on his own vomit should he regurgitate.
History in Pittsburgh
The use of breathing tubes by paramedics was one of the innovations pioneered in Pittsburgh by the Freedom House Ambulance Service, one of the first modern emergency medical systems in the country, in the late 1960s and 1970s.
Just why intubation should increase the death rate for patients is not known. It's possible, of course, that intubation by paramedics keeps alive patients who otherwise would have died before reaching a hospital; they obviously would fare worse than less seriously injured patients intubated in a hospital. But Dr. Yealy said the researchers tried to compare only patients with similar levels of injury.
It could be that conditions in the field are simply less conducive to intubation than the hospital, Dr. Yealy said. If that's the case, he said, paramedics should use other means to help patients breathe. Or, intubation might only be appropriate for certain subsets of patients.