RI’s Civic Society Needs a Breathing Tube


Lynn Arditi’s latest Boston Globe story — “Rhode Island EMS crews brought patients to the hospital with misplaced breathing tubes: None of them survived” — is more disturbing than the headline itself can convey.  If Rhode Island doesn’t respond to the relatively easy diagnosis of its civic illness, then the state won’t long survive.  What makes the story so worrisome is that it brings out the deeper, metastasized corruption behind the most straightforward part problem.

The surface issue is the power of insiders (in this case, the firefighters’ unions that represent most of the state’s emergency medical service workers) to shape public policies in ways that look self-interested.  In Arditi’s telling, a Rhode Island doctor conducting some research on the effectiveness of different care strategies came across a tangential concern:

In the world of emergency medicine, an unrecognized esophageal intubation is a “never event,” meaning that it shouldn’t happen under any circumstances.

In Asselin’s study, the rate of unrecognized esophageal intubations was about 4%.

An esophageal intubation can occur if an EMS provider accidentally misplaces the breathing tube or if the tube slips out of place during chest compressions or while the patient is being moved. EMS providers are supposed to confirm the tube is properly positioned by using special monitoring devices, as well as listening for breath sounds.

As Dr. Nick Asselin worked to bring appropriate attention to this finding, the unions and associated special interests swung into action, overwhelming a push for reform, even getting their friends in the General Assembly to change the makeup of the Ambulance Service Coordinating Advisory Board in their favor, cutting out the state Health Department.  One hearing left Asselin shocked:

Paul Valletta Jr., a lobbyist for the firefighters union, also denounced the proposal [to restrict intubations to paramedics, rather than EMT-Cardiacs] to the board, saying, “we’re the experts … not doctors who are doing it when they’re in nice ORs or nice ERs with bright lights and a lot of people helping them.”

People in the audience applauded.

This attitude, combined with the information that RI is one of only a few states that bucks national standards to let non-paramedics intubate, can go straight on the stack of factors that make Rhode Islanders question whether our way of doing government makes our state a wise investment with our lives.

But the problem isn’t only the plain power of special interests.  That would be bad enough, but look at how Valletta frames the issue in stark language of conflict with people his union’s members ought to consider to be on their team trying to save residents’ lives.  This isn’t how organizations or systems identify and fix problems for the good of all; it’s how thugs keep people from questioning them… ever… if they know what’s good for them.

Worse yet, it’s not just Valletta, whose horrible reputation needs no recitation, here.  Johnston Mayor Joseph Polisena (himself a former EMT-Cardiac) uses the same framing.  “The cardiacs are under a full scale attack,” he told the advisory board.  Changing policies would “punish” EMTs, which he suggested was part of a power grab from doctors.  “I might as well give you the keys and you can run the town hall!”

This attitude is arguably at the core of all of Rhode Island’s problems.  It poisons everything.

Consider that the EMTs might have a reasonable point to make.  Arditi appears, for some reason, to be content to rely on Asselin’s assertion that misplaced breathing tubes are a “never event” that just shouldn’t happen, and therefore 4% is outrageously high. Even a cursory search suggests that might not be reasonable.  A study published in HealthAffairs finds misplaced or dislodged breathing tubes to be found in 3% of cases.  A smaller study found misplacement in 25% of cases.
A summary essay published by the National Center for Biotechnology Information of the National Institutes of Health notes that finding as an outlier, citing other research with a range of 0.4% to 12%, which the authors suggest may be somewhat lower than reality.

Whatever the actual number may be, the point is this:  Rhode Island’s civic system leaves residents with no reason to be confident in its ability to evaluate critical questions and find the best answer.  For that, we would need everybody to feel encouraged to bring potential problems into the light and propose solutions.  We would need other stakeholders — even special interests like the labor unions — to address suggestions and criticism with a collaborative attitude, not confrontation.  And we would need journalists to report all of the relevant information so members of the public and decision makers could come to their own conclusions.  (In fairness, that’s a lot easier for journalists in an environment in which all sides bring forward evidence rather than emotion-laden us-versus-them sneers.)

Until Dr. Asselin stumbled upon his data, we (as a community) had no idea how much of a problem misplaced breathing tubes might be, and we still don’t really know.  Shouldn’t we?  Isn’t it in our interest to track these things and have various constituencies periodically reviewing them?  Of course it’s in our interest, but it’s not in the interest of special interests.  For them, tracking and debating data always carries the risk that somebody might find a problem that leads to a reduction in their compensation and their political power.

  • Joe Smith

    Justin – Shouldn’t we be pushing then for choice when it comes to our selection of EMT services?

    Should town councils be passing ordinances that publish the cost of the various EMS/ambulance providers and what insurance they take?

    Some metrics on their competency (response times, misplaced breathing tubes) and against some benchmarks (like Massachusetts they are so good at everything)?

    Provide for the ability of families to select their preferred provider (and use a lottery if oversubscribed) so (except for extreme emergencies) the dispatch knows the preferred provider to send?

    Wouldn’t choice and transparency/accountability improve EMS services?

    • Justin Katz

      I was going to respond, but as I sat down to do so, it occurred to me how manifold and significant are the differences between the circumstances of EMS and schools (and therefore school choice), which is clearly the connection you’re making.

      • Joe Smith

        So we shouldn’t have metrics and accountability for municipal services, especially ones that are either granted quasi-monopoly status by the government?

        Maybe I’m a little touchy because my child got hit with $1,500 ambulance charge for a non-emergency situation (meaning there was time from my notification to allow me possibly to either pick him up myself or choose a private service at well under half that cost). But I had no choice because there was no mechanism in the dispatch system for me to “choose” my preference so I control the service as opposed to the dispatch system selecting for me based on my location.

        Right, maybe I prefer the closest, but maybe I prefer the cheapest. Maybe I’d prefer the one with the best “scorecard” rating. Why should the government care what my preferences are as long as I take responsibility for the outcome?

        I certainly know there are no published metrics on cost or performance for EMS so it’s a bit of I guess I get whoever the dispatch sends. I mean, why can’t I get a voucher for private EMS and I agree not to use 911 for just EMS?

        and while we’re at it, the local road paving in my neighborhood is awful. Why can’t my neighbors and I get our “share” of what the per mile paving cost is and just let us pick a paving company as opposed to having to use only the town DPW? After all, as long as this company passes some state “certification” as a paver, why should the town care? Maybe more competition will make the local DPW paving better?

        and I’d really like it if I could tap into my neighboring town’s water – it’s softer and tastes better. Why can’t 5% of us enter a lottery to be allowed to opt into their (or another) water system — maybe if we all could pick our water supplier (like I can pick electric supplier and just regulate the distribution network as a natural monopoly) my local water department might do better. Then, I wouldn’t have to pay to supplement my water with my own filtration system!

        • Justin Katz

          OK. As you lay this all out, I’m not seeing the problem. Some services might be easier to do than others, but all these options are worth exploring.

  • Marty MacFly

    Great point Justin. A lot of municipalities in RI and across the country simply assume fire-based EMS is always the best option when in reality there could be better ones. Same goes for what composes an EMS system- the public assumes having more advanced life support (ALS resources) is better for the public, but is it? We hear the phrase “less is more”, and sometimes this is true in EMS. If you have too many ALS units in a system, that can result in skill dilution. Look at Seattle- they have a population that is 6x greater than that of Providence, but both have the same number of ALS units (7). Guess which one has better intubation success rates and pt outcomes? Seattle Medic One. How do they do it? The low acuity calls (stubbed toes, sprains, minor illnesses) are handled by basic life support (BLS) units to free up the ALS units for higher-acuity calls, allowing them to get better at treating these few very sick/injured patients. That is why Providence uses more ALS units- they have to handle both the high and low-acuity calls. Would you rather have the paramedic who has intubated 10 patients in the last year intubate, or the one who has only performed 1 intubation? It’s a matter of fiscal efficiency too- ALS resources cost more than BLS ones. Why invest in so many ALS resources when adding a couple BLS ones instead could effectively manage lower-acuity calls in a more efficient manner? The taxpayers of RI should be furious about hearing this- higher public costs for more inefficient service! So what do you do? I say it’s threefold. A.) Restrict ETI to paramedics only. This is a high-risk low-frequency skill that is not done often. When it is done, it should be done by a provider who is invested in the skill. RI has a lot of cardiacs and not a lot of paramedics. An obvious solution would be to follow NHTSA guidelines and let only medics do it. B.) Further regulate the skill. If you are to be a paramedic eligible to intubate, you should be doing quarterly intubation testing in the state. Every call where a patient was intubated needs to be reviewed thoroughly by the service and medical director. Heck, I believe every medic should have to get X number of intubations on live humans annually in order to continue the skill. If, not they need to go the hospital to practice intubations in the OR or ER. IF the hospitals get upset over this, then they ought to know the community will be deprived of this highly-advantageous intervention if they don’t help train their medics. C.) Mandate better technology to perform ETI. Videolaryngoscopy needs to be a mandated item on all intubation-capable ambulances in the state. Same for RSI and surgical cricothyrotomy. If you cannot trust a paramedic with these, you should not trust them with just a plain old laryngoscope and breathing tube.