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.

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