What the rescue crew can't do to save you

THE BALTIMORE SUN

Maryland's emergency medical system has relinquished it role as a leader in bringing the most advanced lifesaving skills to patients wherever they are injured, say some of the state's top trauma specialists.

Inside and outside Maryland, experts are astonished that many rescue companies do not practice a technique considered the "gold standard" of delivering oxygen to patients who have stopped breathing. The technique, called endotracheal intubation, brings air directly to the lungs via a plastic tube inserted into the windpipe.

Perhaps most disturbing of all, a survey of the 24 largest cities in the United States reveals Baltimore to be the only one where the state-of-the-art method is not practiced.

And while the term "paramedic" is used casually to refer to rescue personnel in Baltimore, the city does not employ paramedics except for six who are forbidden from using many of the lifesaving skills they are trained to perform -- including endotracheal intubation.

"When I tell people on the national scene that we do not intubate in Baltimore, the reaction is disbelief," said Dr. Kimball I. Maull, director of the Maryland Institute for Emergency Medical Services System.

"My reaction is embarrassment."

The system appears headed for an overhaul. Dr. Maull and his hand-picked director of emergency medical services, Dr. Richard Alcorta, plan a thorough -- and expensive -- revamping of the splintered system now delivering emergency care in Maryland.

They hope to prevent the confusion that compromised the treatment this summer of a Baltimore woman who lost consciousness in a choking accident.

City rescue crews were unable to restore her breathing because they couldn't intubate her. With her airway blocked, all other methods were useless. So a rescue worker radioed a dispatcher and arranged to rendezvous with a Baltimore County paramedic who could.

With precious minutes ticking away, the city crew sped toward Franklin Square Hospital. Along the way, city and county ambulances met, and pulled into the parking lot of a fast food restaurant.

A county paramedic hopped into the city ambulance, equipment in hand. She pumped oxygen into the patient's lungs, restoring a pink tone to the victim's cheeks. But the woman had gone without oxygen for at least 15 minutes -- about triple the time a patient can tolerate without suffering severe brain damage.

Once at Franklin Square, she was placed on a respirator. The next day she died.

It remains unclear whether the haphazard rescue was to blame. No one really knows how much time elapsed before her relatives discovered her. But, lacking the ability to bring oxygen to her lungs quickly, officials agree, city rescue workers couldn't give her a chance.

Many may be trained

Changes now being drafted call for the nearly 1,400 people working as cardiac-rescue technicians -- mid-level rescue workers in the hierarchy -- to be trained as paramedics. Along the way, they would learn to perform endotracheal intubation and begin to practice it before they receive their paramedic stripes. The process could take several years.

The plan comes at a time when Dr. Maull has drawn fire for shaking up the Maryland Shock Trauma Center and requesting an independent review that found the center to be inferior to many of the nation's leading trauma centers.

Now, Dr. Maull and his associates admit they face a difficult task. Although they hope to raise grant money to defray costs of what could be a multimillion-dollar task, they must persuade local fire chiefs and volunteers to crank up their own fund-raising to buy new equipment. Volunteers would have to donate more of their own time to get retrained.

"It's a matter of persuasion, peer pressure, ethics," said John Donohue, director of emergency medical services for Baltimore and the surrounding counties.

A look across Maryland reveals a patchwork approach to delivering emergency medical care to citizens.

People living in several counties, including Baltimore, Anne Arundel and Prince George's, are served by paramedics skilled in methods such as endotracheal intubation. Even there, paramedics are barred by state rules from using other lifesaving techniques that have caught on in states such as New Jersey.

In other many other counties, including Carroll and Harford, paramedics work in some communities but not in others. And in Howard and several Eastern Shore counties, citizens aren't served by any paramedics.

This means the best-trained personnel on most of the state's ambulance runs are cardiac rescue technicians -- dedicated people trained in some rescue techniques but not in many state-of-the-art methods such as intubation. Rather than intubating, they deliver air to the lungs with a technique regarded as less effective and sometimes dangerous.

The uneven character of Maryland's emergency medical services is rooted in two decades of local control. In large part, fire departments decide whether to hire paramedics or cardiac rescue technicians. As a result, expertise differs from county to county and, in some cases, from town to town.

System pioneered here

In the 1970s, Maryland pioneered the concept of a statewide emergency system tied together by a communications network and a helicopter fleet. But that doesn't mean that communities enjoy equal services.

In the 1980s, cardiac rescue technicians were an innovation -- field personnel who could monitor a failing heart, shock it into its normal rhythm and deliver essential medications. But Maryland was slow to progress to the next level of expertise: the paramedic. States like New Jersey, Virginia and Pennsylvania forged ahead.

"No one took the system by the ear and shook it and looked at it carefully and said, 'This is what we need and this is what we don't need,' " said Dr. Alexander Keuhl, director of emergency medicine at New York Hospital. "It wasn't like there was terrible progress, compared to most other places. But it's tragic, because there was such a wonderful start."

John Donohue, director of emergency medical services for Baltimore and the surrounding counties, says it will cost nearly $1.4 million to train the state's 1,365 cardiac rescue technicians to become paramedics. Each person will need 360 hours of training. Equipping just the city's ambulances with paramedic equipment could cost $20,000, he said.

Dr. Ameen Ramzy, who directed the emergency medical system before stepping down last spring, said the state has come a long way since the early 1980s, when there were hardly any paramedics working in Maryland. By 1992, there were 681 paramedics.

"While there may be a certain attraction" to converting all cardiac rescue technicians to paramedics, he said, "one has to weigh what the real benefits will be and what the cost in resources and manpower will be."

Asked about the benefits, many physicians start with one subject. Endotracheal intubation.

Only paramedics can do it. Viewing the throat with an optical device, the paramedic threads a plastic tube through the windpipe to a resting place just inches from the lungs. The paramedic can breathe into the tube, or pump oxygen from a plastic bag.

Cardiac rescue technicians use another tube called the esophageal obturator airway, or EOA. The tube fits into the esophagus like a plug, sealed at the end so air cannot travel to the stomach. Air forced down the tube flows out perforations in the throat. Then, it makes its way into the windpipe and lungs.

There can be problems.

The most terrifying one is the occasional mishap that occurs when a technician accidentally slides the plugged tube into the trachea. This seals the trachea, preventing any air from getting to the lungs.

Physicians say such accidents, although far from commonplace, occur from time to time.

"Have I seen this complication? Yeah several times," said Dr. Brian J. Browne, associate director of emergency medicine at the University of Maryland Medical Center. "It's a complication anyone in the population using it will see."

Such patients arrive at hospitals dead. Doctors say it's impossible to determine whether the tube killed the patient or whether the patient was beyond retrieval when rescue workers arrived at the scene. The point, doctors say, is that the patient doesn't have a chance.

Besides its potential danger, doctors say, the esophageal tube isn't efficient even when it is used properly. While the tracheal tube delivers fresh air directly to lungs, the esophageal tube sends air through a column of "dead" air that is low in oxygen.

The patient must also wear a face mask to prevent air from leaking out -- not a problem if the face mask fits properly. If it doesn't, the patient gets cheated further.

There are no studies proving that the endotracheal tube actually saves more lives than its counterpart. But many doctors are persuaded by the mechanical advantages.

"The bottom line is that people tend to think that the other thing is a perfectly adequate thing to have," said Dr. Browne. "It fills the slot. It's a false sense of security. But it just doesn't work as well."

Maryland lags in other ways as well. Even in jurisdictions where paramedics ply their trade, state rules bar them from using techniques such as "pleural decompression" -- a way to reinflate collapsed lungs by sliding a needle through the chest wall.

One result is that students trained as paramedics at the University of Maryland Baltimore County are flocking to other states to practice. Last year, all eight graduates left Maryland. This occurs despite the fact that Maryland taxpayers contribute one-fifth of the program's $380,000 budget.

UMBC plans to play a key role in the reforms now being planned, helping to keep future trainees in Maryland and ease the frustrations of paramedics working here today.

Bruce Walz, a Mount Airy paramedic who teaches in the UMBC program, said he is haunted by his memory of a teen-age boy who fought violently for air after his lungs collapsed in a car accident. The boy desperately needed to have his lungs inflated. But state rules prohibited Mr. Walz from doing it.

"By the time we hit the doors of the Shock Trauma Center, he was in cardiac arrest. The first thing they did there was to stick needles in his chest. But they couldn't revive him. It should have been done 20 minutes earlier.

"It was the most heart-wrenching thing I've witnessed. I get choked up just thinking about it."

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