Colorado Probing Medical Process Used by AMR

Sep. 14--State health officials are investigating an incident involving a patient treated by American Medical Response, and the ambulance company has agreed to temporarily stop using a procedure unless directed by a doctor.

Details of the July incident that gave rise to the 120-day suspension are few because of confidentiality laws regarding medical care.

But Margaret Radford, vice chairwoman of the Emergency Services Agency that oversees El Paso County's AMR contract, said the complaint involved an AMR medic's use of rapid sequence intubation, or RSI, a procedure used to provide an airway.

The procedure did not result in death, Radford said, but added, "This is a serious case."

RSI commonly uses two drugs -- one that puts the patient to sleep and another, a paralytic, to relax the muscles around the jaw to allow a paramedic to insert the tube into the trachea, AMR's clinical specialist Mark Homan said.

D. Randy Kuykendall, chief of emergency medical and trauma services in the Colorado Department of Public Health and Environment, said he couldn't discuss the pending investigation.

The state regulates emergency medical technicians and paramedics. Possible actions for violating standards of care range from probation to certification revocation, he said. Kuykendall said he recalled no other investigation of AMR workers in El Paso County since he became chief in 2004.

Radford said the ESA board's Medical Control Committee investigated the incident and discussed it during a Sept. 5 meeting for which an agenda was not posted publicly and no minutes kept. The panel's meetings are not taped.

Emergency Services Agency Chairwoman Sallie Clark said the committee will begin complying with open-meetings laws immediately.

The medical committee comprises Dr. Jack Sharon, Dr. Marilyn Gifford, AMR's Homan, Memorial Hospital official Bill Mayfield and Colorado Springs Fire Department medical officer Glenn Conklin.

Although the ESA board can direct how AMR delivers service, AMR voluntarily agreed to suspend the procedure to allow discussion by medical providers about it.

Radford said that no one questions the use of the RSI in a hospital or clinical setting, but that its use in the field by ambulance workers is questioned by some, including Gifford, head of emergency medicine at Memorial Hospital System and the Colorado Springs Fire Department's physician adviser.

AMR has used the procedure in the field under standing orders -- or without constant physician supervision -- for the past seven years, AMR spokesman Mark Bruning said.

"It's one of those procedures that can be extraordinarily important in managing certain kinds of situations that can mean the difference between life and death," Bruning said. "We have a very vigorous quality-assurance program and training program around RSI, and it's something we pay very close attention to."

Bruning said AMR is "open to a full and objective review involving the medical community. If there's a concern, let's get it out from the physicians, medical society and have a discussion."

Although Radford called RSI controversial, others say it's widely accepted as a field procedure, although administration of it varies.

"It is a well-accepted procedure nationwide," said Lt. John Fisk, medical service officer with the Seattle Fire Department's Medic One system where medics have performed RSI in the field for 25 years under physician direction.

"I feel that the direct physician contact is a safety net," Fisk said. "It puts one more person with medical judgment and authority in the picture."

Fisk said bag-valve masks are standard equipment for paramedics' use to help a patient breathe if intubation isn't possible, even after paralytic drugs are given.

"I would rather have, by far, the ability of those paramedics to voluntarily intubate someone (in the field) who needed it than someone dying because of a lack of it in certain circumstances," Fisk said.

Radford said during the suspension, AMR will perform RSI only under the advice and guidance of a physician. It's already happened since the suspension took effect a week ago, she said, with no ill effects.

CONTACT THE WRITER: 636-0238 or pam.zubeck@gazette.com

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