By Robert Davis
USA Today
Copyright 2007 Gannett Company, Inc.
All Rights Reserved
HOUSTON — On some emergency runs, Houston Fire Department paramedic Charles Harper calls for his new rescue breathing tool before he has even seen his next patient.
Harper, who has been a medic for 20 years, can often hear the fluid in someone’s lungs from a room away. “You can hear them gurgling before you even get to them,” he says. “They are drowning in their own fluid. It is one terrible way to suffer and die.”
This crisis is often caused by congestive heart failure, which kills 53,800 people and costs the nation nearly $28 billion a year in health care expenses, American Heart Association data show.
For more than 30 years, paramedics have been saving the lives of these patients by inserting, through the vocal cords, a breathing tube about the width of a small garden hose and then pushing air into the lungs with an inflatable bag. Called intubating, it’s the street version of a hospital’s mechanical ventilator.
But the aggressive treatment is very uncomfortable for those on the receiving end, and it carries the risk of dangerous infection. So a device more commonly found in the hospital is making its way into the nation’s ambulances, including Harper’s rig in Houston.
Harper asks firefighters to bring him the breathing device known as CPAP, for continuous positive airway pressure. The football-size device with long plastic tubing and a plastic mask is being used now by emergency crews in seven other big cities, including Miami and Boston. Another 16, including Atlanta and Philadelphia, plan to put the device in ambulances soon, this month’s Journal of Emergency Medical Services (JEMS) reports.
The device has been used by hospitals for about 15 years. More recently, it has been used in homes to help people with sleep apnea get a full night’s rest. An ambulance CPAP costs about $900.
Delay born of fear
Congestive heart failure can cause fluid buildup in the lungs, leading to one of the most dire respiratory emergencies: severe pulmonary edema.
Because the heart has been weakened by disease, blood does not flow through the lungs with normal force. As a result, something as common as eating too much salt can cause plasma to seep into the tiny sacs of the lungs where air is exchanged. Patients feel as if they are suffocating as fluid from their blood fills their lungs.
Heart-failure patients often try to sit up straight and labor through hours of breathing difficulty — hoping their lungs clear with time — before seeking help. Those who have had breathing tubes inserted in the past sometimes delay the call out of fear of another tube.
“Intubating a conscious patient for pulmonary edema is scary for everyone involved. It’s scary for the patient, and it’s scary for the paramedic,” says David Persse, Houston’s EMS medical director.
Even when a breathing tube is placed properly, there is the danger that the patient will contract a particularly deadly infection known as VAP, for ventilator-associated pneumonia. The pneumonia is included in several nationwide patient safety initiatives because about half of the people who develop it die.
The CPAP device often prevents the need for a breathing tube because oxygen can be given through the breathing mask to push the fluid out of the lungs and back into the bloodstream where it belongs.
“The relief is almost immediate,” says James McCarthy, medical director at Memorial Hermann’s emergency center. “It’s incredible to see. From a health-provider standpoint, you look like a hero.”
Once the fluid crisis is resolved, doctors can treat the underlying causes, such as sodium or medication imbalances. Many patients can return home within a day or so.
‘We need an alternative’
Patients who arrive at the hospital with breathing tubes inserted by paramedics typically end up in the intensive care unit, where the first day of ventilator care alone costs $8,000.
If even a fraction of these intubations were prevented by using CPAP, Memorial Hermann officials estimate, at least $800,000 a year would be saved in “vent” costs.
Thomas Flanagan, chief operating officer, says the hospital has given the Houston Fire Department enough CPAP machines and breathing devices to treat 900 patients as part of a growing partnership that aims to provide higher quality care while streamlining emergency medical services.
Persse, who is also the head of Houston’s Public Health Authority, says, “Sure, the paramedics can do the more dramatic thing and intubate the patient, but that is not necessarily the best thing to do. It’s the wise paramedic who knows we need an alternative to intubating patients.”
Some states are going further with CPAP, allowing emergency technicians with only basic training — those not trained as paramedics — to use the device.
Wisconsin started allowing EMTs to use the device in 2003 and now makes it part of their basic training, according to the JEMS report. Other states have followed, including Louisiana, Minnesota, Ohio, Oklahoma, Pennsylvania and Tennessee.
Harper says the device is not always enough for the sickest patients, who still need intubation.
But as patients learn that CPAP is on the rigs, he says, some may call 911 sooner for help: “They sit there for several hours trying to avoid going to the ER.”