EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived.

In the summer of 2018, Dr. Nick Asselin was doing research on cardiac arrests in Rhode Island when he made a horrifying discovery.

Hospital records showed patients had been arriving by ambulance with misplaced breathing tubes, sending air into their stomachs instead of their lungs, essentially suffocating them. At first, he said, there were four cases, then seven. More trickled in.

By the time Asselin presented his findings to a state panel in mid-March, he’d identified 11 patients with so-called esophageal intubations that had gone unrecognized by EMS providers over the previous 2 ½ years. All 11 had died.

Jason M. Rhodes, the state Health Department’s EMS chief, recommended a way to tackle the problem that aligned with national standards: restricting the practice of placing those tubes to paramedics, the most highly trained EMS providers. To Asselin and his colleagues at Brown University’s Department of Emergency Medicine, that approach made sense. Rhode Island is the only state in New England, and among a minority nationally, that allows non-paramedics to intubate patients.

But a coalition of Rhode Island’s EMS practitioners, municipal fire chiefs and a city mayor pushed back. They said the “ET tube,” as it’s known, saves lives. Taking it away, as one fire chief put it, “would be a sin.” A lobbyist for the firefighters union lambasted the doctors for not consulting more of its members before proposing such changes, saying, “We’re the experts ... not the doctors!”

In the end, the board didn’t restrict the practice to paramedics, instead requiring that all providers — paramedics and EMTs alike — consider less invasive measures before inserting a breathing tube.

Days after the meeting, 38-year-old Paula Duarte arrived by ambulance at the emergency room of The Miriam Hospital in Providence. As the mother of two lay on a stretcher, unconscious and in cardiac arrest, a doctor noticed that air wasn’t reaching her lungs. The doctor suspected the breathing tube was lodged in her esophagus, pushing air into her stomach. The doctor immediately removed the tube and reinserted it properly.

It was too late.

What happened to Duarte, and the fierce resistance faced by doctors and state health officials to limit who can perform intubations, offer a window into how politics have shaded health care decisions in Rhode Island, and how difficult it is to implement even incremental changes.

In addition, it shows how the state’s 911 emergency response to cardiac arrests lags other states.

Until recently, Rhode Island was the only state in New England where 911 call takers were not trained to provide guidance over the phone on how to perform CPR. That changed this year after The Public’s Radio and ProPublica reported on the deaths of a 6-month-old baby in Warwick and a 45-year-old woman in Cumberland after 911 call takers failed to give CPR instructions to the family or other bystanders.

Rhode Island now has a new 911 center director, and by late winter, all 911 call takers are expected to be trained in emergency medical dispatch, which includes providing CPR guidance over the phone.

Rhode Island remains one of a dozen states that prohibit the release of 911 recordings or transcripts without the written consent of the caller or by court order. In July, The Public’s Radio and ProPublica reported how Rhode Island’s restrictive law, designed to protect the privacy of callers, also keeps families in the dark about calls involving their loved ones, and keeps the public oblivious to troubling lapses in the state’s emergency system.

Increasingly, those pushing for change are the emergency room doctors like Asselin who treat patients when the EMS providers drop them off.

Asselin’s research assistant stumbled upon the problems with patients’ breathing tubes in July 2018, while studying the effects of a new state protocol for cardiac arrest patients.

Asselin wanted to see whether the “30 minute rule” — which requires EMS personnel to spend at least a half an hour on scene performing CPR before taking them to the hospital — had improved patients’ chances of surviving a cardiac arrest neurologically intact. (Preliminary results were promising; the study is ongoing.)

The assistant, a pre-med student at Brown, was reviewing and assigning codes to 2 ½ years of anonymized patient records from Rhode Island’s largest hospital network, Lifespan Health System. All of the 800-plus patients in the database were treated by local EMS agencies and then taken by ambulance to one of Lifespan’s three hospitals: Rhode Island Hospital, The Miriam Hospital and Newport Hospital.

When the research assistant mentioned to Asselin he had spotted some hospital records of patients with their breathing tubes down the wrong pipes, “that sort of sent a chill down my spine,” Asselin said.

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.

Asselin reviewed each case himself, reading the entire hospital record along with the attached EMS patient care report, checking and rechecking the information.

He alerted the state’s EMS medical director, Dr. Kenneth Williams.

Asselin also wanted to get the word out more widely. The World Health Organization says medical researchers have a duty to report practices discovered in the course of research that may put patients at risk. But Asselin said he knew he had to tread carefully: research data is covered by strict privacy rules governed by Brown’s Institutional Review Board, or IRB.

Asselin shared his concerns with two other Rhode Island emergency physicians who, like him, were medical directors for EMS agencies. “How do we feel about reporting our own departments?” asked one colleague, Dr. Joseph R. Lauro.

Dr. Heather Rybasack-Smith expressed frustration that nobody had been reporting these errors to the state health department. “Physicians don’t want to report,” she said. EMS “agencies don’t seem to self-report. And the problems continue.”

The doctors agreed. “We all decided that regardless of what the service was, we’d report it” to the state Health Department, Lauro said. “It’s too detrimental to patients.”

During the fall of 2018, Asselin said, he emailed seven of the eight medical directors for the EMS agencies linked to the esophageal intubations. (He could not locate one agency’s medical director.) Asselin also gave a presentation to emergency medicine physician trainees, stressing the importance of reporting these errors.

Of the 11 patients, only one had been intubated by a paramedic. Eight had been treated by advanced-level EMS providers, called EMT-Cardiacs, who receive less training than paramedics but are licensed by the state to perform intubations. The records of the remaining two patients, Asselin said, did not identify the EMS provider.

The EMS reports on the 11 patients made no mention of any misplaced breathing tubes, Asselin said, suggesting the errors had gone “unrecognized” by the EMS crews. And none had been reported to state health regulators.

Hospitals are required to report errors like wrong-sided surgeries or X-rays ordered on the wrong body part to the state Health Department. But they are under no such obligation for unrecognized esophageal intubations, which occur outside the hospital, Joseph Wendelken, a department spokesman, said in an email. “The obligation falls on the ambulance service.”

That’s “problematic,” Asselin said, because “if they don’t know it’s happening, they can’t report it.”

Lifespan said in a statement that it “would notify EMS if it was clear that there was misplacement [of a breathing tube] and this was clearly a provider error.”

The hospital system also noted that misplaced breathing tubes “were not the focus” of Asselin’s study, but that “we hope this research will help improve prehospital patient care.”

Asselin declined to identify the EMS agencies that provided care to the 11 patients, citing the IRB confidentiality rules.

The records review, he said, also turned up a “wide documentation gap” between different EMS agencies. In some agencies, he said, records of what the EMS providers did to confirm the proper placement of a breathing tube were either missing or incomplete, so it was impossible to tell if the problem was with record keeping or patient care, or both.

“This is when we realized that we were dealing with a system problem,” Asselin said. “We started saying ... we need to do something about this.”

Asselin knew that if he wanted to try to change the protocols for intubating cardiac patients, he’d need the support of the state’s Ambulance Service Coordinating Advisory Board.

As an ER doctor, Asselin was used to navigating emotionally charged conversations. He’d been yelled at, even punched. But nothing in his professional life had prepared him for the politics of Rhode Island’s emergency medical services.

In Rhode Island, the 25-member advisory board generally reviews any proposed changes or updates to state EMS rules or regulations. Though the board’s role, by definition, is advisory, state health officials routinely seek the board’s approval before making any changes in requirements about how local emergency services operate — from what medications they have to stock on their ambulances to the types of medical interventions their EMTs and paramedics can perform on patients.

The single-largest constituency on the board is made up of municipal fire departments. And those fire departments run almost all of the state’s 89 emergency medical services agencies.

The state firefighters union had been bristling for years at the efforts of young doctors, including Asselin, to change the practices around emergency care, as well as attempts by state health officials to revise outdated regulations. They, as well as some municipal leaders, believed that doctors were trying to encroach on their autonomy and drive up costs.

Last year, when Asselin and his physician colleagues wanted to spell out the role of medical directors in state regulations, Johnston Mayor Joseph M. Polisena had accused the doctors of attempting a power grab, saying: “I might as well give you the keys and you can run the town hall!”

One afternoon in mid-March, an unusually large crowd — fire chiefs, unionized firefighters, municipal leaders and their supporters, among others — packed into a conference room at the Community College of Rhode Island in Warwick, spilling into an adjacent room. Asselin took a seat between his two emergency physician colleagues, Lauro and Rybasack-Smith. (Asselin wasn’t a board member; nor was he there on behalf of his employer, Lifespan. He’d been invited that day to sit in for another doctor who represents the Rhode Island Medical Society.)

Asselin, 40, fell in love with emergency medicine while volunteering at a local fire department in Massachusetts, where he was teaching marine biology at a boarding school. If his pager went off, he said, he would sometimes bolt out of class to respond. He later quit teaching to work full time as an EMT before enrolling in medical school.

Asselin knew that to get his message across, he’d have to persuade a majority of the board members that the safety of patients was at stake.

The proposal to restrict EMT-Cardiacs from intubating patients drew swift fire.

Polisena stood to speak. “The cardiacs are under a full scale attack,” he said.

A retired firefighter and licensed EMT-Cardiac, the mayor called endotracheal intubations a “lifesaving” tool. And he urged the board not to restrict them from performing intubations because of “a few misses.” If a particular EMS service is having problems, Polisena said, the board should offer them more training, not “punish” everyone.

During a follow-up interview this fall, Polisena, who had previously served on the advisory board, said that he thinks some board members and the state EMS agency have “an agenda” that includes reducing the role of EMT-Cardiacs and shifting emergency medical services to private companies. “They feel they would have more strength to push them around,” he said.

Paul Valletta Jr., a lobbyist for the firefighters union, also denounced the proposal 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.

Asselin was stunned. He’d worked 11 years as a firefighter/EMT before becoming a doctor. But instead of being seen as their advocate, he was being cast as an adversary.

Smithfield Fire Department Chief Robert W. Seltzer, himself a licensed EMT-Cardiac, told the board that when it comes to performing intubations, the state’s EMT-Cardiacs have more experience than many paramedics. Indeed, “cardiacs” who are licensed to perform intubations now outnumber paramedics by a ratio of 4 to 1. And even some paramedics acknowledge they don’t perform enough intubations to remain proficient.

“If we’re gonna take this skill away because it’s a problem in the field,” Seltzer said, “it needs to be taken away from everybody, not just the cardiacs.”

Seltzer and Polisena got their “cardiac” licenses decades ago, when Rhode Island EMTs trained side-by-side with doctors in hospital operating rooms. Back then, cities and towns wanted EMS providers on their ambulances trained in advanced lifesaving skills, so in the 1970s Rhode Island created a hybrid certification of the EMT and paramedic: EMT-Cardiac.

To get licensed to perform intubations, EMTs had to successfully intubate a dozen patients, the 12th observed by an anesthesiologist. As these EMT-Cardiacs rose through the fire department ranks, they shaped the culture and practice of emergency medical services. These days, most EMT-Cardiacs are taught to intubate only on mannequins.

Asselin offered no impassioned pleas about patient safety. He thought the data was “damning” evidence, he recently said. He’d distributed a summary to a board subcommittee a few weeks earlier, in which he described the findings as “alarming.”

Several of the 11 patients who died, Asselin said, had a lot working in their favor. They had cardiac arrests that were witnessed, so they had quick access to CPR. And they had heart rhythms that could have responded to shocks from a defibrillator when EMS crews arrived, increasing their odds of survival.

But Asselin’s sense of alarm seemed to barely register.

The board voted 15 to 7 to send the proposal back to its rules and regulations subcommittee, putting off any chance of considering it again until next year.

Asselin took the glass-half-full view. He and his colleagues had won an earlier vote requiring that EMS providers refrain from intubating patients unless they’ve tried less invasive airway devices first; that should reduce the use of intubations, he thought, and lower the risk to patients.

Days after the vote, on a Sunday morning in late March, Kerry Duarte of Providence, Rhode Island, was awakened by a phone call from his 11-year-old niece. She had been sleeping next to her mom — Duarte’s 38-year-old sister, Paula — and had awakened to find her mom shaking and unresponsive.

At 6:03 a.m., Kerry Duarte’s 911 call was patched through to the dispatcher at the Pawtucket Fire Department. Within eight minutes, an EMS crew had arrived at the Goff Avenue apartment and began CPR, according to hospital records provided by the family to The Public’s Radio and ProPublica. Paula Duarte had no pulse and her heart rhythm was asystolic, or flatline.

The EMS crew continued CPR for 11 minutes before one of the crew members — a licensed EMT-Cardiac — performed what he later described in his run report as a “successful intubation.” The placement of the tube was “confirmed 3 times ... by 3 different personnel,” according to a copy of the report attached to the hospital record.

As the EMS crew carried his sister out of the apartment on a stretcher, Duarte said, he noticed something odd about her belly. “It looked like it was inflated,” he said.

Duarte, a driver for an ambulance company, had EMS training but never got his license. He’d later recall that a bloated abdomen is a red flag that the breathing tube may be blowing air into the stomach instead of the lungs. But at the time, Duarte said, he was too distraught to question it.

In the emergency department of The Miriam Hospital, a doctor noticed that Paula Duarte’s breathing tube was “malpositioned.” Duarte’s abdominal area was “distended,” the doctor noted in her report, and when the respirator bag was squeezed, “gurgling sounds” could be heard over the patient’s stomach. The report reads: “Suspicion for esophageal intubation.”

The doctor removed Duarte’s endotracheal tube and reintubated her. Then she was given more CPR and more medication. At 7:02 a.m., she was pronounced dead.

It’s impossible to know whether Duarte could have survived if she’d been properly intubated. Duarte had been unconscious for about 30 minutes before the ambulance arrived, the EMS report said.

Pawtucket Fire Chief William Sisson said in a statement that firefighters are held to a high standard and that “the department takes this very seriously and holds every individual accountable for providing the necessary service to our residents.”

But unlike the 11 other patients who arrived at hospital emergency rooms with misplaced breathing tubes, Duarte’s case was reported to the state Health Department, triggering a formal investigation.

Williams, the state EMS agency’s medical director, did not investigate the 11 unrecognized esophageal intubations identified in Asselin’s research data. Those cases, he said, “weren’t officially reported to me in this role or to the Department of Health.” And since the department had not conducted its own investigation, he said, the findings had not been confirmed.

“There is a big difference between knowing that someone has said in a retrospective research study that something occurred,” Williams said, “and actually having investigated it looking at the run reports. So without that detailed information … we couldn’t say what exactly happened.”

Rhodes, the EMS chief who runs the agency’s day-to-day operations, said that with only five other employees in his department, he lacks the staff and resources to proactively investigate. Culling through “several thousand” hospital records, he said, would mean that all of his office’s other work would “grind to a halt.”

A month after Duarte died, though, the state Health Department issued a stern warning to state emergency medical service providers. Without naming Duarte, it sent an advisory saying that a patient had been taken to the emergency department with “an unrecognized intubation tube that was in the esophagus and not the trachea, resulting in death.”

The notice referenced the 11 other cases, saying they represented an “unacceptable high rate” for such errors. It reiterated that providers should try other means before inserting a breathing tube.

The department’s investigation into Duarte’s case found that the EMT-Cardiac who intubated her, Wesley J. Meyer, “never attempted” to use a device to monitor the patient’s exhaled carbon dioxide levels, according to a consent order he signed in September. The device, which plugs into a heart monitor, sounds an alarm if the patient’s carbon dioxide level drops too low. The state’s protocols require that the device be used.

Meyer wouldn’t answer questions about the case, telling a reporter who came to his door, “I don’t want to talk about this.”

Not recognizing that Duarte’s breathing tube was misplaced, and not using the mandated monitoring device, known as waveform capnography, amounts to “unprofessional conduct,” the state’s order said. But those “breaches,” it continued, were “tempered” by the fact that Meyer had already taken steps to “retrain himself on the relevant subject matter,” and that his past performance in EMS is “unblemished.”

Meyer’s EMT license was placed on two years’ probation; his 30-day license suspension was “stayed,” meaning he can continue to practice uninterrupted, according to a state Health Department spokeswoman.

If Duarte’s death and its aftermath chastened EMS providers, it was hard to tell.

During the next few months, the most vocal proponents of intubation went on the offensive.

Polisena, Johnston’s mayor and a former state senator — along with the League of Cities and Towns and the firefighters union — pushed legislation in the General Assembly to remove two Health Department officials from the state Ambulance Service Coordinating Advisory Board.

Rhode Island’s health director, Dr. Nicole Alexander-Scott, opposed their removal, saying in a June 11 letter to a Senate committee chair that doing so “compromises the board’s ability to improve care” in the state. Connecticut and Massachusetts, she said, both have top health officials on their state advisory boards.

The legislation was signed into law by Gov. Gina Raimondo, a Democrat. It replaced Rhodes, the state EMS chief, and his colleague, Dr. Carolina Roberts-Santana, with one seat to be filled by a city mayor, town manager or other municipal official, and another by a licensed EMT. “Rather than having internal employees advise the director, the governor is supportive of expanding outside perspectives,” her spokeswoman, Jennifer Bogdan, said.

The new appointees were Polisena and Albert F. Peterson III, a licensed EMT-Cardiac and retired North Providence fire captain. Peterson heads a private company, American Safety Programs & Training Inc., that trains EMTs and paramedics.

As the battle for control of the board played out, Duarte’s family has been left with questions.

One afternoon in October, Ilidio Duarte, 64, sat in the second-floor kitchen that he’d built for his daughter and her family in his house in Pawtucket.

Paula Duarte was the oldest of four children, and the only daughter of Cape Verdean immigrants who moved to Rhode Island when Paula was 2 years old. Her parents worked in a textile factory in Central Falls. Her father had risen through the ranks to become a production manager before retiring; her mother, who has heart problems, receives disability assistance. (Paula’s parents divorced in 2008.)

Ilidio Duarte scanned a copy of the consent order that sanctioned the EMT who cared for his daughter. “It’s serious,” he said, turning the pages.

Kerry Duarte, Paula’s brother, said he is keeping busy working and taking classes. When he recounted what happened the night his sister died to a reporter in July, his mother sat nearby, quietly weeping.

“For it to happen to somebody else would be pretty sad, you know?” he said then. “And if it does take my sister’s death to awaken the situation, we’ll definitely want to figure out what’s going on and get to the bottom of it.”