In 2013, a 13-year-old boy was involved in a skateboarding accident in North Carolina.1 He went to a local hospital, where a CT scan found no signs of bleeding, but doctors suspected a skull fracture and transferred him to a trauma center. Prior to putting him into the ambulance, they sedated and intubated him. En route to the hospital, according to a lawsuit filed by his family, the sedation wore off and he woke up. He pulled out his tube and had to be restrained by the paramedic, nurse, EMT, and respiratory therapist in the ambulance. They administered sedatives and paralytics, and reintubated him.
They did not, however, use end-tidal carbon dioxide (etCO2) monitoring to confirm tube placement or continuously monitor his airway. As his oxygen saturation levels decreased and his heart stopped beating, they never discovered the tube was in his esophagus, effectively cutting off his air and oxygen supply. Doctors later discovered the problem and reintubated. He regained a pulse and his oxygen saturation levels immediately returned to normal. But by then it was too late. He had gone too long without oxygen and it was determined he had no brain activity. Life support was withdrawn and he died soon after.
Better monitoring of airways with continuous capnography and pulse oximetry can help prevent more cases like this.