To the Editor:
Timmermann et al. (1) reveal a troublesome, but not surprising truth about prehospital emergency care: esophageal intubations occur, depending on the person performing the task, the level of training, the patient, and the situation at the scene. The fact that a certain percentage of esophageal intubations go unnoticed is caused by the same reasons—but also by equipment (not) available to the emergency response team, as Timmermann and von Goedecke et al. (2) point out in their editorial.
The key problem seems to be that those involved on an organizational level, the providers of the ambulance services, not only lack understanding for this rather simple connection, but also do not obey legal requirements published in 2002: availability of a capnometer is mandatory for physician-staffed ambulances and helicopters due to the German and European norms (3,4) setting a minimum standard for equipment.
Years before the 2004 survey of Bavarian physician-staffed ambulance services quoted in the editorial revealing availability of end-tidal carbon dioxide detection devices of only 32.2% (capnometers 28.8%) (5), we had conducted a survey in the neighboring state of Baden-Wuerttemberg: in 2001, a capnometer was available to only 23.3% of physician-staffed services, with an esophageal detection device additionally available in one service, and colorimetric CO2 detection devices carried in 3.5% (6). When we repeated the state-wide survey in fall 2005, these numbers had increased dramatically: capnometer 66.4%, additional esophageal detection device (EDD) in one service, colorimetric devices in 7.5%. However, it remains that a large percentage of emergency medical services send physicians to the scene but does not invest money in mandatory equipment to provide for an adequate standard of care.
Colorimetric devices must be considered an option, but not a standard for the German rescue setting both in light of the wording of the aforementioned norms as well as scientific findings (7) and case reports (8).
Harald V. Genzwuerker, Dr Med
Clinic of Anesthesiology and Critical Care Medicine
University Hospital Mannheim
1. Timmermann A, Russo SG, Eich C, Roessler M, Braun U, Rosenblatt WH, Quintel M. The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians. Anesth Analg 2007;104:619–23
2. von Goedecke A, Herff H, Paal P, Dorges V, Wenzel V. Field airway management disasters. Anesth Analg 2007;104:481–3
3. DIN 75079:2002-08. [Fast emergency car for first aid by special medical doctor]
4. EN 13718-2:2002 (D). [Air, water and difficult terrain ambulances]
5. Schmid MC, Deisenberg M, Strauss H, Schuttler J, Birkholz T. Equipment of a land-based emergency medical service in Bavaria: a questionnaire. Anaesthesist 2006;55:1051–7
6. Genzwürker H, Isovic H, Finteis T, Hinkelbein J, Denz C, Gröschel J, Ellinger K. [Equipment of physician-staffed ambulance systems in the state of Baden-Wuerttemberg] Anaesthesist 2002;51:367–73
7. Putervoll SA, Søreide E, Jacewicz W, Bjelland E. Rapid detection of oesophageal intubation: take care when using colorimetric capnometry. Acta Anaesthesiol Scand 2002;46:455–7
8. Srinivasa V, Kodali BS. Caution when using colorimetry to confirm endotracheal intubation [Letters to the Editor]. Anesth Analg 2007;104:738