A Tragic Medical Mistake

In a medical emergency, intubation -- a tube that brings oxygen to the lungs -- is often the first step in saving a person's life. But in the throat -- right behind the windpipe -- lies the food pipe that leads not to the lungs, but the stomach. As CBS News Correspondent Paula Zahn reports for Eye on America, emergency personnel don't always realize when they've put the tube in the wrong place -- a mistake they could easily avoid.

About five years ago, when seven-year-old Abbey Ramos woke with a fever, her grandmother, Alicia Rodriguez, walked her into a Texas Panhandle emergency room. Almost immediately, complications arose. Abbey had trouble breathing; doctors had to intubate her.


Within seven hours, Abbey's life changed. Abby had become brain damaged, doctors say, because the intubation air tube went to her stomach, not her lungs. Her brain was deprived of much needed oxygen.

Abbey's lawyer, Kent Buckingham, showed CBS News an X-ray that was taken somewhat shortly after the child went into the emergency room. After the intubation, her stomach was distended with air.

Medical studies indicate Abbey's misplaced tube was not an isolated catastrophe; paramedics and emergency doctors can initially misintubate anywhere from 12 to 50 percent of their patients.

"Hundreds or thousands of people that probably could have been saved have died needlessly because we didn't realize where the tube was," says Dr. Corey Slovis, who runs the emergency department at Vanderbilt University Medical Center in Nashville, Tenn.

"Good doctors and good paramedics have made bad mistakes and not realized it," Slovis says. "Sometimes it s that with all the noise, all the excitement, everything else that's going on, you don t realize that you re in the wrong location. And sometimes you can't tell where the tube is," he adds.

Abbey's story is just one of hundreds, experts say, where tragedy might have been avoided with proper intubation. And if that's not enough, consider this: nearly all of these misintubations, doctors add, could have been prevented.

In fact, Salt Lake City doctor Tim Wolfe found that something as simple as a $6 suction device could determine whether the tube was in the right place. Once squeezed, if the bulb does not refill with air, the intubation is not working. Dr. Wolfe designed and markets one of these devices today. Another, more common one measures carbon dioxide. If the lungs are producing carbon dioxide, the intubation is good.

But amazingly, Dr. Wolfe says, the majority of emergency rooms across the country don't use them.

Why? Some doctors and paramedics say they cost too much. Others say they're not necessary, that good medical judgment is enough.

"What this comes down to i hubris, sinful pride," Slovis says. "I know that I can intubate. I know where that tube isÂ…The problem with being wrong is it won't hurt my pride, but it might kill somebody."

"She used to be just a normal little girl," Rodriguez says.

"It's very hardÂ…I don't have the words to tell you how hard it is."

Reported By Paula Zahn
  • CBSNews.com staff CBSNews.com staff

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