- © 2004 Canadian Medical Association or its licensors
Richard Verbeek and associates1 conclude that “paramedics should not intubate patients with SARS-like symptoms in the prehospital setting,” presumably because of the risk of contracting severe acute respiratory syndrome (SARS). I disagree with this sweeping prohibition.
First, the only evidence provided that such intubations pose a risk is a single case report,2 which did not even involve paramedics. That intubation occurred in the intensive care unit of a teaching hospital and was anything but typical. The procedure was prolonged, and both bilevel positive airway pressure and high-frequency oscillatory ventilation were used, procedures likely to create a viral aerosol and considered unacceptably dangerous by physicians experienced in the treatment of SARS (H. Dwosh and H. Wong, Department of Medicine, York Central Hospital, Richmond Hill, Ont.: personal communication, 2003). In contrast, many straightforward intubations of patients with SARS were performed without incident during the Toronto outbreak.
Second, the authors make no attempt to quantify the risk to paramedics. Instead, their recommendation is based on the conclusion that it is difficult to follow the procedures required by the provincial government's directive.3 However, this directive is not evidence-based. A more reasonable conclusion would be that the Ontario government directive is impractical and should be reconsidered.
Third, the authors fail to place SARS-like illness into an epidemiological context. Obviously, SARS is a meaningful risk only in communities that are experiencing a SARS outbreak. At the moment, this does not apply anywhere on the planet. Even in a community that is experiencing a SARS outbreak, the probability that a prehospital patient who has “SARS-like symptoms” and who requires prehospital intubation actually has the disease is small. If it can be ascertained that the patient is not a hospital worker or a recently discharged (within 10 days) inpatient, the probability becomes very small indeed.
There is no reason to believe that a straightforward intubation of a low-risk patient poses an unacceptable risk to paramedics using reasonable and practical precautions. This risk analysis applies to the great majority of prehospital intubations during a SARS outbreak and, at present, it applies to all prehospital intubations throughout the world.
The sweeping recommendation of Verbeek and associates1 will compromise patient care while offering no benefit to paramedics. This is just the latest example of a self-inflicted wound from our misguided response to SARS.4
Richard E. Schabas Chief of Staff York Central Hospital Toronto, Ont.