Prehospital intubation and SARS
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* Robert J. Burgess
* P. Richard Verbeek
* Brian Schwartz

*   © 2004 Canadian Medical Association or its licensors

We are not surprised by the wide-ranging opinions expressed in response to our commentary.1 The 2 physicians suggest that our level of concern for paramedic protection is unwarranted. Although our commentary did not clearly state that our position was in the context of a SARS outbreak as intended, we continue to feel that prehospital intubation of patients with SARS-like symptoms (SLS) in this circumstance poses an unacceptable risk to paramedics. During a SARS outbreak, all patients with SLS should be considered to have SARS until proven otherwise. Schabas' statements regarding ascertainment and the risk of intubation lack insight into the uniqueness of the prehospital environment where occupational and admission histories are frequently unavailable and intubation of a febrile, coughing patient is never straightforward. Moreover, he fails to recognize the evidence that all paramedics who contracted SARS did so by coming into contact with people who were neither hospital workers nor recent inpatients.2 Interestingly, the situations in which Ovens prescribes risk-taking behaviour for paramedics are areas where efforts to reduce risk are ongoing. These include limitations on the use of lights and sirens and the introduction of safe catheters for intravenous initiation.3,4 

We feel it is no more acceptable to expect underprotected paramedics to intubate patients with SLS during a SARS outbreak than to have underprotected paramedics enter a building with a suspected Sarin gas release. Would Ovens want to send paramedics headlong into the Sarin fog under the guise of an “occupational hazard”? Who would want to perform an awake intubation, on a patient with SLS lying on a landing between 2 staircases, without having access to the specialized protective equipment he calls for in a recent Canadian Association of Emergency Physicians position statement?5 

Urszenyi construed our commentary to suggest that all situations requiring airway management pose an identical threat. Our premise is quite the opposite. In the end, the paramedic will make the final decision as to whether to intubate a patient with SLS. Our responsibility is to define potential risk, provide guidance and suggest alternatives. We do not feel it is appropriate for paramedics to be expected to “go it on their own.”

We are unaware of any evidence that the “new normal” standard of PPE fails to protect paramedics, as asserted by Hutcheon. Nor are we personally aware of any paramedic who developed probable or suspect SARS once PPE was introduced for all patient encounters. Hutcheon's description of a powered helmet-style PPS is intriguing. We and many others consider this equipment to be necessary but not sufficient to create optimal circumstances for intubation of patients with SARS and SLS.5,6 

Our recommendations are in no way a disservice to the bravery and commitment of paramedics. Instead they demonstrate that we consider paramedics to be “canaries in the mine” and at higher risk than most other health care workers. Emergency medical services administrators and medical directors understand this and are working to create guidelines that respect the primacy of the “principle of paramedic safety.”4 Our paramedics deserve no less.

**Robert J. Burgess** Advanced Care Paramedic **P. Richard Verbeek** **Brian Schwartz** Divison of Prehospital Care Sunnybrook and Women's College Health Sciences Centre University of Toronto Toronto, Ont. 

## References

1.  1. Verbeek PR, Schwartz B, Burgess RJ. Should paramedics intubate patients with SARS-like symptoms? [editorial]. CMAJ 2003;169(4):299-300.
    
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2.  2. Varia M, Wilson S, Sarwal S, McGeer A, Gournis E, Galanis E, et al. Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS) in Toronto, Canada. CMAJ 2003;169(4):285-92.
    
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3.  3. Peate WF. Preventing needlesticks in emergency medical system workers. J Occup Environ Med 2001;43(6):554-7.
    
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4.  4. Kahn CA, Pirrallo RG, Kuhn EM. Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis. Prehosp Emerg Care 2001;5(3):261-9.
    
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5.  5. Ovens H, Thompson J, Lyver M, Murray MJ, Innes G, on behalf of the Canadian Association of Emergency Physicians (CAEP). Implications of the SARS outbreak for Canadian emergency departments [position statement]. *Can J Emerg Med* 2003:5(5);343-7.
    
    

6.  6. Cooper A, Joglekar A, Adhikari N. A practical approach to airway management in patients with SARS. CMAJ 2003;169(8):785-7.
    
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