Nasal intubation or rapid sequence intubation

into similar billing lengths, except that lacerations between

2.6 and 7.5 cm are grouped into a single billing level [3]. The impact of misestimates of laceration length on billing de- pends on the location of the laceration and where the actual laceration length is within the billing range. Misestimates of laceration length when the actual laceration length is close to either end of the billing range are more likely to result in incorrect billing. For example, a laceration requiring simple repair on the trunk that is 4.5 cm and is misestimated by 1 cm either too long or too short will still be within the correct billing range of 2.5 to 7.5 cm. A 4.5-cm laceration on the face that is overestimated by 1 cm will result in overbilling, but underestimates of 1 cm will not impact billing.

This study is limited in several important ways. It is a survey of simulated laceration instead of actual lacerations. Participants were asked to not use a measuring tool even if they usually do in clinical practice. The survey did not include lacerations of all shapes and sizes that normally occur in practice. Finally, the survey was not designed to determine the actual impact of misestimates of laceration length on billing.

We conclude that emergency physicians frequently mises- timate the length of simulated lacerations when not using a measuring device. Misestimates increase with laceration length and complexity of shape. Misestimates of laceration length may affect patient billing. Use of a simple tape measure may improve accuracy of estimating laceration length.

Michael Lemanski, MD Howard Smithline, MD Fidela S. Blank, RN, MN Philip L. Henneman, MD

Department of Emergency Medicine

Baystate Medical Center Springfield, MA 01199, USA

Tufts University School of Medicine Department of Emergency Medicine

Boston, MA 02111, USA

doi: 10.1016/j.ajem.2005.05.003


  1. Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey; 2002.
  2. Center for Medicare and Medicaid Services (CMS), Washington, DC; 2003.
  3. Current procedural terminology, (CPT). 4th ed. Chicago (Ill)7 American

Medical Association; 2004.

  1. PubMed, U.S. National Library of Medicine’s digital archive of life sciences journal literature.
  2. Google search engine, Google Inc, Mountain View, CA, 94043.
  3. American College of Emergency Physicians (ACEP), Irving, TX, 75038. Personal oral communication with David McKenzie, MD, 2002, reimbursement director, ACEP, Irving, TX. Kenneth DeHart, MD, Carolina Health Specialists, Myrtle Beach, S.C. Mason Smith, Lynx Medical Systems, Bellevue, WA.

Nasal intubation or rapid sequence intubation

To the Editor,

Nasal intubation as a form of Emergency airway management has been largely replaced by Rapid Sequence Intubation [1]. The benefit of RSI, by virtue of paralysis by Neuromuscular blocking agents, is that it facilitates laryngoscopy. The downside is that, with paral- ysis, the patient becomes entirely dependent on the health care providers for oxygenation and ventilation. In nasal intubation, on the other hand, spontaneous breathing is maintained. This mitigates the harm caused by lack of adequate oxygenation and ventilation that may occur if there are difficulties in intubating the patient, or if there is an Esophageal intubation that is unrecognized.

In Jackson county hospital v Aldrich[2], an adult man was severely burned when he used a cutting torch on a barrel containing flammable liquid. After an explosion, he was engulfed in flames for 30 seconds and had extensive and deep burns including the face and neck. While en route to the hospital by ambulance, he received High-flow oxygen. In the ED, he was found to have an increased respiratory rate and had decreased oxygen saturations. The ED physician called a certified registered nurse anesthetist (CRNA) to intubate the patient. In assessing the patient by performing a bquick-look Q laryngoscopy, the CRNA was unable to visualize his vocal cords. Given this, and because the patient was conscious and breathing spontaneously, the CRNA recommended nasal intubation. The ED physician, however, overruled nasal intubation in favor of RSI. During intubation, the CRNA was unable to visualize the vocal cords (she attributed this to burns, swelling, and the patient’s short mandible), and so she was not certain if the endotracheal (ET) tube was in the trachea or in the esophagus. A device attached to the ET tube did not detect the production of carbon dioxide, and the patient’s oxygen saturation did not increase. Concerns about proper place- ment were alleviated by the ED physician’s auscultation of breath sounds over the lung fields and the absence of sounds over the stomach. The patient then received a narcotic pain medication, which was followed within minutes by the loss of his pulse. Resuscitation efforts were unsuccessful. On autopsy, the Medical Examiner found the ET tube in the esophagus.

Nasal intubation is indicated when both of 2 criteria are

present. The first is the inability of the health care provider to perform oral intubation using the preferred technique of laryngoscopy, for example, because the patient is either awake or is unconscious but maintains airway reflexes (the gag reflex or clenching of the jaw) that preclude adequate visualization of airway structures. The second criteria has

2 components: either the lack of availability of use of neuromuscular blockade (the prehospital setting) or the lack of reasonable assurance that laryngoscopy, even with the

muscle paralysis caused by neuromuscular blockade, will provide adequate visualization of airway structures (a known difficult airway).

The patient in Jackson County, having been severely burned, was hypoxic and, because the burns involved the face, required protection against mechanical obstruction of the airway. The patient was awake and breathing spontane- ously. The CRNA, by bquick-lookQ laryngoscopy, recog- nized the presence of a difficult airway. Despite her preference for awake nasal intubation, RSI was performed on the recommendation of the ED physician. Subsequent complications resulted in the patient’s death.

Putting aside the critical importance in ensuring proper placement of the ET tube in the trachea, the degree of sophistication required in choosing between various meth- ods of airway management is highlighted by this case. Although RSI offers important advantages over other forms of airway management, primarily, in its improving laryngo- scopic view, it is not universally available (eg, to emergency medical service providers), and its use does not guarantee success (as demonstrated in this case). Consequently, despite the widespread use of the RSI procedure, nasal intubation should remain an option for health care providers in the management of ED patients.

The legal conclusion to the case was unfortunate for the CRNA [3]. The emergency physician, employed by the hospital, was protected under the state (Florida) Good Samaritan Act. The CRNA, as an independent contractor, was not protected by the Act and was held to a mere negligence standard. The jury found that the physician, by failing to ensure appropriate ET tube place- ment, acted with reckless disregard, thus exempting him from the Act. However, an appellate court reversed these findings and found the physician immune from liability under the Act. Accordingly, the corporation employing the CNRA was wholly liable for the damages. This result was despite the reasoning (as articulated in a dissenting opinion) that it is billogical to infer the legislature intended application of a different standard to medical professionals working as part of the same team, affording greater protection to the person in charge than to those carrying out the orders.. .Q[4]





(blunt, %)

Mark J. Greenwood, DO, JD

Location of injury




  1. Bay Anesthesia v. Aldrich, 863 So.2d 310 (Fla. 2003) (review improvidently allowed; appeal dismissed).
  2. Jackson County Hospital v. Aldrich, 835 So.2d 318 (Fla. App. 2002) at 332 (Miner, J., dissenting).

Predictors of inner-city recurrent violence-related injuries

violence-related injury (VRI) is a major source of morbidity and mortality in inner-city populations. Nation- wide, there are roughly 1.6 million ED visits for assault- related injuries annually [1]. Violence is the second leading cause of death nationally for individuals between the ages of 10 and 24 years and the leading cause of death of African Americans in this age group. In Brooklyn/Kings County, the focal area for this study, there were 189.64 annual hospital- izations per 100000 because of Violent injury [2]. This number is higher than the average VRI hospital admissions rate for New York City (156.1) [3] and the United States (63.9) [3].

ED-based research on Violence prevention typically centers on victims of violence and how best to decrease the risk for recurrent VRI (RVRI) in these populations [4,5]. The approach seems valid, as individuals presenting to the ED with VRI have an increased risk of repeat injury, criminal prosecution, and 5-year mortality [6,7]. However,

Aero Med Spectrum Health Grand Rapids, MI 48875, USA

Table 1 Comparison of the demographic and social

characteristics of patients with RVRIs to those without RVRI

Mean age F SD (y) Male sex (%)


(African American, %)

marital status (single, %)

Education (less than high school diploma, %)

Childhood (single parent, %)

Employment (unemployed, %)


30 F 11




28 F 11



















(own neighborhood, %)

Weapon of assault (gun, %)

Perpetrator (known, %)

Drug abuse

(alcohol and/or drugs, %)

History of criminal arrest/conviction (%)

History of psychiatric disorder (%)
















a Student t test for age, Fisher exact test for all other variables; level of significance, P b .05.

E-mail address: [email protected] doi: 10.1016/j.ajem.2005.05.005


  1. Roppolo LP, Vilke GM, Chan TC, et al. Nasotracheal intubation in the emergency department, revisited. J Emerg Med 1999;17(5):791 – 9.
  2. Jackson County Hospital v. Aldrich, 835 So.2d 318 (Fla. App. 2002).

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