The Lost Endotracheal Tube

Abstract

This case describes a previously unreported rare, but potentially disastrous, complication of endotracheal tube intubation initiated by prehospital emergency medical services personnel. This report details an inadvertent prehospital esophageal intubation and a critical error in communication between the prehospital and hospital service that resulted in failure to identify or remove the tube until after admission. The discussion includes complications of endotracheal tube intubation and esophageal foreign bodies. Proper communication between medical personnel is essential to reduce medical errors. Refraining from the use of slang terms may help prevent miscommunication between personnel upon transfer of patient care. This case shows the need be critical, observant, and wary at all times for even the most implausible findings in medicine.