RSI - High-risk EMS procedure gets a low level of oversight

[spenac]

My question is while mistakes appear to have been made in the 3 cases, why does it not address all those alive today because we had it available?

http://www.star-telegram.com/state_news/story/593026.html

[web:8e6edb1e75]http://www.star-telegram.com/state_news/story/593026.html[/web:8e6edb1e75]

[Spock]

"Should EMS still have RSI?" I don't know the national or international percentage but I suspect the majority of paramedics are not permitted to use RSI at all. RSI by ground medics is prohibited in Pennsylvania. We do have a state protocol for etomidate only intubation but so far most medical directors have stayed away from it. Frankly etomidate only makes little sense since no ER doctor would do anything less than RSI.

I think the Star-Telegram is biased because they quoted Henry Wang. Dr. Wang thinks paramedics shouldn't be allowed to intubate anybody including cardiac arrests.

I've said before that any medication assisted intubation has to have close medical control and a very strict training and QA mechanism. It is not for everyone.

This topic has been discussed extensively before but since there is a poll attached I guess it is OK to bring it up again. Let's not beat a dead horse. If RSI is the standard in Texas then the poll applies to Texas.

Live long and prosper.

Spock

[spenac]

It is not that complicated if you stay on top of your education and get practice. The biggest problem in all cases listed were they failed to confirm placement and to monitor placement. I hate that so many here seem to want to dumb down what we do. If anything our scope of practice needs to expand. Yes more education is required so most will fight that at all cost.

Why not RSI? If we are going to RSI somebody we understand they will not make it to the hospital if we do not secure their airway. They will be dead if we do not attempt. At least we give them a chance.

Intubation is not a complicated skill. Have I ever missed? Yes but when I attempted to confirm placement I found the error and quickly placed another tube. I have seen the same by Doctors and other experts, so it is not just an EMS problem. The problem in EMS seems to be to many do not know how to check and confirm placement and even fewer know how to monitor placement. Confirmed multiple ways and monitored all the way to the hospital is the key.

Another point that has been brought up is intubating going down the road. Why? I have been thrown around to often to take that chance. Pull the ambulance over and do it right.

[emsmedic39]

I hate to say it but yet again pay is a big problem. You get what you pay for. We all know people that are in EMS that should not do RSI and still would. EMS need to be a education not a training. The vo-tech system need to get out of EMS. And Higher Edu. need to stop acting like some training systems. They need to produce educated medics.

[VentMedic]

I hate to say it but yet again pay is a big problem. You get what you pay for. We all know people that are in EMS that should not do RSI and still would. EMS need to be a education not a training. The vo-tech system need to get out of EMS. And Higher Edu. need to stop acting like some training systems. They need to produce educated medics.

The statutes for higher mandatory minimum eduation for entry into the profession will have to change first. Paying better now will just encourage more to rush through the Medic Mill to get to that higher paying job. There will be no incentive to continue with their educaton beyond that. And, if there is a union, they will only support those that think it is unfair that they become educated.

[Dustdevil]

I think the Star-Telegram is biased because they quoted Henry Wang. Dr. Wang thinks paramedics shouldn't be allowed to intubate anybody including cardiac arrests.

Like a lot of newspapers who consider themselves to be the public guardians, the Star-Telegram does have a typical hard-on for any government or "public safety" entity. I don't really consider that to be a bad thing, most of the time. But I'm not sure I see an intentional bias here. Any bias would seem to be a direct result of the research they found. Google "paramedic rsi" and the resulting stories are not flattering. It presents the appearance that RSI is indeed a risky and dangerous procedure. And with Wang being an outspoken big name in the debate, it is only probable that they would eventually get around to talking to him. That's just the natural progression of any investigative report.

I am glad to see that the education aspect was hit upon, though. Although they did not specifically draw the logical conclusion, it is there for the making. Look at what was said. The point was laid out that paramedic education standards are abhorrently low, and that RSI is just a quickie, add-on, merit badge course above that. And Simonson (my former Medical Director, and a good one) talks about how his flight crews are constantly having to bail out ground providers who botch airways. That screams out the obvious, which is that a better trained and experienced provider can be entrusted to competently provide RSI, while your average 12-week wonder cannot. Duh!

If the field were populated by degreed professionals instead of part-time firemonkey wannabes, this would not even be an issue. This is not a case of the big bad meanies taking away our well earned toys. This is a case of us never having earned them in the first place. And, so long as we FAIL to achieve a reasonable standard of education, we have nobody but ourselves to blame when the system takes a critical eye to both our practices and our results.

[FormerEMSLT297]

How can you be expected to perform or allow someone to perform RSI, if you as a meidc have never seen the effects of the meds you are administering.??? We are required to do RSI retraining, on real OR patients 2 x a year... that is how we stay current.

I find it hard to believe that any agency would allow someone to RSI, if the only Intubation training they have received is on a manequin...

That being said, There is no excuse for not connecting an ETCO2 monitor to the ET tube, that along with direct vis, Ascultation of lung sounds, and a silent stomach is the only way to ensure the tube is properly placed. Not to mention the fact that ETCO2 monitoring acts as a safety to verify tube placement after every patient move.

Like dust said, the problems are not with RSI, but with the con. edu, and continuing training that some EMS units provide. IMHO

[Spock]

Your comments about bias are well taken Dust. I guess the bias is on my part. Dr. Wang's solution to problems with paramedic intubation are to remove intubation from the scope of practice instead of education and close medical control which are more difficult and requires work on the part of the medical director.

Every time I read a newspaper account of failed RSI by ground paramedics the cause almost always is poor decision making and failure to follow proper procedures.

I have to ask again, how wide spread is the use of RSI by ground services?

Live long and prosper.

Spock

[VentMedic]

Your comments about bias are well taken Dust. I guess the bias is on my part. Dr. Wang's solution to problems with paramedic intubation are to remove intubation from the scope of practice instead of education and close medical control which are more difficult and requires work on the part of the medical director.

Spock

We knew that education and medical oversight was going to become a problem starting in circa 1985 when the Paramedic program began moving further away from the 2 year degree or any education higher than a 700 - 1000 hour cert. Even with the threat of removing intubation there has been little done, except in a few quality services, to improve. The states still have not seen this as a problem and continue to offer individual "skill" certs without enhancing the overall licensing criteria.

[Arkymedic]

Your comments about bias are well taken Dust. I guess the bias is on my part. Dr. Wang's solution to problems with paramedic intubation are to remove intubation from the scope of practice instead of education and close medical control which are more difficult and requires work on the part of the medical director.

Every time I read a newspaper account of failed RSI by ground paramedics the cause almost always is poor decision making and failure to follow proper procedures.

I have to ask again, how wide spread is the use of RSI by ground services?

Live long and prosper.

Spock

We use RSI (Succinylcholine and Vecuronium) at my service in OK and Arkansas has approved it for introductory field study among approved services.