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

[Dustdevil]

So that patient on the 20th floor will just hve to hold their breath, I guess.

Well, to be fair. the tallest buildings in Arlington are ten stories, and there are only two of those.

But yeah, when Rural Metro (and every previous provider in the city since 1986) was running Arlington, they were dual medic trucks, and serious about education. When AMR took over some years back, they whined until they got a waiver to run I/P trucks. You see, unlike Dallas, there are no 90-day medic mills in the county, so they are forced to hire mostly people with more invested in their career, which is a real hardship on them. So now, what you have are low or no-time medics partnered with Intermediates who just fell off some passing turnip truck, because there are no Intermediate schools around here. It's the blind leading the blind.

Of course, the Arlington firemonkeys are over fifty-percent medic certified too, and they respond on everything that isn't a nursing home run. Never have figured out why the elderly (i.e. the people that have paid the most taxes in life) rate less care than anybody else, but I digress. But with three to five ambulances serving 350,000 people in a city that takes forty-five minutes to traverse, response times are frequently over the ten-minute mark. Of course, they don't send those numbers to the city council. They only send the FD response times to the city council, in order to make it look like the system is adequate. Three to five times a day, Arlington has to call the tiny, one-ambulance, suburban fire departments for mutual aid because they are level zero. Yesterday, I heard one of those mutual aid ambulances sent on a thirty minute response to a scene on the other side of town.

Don't get me started.

But yeah, still light years ahead of Dallas.

[Happiness]

Again you guys can't pull your head out of your asses and see the light. I am not going to sit here and have the likes of you say that I am not good at what I do you don't even have a clue of what my accomplishments are in my profession. I am very good at what I do and your narrow minded opinions do not hurt my feelings. I do outside learning and yes I have learned alot in this forum and probably from some of you thanks for that. The unfortunant thing is I can learn from a book how to do all these things but I can't use them.

Did I say I didn't know what caused those siezures well as it happens I do know the cause of his condition. 6 years ago he was dirtbiking (in full gear) with a buddy (oh I will mention that his buddy is a lowly BCAS also and he saved his life). He went over a dune and hit a tree, the branch in the tree when through his eye socket and through his brain. Now since this was a ceaar branch he went through cedar poisoning. So now he suffers from the seizures.

So My coat says that Im a paramedic so I must be one right. Isn't it like i still have cheqs so I must still have money in my account.

There is an ER here but I may have missunderstood the question. It is the 35-40 heli ride for the closest surgery room. My apologies.

Now for personal attacks I think you all should read what you have said about my intellagence. Like I said before I don't care what you think of me as I do my job to the best of my abilities. So If you would like to know what my skill level is then come and go fishing and do a few calls with and then would truely undstand how it is here and not in the cement jungle.

So my last comment is this I never said that it wasn't a good Idea to intibate ever the two statements I made is that Im glad I can only use a airway and bag em and the other comment is that I have never thought after any of my calls "boy i wish i knew how to Intibate. From these comments you all took it and ran. So if ya want to keep slamming me have a blast and enjoy but I will still be here to learn from the ones that have the abilty to teach me with alittle respect and not because they think they are better then me.

Again still Happy

[Doczilla]

There is a brisk discussion on this very topic online right now among the docs in the ACEP EMS Section. I will post here what I sent there.

I have performed a number of intubations in the field with RSI with my squad. Few have been trauma patients; most were respiratory failure due to medical causes such as CHF that did not respond to therapy. Perhaps it's our patient population of morbidly obese chain smoking hypertensive type II diabetic vasculopaths with CHF that prefer to call 911 only when there is a large hooded figure with a scythe standing in the corner of the room, but we get some sick folks. We are in the process of training the medics for RSI to see if we can sustain the skill retention through training and periodic retesting before we implement it. On our SWAT team, the medics are trained and authorized to use RSI (easier to implement, since this is a small cadre of very experienced medics with dedicated monthly training time).

One important thing to consider when looking at those studies is the fact that they include intubation of patients who are incompletely relaxed, the "cowboy tube" that is undertaken with nothing but a laryngoscope and Brutane. Not only do the paramedics get the really bad airways, as pointed out, but we ask them to intubate patients that we as physicians would never consider intubating without RSI. By asking them to do so, are we not setting them up for failure? What would our intubation success rate be as physicians without RSI?

Several studies have demonstrated the value of RSI in prehospital settings. Whether by improving intubation conditions, or improving training, improved airway decision-making, periodic skills reassessment, or improvement of conditions for intubation by use of the drugs, RSI (with appropriate oversight and training) seems to improve intubation rates.

A 2004 study by Jones et al found that rates of unrecognized esophageal placement of endotracheal tubes was as high as 6%. The standard for placement verification was auscultation by the receiving emergency physician. This rate was lower (3% vs. 9%) when a confirmation device, such as Esophageal Detector Device or end-tidal CO2 detector was used. Small study size limits the scope of this study, but the results are concerning nonetheless.

An analysis of failed intubations revealed that of the 10% of patients who had failed intubation attempts in the field, nearly 50% were attributable to inadequate relaxation, 20% to poor anatomy, and 10% to obstruction..[iii] Of these that could not be intubated in the field, 41% were successfully intubated after RSI in the Emergency Department. The estimate of “truly difficult” airways, defined as requiring 3 or more intubation attempts in the ED, was 0.8-1.6%.

A 2003 study from the University of Pittsburgh showed an overall intubation success rate of 90%. Patients with vital signs were successfully intubated only 72% of the time, while patients in cardiac arrest were successfully intubated 93% of the time. Factors attributed to failed intubation which may be remedied through RSI include clenched jaw (30%), combativeness (11%), inadequate relaxation (25%), intact gag reflex (38%).[iv]

A 2005 study from Wake Forest University utilizing an air transport service compared etomidate only intubation (EOI) to RSI.[v] This small study, with younger (mean 38 years) mostly trauma patients (90%) used a subjective scale to rate “adequate” conditions for intubation. EOI produced these conditions only 13% of the time, while RSI produced them 80% of the time. Intubation success rate was 25% in the EOI group and 92% in the RSI group. Studies from Dickenson et al and Wang et al showed limited success with midazolam (Versed) as a single-line agent to facilitate intubation, citing success rates of 62-75%.[vi],[vii] This mirrors our experience with our "sedate to intubate" protocol, which allows use of versed or etomidate to facilitate intubation.

Alicandro reported RSI success in a paramedic air transport system to be 90%, compared with conventional ETI success rate of 69%.[viii]

A study by Hedges et al recounted 95 occurrences of RSI in a ground ALS system, which showed an overall success rate of 96% and no misplaced tubes or cricothyroidotomies performed.[ix] Pace and Fuller found success rates of 92% vs. 66% with conventional intubation.[x] Krisanda et al reported a 94% success rate with RSI in seven ground ALS services.[xi]

Pearson’s 2003 study in the Air Medical Journal examined the impact of implementation of an RSI protocol on number of intubation attempts and time to successful intubation. The study, though small (140 patients) found that both the number of attempts and the time to intubation decreased significantly once succinylcholine was added to the drug box.[xii]

A study by Ochs and Davis from San Diego enrolled 114 patients with head injury who underwent RSI. 84% were intubated successfully, the rest were managed with combitube. There was only one airway failure.[xiii]

Wayne and Friedland’s 20 year review of RSI with succinylcholine in a ground ALS service found a success rate of 95% in their analysis of 1657 patients. Only 3 of the 74 patients where intubation was unsuccessful required cricothyroidotomy.[xiv] This study seems to suggest 2 things: paramedics CAN successfully perform RSI, and paralysis + failed intubation do not necessarily equal surgical cricothyroidotomy. If the patient can be managed with a rescue airway or oral airway and BVM, then they don't need to be cut. This study I think shows the value of training: medics had 20 OR intubations, and were required to get OR time and a minimum number of tubes per year.

Some recent studies have questioned the use of RSI on specific populations in the prehospital environment. RSI has been associated with worse outcomes in patients with severe head injury in a landmark study by Davis, Hoyt et al from San Diego.[xv] A follow-up analysis of these patients suggested the association between increased mortality and hyperventilation.[xvi]

I agree completely that RSI is a potentially disastrous tool to have without proper training and oversight. Our currently planned regimen involves monthly skill time on the mannekin, quarterly retesting (written and practical), tracking of individual paramedic intubation rates with quarterly minimums (to be made up on mannekin testing if inadequate), and QA review of all intubation cases. Currently, run sheets are kicked to my inbox automatically for advanced airways, arrests, AMI, "significant ALS care", pediatrics, obstetrics, refusals, and any other issue as seen fit by the QA supervisor.

Two other important factors I think must be in place when allowing RSI: confirmation of tube placement, and backup airway devices. We've already touched on the use of capnography, which I think is an invaluable tool for confirming and monitoring intubation. Despite what the studies suggest regarding the EDD, I don't think anything else yet matches EtCO2.

As far as backup airways and adjuncts go, I'm a big believer in the Airtraq, the Glidescope (though right now we can't afford to put them on the trucks, this is on the wish list), the bougie, and the King LT-D. As a matter of disclosure, I have no financial or other conflicting interests in these products whatsoever. Medics have to have them and be comfortable with them.

The real question we need to be asking is, how can we get our medics into the OR to practice intubation? Many anesthesiology groups here are shut down tight when it comes to paramedic intubation time, and unfortunately, concerned about the liability of having a less experienced provider perform the intubation. This leaves cadaver labs as the most accessible solution.

So to summarize (everyone wake up, lights are coming on again, powerpoint is coming to an end, urinals and coffee urns await you...)

1) I think that RSI does belong in the field under the right conditions.

2) That said, training and oversight are crucial and are the difference between a successful RSI program and one that is dangerous.

3) Medics should have the right tools. That includes not only the tools to intubate successfully but the tools to manage the patient when they can't. We can't set them up for failure and then complain that their skills are inadequate.

'zilla

Jones JH, Murphy MP, DicksonRL. Emergency Physician-Verified Out-Of-Hospital Intubation: Miss rates by paramedics. Acad Emerg Med. 2004 Jun;11(6):707-709.

[ii] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10(7) 717-724.

[iii] Wang HE, Sweeney TA, et al. Failed Prehospital Intubations: An analysis of emergency department courses and outcomes. Prehosp Emer Care. 2001;5:134-141.

[iv] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10(7) 717-724.

[v] Bozeman WP, Kleiner DM, Hugget V. A comparison of rapid-sequence intubation and etomidate-only intubation in the prehospital air medical setting. Prehosp Emer Care. 2006;10:8-13.

[vi] Wang HE, O’Connor RE, Megargel RE, et al. The utilization of midazolam as a pharmacologic adjunct to endotracheal intubation by paramedics. Prehosp Emerg Care. 2000;4:14–8.

[vii] Dickinson ET, Cohen JE, Mechem CC. The effectiveness of midazolam as a single pharmacologic agent to facilitate endotracheal intubation by paramedics. Prehosp Emerg Care. 1999;3:191–3. 84.

[viii] Alicandro JM, Henry MC, Hollander JE, Johnson S, Kaufman M, Niegelberg E. Improved success rate of out-of-hospital intubation with rapid-sequence induction . Acad Emerg Med. 1996; 3:408.

[ix] Hedges JR, Dronen SC, Feero S, Hawkins S, Syverud SA, Shultz B. Succinylcholine-assisted intubations in prehospital care. Ann Emerg Med. 1988;17:469–72.36.

[x] Pace SA, Fuller FP. Out-of-hospital use of succinylcholine by paramedics. Acad Emerg Med. 1996;3: 407–8.

[xi] Krisanda T, Eitel D, Cooley M, et al. Succinylcholine-assisted intubation by responding advanced life support ground units: results of a four-year pilot study for the state of Pennsylvania. Acad Emerg Med. 1997;4:460.

[xii] Pearson S. Comparison of intubation attempts and completion times before and after the initiation of a rapid sequence intubation protocol in an air medical transport program. Air Med J. 2003 Nov-Dec;22(6):28-33.

[xiii] Davis DP, Ochs M, Hoyt DB, Bailey D, Marshall LK, Rosen P. Paramedic-administered neuromuscular blockade improves prehospital intubation success in severely head-injured patients. J Trauma. 2003 Oct;55(4):713-9.

[xiv] Wayne MA, Friedland E. Prehospital use of succinylcholine: a 20-year review. Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.

[xv] Davis DP, Hoyt DB, Ochs M. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma. 2003 Mar;54(3):444-53.

[xvi] Davis DP, Stern J, Sise MJ, Hoyt DB. A follow-up analysis of factors associated with head-injury mortality after paramedic rapid sequence intubation. J Trauma. 2005 Aug;59(2):486-90.

[p3medic]

Well said Doc!

[spenac]

Like that response 'zilla. You should forward that to the newspaper to present a truly educated and fact filled response to an obviously biased article.

[Happiness]

Doc that was a great explaination. I totally agree with all the training and monthly training to keep up the skills. We can teach anyone anything but it is the keeping up of those skills that is a challange in many small communities and of course the financial side of the employer. Thank you for teaching me something about the intabation education from a Drs point of view.

[tniuqs]

Firstly: LMAO @ Brutane, I am so plagerizing that ! 8)

Doczilla a query:

Have you reviewed the OPALs Trauma Study the ALS vs BLS outcomes in survival and morbidity ? I certianly would like to see that study viewed from your critical perspective, in fact I am not even aware if ground in Ontario even has access to Paraylytics and as it is not mentioned in the study. I believe it is the realm of the CCP in Ontario only, but not certain, it could fit into this thread without too much of a stretch persay and thanks for getting us/me back on topic. :roll:

Your most realistic commentary and presentation of these concepts indicates real insight of the field setting, thanks we so need THIS type of oversight and perspective.

After my first readings and review of this new OPALs study, the presumption is made that ALS has failed to decrease mortality in the trauma patient and this too becomes rather curious as there is a

fair involvement

from the 'surgery' side of things. For some reason the OPAL group is bound and determined to put Paramedicine back into the funeral/ambulance transport medium as the first OPALs study in out of hospital survivability of the cardiac arrest patient proved conclusively that time to ALS intervention and outcomes was the biggest factor, although it took quite a bit more wasted tax dollars to prove that point.

Could a finger be pointed sharply at the MOH/ Medical Direction in itself ? A failure to recognise that they may be the responsible party a failure to provide the medications needed ? That in regards to no volume expander, your only as good as your tools. I do believe they are still making kool-aid out east, that said far too many "in most parts of Canada" "just have" N/S on car. :oops: and most places in Alberta as well.

Although we in the vast majority of cases we do carry paralytics, and please correct me if I am wrong there Ontario types!

I do need a safe place to go fishing on my holidays .... well NOW... :shock:

CMAJ • April 22, 2008 • 178(9)

Ian G. Stiell MD MSc, Lisa P. Nesbitt MHA, William Pickett PhD, Douglas Munkley MD,

Daniel W. Spaite MD, Jane Banek CHIM, Brian Field MBA EMCA, Lorraine Luinstra-Toohey BScN MHA, Justin Maloney MD, Jon Dreyer MD, Marion Lyver MD, Tony Campeau MAEd PhD,

George A. Wells PhD, for the OPALS Study Group

cheers and still laughing at Brutane !

[Happiness]

Never said you would be safe lol sorry couldn't resist its my type a personality comming through. anyways everyone who reads this thread enjoy the antics and take what you can as in our profession its all about learning and being the best you can be. Thats the military comming out in me

[mediccjh]

Doc, that was a well written and thought-out post. Maybe you should send it to Dr. Henry Wang in Pittsburgh.

[Doczilla]

Before anyone is too hard on Dr. Wang, they should know that he authored the NAEMSP's original position paper on prehospital RSI [Prehosp Emerg Care. Jan/Mar 2001; 5(1):40-8], which encompassed much of the evidence I presented (up to it's publication date of 2001). This paper presented very strong evidence in favor of the use of RSI in the field.

'zilla