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

[Dustdevil]

:notworthy:

[EMSDoc]

Hey all,

Doczilla asked I join the discussion. We both have been posting on the ACEP listserver about this topic, so this is what I posted:

A few points:

1. All agencies should be using waveform capnography as the "gold standard" to determine tube placement. With properly used waveform capnography there should be an almost zero percent missed esophageal intubation rate. This method of tube verification was advocated by a position paper from the National Association of EMS Physicians in 1999. ( http://www.naemsp.org/pdf/verificationtubeplacement.pdf ) It is a rapid and very reliable method of determining tube placement, much better than auscultation, tube fogging, colorometric CO2 detectors, etc. Why this has not become the standard of care in both the pre-hospital and ED settings is surprising, as if you ask our colleagues in anesthesia, no one is intubated without waveform capnography and it has been the standard of care in the OR for many years.

2. I believe that the current system by which we train paramedics to perform intubation is set up with the deck stacked against them. I worked as an EMT for many years before becoming a physician, and all my initial intubations were in either the OR or the ED. The first time I had to place a tube as the physician on an ambulance I was face down in a field with an anaphylactic patient deep in the woods on a very bright sunny day. It was an eye opener for me how much more difficult this was than placing a tube in the ED. Think about it -- as physicians we are accustomed to a well lit exam room, with an adjustable bed, staff to assist us, maybe anesthesia backup. Being in the middle of a field face down in the dirt without support staff is a very different experience. There is an interesting article from the Anesthesia literature in 2007 that shows that physicians that normally work in a hospital setting, when placed with a helicopter service, often had unrecognized esophageal intubations (no capnography was available) http://www.anesthesia-analgesia.org/cgi/co...tract/104/3/619

Flash to how we train our EMS providers: we place them in a sterile OR or ED, then once they get the "right number" of tubes send them out into the field to get a couple of "field tubes" and then that's it. Most never have the opportunity to come back to the ED/OR to practice, nor do we actually train them in the environment in which they work. Paramedic students should be getting many intubations using airway mannequins in real field conditions (dark rooms, bathrooms, dusty fields, etc.), and all practicing paramedics should have the opportunity (and be mandated) to continue to practice intubations both on airway mannequins, and back in the ED/OR to maintain their skills.

The combination of training the medics in our controlled ED environment and then sending them into a very different field environment, coupled with the lack of continuing education/practice, I feel is the source of many of the issues that have been raised within this discussion. Then, factor in the lack of waveform capnogrpahy in many places, and this just compounds the issue.

A recent article from the British Journal of Anesthesia shows intubation to be safe and beneficial for head injured patients with well trained providers: http://bja.oxfordjournals.org/cgi/content/full/96/1/67 Again training and education -- coupled with practice and good monitoring equipment -- is the key.

3. In the San Diego study that is often quoted (The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma. 2003 Mar;54(3):444-53.), the authors themselves noted that RSI improved paramedic success rates: "Paramedic RSI improves intubation success rates but is associated with an increase in mortality and decrease in 'good outcomes' when compared with hand-matched controls. These differences may reflect inherent inequities between the two groups, although they appeared similar on all parameters we measured. Alternatively, the increase in mortality may be related to inadvertent hyperventilation, transient hypoxic episodes, and prolonged scene times associated with the RSI procedure."

As the authors noted in their last sentence, further analysis of the data showed that hypertventilation and hypoxia was a large factor in the poor outcome of the patients, not the RSI procedure itself. (http://www.ncbi.nlm.nih.gov/pubmed/15284540 ) Well trained EMS providers with appropriate monitoring (continous ETCO2 and SPO2) and all available airway tools (including intubation/RSI when necessary) is the best way to minimize these complications. In fact, if you look at the literature from Europe (i.e. Acta Anaesthesiologica Scandinavica. 50(10):1250-4, 2006 Nov. "Effect of pre-hospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury.") many trauma patients were dying from hypoxia from lack of airway control in BLS only systems, and the introduction of ALS showed a decrease in mortality for TBI patients.

A follow up study in the Journal of Trauma in 2007 showed that if TBI patients maintained normocapnea after intubation by medics, they did not have an increased mortality. ( http://www.ncbi.nlm.nih.gov/pubmed/17563643 )

In addition, a study from Journal of Trauma in 2005 showed that the use of a neuromuscular blocking agents by medics, when adjusted for confounding variables, actually improves outcomes for patients with TBI. ( http://www.ncbi.nlm.nih.gov/pubmed/15824647 )

Interestingly enough, there is an article in Archives of Surgery from San Diego pre-RSI that actually shows an improvement in patient outcome with pre-hospital intubation of head injuries ( http://archsurg.ama-assn.org/cgi/content/abstract/132/6/592 ). This further suggests that it is not the intubation that was the issue, but unrecognized hypoxia/hyperventilation/hypocapnea as noted.

A recent expert panel summarized this best:

"The Brain Trauma Foundation assembled a panel of experts to interpret the existing literature regarding paramedic RSI for severe TBI and offer guidance for EMS systems considering adding this skill to the paramedic scope of practice. The interpretation of this panel can be summarized as follows: (1) the existing literature regarding paramedic RSI is inconclusive, and apparent differences in outcome can be explained by use of different methodologies and variability in comparison groups; (2) the use of Glasgow Coma Scale score alone to identify TBI patients requiring RSI is limited, with additional research needed to refine our screening criteria; (3) suboptimal RSI technique as well as subsequent hyperventilation may account for some of the mortality increase reported with the procedure; (4) initial and ongoing training as well as experience with RSI appear to affect performance; and (5) the success of a paramedic RSI program is dependent on particular EMS and trauma system characteristics. (link: http://www.ncbi.nlm.nih.gov/pubmed/17169868 )

4. My opinion -- backed by a recent article in Journal of Trauma-Injury Infection & Critical Care [ "Prehospital Rapid Sequence Intubation for Head Trauma: Conditions for a Successful Program" 60(5):997-1001, 2006 May. ] -- is that RSI should be reserved for a small cadre of well trained paramedics that are available for the right cases and the sickest patients. It should not be every medic, every patient with a GCS < 8, or every CHF'er. The conclusion from their article is the same: "Prehospital RSI for trauma patients can be safely and effectively performed with low rates of complication and without significant delay in transport. This study suggests that resources for prehospital airway management should be focused on training, regular experience, and close monitoring of a limited group of providers, thereby maximizing their exposure and experience with this procedure."

Best regards,

EMSDoc 8)

[p3medic]

4. My opinion -- backed by a recent article in Journal of Trauma-Injury Infection & Critical Care [ "Prehospital Rapid Sequence Intubation for Head Trauma: Conditions for a Successful Program" 60(5):997-1001, 2006 May. ] -- is that RSI should be reserved for a small cadre of well trained paramedics that are available for the right cases and the sickest patients. It should not be every medic, every patient with a GCS < 8, or every CHF'er. The conclusion from their article is the same: "Prehospital RSI for trauma patients can be safely and effectively performed with low rates of complication and without significant delay in transport. This study suggests that resources for prehospital airway management should be focused on training, regular experience, and close monitoring of a limited group of providers, thereby maximizing their exposure and experience with this procedure."

Best regards,

EMSDoc 8)

This is why systems with medic over-saturation have such an abysmal intubation success rate, and for that matter cardiac arrest survival to discharge. Take a system like LA, with an over abundance of medics and compare to another system like Seattle. Fewer medics, with excellent oversite and frequent exposure to the sickest of patients = better patient outcomes.

RSI is a great tool, however without strong physician oversite and frequent exposure to patients requiring urgent airway management is a recipe for disaster. If the system in question is a very low volume one, then ED/OR intubations should be an absolute requirement. Intubation manequins are NO substitute for the real thing in my opinion.

[rock_shoes]

The irony of it all is that patients in rural areas with long transport times stand to benefit the most from interventions like RSI. For these lower call volume medics to maintain there abilities, excellent medical oversight, regular ED/OR intubations, and frequent "tours of duty" in busier areas would be needed. All this lowest common denominator stuff really irks me. As far as I'm concerned the lowest common denominator either needs to up there standard of care or get the hell out.

[AZCEP]

EMSDoc,

I agree with most of your post, and would venture that medical oversight is not viewed as an added burden to your practice.

One thing that I will disagree with is the utility of having a "well lit room" to work in. Because of the prehospital environment I work in, one could suggest that a summer afternoon in AZ provides superior lighting to any hospital room in existence. I've often found that the patient that is in a dark room is much easier to secure an airway in than the one I find outside. You do mention this in the bright ambient light situation though it seems a bit contradictory.

Could be I'm just reading into things a bit much.

[EMSDoc]

I agree with you that in a dark room with a really bright bulb on the end of your blade it is at times much easier to intubate then outside on a bright sunny day.

Sterile flourescent lights is what most docs are used to and they actually provide a nice backlight for tubes. Trust me, it is MUCH easier to intubate in a hospital where I have many people there to help out -- one to hold the tube, one to hold the suction, one to listen to lung sounds, one to massage my ego... just kidding :wink:

All joking aside, I give field medics a lot of credit -- it's a tough job. I still work in the field as a doc to ensure I never lose my field perspective. EMS medical direction is a very rewarding part of my practice -- and my way to "give back" for all of those that helped me out along the way to my MD.

EMSDoc 8)

[tniuqs]

EMSdoc:

Thanks for your positive input from Doczilla's request we are honoured that you fellow's would take time out of your busy days to comment intellegently and list studies, and links as these are read by many.

In regards to your comment re capnograhy as the 2 types available to most EMS providers are Mainstream and Sidestream. JMHO that the sidestream is a superiour device as it is multi-rolled applications for intubated and spontaneously breathing patients as a tool to further evaluate possible impending ventilatory failure/ and monitoring the consciously sedated patient, sidestream it is far less subject to fogging as most have a hydophobic filter in line (very advantageous when moving ventilated patients from warm enviroments to cold) as well far less expensive sampling lines as opposed to the Mainstream variety as the cost of the cable and the high risk for damage is potentially huge. And which as mentioned can go unsevicable due fogging (a trick I use is put a artificial/humidivent between ETT adapter and Mainstream adapter to reduce fogging)

My personal opinion of colorometric CO2 detectors (having used far too many of them) is they are a waste of money (they can give false positives due to the entry of CO2 into the stomach during BVM with/ without OPA) Ascultation in my opinion is far accurate than this device, and in many of these outlying clinics CXR is readily available just my opionion again this is the platinum standard .... realistically not in the circumstances that you are familliar, but colourmetric make for pretty ornaments on the base chistmas tree during the holiday season.

P3:

I see your point in oversaturation of ALS providers but in our "hood" its the quite the opposite in fact the local GPs in many outlying areas, many just doing locums as well. I would suspect would lack the experiance in ETT intubation themselves with/without paralytic's let alone good oversight as most remote areas lack an OR and ERs are more akin to clinics ... We live in very different worlds but perhaps for debate sake we should include this type of astere and remote settings that of having to intubate in a logging camp or worse a patient on a logging landing ... and BEFORE loading into a 206 long ranger or A-star.

The irony of it all is that patients in rural areas with long transport times stand to benefit the most from interventions like RSI. For these lower call volume medics to maintain there abilities, excellent medical oversight, regular ED/OR intubations, and frequent "tours of duty" in busier areas would be needed. All this lowest common denominator stuff really irks me. As far as I'm concerned the lowest common denominator either needs to up there standard of care or get the hell out.

The lowest common denominator portion of your commentary not only 'irks" me but I find this methodology (when it comes to a socialist type government that regulates all aspects in the delivery of health care) is a true tragedy and becomes quite unacceptable, why when transport times on the Lower mainland are very short and other areas are > 6 hours .... it makes NO logical sence to me either !

Rock_shoes as you can clearly observe from some past posts this becomes somehow ego of subordintate level's and perhaps even some union propaganda that negatively impact the education of the taxpayers that deserve, correction have "rights" to this level of care.

I am SO on board with your idea to shift experianced providers from major centers and do locums in remote areas, it is a win win situation for everyone. But as you also can see that education of your collegues maybe the first hurdle to overcome, then perhaps lower the silly barriers of reciprocity.... I digress ... sorry, but I write letters to my MLAs too.

cheers

fight the good fight my friends !

[FormerEMSLT297]

Great posts both Docs.... Very true,, appreciate both of you stepping up and defending us lowly street medics....

That being said,, YEAH, how can you even try RSI without capnography,,,,, in addition to the Propaq, we carryt a hand held capnography asa back up in case we have "equipment issues"

No excuse in my mind not to have capnography available. IMHO

[spenac]

Hey doczilla and EMSdoc, did ya'll forward your responses to the writer that wrote the article?

If so wonder if we will ever see another article based on these facts?

Thank you both for your efforts.

[Doczilla]

I'm sure this is going to tick some people off.

I've gone and re-read the article now after much of the debate on the ACEP listserv, and can't really find any meaningful inaccuracies. None of those interviewed outright says it "doesn't belong in the hands of EMS", except maybe the doc from Kentucky. They all emphasize the need for close oversight and extensive and ongoing training, which we all here seem to agree with. They also emphasize the importance of EtCO2 monitoring, which I also agree with. Yes, they use tragic cases to illustrate it, but I think the writer did a good job of laying out what is a very complex topic, and probably will continue to be within my lifetime, a key controversy in EMS.

'zilla