What are your RSI protocols?

[usalsfyre]

Then NYC is way behind. I've sent letters and emails to NYC REMSCO regarding RSI and admitting it into the Training and Protocol. I have not heard anything; I been at this for over a year...

I can't honestly say I consider direct laryngoscopy necessary or even a good idea to put in the hands of the majority of paramedics. Still something useful to have available? Absolutely! But restricted to a small pool of well educated/tightly monitored providers.

Edited April 18, 2011 by usalsfyre

[tcripp]

I can't honestly say I consider direct laryngoscopy necessary or even a good idea to put in the hands of the majority of paramedics. Still something useful to have available? Absolutely! But restricted to a small pool of well educated/tightly monitored providers.

Are you relating this statement to NYC paramedics or all paramedics in general?

Do you envision a small pit crew of medics who can intubate? How would that work? You'd be on a call and have a need for intubation and so you'd call in that special crew? What if they were not in close proximity and you needed to get that airway established? What if they are on another call?

Wouldn't it make more sense to determine that a skill is necessary and then train everyone?

[AnthonyM83]

Then NYC is way behind. I've sent letters and emails to NYC REMSCO regarding RSI and admitting it into the Training and Protocol. I have not heard anything; I been at this for over a year...

Do they have sedation-assisted intubation? Do they have a good intubation rate? It'd be a pretty huge leap to go from nothing all the way to RSI. RSI is pretty rare for ground medics. While in textbooks, I've been told it's not technically even national curriculum/scope. A lot of big cities are looking at yanking intubation altogether...much less moving to give full RSI protocols...

Edited April 18, 2011 by AnthonyM83

[usalsfyre]

Are you relating this statement to NYC paramedics or all paramedics in general?

Paramedics is general. I've never worked in New York, but from what I've seen in Texas and Virginia we as a whole aren't that good at it.

Do you envision a small pit crew of medics who can intubate? How would that work? You'd be on a call and have a need for intubation and so you'd call in that special crew? What if they were not in close proximity and you needed to get that airway established? What if they are on another call?

Pretty well exactly what I envision. EMS clings to a "we all do it all" philosophy. If the patient could benefit from intubation and qualified crew isn't available, you do the best you can. Hospitals occasionally end up with two patients that need a particular service at the same time. It's expected to happen.

Wouldn't it make more sense to determine that a skill is necessary and then train everyone?

The problem is their are serious issues with experience level needed and skill degradation. If I have one medic covering 4 stations worth of intubations, he's going to get comfortable with the procedure and do it enough to be good at it. If I have 4 or 8 medics doing those, it gets a lot less sure. Aus and NZ currently utilize LMAs for their regular road paramedics and call Intensive Care Paramedics (smaller pool)for patients who could benefit from intubation. I believe Melbourne was the first place to show improved outcomes from prehospital RSI beyond a shadow of a doubt.

[tcripp]

I can see your side of the coin, but I can see the flip side as well...and that is for the more rural services. We have 4 units cover 950 square miles. We, fairly often, will see all units out at the same time. So, if our individual crews aren't trained on "everything", we could have a unit out with a patient who might not get the care he/she needs. And, even if all units aren't in service, it could take 1/2 hour for another unit to make scene.

[usalsfyre]

I can see your side of the coin, but I can see the flip side as well...and that is for the more rural services. We have 4 units cover 950 square miles. We, fairly often, will see all units out at the same time. So, if our individual crews aren't trained on "everything", we could have a unit out with a patient who might not get the care he/she needs. And, even if all units aren't in service, it could take 1/2 hour for another unit to make scene.

Our services areas sound similar, we have 3 trucks for 850 sq miles. We dump every truck in our station regularly as well. It comes down to how many times do medics perform ETT and it improves outcome vs complicates clinical course? The numbers aren't in US EMS's favor right now. If one patient who needs and ETT gets it and it improves his course vs four who die or have a more complicated course because of paramedic ETT we're not really helping much in the grand scheme.

Really analyzing numbers like that is a cold, hard reality that many field medics don't seem to have the stomach for. The truth is some resources are simply not going to be available when they're needed. Their are easier ways of securing airways. Truthfully I'd rather see King airways with percutaneous cricothyrotomy as back up than ETT if the service is not willing to make the commitment to endotracheal intubation.

Edited April 18, 2011 by usalsfyre

[AnthonyM83]

Or your medics could just practice on dummies more often and increase their skill proficiency. Studies have shown that correlates to increased success rates on real people. I'm sure your area trains for fires often, yet doesn't get them much. Why not train like that....

[usalsfyre]

Or your medics could just practice on dummies more often and increase their skill proficiency. Studies have shown that correlates to increased success rates on real people.

Even systems and paramedics that do the actual skill of endotracheal intubation well often fail in the "when to place a tube" category. My system has excellent first time and overall success rates. The errors I've seen over and over again here are not failing to place the tube correctly, it's poorly managing them or placing the tube when it very well may be a detriment. Distilling indications down to a list oversimplifies things significantly. Maybe just facilitated intubation needs to go in the hands of a small pool of medics, but then that begs the question, "can these folks be managed more easily with a blind insertion device?"

I'm sure your area trains for fires often, yet doesn't get them much. Why not train like that....

No idea, I'm hospital and not fire-based.

[Kiwiology]

I don't really trust these "Paramedics make outcomes worse by intubating" studies. If you are a shitty rig pig whose skills rot away, or worse yet some Firemedic who has gone septic sitting on one of those "non transporting ALS first response engines" and intubate one person a year maybe.

RSI is something I am a huge proponent of and it has proven itself very useful, and that it can be done properly. We have had RSI here in Metro Auckland for about 5 years and in the last year or so have piloted it in another area with long transport times and predominantly rural features. It has proven to work excellently with consistent success rate for intubation since 2006 of damn close to 100%

Initially it is available only to selected Intensive Care Paramedics because it is early days expanding the program outside Metro Auckland which has a high call volume and good utilisation rate. We are careful to avoid giving it to everybody and getting into trouble with skill burnout. In time it is expected to be rolled out to all Intensive Care Paramedics but we must not let the cart come before the horse.

It takes a minimally skilled technician to shove a laryngascope into somebodies gob and identify vocal cords but a true clinician to be capable of deciding to knock somebody out and paralyse them in order to intubate upside down in a ditch or on thier living room floor

[tcripp]

I agree with Anthony. I don't think the right answer is to yank the skill from everyone but rather to figure out a better way to get everyone better trained and have an ability to maintain that skill. That is where we are lacking.

I find it interesting that, in some areas, we are willing to give an advanced skill to an EMT because we don't have enough paramedics around to do them and then, in others, we are willing to take away skills because the paramedic doesn't get to do them often enough to maintain that skill.

After all the dust settles, what will be left for the paramedic?