What are your RSI protocols?

[usalsfyre]

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

Very well said

[NYCEMS9115]

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?

I also have had one-way correspondence with

NYS DOH EMS to add the CCEMTP into the Paramedic Curriculum and have it only available as a Associates Degree Program. The time line will be 10 years for all NYS Paramedics to get the CCEMTP and AAS. Of course I've heard nothing. Hence one-way correspondence. I've been at this for 1 year now... In addition, many had rejected my notion to change the NYS Paramedic. Claiming less people will pass and many will not do this job. I'm sorry but we need to separate the Paramedic from the EMT-B; where almost anyone can be an EMT-B. That's not good. I've pitched the idea to increase class hours, add more rotations, and require all candidates to have a HS/GED Diploma. It seems like I'm just talking to the wall.

[2Rude4MyOwnGood]

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.

Great point. I can only speak for the training that i received but i feel that ive been prepared quite well for ET intubation.

Whats going on in other programs? Yes, that is a serious question. Im assuming that some programs only give their students practice on the mannequins in class, no live tubes before being released?

[tcripp]

Great point. I can only speak for the training that i received but i feel that ive been prepared quite well for ET intubation.

Whats going on in other programs? Yes, that is a serious question. Im assuming that some programs only give their students practice on the mannequins in class, no live tubes before being released?

Can't speak to other programs but, in my own, we had several sessions in the OR over the 2 years where we "managed airways" on patients in a controlled environment. We weren't there to "tube", but rather to manage the airway which is ultimately what we should be doing in the field in the first place.

For some, I used an LMA. For others, I orally intubated. And, there was even one where I did nothing more than bag the patient for the duration of his (20 min) surgery. What an opportunity to learn how best to work your own muscles during an extended period of time. In addition, I made sure that when it would be one that I wasn't "allowed" to intubate. for whatever reason, that I observed to see the issues and how to overcome them.

Edited April 18, 2011 by tcripp

[2Rude4MyOwnGood]

Thats similar to what we have done at the Intermediate level. Obviously, we started out on simple mannequins, then we moved to the simulation lab where my school has a great "computerized" mannequin which is controlled by an instructor who can manipulate the airway (laryngospasm, edema, etc.). Then its on the OR where we work with live patients under the supervision of an anesthesiologist. LMAs and ETTs are pretty much the only advanced airways used in hospitals here so it would have been nice to get more practice with Kings and Combitubes, but thats out of my hands.

I agree that 1 year isnt enough training though. Just because i feel comfortable with my skills doesnt mean that everyone does. There are absolutely some students in my class who struggle with airway management, hopefully they will get weeded out come registry.

[AnthonyM83]

NYS,

Are contacting them asking for everyone to be ccemtp trained within 10 years just out of the blue? Or is there some kind of movement going on locally that this is in reference to. If its out of the blue with a demand even with explanations, I can definitely see them not responding. That's why I was asking what the current protocols are now.

Even extremely progressive systems don't have RSI nor is it a national registry item ( I'm told ), so wondering why that protocol versus so many others that there might he a push for is the one you're going for to consider NY progressive

[usalsfyre]

Thats similar to what we have done at the Intermediate level. Obviously, we started out on simple mannequins, then we moved to the simulation lab where my school has a great "computerized" mannequin which is controlled by an instructor who can manipulate the airway (laryngospasm, edema, etc.). Then its on the OR where we work with live patients under the supervision of an anesthesiologist. LMAs and ETTs are pretty much the only advanced airways used in hospitals here so it would have been nice to get more practice with Kings and Combitubes, but thats out of my hands.

I agree that 1 year isnt enough training though. Just because i feel comfortable with my skills doesnt mean that everyone does. There are absolutely some students in my class who struggle with airway management, hopefully they will get weeded out come registry.

I can teach you to pass a tube. Give me a week and I can make you extremely ready to pass a tube. What I can't do is given the current level of education and low clinical experince requirements is teach you the approprite time to knock someone down, vs do an awake intubation, vs use something like ketamine as a conscious sedation aide to intubation vs jumping straight to a rescue airway or cric. It's far more complicated than just listing out indications, and requires a very firm grasp on not only the immediate treatment modality but the expected clinical course once they get to the hospital (meaning looking sometimes a week or more down the road).

So despite my earlier comments, y'all are right, it is possible to keep the psychomotor skill of intubation up. The clinical accumen of making the judgement to tube? Much, much tougher, and as much a skill that deteriorates just like the psychomotor part of it.

[tcripp]

The clinical accumen of making the judgement to tube? Much, much tougher, and as much a skill that deteriorates just like the psychomotor part of it.

When I say continued education vs. removal of a skill...I'm talking about this piece as well.

[usalsfyre]

When I say continued education vs. removal of a skill...I'm talking about this piece as well.

I have no doubt you are, but outside of going in busy EDs and discussing airway control on the patients that need it with the physicians I'm not sure how you'd do this. In a busy system, tight, nonpunitive, corrective QA would work, but tight QA on a couple of RSIs a year for the rural provider isn't enough feedback. Maybe someone else has gone through this and has a way that I son't know about?

[1EMT-P]

I currently work in an ICU, but when I did work in the field we used Versed + Morphine + Sux + Vec. There have been studies done that suggest that pre-hospital intubation is causing harm, so it is likely that intubation will be removed from the scope of practice of ground based Paramedics in the future & be replaced with blind insertion devices unless we increase provider education, improve provider airway assessment & intubation skills..