RSI vs. Pharmacologicaly Induced intubation

[Spock]

There is no question in my mind that Dr. Wang has a "hidden agenda" which brings into question his objectivity as a researcher. Nevertheless his work is out there and nobody is refuting it. Medics must begin to develop their own body of research if they are to survive in this "evidence based medicine" climate.

I'm not sure I would compare placing an NG with intubation. Nobody ever died from a failed NG placement. Can't intubate/can't ventilate is fatal.

Live long and prosper.

Spock

[kevkei]

The belief is simple: oversaturate an area, the number of patients an individual sees goes down, and more importantly, the number of skills the provider does, ie endotracheal intubation.

Even that philosophy is flawed. Just because you see a higher number of patients, that doesn't mean you will keep your skills up. What about those highly skilled practitioners that work in services with low call volumes?

It should also be mentioned that continuous training and education will keep your knowledge and skills up. I think this is something that people neglect more than the number of patients they see.

[chbare]

Spock, your response relates well to the education threads. Without more post graduate and PhD educated providers we cannot hope to have EMS based and EMS specific research. In addition, post graduate and PhD progams that are EMS specific would ensure that we continue to have EMS research and stay in the game of EMB.

Take care,

chbare.

[tniuqs]

Even that philosophy is flawed. Just because you see a higher number of patients, that doesn't mean you will keep your skills up. What about those highly skilled practitioners that work in services with low call volumes?

It should also be mentioned that continuous training and education will keep your knowledge and skills up. I think this is something that people neglect more than the number of patients they see.

On the Money again and absolutely in agreement kev, the tiered response does not work to provide cost effective care, a BLS car and an ALS car on scene is twice the cost and the delay in providing ALS (when its required) is life threatening plain and simple in my view.

Just my 2 cents but the definition of "tiered" should be redefined:

One EMT and One Paramedic per car.

Paramedic drives when no invasive therapy is needed and vice a versa.

This fosters an excellent learning experience and motivation for the EMT to move up the ladder.

[Niftymedi911]

The RSI protocol we have called CAM (Crash Airway Management), is I feel very aggressive, sometimes a little too aggressive, but it gets the job done.

We ultilize the combo of Succ's, Etomidate to chemically render them useless and the Diprivan to maintain the sedation

[pinymayu]

The RSI protocol we have called CAM (Crash Airway Management), is I feel very aggressive, sometimes a little too aggressive, but it gets the job done.

We ultilize the combo of Succ's, Etomidate to chemically render them useless and the Diprivan to maintain the sedation

What about analgesia and longer term paralytics? Failure to to do either is both cruel and below the standard of care, why doesnt your system do either?

[Ridryder 911]

What about analgesia and longer term paralytics? Failure to to do either is both cruel and below the standard of care, why doesnt your system do either?

Actually, Etomidate and Diprivan are long term enough for analgesia.. Both are very strong and have potentially dangerous side effects. Diprivan is a very potent analgesic. Remember, NO EMS is licensed or permitted to perform anesthesia. That is why the initial term RSI was changed from Rapid Sequence Induction to Intubation. This is a very touch legal issue and definitely getting into grades of anesthesia is way out of a Paramedic scope of practice.

The patient is usually only needed to be sedated for a short period of time for transport (<2-4 hrs). Albeit, it is preferred to sedate for ventilator care, it is not always necessary if coaching and patient acceptance of therapy is possible. Long term sedation can be very dangerous.

R/r 911

[pinymayu]

Actually, Etomidate and Diprivan are long term enough for analgesia.. Both are very strong and have potentially dangerous side effects. Diprivan is a very potent analgesic. Remember, NO EMS is licensed or permitted to perform anesthesia. That is why the initial term RSI was changed from Rapid Sequence Induction to Intubation. This is a very touch legal issue and definitely getting into grades of anesthesia is way out of a Paramedic scope of practice.

The patient is usually only needed to be sedated for a short period of time for transport (<2-4 hrs). Albeit, it is preferred to sedate for ventilator care, it is not always necessary if coaching and patient acceptance of therapy is possible. Long term sedation can be very dangerous.

R/r 911

"Rid,"

As your my respected, learned, colleague from OK, as well I know you've agreed with the preceding statement in the past. If not tacitly, then ceratinly passively many times here in the past. Please read on and understand this is no personal attack. This statement (above) is one which you ( I believe mistakenly, I've made this mistake myself in the past) misquote (pinymayu) in the regard that it was they who stated it as opposed to the cleverly if potentially dyslexiclly (?, nuttin but love for the grizzled and distinguished kodiak of the north :wink: ) albeit certainly facetiously applied screen name "tniuqs"(aka:"squint" and is certainly one of my fav canuks :shock: 8) ).That being said it appears that the terms sedation and analgesia are being mistakenly used and or potentially mixed up.

There was a thread here sometime ago started by FL_Medic (If I recall correctly) which covered this. Additionally "Spock" also clarified on the subject in that thread as well. I'll try to dig the link up and dust it off from the database for you. My point was essntially thus. If your going to do the procedure, and administer the sequence, do all of it, completely and correctly (Unless contraindications or circumstances which warrant a change exist).

Here is the link with the appropriate resources, info and citations, etc.., to back up my statements. If your asking yourself is it worth it to read the 6 pages the answer is yes, but the debate really begins on page 3-4 and moves on.

http://www.emtcity.com/phpBB2/viewtopic.php?t=687

Hope this helps,

pinymayu

[kevkei]

Though the statement is true that we don't perform 'anesthesia', with anesthetic agents, would you not say that it is actually what we do if we do our job correctly, even in MFI or RSI. I don't think talking about grades of anesthesia is way our of a paramedic scope of practice, perhaps if it is a blanket statement to the lowest common denominator yes, but not for many with the appropriate education (which inherently is covered in the curriculum from my school). For example, on another thread, a group of Paramedics are discussing the use of antibiotics at a very high level, do we use the same paint brush?

For example, people that use a combination of midazolam and fentanyl (our service) in combination, if you are dosing appropriately, you are entering into the world of anesthesia. I prefer where possible to use both to achieve both analgesia and sedation. If I can't use both, I would prefer midazolam due to duration of action and it's amnestic properties. If the patient 'feels' pain or discomfort, they have dissociation plus retrograde amnesia It is a form of induction, albeit not rapid. How about conscious sedation?

Why don't you? Are you limited by your medical director and their drug box? It is within the formulary from ACoP to carry and use.

[CBEMT]

My view would be get the best qualified to the scene FIRST, not LAST!

It's those kinds of over-triage dispatch protocols that sends 5 medics to a stubbed toe.