RSI vs. Pharmacologicaly Induced intubation

[Spock]

OK, neither propofol nor etomidate have analgesic properties. Both are short acting and would not be suitable for sedation beyond about 10 minutes. Repeat doses of etomidate have been associated with adrenal suppression which may result in severe hypotension. In fact, this adrenal suppression has been reported with single doses. If this occurs hydrocortisone must be administered in order to reverse the hypotension.

Propofol is usually restricted in the hospital for sedation of intubated ICU patients. Use for non-intubated patients is usually restricted to anesthesia personnel. Our ER docs are pushing my department to allow them to use propofol for sedation. Our chairman is forcing them to get capnography before he will authorize propofol. It will be interesting.

Paramedics do not have the education nor experience to administer anesthesia. That is why Rid is absolutely correct in pointing out RSI in the prehospital realm is rapid sequence intubation and not induction.

Live long and prosper.

Spock

[pinymayu]

OK, neither propofol nor etomidate have analgesic properties. Both are short acting and would not be suitable for sedation beyond about 10 minutes. Repeat doses of etomidate have been associated with adrenal suppression which may result in severe hypotension. In fact, this adrenal suppression has been reported with single doses. If this occurs hydrocortisone must be administered in order to reverse the hypotension.

Propofol is usually restricted in the hospital for sedation of intubated ICU patients. Use for non-intubated patients is usually restricted to anesthesia personnel. Our ER docs are pushing my department to allow them to use propofol for sedation. Our chairman is forcing them to get capnography before he will authorize propofol. It will be interesting.

Paramedics do not have the education nor experience to administer anesthesia. That is why Rid is absolutely correct in pointing out RSI in the prehospital realm is rapid sequence intubation and not induction.

Live long and prosper.

Spock

"Spock,"

Thanks for taking the time to re-iterate and share you expertise on this. You have yet again made clear the all to important difference between sedation-anxiolysis-amnestics, and analgesic medications usage yet again.. The only two points of "Rids," statement I disagreed with were the aforementioned and who said what. Your both great resources here. Thanks,

pinymayu

***NOTE:: Sadly, due to recent publicity of cases where organisations and individuals are having their professional and personal lives and livliehood put in jeopardy by postings on the internet I am now adding this disclaimer to my scenarios, posts, threads, etc... If there are any blatant violations of HIPPA, State-Local-Federal Laws or Statutes, etc.. please bring them to the attention of the author and site admin.

DISCLAIMER: This TEACHING scenario-post-thread-etc.., (authored with Q/A and learning intent) maybe real, imagined, or any combination thereof. It is not the intent of the author or (and as best the author may be able to determine the replies of the) respondents that the issues, care, and or anything else mentioned in replies previously or in the future to represent actual real events. If so this is pure coincidence and unintentional. I will refer those with any further issues to the TOS of the site. The opinions posts, and responses mentioned and posted in this and other threads, forums, etc...; like these are infact the opinions of the individual and not those of any organisation, agency, club, assn., etc... to which or with which they are affiliated. The purpose of this post is meant to beg discussion, learning, Q/A- professional peer review, and address moral, ethical, and clinical management, and other mentioned and or not mentioned concerns. All attempts reasonably possible have been made to protect the identites of the guilty, innocent, involved, treated, concerned rubbernecked bystanders, etc....

Pinymayu's AUTHORS NOTE:

Sadly for you , if your looking to hang someone out to dry, by effecting their abilty to be employed, and or effect their professional certifications-liscence due to a valid, constitutionally protected 1st ammendmendment opinion post on a professional educational EMS forum. If this refers to you; your in the wrong place. Pick on someone else, and please don't try again. If you wish to pursue your nefarious concerns good luck as I hope you like losing your case and expending useless wasted effort. If you feel your concern is valid than please first address in concert either the author and or site admin to resolve the issue and bring it to everyones attention. Thank you!

[croaker260]

For those who don't believe the over saturation argument (Kev Kie and tniuqs), or more importantly, the solution, one has to only look at the success in the King County Medic One system to see this principle is real and the solution WORKS. You have not only the highest cardiac arrest survival rates in the nation (in te 40's for working codes, when most places cant get above 2%), but probably the highest ET success rate in the nation (over 99%), doing RSI and doing a lot of tubes. (this tells me that the principles we are talking about here not only work for intubation, but patient care in general)

In addition you can extrapolate the successes of many high end air medical providers compared to many ground services, and the reasons why for those successes, you should get the same conclusions.

The are four parts to this solution. They are :

- Higher pre-employment and post employment standards (i.e. FTO and credentialing programs)

- Better specialist/physician lead continuing training and ongoing clinical education.

- (very important) High volume of patient contacts

- (And most importantly) High patient acuity in the majority of those same contacts.

Its not just about over saturation, its about low patient acuity. In the end you still want the medics you have to stay busy, only you want them busy on high acuity patients. You miss ANY PART of this equation, the whole skill set falls apart. That is why many services (like LA,) fail in the big picture of airway management. And you want a LOT of BLS/ILS units to handle everything else. A lot of them. 3:1 maybe? More even? (no one is saying everyone does not get an ambulance in 8 minutes or less, just that most of the time is doesn't need to be a paramedic)

While this philosophy only works in an urban/suburban area due to total tun volume and high acuity run volume, many of the principles can be successfully applied in rural areas. In fact we see some of them in the air medical industry, the difference is their area of response and their ability to get higher acuity patients is larger and more refined.

You only get this in a tiered system. Anything else is not sustainable. This is the same reason why you ddon'thave a cardiologist, an oncologist, and a trauma surgeon for every ER bed "just in case". This is why you ddon'thave a truck company in single every fire house, "just in case". And this is why you ddon'tsend a medic, much less 5 of them , on every call, "just in case".

One final comment:

Regarding the repeated, and often believed comment that any MONKEY can intubate, you are right. Intubation is a SKILL. But airway management is an art. And requires considerably more than sticking a blade in a mannequin to perfect, and it takes more than tubing one dead floppy corpse every six months (if your lucky) to perfect too.

And this is what WANG, and others are trying to get us to believe.

Wake up people. Just because you bull-shitted your way into a medic patch no longer means you are an airway master. You have to earn that, every day. And the day you stop earning that, it starts to go away.

And even if you are competent, in most services, nothing says the dude next to you is. In fact, chances are he doesn't give a crap about patient care, and is waiting for the sweet job on the engine to come in, or his next heroin fix, or the union contract negotiations, or bangin the nurse in the ER, or bangin the 16 year old FIRE/EMS explorer, or anything OTHER than how to MASTER his craft.

And with the paramedic mills, the BS hiring standards, the "Pulse and a patch" mentality of many services...this is going to get worse.

We need to FIX our approach to airway management, not just intubation, to paramedic deployment, and to hiring, to training, to FTO programs, and our whole profession. We need degrees, we need higher standards, and we need to kick all the scmucks giving people like you and me a bad name to the curb.

[Niftymedi911]

OK, neither propofol nor etomidate have analgesic properties. Both are short acting and would not be suitable for sedation beyond about 10 minutes. Repeat doses of etomidate have been associated with adrenal suppression which may result in severe hypotension. In fact, this adrenal suppression has been reported with single doses. If this occurs hydrocortisone must be administered in order to reverse the hypotension.

Propofol is usually restricted in the hospital for sedation of intubated ICU patients. Use for non-intubated patients is usually restricted to anesthesia personnel. Our ER docs are pushing my department to allow them to use propofol for sedation. Our chairman is forcing them to get capnography before he will authorize propofol. It will be interesting.

Paramedics do not have the education nor experience to administer anesthesia. That is why Rid is absolutely correct in pointing out RSI in the prehospital realm is rapid sequence intubation and not induction.

Live long and prosper.

Spock

We just don't give propofol as a single dose. A propofol drip is given in a dedicated line, at the correct flow rate (our protocol). This rate keeps a pt under sedation. The only thing that sucks is the half life for the drug is so short. By the time the nurse asks you to DC the Diprivan and remove it from the hub, the pt is already slowly coming around. We just recieved capnography down here, oh by the way if you want capnography, do not buy the Zoll M series!! It took 2 yrs and 6 months for them to design, test and install a ETCO2 module for our monitors. We just got capnography about 4 months ago bc of Zoll. But our RSI program has been in effect since 2004.

I've also been caught laughing at the nurses' sometimes, bc as soon as they tell us to stop the drip, (the doc's in the ER's down here flip out when we bring a pt in on propofol, I don't know why Spock, seeing as I too have seen it widely used in the ICU's) they're screaming for the doc for orders, bc they can't keep the pt down.

[kevkei]

For those who don't believe the over saturation argument (Kev Kie and tniuqs), or more importantly, the solution...

Steve,

I have never suggested or indicated that I don't believe the over saturation argument. What I indicated is that the oversturation argument by itself is inadequate and inaccurate. If it occurs in a system, it can be overcome through continued training, education and clinical exposure in other areas.

The danger is those that oppose an all ALS system because of skill degredation of it's Paramedics, which is also inaccurate on a global perspective. I don't think we can generalize with a broad brush that all systems are similar or equal. Sure King Co. has a pretty good system with a good survival rate, but can that only be attributed to the system itself? What about other factors such as more frequent bystander CPR?

[Niftymedi911]

I have to agree with above.

Simply put, one of the 5 rings of survival for CPR is early bystander CPR. The less time the body is without the pulse the better. King County system captializes on this issue. You can't really compare different agencies, they are all different in areas others aren't. But we still try to anyway, its fun

Of course, you have the old dinosaurs of yesterday still in effect, like in our county. 17 of our 22 fire districts in Lee County are "ALS" and 1 "EMS" ALS transport agency that covers all of Lee County and serves a mutual aid agreement between Lehigh Acres (ALS FD transport) and Fort Myers Beach (ALS FD transport), we dont have a tiered response system. Of course in fashion we still send an engine and ambulance to every call and run L&S to everything

[croaker260]

You are actually making my argument for me...I think you are looking at bystander CPR as a different and separate quantity than regular (HCP) CPR. IN THIS ARGUMENT, CPR is CPR, and does not require a paramedic to do it well, in fact many paramedics unfortunately do crappy cpr . FOR THIS ARGUMENT, what is important is that rapid BLS with AED, be it bystander CPR, HCP CPR is far more important that rapid ALS will ever be. If that is lay persons,, great, if it is a 1st response engine with BLS capability , equally great.

The King COUNTY system is the very reason why they have such great bystander CPR rates. They didn't do it because it was cool, or good PR...they did it for the scientific and clinical benefit in a sytems approach. The same reason why they push rapid BLS and high end ALS over all ALS model..for the clinical benifit. The two are not separate approaches, they are different sides of the same coin.

Simply put the arguments that all ALS is just magically somehow better is hogwash IMHO, and based solely on the thought process that "more is better", and that one paramedic is as good as another. In fact ..only BETTER is BETTER, and as Wang has proven in airway management a bad medic is worse than a good EMT any day, at least in regards to airway management.

No one is saying neglect training, training is very important as well. As discussed before the King County System addresses it very agressively. But this is a fact, many KCM1 system (seattle, So KC, etc) medics get over 40 tubes a year (I have it from several first hand sources), you dont find that anywhere else on the ground and not in too many air services either. Therefore given their studied and documented success rate of over 99%, and considering that many other service have success rates less than 70% in some cases FAR less....with and with out RSI...with and with out trainign and QA/QI...we MUST consider that PROPERLY STRUCTURED experience plays a vital role as well.

In short training is an important, but not the only, piece of the puzzle. We must address the clinical benefit of managing the experience of the medics..we manage everything else right..training, hiring, EBM and protocols development, the experience of the provider is the LAST piece of the puzzle..again not just quantity but quality...we can only get the most out of this ..and have the greatest impact on patient care...by putting aside preconcived notions of what EMS should be based on political and labor agendas..and make it what it should be..for the patients benifit.

The experience component of the equation is best managed when we realize that not every patient, or even most need a medic, so we MANAGE the number of medics, the position of medics, and the training of medics to make sure they are used on calls that need them. This improves the clinical competence of the medics as well as provides better care to the patient and better use of taxpayer dollars (not cheaper, better)

Let the EMTs handle the rest. The BLS is the safety net, the other component is a fast, large, efficient BLS response both transport and first response. with both a BLS and ALS ambulance being on scene together a rare thing but almost always a BLS first response, because BLS is far more imprtant than ALS in many cases.

The big question is how is this adapted to rural and suburban ALS systems.

1st, perhaps rural systems should have to prove the ability to sustain, not just want, a paramedic response. Otherwise they should have to maintain a more aggressive ILS response instead (which is really what many of these areas really need anyway ) The recent draft scope of practice model actually had a lower level paramedic that would be perfect for this, yet still called a paramedic, removing the stigma of "not having a paramedic" system. of course the IAFF fought the higher trained, higher standard, degreed paramedic concept of the same document, essentially keeping EMS in the dark ages...another argument I know...

2nd, there should be grants and incentive for hospital agencies to support EMS agencies through clinical and educational resources,like OR rotations.

3rd, Laws and regulations that have been used to shut out EMS providers from more active and QUALITY clinical experiences should be amended to allow this, in the interest of public health. Medicare reimbursement should be tied to a hospitals support of the public health system, which as a side note should include EMS, instead of it buried in DOT.

Thats my rambling for now.

[tniuqs]

pinymayu

(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) albeit certainly facetiously applied screen name "tniuqs"(aka:"squint" and is certainly one of my fav canuks).That being said it appears that the terms sedation and analgesia are being mistakenly used and or potentially mixed up.

Gee thanks uyamynip... I now give you permission to call me "turnip" LMAO a much more succinct description of my personality... again thanks to TERRI! The reason I have been called squint is that is the appearance I get when venturing into an area of controversy or conjecture need I say more, oh yea I can't play poker too, I lose every hand.

I believe that the reason for some comments here in the "City" is that some forget that these discussions are "across borders" and sometime the "legalities in one area are very different than others" making blanket statements do tend to make one appear overly focused in one locale.

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.

For those that misunderstood this comment please reread it, in our hood a BLS x 2 EMTs and ALS 2 Paramedics in PAST were dispatched for a call on many occasions, we do not have the staff nor number of units to make this financial feasible, it is very different means of funding these EMS services north of the border, there is really no competition for calls as in the US (in some areas) or is that just a Kanukistanian misunderstanding based on Mother, Jugs, and Speed....a training prerequisite in Canada.

As for believing that kev posted this view so how not true but:

I do try to suck him into every discussion that I can....so Thanks.....again ROTFLMFAO!

Kev

Propofol: I have the "big guns" ie SUX in my kit, really I don't need it for most of the Tubes I have had in the past 2 years only needed Versed, and Fentanyl, but really nice to have SUX as the hammer if you need it! The whole idea of getting the tube on the first attempt is a "red herring" in my view, capturing the airway with proper ventilation and oxygenation are the Key factor (s).... not The Only Factor, these studies should include this and patient outcomes should are the KEY indicators, not the # of Attempts are we evaluating speed not skill once again?

EDIT Headlines "THE MAN WAS RUSHED TO THE HOSPITAL" instead of "EVERY ATTEMPT ON SCENE WAS USED TO INCREASE HIS SURVIVAL" (something like that anyway, This mentality needs re: education of the public at large!) Ever hear in the news the patient was revived on scene? I have not, I digresss once again opps.

I am working more actively with some of the ideas that we share ie your innovation thread, delivering improved "field care" in primary aspects, transporting every Tom dick and Harry to Hospital for care that can be appropriately delivered in the home and putting the Truck back in service without a 24 hour stay in ER for a simple Lac, or toothache is more my focus these days, If I can prove its worth in remote deployments for industry, with all their paranoia on legal ramifications, maybe it can filter down to rural the urban.....wish be luck or send me halodol for all these delusions......!

In regards to CPR for the masses, should I mention in passing that this has been attempt in Edmonton, like over 20 years ago in a massive campaign to high school students over 10,000 trained in 2 days..... was based on the very old Seattle study, CPR was offered at every fire hall, a 4 hour deal and FREE! Firefighters in that Study in the US donated their time ...NOT EMS providers.

Sometimes I wonder with the cost and time frame involved to obtain the "CPR TICKET" in that the American Heart Foundation and its Canadian puppets/counterparts in fact defeat their own goals, or just perhaps it is a financial ends to a means in? Cash for research? It sure costs me a lot every time standards are changed...YOU?

cheers

I dunno?

[Spock]

All I can say is croaker is right. RSI in ground services has proven effective but only if there is strict medical control and QA. Every article regarding successful RSI has these two items in common. Croaker--you da man! If you ever get to Pittsburgh let me know because I'll buy you a beer or four!

Nifty My experience with people running propofol drips outside of anesthesia are they don't give enough of the drug. I routinely go to the ICU and see patients on propofol at 10 cc/hr and the nurse thinks this is a high dose. Wrong. While no two patients are the same and there are many variables, you need to run propofol at at least 50 mcg/kg/min in order to obtain sedation. If you give versed and fentanyl up front you may get away with less but not by much. Rarely does this occur outside of anesthesia. Either folks need to improve their understanding of the drug or they need to quit using it. In either case, use of propofol should be restricted to those who can intubate and have capnography in use. If the patient is already intubated then others may use the drug and let the blood pressure be your guide. If the SBP is > 100 you aren't giving enough! Just kidding but you get my point.

Live long and prosper.

Spock

[kevkei]

You are actually making my argument for me...I think you are looking at bystander CPR as a different and separate quantity than regular (HCP) CPR. IN THIS ARGUMENT, CPR is CPR, and does not require a paramedic to do it well, in fact many paramedics unfortunately do crappy cpr .

I'm not debating it, as I agree with your that CPR is good regardless of who is doing it. Timely CPR and defibrillation (regardless of who does it) is what saves lives, not ALS (it is in the periarrest state where it makes a difference). My problem is that I don't think we can't define EMS based on cardiac arrest survival rates, as it is a poor prognisticator at the best of times and is typically such a small part of our total call volume. Out of hospital cardiac arrests have a horrible outcome in general, most services (Like KCM1) only report success rates when VF is the initial rhythm (selective criteria to exclude those that have no chance of survival). So, everything else - PEA (high mortality rate due to underlying cause) and asystole are excluded. There is still not a universally applied international standard for collecting and reporting data to compare apples to apples, although Utstein is a start. Likewise, we can't define how good a Medic is by how many tubes they get in a year.

Are we trying to let the system define the Paramedic or the Paramedic define the system?

What I'm trying to suggest is there is no perfect system that can be implimented everwhere. What works for KCM1, may not work in most other states.