RSI

[Aussieaid]

Ventmedic, I agree with a lot of the things you have said and I do understand that budgets are a real issue. Definitely agree that technology should not replace good assessment skills and education but that it enhances these.

I know many departments would rather have more hands than equipment but the sad reality is that most departments are short staffed and this is where having good equipment comes in. If you are not able to be in the room with the patient all the time at least a nurse can let you know what is happening with your ETCO2 and frequently assist the RT with suctioning the pt when they are too busy or let the RT know they need suctioning or vent adjustments when the nurse is unable to.

Technology will not make a better clinician but it certainly enhances a good clinician and can be beneficial with a less than good clinician.

Depends on your P&P. At many teaching hospitals, 3 confirmations are taught, one has to be phyical assessment.

This is just my understanding but assessing ETCO2 by two different methods is really still just one confirmation out of the three.

Although they say that direct visualization of the cords is the "gold standard" I have heard it argued a lot more recently that capnography is the new "gold standard" as how many times has someone visualized the cords and still gone in the esophagus. May be poor technique sometimes but it can still happen to the best of us. The EZYCAP has more chance of a false positive than the capnography as you can still tell by the waveform that it is in the esophagus even if you get a number. (that is as long as you understand the waveforms as you pointed out not everyone does :wink: )

I was referring to the EZYCAP and no it isn't good. It definitely could refer to both as I had the "privilege" of doing an RSI in the ER (I brought the pt in and they deteriorated enroute to the ER so the doc let me intubate- oh the joys of a controlled environment with lots of assistance!!!). The RT must have been new or just maybe "substandard" as they put a NC on the pt who was breathing adequately while they set up and then she was trying to give him blow by with the ambu bag and squeezing it occasionally to let air through. He was on a NRB when we brought him in :roll: . She definitely did not have a good grasp on RSI.

I also agree that some people do rely too much on technology rather than assessing the pt appropriately. I have seen people messing with the monitor when it alarms rather than checking the pt first. I also work in a hospital environment and have to deal with less than adequate equipment at times so understand where you are coming from. I was actually having a go at the budget obsessed management that often likes to put the $$ ahead of the bests interests of the pt. I know that the majority of practioners in either hospital or pre-hospital environments really care about pt safety and often have to do the best they can with what they have available.

Cheers and have a fun winter!!

[fireflymedic]

My service has RSI however, with it comes alot of responsibility and we have the following safeguards in place to ensure our skills are maintained. Two medics are required before even attempted - none of this I'm a medic, I can do this by myself. You better have a back up airway other than a cric. The patient should be a good candidate (ie a reasonable belief that you can get the tube). You are required to do OR rotations every year to maintain the skill. Every single RSI performed gets a full review by the medical director in addition to an inhouse to ensure it was used appropriately. Also, all of our medics which are permitted to do RSI (and just because you are a medic with our service, does not mean you automatically get to do RSI) are critical care certified.

RSI is a very useful tool in competent hands in the appropriate situations. However, in inexperienced hands and not in the right situations it could be deadly. Right now, RSI is the "new toy" that everyone wants to play with. It doesn't mean it is right for everyone. It is like any skill, if it is not used enough or properly with safeguards in check, it's a recipe for disaster. Think about this long and hard before considering implementing this within your protocols.

[Just Plain Ruff]

give it one or two years and something new will be the Rage.

AS for how did we get along without defibs and pulse ox and all that, well in 20 years we are going to wonder how we got along only with the defib, pulse ox and other items we have now. There will be new toys, there will be new techniques and there will be new ways of charging patients their 2nd arm and 2nd leg for healthcare.

Our toys are state of the art now but in the future there will be bigger and better toys to use and we will still be having this debate.

I personally think that unless you have extensive training in RSI and it should be reviewed and if you don't have a backup airway ready for use then don't consider RSI.

If you have a service like one I used to work in that ran 1000 calls a month, had maybe 2-5 codes or patients that needed intubation and you have 15 staff members to staff the units then you can imagine how often each medic got to tube someone.

Now take those 2-5 patients who needed intubation, maybe 1 in that month would need RSI. Is RSI worth it in this service? I don't think it's worth training everyone and keeping them current for the Return on investment.

I know that when I worked there, I would go weeks if not a month or two between intubations.

So RSI could be a good idea for the right service but there are so many variables per patient and per medic that it may be a good idea for some medics yet not for many others.

[VentMedic]

RSI has been utilized outside of the hospital for around 20 years by specialty teams that include Paramedics and many other health professionals. It actually was easier, and still is, to have Paramedics included in the protocols especially for Flight since some States have more regulations for nurses.

Perhaps if EMS had continued with the push for standardization of education and licensing which was attempted in the 1970s, this would not even be a controversial topic.

Training and skills competencies will be difficult for many services. It was mentioned at the very beginning of this thread all the things that have no measurable standards within the industry that hinder the progress.

There is still a lack of adequate and appropiate education for the devices used now that still needs to be addressed. CPAP, Pulse Oximeters and ETCO2 monitors all have their place if they are understood.

Some EMT-Bs and EMT-Is do ETI but may not have access to the other devices mentioned above. There are very few standards one can use across the board of EMS when comparing systems in the U.S.

Physical assessment should still be the "gold standard" whether it is visualizing the cords, assessing breath sounds or just looking at and listening to the patient.

The pulse oximetry: excellent device but am I going to withhold oxygen when the patient c/o shortness of breath just because the patient has a "good sat"?

The ETCO2: excellent device for "getting a wave" for tube confirmation. Great to have in a noisy environment such as the back of a truck or helicopter. But, the numbers may not be a true representation of "ventilation" as one is taught in a brief inservice. In the hospital, it is used for shunt and deadspace determinations. For many patients, that is not always needed. I use it to determine how FUBAR a trauma or ARDS patient is by the deadspace ratio. The sophistication of the ventilators will let us know if there are any compliance or resistance changes as well as increases or decreases in respiratory status. And, heaven forbid one does a "vent check" and not a patient check also.

So there are appropriate times and places for everything. Common sense should not be replaced by technology. Also, just because you can, doesn't always mean you should.

Standardization of the Paramedic basic standards (education, training, licensing, competency maintenance, medical oversight, leadership) may have to come before "standard of care" will really be adequately defined.

[Just Plain Ruff]

Standardization of the Paramedic basic standards (education, training, licensing, competency maintenance, medical oversight, leadership) may have to come before "standard of care" will really be adequately defined

Leave it to Vent to sum this entire discussion in 25 words or less.

[p3medic]

Agreed.

[spenac]

Standardization of the Paramedic basic standards (education, training, licensing, competency maintenance, medical oversight, leadership) may have to come before "standard of care" will really be adequately defined

Leave it to Vent to sum this entire discussion in 25 words or less.

Make that 27 words or less.

[Just Plain Ruff]

Dang it Spenac, stop that.

[spenac]

Dang it Spenac, stop that.

Sorry, couldn't resist.

[Just Plain Ruff]

Well, STOP IT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! :roll: