RSI

[ERDoc]

Before this thread deteriorates any further I will add my 2 cents. As for the anesthesiologists, they need to be able to justify their existence (and with good reason). Anesthieologists practice in a well controlled enviroment where conditions are maximized for success. When we are intubating people in the ER it is generally in an emergency situation with little time to prepare (though it does not mean that she should not maximize the situation as much as you can. A lot of time we don't have the chance to do a pre-assessment on the patient. We often don't have a chance to look at the airway before we are actually tubing the person. I would expect that ER docs would have a higher miss rate just based on the situation. If you look at the literature, it shows that ER docs and anesthesiologists have the same miss rate under the same coniditions. Here is one such article. There are more out there, I just don't have the time to look right now.

http://www.ncbi.nlm.nih.gov/sites/entrez?D..._RVAbstractPlus

Speaking of anesthesiologists, what is the anesthesiologist's ABCs?

Airway

Book

Chair

Sorry Spock, couldn't let it go.

[AnthonyM83]

should RSi be standard care aross the country

Yes. It should be a BLS skill since it requires no educational knowledge other than see hole, put pointy thing inside said hole. Like pie!

I further recommend it be taught as a merit badge skill to local Boy Scout troops because of long response times during night hike campouts.

[paramedicmike]

Before this thread deteriorates any further I will add my 2 cents. As for the anesthesiologists, they need to be able to justify their existence (and with good reason). Anesthieologists practice in a well controlled enviroment where conditions are maximized for success. When we are intubating people in the ER it is generally in an emergency situation with little time to prepare (though it does not mean that she should not maximize the situation as much as you can. A lot of time we don't have the chance to do a pre-assessment on the patient. We often don't have a chance to look at the airway before we are actually tubing the person. I would expect that ER docs would have a higher miss rate just based on the situation. If you look at the literature, it shows that ER docs and anesthesiologists have the same miss rate under the same coniditions. Here is one such article. There are more out there, I just don't have the time to look right now.

http://www.ncbi.nlm.nih.gov/sites/entrez?D..._RVAbstractPlus

Couldn't the same argument be made about paramedics intubating? We have even less controlled environments than ERs (nevermind the ORs) yet have the same expectations that we manage the airways effectively.

I don't know that this necessarily addresses some of the studies that negatively reflect on paramedic intubations. But it might have something to do with it. (I think the crappy educational programs for paramedics has something to do with it, too. As does the type of person EMS tends to attract.)

Just playing devil's advocate. No need for anyone to get bent all out of shape.

Speaking of anesthesiologists, what is the anesthesiologist's ABCs?

Airway

Book

Chair

That's funny!

-be safe

[chbare]

Perhaps we have gone a little off topic? I thought the thread was about RSI. RSI and intubation are not one in the same. True, RSI is a procedure that involves intubation; however, we should not confuse the two terms. I think this is a thread that asks if RSI should be standard practice in the pre-hospital environment?

I am not sure anesthesia and ER docs have a generalized clash regarding RSI as some seem to think. Perhaps I am wrong? I never had ER anesthesia problems at any of the hospitals I have worked at to date. The big "debate" in anesthesia circles seems to be around allowing non anesthesia providers to provide sedation and analgesia type techniques in the ER and GI labs that have traditionally been performed by anesthesia educated providers.

I do not think anybody is arguing against intubation per say? RSI is an entirely different can of worms. Nearly all of our pre hospital airways in systems without RSI are crash airways. So, essentially in many cases we are forced to take measures to secure some kind of airway. Obviously, if we choose to RSI, we are not talking about a crash airway. RSI is a decision we make based on a predicted clinical course.

When we RSI, we essentially induce a crash airway. This has been called our one chance to get a "clean kill." When we RSI we have an awake, breathing, living patient, and take away what protective reflexes they may have. With a crash airway, we have a dead or near dead patient. The stakes are quite high when we RSI and the question still stands. Is this a procedure that should be a pre-hospital standard of care?

Take care,

chbare.

[FormerEMSLT297]

No, RSI should not be standard ... for all of the mentioned reasons, and several others.

Our RSI program requires quarterly evaluations in a clinical setting. That means with an anesthesiologist. Think about taking all of your medics out of the system 4 times a year for a day in the O.R.

RSI definitely has its place in HEMS, Rural settings, and some other specialized units, but in major cities, where the transport tims is an average 10 minutes or so, there are too many complications that can go wrong with RSI.

That being said, if you have a committed Anesthesiologist/medical director, and a good QAI program, then it is something to be considered. But to make it a blanket standard of care, No just no HELL NO.

[captainstandup]

We too are allowed to RSI and do so without physician orders and even carry diprivan and a host of other really cool meds and you know what? We rarely use even half of this stuff.

How many of us give even a second thought to the value of the "stuff we do"? Its really nice to be able to reach into our bag of tricks and pull out things that no EMS service in the region gets to use, and to hear the oohh and aahhhh, but is this truly science based medicine? I feel we have reached a point to where we can’t see the forest due to the trees in the way.

There exists painfully little research to prove the value of RSI or even intubation in the field. I haven’t read the other threads on this subject but they are likely filled with this and other redundant claims both for and against RSI. Like myself many would probably loose their mind if the “Excalibur of paramedicine” (our laryngoscope) was taken away in favor of a less invasive device. Now, before you folks start slamming me on this please read on as I am not giving up my laryngoscope willingly.

At some point during the evolution of paramedics, perhaps during the Pre-Cambrian period, we became competitive and fault finding with others perceived as less skilled. The focus became a matter of successful skills completed as opposed to appropriate patient care that was evidence based.

I too, was a training officer before moving to admin and am guilty of tallysheet measurement of a paramedic or EMT-I's ability. They say with age comes wisdom and I now possess the former, hopefully I possess the latter as well. Instead of focusing on successful skills completed and berating those with poor rates we should have been looking at the whole picture. This isn’t one of those touchy feely everyone can do this posts, because I have seen those who were much better suited on the fry maker at Burger King and I sent them there.

In terms of airway there are a few undeniable truths 1) Oxygen is good (I know, I know the research about free radicals in stroke patients, but we will save that one for another time) 2) Blue is bad 3) Air goes in and out. That’s where the "truths" end and the lines blur.

If we listen to the American Heart Association (for $ale to the highe$t pharmaceutical or airway adjunct vendor) the LMA is just as good as the endotracheal tube in cardiac arrest, is easier to utilize, can be utilized by a broader group of providers with less training and less complications. Now you ask could this be? To that I reply possibly, but there is no data to prove this. Just like the "science" behind vasopressin which was absurd and failed to proved its value yet guess who gets invited to the algorhythm.

The point I’m trying to make is that we simply must begin a process of putting forth the effort to prove our skills, procedures and medications have intrinsic value to the patients. With few exceptions there is little pre hospital based research that is actually based on field conditions. Unlike the power brokers and fraudulent research that exists in the AHA for the sake of money, our research must be real world, down in the ditch, nursing home floor, along the roadside, in the back of a truck designed for hauling freight as opposed to people; realistic research that either proves or disproves the value of what we do.

In absence of the research we can skip the silly recriminations and tallysheet nonsense and truly evaluate skill success on a case by case basis. If we can’t get the patient intubated or RSI isn’t successful then is ok to go to a backup airway such as the LMA or combiube or are we to draw and quarter those failing to complete the precious skill. Our focus must be only one thing; did the patient receive appropriate care? Were they successfully ventilated by appropriate means which may mean only a BVM with OPA and supplemental oxygen or it may include devices such as the LMA or Combitube.

This isn’t to imply we accept "good enough" and excuse those poorly skilled as clinicians, but I do feel we need to instill in all of our personnel to have a backup plan and a backup plan to the backup and so on. Then when things don’t go well our folks are able to adapt and overcome.

In the days before RSI I vividly remember patients that would clearly have benefited from this skill and in retrospect I really wish I had it then. I think RSI is now merely a component or tool that we have to accomplish appropriate airway management in certain situations. Not everyone should be armed with this skill, but I believe if we gain the necessary education then training and support both with good recurrent training accompanied by QA/QI that is patient care centered RSI and many other skills procedures and medications will remain available to our prehospital patients.

Oh and by the way if any of you have trouble getting and airway on me I'll expect a nice vertical scar somewhere around the cricoid cartilage, I'll wear it with pride!

[Dustdevil]

RSI definitely has its place in HEMS, Rural settings, and some other specialized units, but in major cities, where the transport tims is an average 10 minutes or so, there are too many complications that can go wrong with RSI.

I see some contradictions in your statement.

If you are going to risk complications, doesn't it make more sense to do so ten minutes from the ER than an hour away? And, if so, doesn't that make urban a more logical deployment for RSI than rural? And, since it is extremely rare for HEMS to be the first ALS on a scene, why would RSI be more valuable to them than to a primary provider? If I haven't gotten that tube by the time you get there in the bird, it's about too late for you to save the day with teh RSI.

I'm not asserting either of those claims myself. I'm just pointing out your contradictions.

[p3medic]

Try holding your breath for ten minutes.....I don't think proximity to a hospital should be the deciding factor, if a patient needs an airway now, they get it. I do agree however that with the lack of education and oversite, the tool is not for everyone. In a perfect world all prehospital clinicians would have the expertise in airway management to justify it, but alas, we don't live in a perfect world.

[spenac]

Any chance of getting that in english?

Holy crap batman what was I typing. Guess thats why you should not type after a 48 hour shift and then having taken benadryl.

My response I believe should have read more like. Zilla you stated that "anesthesiologists who feel this way should keep in mind that ER docs handle 99% of the airways in the emergency department without any help from them."

So now based on that reasoning the following could be said: ER docs and anesthesiologists who feel this way should keep in mind that Paramedics handle 99% of the airways in the field without any help from them.

I personally think RSI is an important part of field care. I do think we should be educated on it more and also be required to take additional clinals and CE's each year to to keep up and improve our skill level on it, just as I feel ER docs and anesthesiologists should. Yes I said our skill level because as an EMT-I I perform RSI in my current system. RSI and surgical crics are important life saving skills.

[Doczilla]

My response I believe should have read more like. Zilla you stated that "anesthesiologists who feel this way should keep in mind that ER docs handle 99% of the airways in the emergency department without any help from them."

So now based on that reasoning the following could be said: ER docs and anesthesiologists who feel this way should keep in mind that Paramedics handle 99% of the airways in the field without any help from them.

According to the literature, they handle 60-80% of airways without them.

Sorry. Couldn't resist.

And Akroeze: My mistake. I thought you were trying to pick a fight. Or had been talking with an anesthesiologist or CRNA who was shooting his mouth off.

'zilla