# Rsi



## Natren (Aug 20, 2012)

I'm originally from WA state where we RSI patients when needed. I am a Paramedic student currently out of state and am understanding how much different this concept/skill is not utilized in other EMS systems. I'm wondering if anyone has any advice for me about this when I go into my field rotations. I have the opportunity to ride at some places where they RSI but are not as busy as a big city that doesn't. Wondering what some seasoned Medics think about being a student and the importance of learning this skill in the field as a student is? And how you might deal with a pt who would benefit from RSI but it may not fall under the protocols of your service? And if there are any good places to look into as far as field time besides places in WA that practice this skill that take students?


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## STXmedic (Aug 20, 2012)

Go with the busier system for your clinical time*. There is much more to being a paramedic than RSI. If you run across a patient in the field that needs RSI, and you can't give it to them (not in your protocols), then call med control if you have the appropriate meds available, or drive fast.

*Assuming the busier system is still decent and just doesn't have RSI


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## hibiti87 (Aug 21, 2012)

i agree RSI is a nifty trick but not an integral part of being a paramedic that you should base your internship decision on. Patient assessments of course are the key in becoming a good paramedic and therefore the system that will provide you with more patient contacts will be the most beneficial to participate in.


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## lightsandsirens5 (Aug 21, 2012)

hibiti87 said:


> i agree RSI is a nifty trick but not an integral part of being a paramedic that you should base your internship decision on. Patient assessments of course are the key in becoming a good paramedic and therefore the system that will provide you with more patient contacts will be the most beneficial to participate in.



Exactly. For example Memorial Herman Life Flight is one of the most high speed flight services in the country, and as far as I know, they don't RSI.


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## Aidey (Aug 21, 2012)

Nifty trick...:blink::blink::blink:


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## usalsfyre (Aug 21, 2012)

lightsandsirens5 said:


> Exactly. For example Memorial Herman Life Flight is one of the most high speed flight services in the country, and as far as I know, they don't RSI.



While I don't know for sure, I would be DUMBSTRUCK if this were actually the case.


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## usalsfyre (Aug 21, 2012)

Natren said:


> I'm originally from WA state where we RSI patients when needed. I am a Paramedic student currently out of state and am understanding how much different this concept/skill is not utilized in other EMS systems. I'm wondering if anyone has any advice for me about this when I go into my field rotations. I have the opportunity to ride at some places where they RSI but are not as busy as a big city that doesn't. Wondering what some seasoned Medics think about being a student and the importance of learning this skill in the field as a student is? And how you might deal with a pt who would benefit from RSI but it may not fall under the protocols of your service? And if there are any good places to look into as far as field time besides places in WA that practice this skill that take students?



Very simply, it's a dangerous, possibly over utilized and usually under prepared for skill set that your "average" paramedic has no business performing.


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## abckidsmom (Aug 21, 2012)

usalsfyre said:


> Very simply, it's a dangerous, possibly over utilized and usually under prepared for skill set that your "average" paramedic has no business performing.



Quoted for truth. 

I know a medic who "ghetto RSIs" with versed and fentanyl and a Benadryl chaser. He apparently does this quite frequently, and off protocol. 

It's dangerous, and if we got RSI he would be even more dangerous. I would like to see more people actually knowing when the airway is ok to be managed bls rather than jumping the gun and tubing everyone.


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## med51fl (Aug 21, 2012)

usalsfyre said:


> Very simply, it's a dangerous, possibly over utilized and usually under prepared for skill set that your "average" paramedic has no business performing.



This is very true.  Just because you *can* do something doesn't mean you *should*.


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## Doczilla (Aug 21, 2012)

abckidsmom said:


> Quoted for truth.
> 
> I know a medic who "ghetto RSIs" with versed and fentanyl and a Benadryl chaser. He apparently does this quite frequently, and off protocol.
> 
> It's dangerous, and if we got RSI he would be even more dangerous. I would like to see more people actually knowing when the airway is ok to be managed bls rather than jumping the gun and tubing everyone.



It's all about the ego. I've seen some peers sit in the bay of the trauma center trying to RSI, with the trauma surgeon staring at them through the window, tapping his foot.


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## lightsandsirens5 (Aug 21, 2012)

usalsfyre said:


> While I don't know for sure, I would be DUMBSTRUCK if this were actually the case.



One of my best friends is a flight medic with them. Now....I know they have been talking about getting it, so they may have by now. That info is about a year old.


Or were you talking about being dumbstruck if Memorial was actually high speed?


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## Shishkabob (Aug 21, 2012)

I did 2 RSIs in a rural system in 10 months.  I've assisted on one in a busy urban system in the same time.  While I think RSI should be available everywhere, it's more likely to be needed in a rural system due to the length of transport.  (Having said that, if I need to RSI someone in a hospital ambulance bay, I will).  On top of that, hate to break it to ya, but with RSIs being so rare, complicated and dangerous, I'm not letting my student do it.  



As I said, I believe it should be available in every system, rural, urban or suburban, as when it's needed, trust me, it's needed.  It's beneficial to a multitude of patients in a multitude of situations, and infact is beneficial/needed more than a few of the medications we carry.


Instead of not allowing the skill to be done, just don't allow those you don't trust to do it not practice as medics in your system.


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## NomadicMedic (Aug 21, 2012)

Linuss said:


> On top of that, hate to break it to ya, but with RSIs being so rare, complicated and dangerous, I'm not letting my student do it.



That's a shame. I performed several RSIs in the field as a paramedic student, under the watchful eye of my preceptor. And what do you know; I was a paramedic student in Washington.  Of course, the skills you practice will be directly proportionate to your preceptor’s comfort level. I will say I was glad I had the opportunity to practice with a preceptor before I did my first one in the field alone. 

We have RSI at my current service and due to our long transport times and frequent helo fly outs, we RSI quite frequently and we’re very good at it. Having said that, ONE bad RSI can spoil the entire program. We practice, practice, practice. We are expected to make frequent visits to the OR for Pedi and Adult tubes. And we follow very tightly defined protocols and run through exhaustive QI on every RSI. Subsequently, we continue to have an awesome success rate and every RSI has been deemed appropriate by medical directors and the QI division. 

Should every service be allowed RSI? No. Should well trained paramedics who use the skill often have it? Absolutely.


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## WTEngel (Aug 21, 2012)

I have worked in systems with RSI, and I have worked in systems without it. 

I didn't really miss it when I didn't have it, and I had a high degree of respect and humility when I did have it.

Most patients can be managed quite effectively with PAI and don't require a paralytic. I have mixed feelings on the issue, but all in all, this has been my experience.

I think the real goal should be to build the skills that keep you from getting to the point of needing RSI, and you will be better off.

As far as people saying they do this as a field intern, I have some reservations about that... Most medic students can barely bumble through a good field interview with a patient, much less walk the tightrope that is RSI... I don't fault them for this, they are students and they are learning, but you also must crawl before you walk... doing RSI in field internship is not crawling before you walk.


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## NomadicMedic (Aug 21, 2012)

WTEngel said:


> I have worked in systems with RSI, and I have worked in systems without it.
> 
> I didn't really miss it when I didn't have it, and I had a high degree of respect and humility when I did have it.
> 
> ...



Agreed on all points. 

As for students not performing RSI, when is it ok? After they pass national registry?

Every student is different, and while not every student should be allowed to perform advanced procedures, in much of Washington, RSI was a regular paramedic skill, the same as any non drug assisted intubation or any other skill that new medics learn. To become proficient, you have to practice.  I know that RSI is a dangerous procedure, and I know that I am nervous every time I push the drugs... But I have had opportunity to practice. Much more so than many of the other medics that frequent this forum. That's not bragging, it's just a simple fact. If you infrequently intubate, then a drug assisted intubation will be even more of a high pressure situation. If you have opportunity to intubate frequently, if you practice and have a clearly defined protocol for intubation and a back up plan B and C and maybe even D for failed intubations, then a drug assisted intubation is just another tube.

To be fair, there were some students in my class that were not given the opportunity to practice advanced skills. But the high performers in my program, of which I was one, were encouraged to learn and gain experience and practice  skills in the field that I'd guess many medics have never seen. 

As for crawling before you walk, you know as well as I do that some students are far more skilled than others. It should be at the preceptors discretion as to what skills those students should be able to practice when in their field internship. Just because a student is cleared to put a laryngoscope into someone's mouth doesn't mean they should be intubating. Conversely, an exceptional student who has skills that are potentially far more developed than other students should not be held back from opportunities to practice in the field simply because he is a "paramedic intern".


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## WTEngel (Aug 21, 2012)

Fair enough. The USA is a big place...what's right for Washington may not be right in my neck of the woods.

As far as when paramedic students or newly certified paramedics should practice, this is just my opinion, it should be after they have become certified and ridden as first assist for at least 6 months...incrementally getting more experience during that time period. 

Granted, I know this isn't always possible, but unfortunately we live in a country where some systems are just fine putting a newly certified paramedic on critical care transfer calls simply to make a dollar. 

I have digressed a bit, and I am definitely not trying to imply that anyone posting here is working in a system like that...but it is that type of system where a mistake is just waiting to happen. 

A lot of the backlash that medics have been getting for years regarding intubation and advanced procedures, or the taking away of those privileges, has come from poorly managed systems that had RSI in place without responsible oversight of that skill. 

I always found it frustrating to hear the ego trip that some people get on touting how they have RSId "x number of people in the last x months" or whatever. Again, I am not accusing anyone here of doing this, just simply stating. 

I guess I always like to get on a little soap box during discussions like this because, as nearly 100% of the people posting on this forum have recognized, RSI is a skill that almost every paramedic thinks they can handle, yet very few can actually hack it...they have simply been getting lucky thus far...

Any paramedic worth their grit knows it is only a matter of time before the call that is going to bite you in the rear comes out over the radio. The good paramedic accepts this fact and begins to learn his enemy so that he can defend himself and protect his patient should the need arise...the novice paramedic rests on his laurels and fools himself into thinking that enemy would never dare confront him because he is just such a dang hotshot...woefully ignorant of his previous good fortune.

One of those paramedics is right, and the other is wrong...


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## Natren (Aug 21, 2012)

Thank you all for your in put! I was an EMT in a high call volume service in which you were expected to be assistant to the paramedic and I had a lot of confidence MOST of the medics who RSIed in WA. All the students that came to work for us were taught it as a skill in school and we def had "red button" protocol that you were never to RSI as a single medic unless a supervisor was present or at least enroute. I can honestly say I have seen very few unsuccessful RSI intubations where I'm from. I feel as though it is highly respected there and not taken lightly at all. 
All that being said, I do agree that I would rather learn as a student than be put in a situation as a paramedic where I there might be an expectation of me when I don't have the skill set not learned as a student. Being busy tho however I know should be my priority. Such is my dilemma currently! I know there is A LOT more to being a paramedic than just focusing on that skill, but its a difficult thing for me to understand coming from a system after 4 years that does this skill. 
I feel like they have skimmed over it in school because they don't believe in it too much in the state I'm in currently. Which frustrates me a little because I feel like we should be educated thoroughly about HOW dangerous it is, but how we do need to be good at intubating and be prepared for the worse since many students in my program have NO prior EMS experience.
So new question....let's say you have a pt who does have a swelling airway (burn/anaphylaxsis, etc) what do you do when you can't RSI this pt? I have seen both as an EMT and I just don't know that any other option would have been available left over except surgical airway had we not been able to RSI this pt...being 20 min or so from the hospital.
I know I'm a student, I'm def very familiar with the dangers of this skill. But I want to know if I don't have it, what do I do?


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## Natren (Aug 21, 2012)

WTEngel,
Do they RSI there in Fort Worth? Curious what its like down there...I don't know much about the Texas systems but have heard they are good!


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## Natren (Aug 21, 2012)

n7lxi,
I take you still work in WA then??


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## NomadicMedic (Aug 21, 2012)

Natren said:


> n7lxi,
> I take you still work in WA then??



Negative. I'm on the east coast.


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## Natren (Aug 21, 2012)

Nice. Hoping to head that direction eventually. Know any good systems to start out over there running 911 as a new medic? I looked into NC and Virginia. Just tryin to not go back to my private in WA or get too stuck in the midwest.


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## usalsfyre (Aug 21, 2012)

Natren said:


> WTEngel,
> Do they RSI there in Fort Worth? Curious what its like down there...I don't know much about the Texas systems but have heard they are good!



MedStar allows a small pool, a few other systems in the area also allow it. It varies throughout the state how common it is.


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## Shishkabob (Aug 21, 2012)

n7lxi said:


> That's a shame. I performed several RSIs in the field as a paramedic student, under the watchful eye of my preceptor. And what do you know; I was a paramedic student in Washington.  Of course, the skills you practice will be directly proportionate to your preceptor’s comfort level. I will say I was glad I had the opportunity to practice with a preceptor before I did my first one in the field alone.




As you said, it's all down to comfort and most preceptors just do not get enough time with a student in actual critical calls to validate a student doing it (in my opinion).  Now, if it's just the intubation aspect of the call, and they've already proven to me that they can get the tube in the hole, ok.  But at my current agency, we're allowed a single shot at the tube, and I truly do not want to waste my one shot on a critical patient that's paralyzed without their own ventilatory ability to fall on a student that's probably never done a tube, let alone in a situation as the one presented.  


My first ever RSI was also my first ever field intubation, and I got it first try.  I know I'm awesome and all, but even you normal people can do that!  :lol:




Natren said:


> Do they RSI there in Fort Worth? Curious what its like down there...I don't know much about the Texas systems but have heard they are good!



Yes, it's done in Ft Worth.  Besides the physicians that show up on scene who obviously can do it, also the APPs (Advanced Practice Paramedics) and the more senior/experienced Paramedics all go through a crash airway course and extensive airway control classes before being allowed to do it.  The average truck Paramedic doesn't have it, but there's someone within 10 minutes driving that does if you call for them.


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## WTEngel (Aug 21, 2012)

It isn't that uncommon to find systems with RSI around North Texas, but it is implemented a bit differently.

Like Linuss said, in Fort Worth, the system is tiered. It isn't uncommon to have physician medical directors or advanced practice paramedics show up to the higher acuity calls where the need for additional hands on deck with more advanced capabilities is likely. The advanced practice paramedic is a designation specific to MedStar in Fort Worth though, and not a level recognized by the state. It is simply a small pool of up-skilled paramedics authorized by the medical director to have a few more tricks up their sleeve.

The nice thing about that type of system is that it is easier to track and assure quality in a smaller pool of providers.

There are also a handful of smaller cities that are under the medical direction of a pretty well known medical director in the area that for the most part all have RSI capability. The nice thing is that these small cities are compartmentalized and generally have a pretty active EMS command to help track and control quality. 

Now, as for the city of Dallas, the EMS is run by Dallas Fire Department, and they do not have RSI, should not have RSI, and I hope to God never get RSI. They actually no longer carry ET tubes to my understanding, and run with only king airways...I could be wrong, but that is the last I heard. 

All of the systems in between these two extremes have PAI for the most part, which seems to work really well for them. The fact that most are not any more than 10-15 minutes from the hospital ever makes PAI a reasonable alternative. 

Additionally, we have a number of critical care services that have RSI capability and beyond...but that accounts for a handful of a handful of medics in the area, and typically they are rolling with a nurse and a RT...

EMS in Texas is pretty diverse. I personally believe we have some of the best EMS systems in the world here in Texas, along with some of the most underperforming systems.


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## Shishkabob (Aug 21, 2012)

WTEngel said:


> There are also a handful of smaller cities that are under the medical direction of a pretty well known medical director in the area that for the most part all have RSI capability. The nice thing is that these small cities are compartmentalized and generally have a pretty active EMS command to help track and control quality.


  Having ridden with a couple of those departments and seen them work, I'm still on the fence on if they should have the ability.  Dr Yamada is really well respected, but those agencies... ehh.



> Now, as for the city of Dallas, the EMS is run by Dallas Fire Department, and they do not have RSI, should not have RSI, and I hope to God never get RSI. They actually no longer carry ET tubes to my understanding, and run with only king airways...I could be wrong, but that is the last I heard.


  Last I heard they also didn't have narcotics for pain control. 

But that was also about the time that they were being investigated federally for illegal billing practices and rumors were rampant that they were going to pull out of EMS for AMR to take over.  Ha.


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## Natren (Aug 21, 2012)

Thanks for the insight. I'm learning a lot being out of WA. I have a list of possible places I'd like to ride/apply. Fort Worth is on my list as well as some places on the East Coast. But I think I will end up heading to Kansas City for my ride time since it seems to be the least difficult for us to get a contract with at our school and they are really busy from what I hear...
All in all I think I will just have to see how the whole RSI thing will work out. I am nervous not have it since I have seen many pt's benefit from it...but the Fort Worth system sounds like they have a great support system. Some places I know don't have that. I guess its an arguement of what the best pt care really is and there are lots of perspectives.


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## usalsfyre (Aug 21, 2012)

WTEngel said:


> Now, as for the city of Dallas, the EMS is run by Dallas Fire Department, and they do not have RSI, should not have RSI, and I hope to God never get RSI.


Amen and hallelujah 



WTEngel said:


> They actually no longer carry ET tubes to my understanding, and run with only king airways...I could be wrong, but that is the last I heard. .


This would explain why the last couple of times I've done a field ETT I've gotten a strange look and "you did a real tube?"


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## MSDeltaFlt (Aug 22, 2012)

The trick to healthcare on every single level is not knowing what to do and being able to do it. The trick here is being able to to do something and knowing when and when NOT to do it.  My advise is to take care of your pt whether you have RSI oor not.  Managing the airway and intubating are not necessarily the same thing.


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## NomadicMedic (Aug 22, 2012)

Not to be critical, but Linuss, you've only been a medic just a little longer than me. Are you precepting students? 

Here, only FTOs can have paramedic students, and the FTO process requires a significant amount of education and experience. You're not eligible to even apply until you've been working in the system for 4 years. And here, students are not allowed to participate in the RSI procedure. 

RSI in Delaware is at the Medical Director's discretion. There's a "certification process" that involves classes, a written test, a long crash airway skill test on the SimMan and an interview with the medical directors. 

Even then, we still require two medics be part of every RSI.


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## Shishkabob (Aug 22, 2012)

n7lxi said:


> Not to be critical, but Linuss, you've only been a medic just a little longer than me. Are you precepting students?


  I did at my last agency a few times.  Just ask usal how they delegate student, haha.


Didn't you get your medic in '11?  I don't know, everyone getting their medics confuses me.




> You're not eligible to even apply until you've been working in the system for 4 years. And here, students are not allowed to participate in the RSI procedure.


  To be fair, we've established that I'm just awesome ^_^

I plan to go for my FTO at my new agency in the coming months where they start Paramedic FTOs training EMTs and Intermediates at first, then move on up to medics.


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## NomadicMedic (Aug 22, 2012)

Nope. 2010.


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## Shishkabob (Aug 22, 2012)

Still beat you. 

And I'm probably taller, too.


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## NomadicMedic (Aug 22, 2012)

Hahah. Yeah, I'm only 6'1". And I didn't mean any disrespect... I know you're awesome.


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## Shishkabob (Aug 22, 2012)

6'2"!  Got a full inch on you son!


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## RocketMedic (Aug 25, 2012)

Wait....Linuss you left MedStar?
We don't have RSI in New Mexico, unless online medical control authorizes. My AMR operation also sends the on duty supervisor in a truck to high acuity calls, which is a help. 
NM as a state is pretty backwards on airway management, but we do have full ETI .

How's the job market in DFW?


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