# RSI checklists



## Carlos Danger (Dec 19, 2014)

Interesting talk here: Should Real Airway Docs Need Checklists?

Personally, I think a well designed pre-RSI checklist is a great, common-sense idea. A good way to slow everything down a little, get everyone who is involved on the same page, and make sure you haven't overlooked anything important (suction, proper positioning, etc.) in the heat of the situation.

I love Minh (the second speaker), but I don't think he makes a good case at all against checklists.

I'll be working in the field again in a few months, and even though I intubate several times a day at my full-time job, I'll use my own checklist for every prehospital RSI I'm involved in if I can't get my EMS agency to adopt one.


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## MonkeyArrow (Dec 19, 2014)

Man, I love these critical care/resuscitation videos from SMACC. Always foster interesting discussion. Anyways, I'll bite. I don't think real airway doctors need checklists. However, before I go any further, I must define what I think is a real airway doctor. A real airway doctor is someone who is extensively trained to, and on a consistent and frequent basis, practices the management of airway both in controlled settings (elective surgery) and in the uncontrolled settings (trauma/codes/resuscitations/ED ETI). Said doctor performs a minimal amount of procedures in airway management a month (let's say 10 tubes, 10 BVMings, 1 surgical airway, 1 rescue/SGA). 

Now, based on that definition, I feel like a real airway doctor does not need to run through a checklist because a real airway doctor should know how to manage the airway proficiently. Checklists and algorithms inevitably have to be something that caters to everyone, and mandating everyone to follow a cookie cutter checklist will foster complacency and deterioration of skills. This is why: a checklist cannot fundamentally be aggressively structured, which is how airways should be managed. Therefore, you either have a checklist restricting the discretion of the physician, or you have a checklist suggesting everyone should get crics. A cric for you, you and you!!!

An inherent problem of checklists is the fact that they cannot be tailored to meet every individual patient. Only the provider in the field with physical boots on the ground can fully understand the entirety of the patient's circumstances. A checklist cannot do that, and you will eventually run into a situation that the checklist doesn't have an answer for. A real airway doc should be able to operate at a lever where he can evaluate the status of the airway and make a concise decision without having to check off boxes on a clipboard. If said doctor is forced to check off boxes for every scenario, then for the situation where he has run out of boxes on the checklist, he and his patent are in a bad place since he doesn't know how to think for himself and manage the airway independent of algorithm. 

This problem is seen over and over again, the first example coming to my mind being ACLS. As Dr. Weingart of EMCrit likes to call it, resuscitation for skin doctors. Algorithms are there to supervise or facilitate something for a wide group of people to be able to do it, inevitably leading to the dumbing down of said protocol so it does cater to everyone's needs. 

However, keep in mind that at the level of education and training that we have in the field as medics, we are *NOWHERE* near real airway docs and therefore, probably should have a checklist.


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## NomadicMedic (Dec 19, 2014)

I think an RSI checklist is a great way to slow things down and eliminate mistakes. I think just prior to pushing the meds there should be a timeout when you go over the list and make sure everyone agrees that the RSI should go on.


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## Tigger (Dec 19, 2014)

That is how our procedures are supposed to be done. The RSIing paramedic draws up the medications and leaves the syringes in the vials. At the same time the other partner sets up the airway equipment. The two switch and doses are confirmed and the intubating paramedic gets things in place to his liking.


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## Akulahawk (Dec 19, 2014)

Checklists are great tools if they're appropriately designed and used. I would expect that someone doing RSI would be very familiar with the procedure... but having the checklist simply ensures that all tools necessary are on hand.


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## TransportJockey (Dec 19, 2014)

Tigger said:


> That is how our procedures are supposed to be done. The RSIing paramedic draws up the medications and leaves the syringes in the vials. At the same time the other partner sets up the airway equipment. The two switch and doses are confirmed and the intubating paramedic gets things in place to his liking.


This. This is generally how we do it, if there's two medics on the call.
IF there's not, the medic doing the RSI follows a rough check sheet that my shift uses. I'll carry it over with me to the other shift once I transfer to that tour.


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## Tigger (Dec 20, 2014)

TransportJockey said:


> This. This is generally how we do it, if there's two medics on the call.
> IF there's not, the medic doing the RSI follows a rough check sheet that my shift uses. I'll carry it over with me to the other shift once I transfer to that tour.



Part of our EMT internship includes learning to play the second provider role, as we often do not have any sort of professional backup. This I'm sure is similar for you.


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## CANMAN (Dec 21, 2014)

Akulahawk said:


> Checklists are great tools if they're appropriately designed and used. I would expect that someone doing RSI would be very familiar with the procedure... but having the checklist simply ensures that all tools necessary are on hand.



I completely agree. My system uses an RSI checklist on every patient we tube. Generally for our trauma scene calls when we land and climb into the back of an ambo or arrive at a scene there is an overwhelming amount of people, which hinders access to the patient. I normally task one of the BLS providers to call out the items on the checklist, pre-procedure, which tasks them with something to do however keeps only the players involved in care close to the patient.

Also to this statement " I feel like a real airway doctor does not need to run through a checklist because a real airway doctor should know how to manage the airway proficiently." I couldn't disagree more and running through a checklist has nothing to do with how proficient at airway management a provider is.......


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## jwk (Jan 8, 2015)

CANMAN said:


> Also to this statement " I feel like a real airway doctor does not need to run through a checklist because a real airway doctor should know how to manage the airway proficiently." I couldn't disagree more and running through a checklist has nothing to do with how proficient at airway management a provider is.......



Not sure what a "real airway doctor" is, but anesthesia personnel are universally recognized as the airway experts, and RSI is part of our daily routine.  I anesthetize a thousand patients a year, and each one of them requires airway management of some sort.  Intubation +/- RSI is an urgent/emergent procedure anywhere else in the hospital (including the ER) or in the field, but for us, it's a matter of routine and a checklist would be somewhat absurd.  You think a surgeon is going through a checklist as he's performing surgery?  Of course not.  

However, I'm all for checklists and algorithms to deal with relatively uncommon occurrences, including, among other things, airway management outside the OR.


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## Carlos Danger (Jan 9, 2015)

Yeah, I don't think the concept applies to people who literally do airway management _for a living_....especially when the airways are managed in the same controlled setting, virtually the same exact way, every time. 

But as soon as you leave that familiar setting, it's real easy to overlook something that you would never forget in your normal environment.

I was interested in the concept of checklists more as they apply to the prehospital realm, where every airway encounter is done in a non-routine setting and most paramedics don't even intubate very often.


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## CANMAN (Jan 9, 2015)

jwk said:


> Not sure what a "real airway doctor" is, but anesthesia personnel are universally recognized as the airway experts, and RSI is part of our daily routine.  I anesthetize a thousand patients a year, and each one of them requires airway management of some sort.  Intubation +/- RSI is an urgent/emergent procedure anywhere else in the hospital (including the ER) or in the field, but for us, it's a matter of routine and a checklist would be somewhat absurd.  You think a surgeon is going through a checklist as he's performing surgery?  Of course not.
> 
> However, I'm all for checklists and algorithms to deal with relatively uncommon occurrences, including, among other things, airway management outside the OR.



I don't know if your post was directed at me, but I did not make the "real airway doctor" reference. I was replying to the OP who made that reference. Do I think a surgeon or someone doing anesthesia for a living should run through a checklist, of course not, and I never made such a statement. I was simply saying to the person who posted that I do not think you can judge someone's experience level or airway management competency based off if they use a checklist or not. My employer mandates it, regardless or your level of training, and we have more then one CRNA who still maintains their position as a flight nurse within our program. I am not sure what is up with the forum lately, but to me it seems like we have a few anesthesia providers on the board that feel like they have to prove superior knowledge and experience. I don't think anyone here has question those things in any of the posts I have seen.


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## Carlos Danger (Jan 9, 2015)

CANMAN said:


> I am not sure what is up with the forum internet lately, but to me it seems like we have a few anesthesia providers lot of people on the board that feel like they have to prove superior knowledge and experience.



Fixed it for you.


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## NomadicMedic (Jan 9, 2015)

Do Pilots follow a checklist?
Is there a checklist and timeout before every surgical procedure?

If you haven't, maybe read "The Checklist Manifesto" from Atul Gawande. The great takeaway message? "No matter how expert you may be, well-designed check lists can improve outcomes."

Even for people who perform the same tasks everyday. Like airway management. 

If you don't want to read the book, it's reviewed here:

http://www.npr.org/templates/story/story.php?storyId=122226184


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## PotatoMedic (Jan 9, 2015)

jwk said:


> Not sure what a "real airway doctor" is, but anesthesia personnel are universally recognized as the airway experts, and RSI is part of our daily routine.  I anesthetize a thousand patients a year, and each one of them requires airway management of some sort.  Intubation +/- RSI is an urgent/emergent procedure anywhere else in the hospital (including the ER) or in the field, but for us, it's a matter of routine and a checklist would be somewhat absurd.


Look.  The ASA suggests that you use checklists! https://www.asahq.org/For-Members/P...letter-Articles/2014/May-2014/checklists.aspx

And I can't find the article but they also reccomend that you use a pre induction and intubation checklist.

No I don't think you need to consult the written checklist every time.  But you should know it.  What it says and in what order.  And you should use it every time. 

I know a few private and commercial airline pilots and they always use the written checklist.  And they have the think memorized verbatim.  So yes you do it every day.  But checklists are not something that are "absurd."


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## Carlos Danger (Jan 9, 2015)

DEmedic said:


> Do Pilots follow a checklist?
> Is there a checklist and timeout before every surgical procedure?
> 
> If you haven't, maybe read "The Checklist Manifesto" from Atul Gawande. The great takeaway message? "No matter how expert you may be, well-designed check lists can improve outcomes."
> ...



I'm not really sure how the discussion got turned from "are checklists a good idea in emergency airway management" to whether or not we should be using them in routine anesthetics. The two are very much apples & oranges. 

Checklists are used in anesthesia, just not the way they are described in the debate that I posted. For example, every time I prepare for a case I set the room up exactly the same way, using a simple mnemonic (a mental checklist) to make sure I haven't forgotten anything important. When I do a pre-op, my facility has a pre-op form that helps make sure I don't forget to assess for things that could impact the patient during the anesthetic.

Though parallels are often drawn between anesthesia and aviation, a routine induction is really very different from flying a plane. Most of the critical steps (setting up the room, assessing the patient, developing an anesthetic plan, etc.) are done before the patient even enters the OR. The induction itself - whether RSI or not - only takes 2 minutes and only requires a handful of steps....unlike operating a highly complex aircraft. Also unlike operating an aircraft, critical systems components (suction set up and turned on, breathing circuit working) are visually apparent. As a result, routine anesthesia is extremely safe and getting safer all the time, even without the use of formal checklists.

When things do go seriously wrong on induction, it is usually related to some patient factor (undiagnosed DMD or valvular disorder or airway anomaly, for instance) that would not have been detected or prevented by a simple 5 of 10 point checklist.

Emergency cases are different. When a sick patient crashes into your OR with no or very little warning, or when you get called to the ED or ICU to intubate a train wreck with Sp02's in the toilet, your routine is disrupted, your environment is different, and the patient is much less likely to tolerate mistakes. Complication rates are much higher in those situations. So I think simple checklists might be valuable there, the same way I think they would be in EMS.



FireWA1 said:


> Look.  The ASA suggests that you use checklists! https://www.asahq.org/For-Members/P...letter-Articles/2014/May-2014/checklists.aspx



That is just an article, not a recommendation. And it refers to emergency procedures, not routine inductions.


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## Akulahawk (Jan 10, 2015)

Remi said:


> Though parallels are often drawn between anesthesia and aviation, a routine induction is really very different from flying a plane. Most of the critical steps (setting up the room, assessing the patient, developing an anesthetic plan, etc.) are done before the patient even enters the OR. The induction itself - whether RSI or not - only takes 2 minutes and only requires a handful of steps....unlike operating a highly complex aircraft.


For the most part, flying a plane (airliner) is very routine. All the prep work is done prior to takeoff and they follow a checklist. 

You just admitted to using a checklist of sorts as well. It's not the mechanics of doing the deed, so to speak, that requires a checklist... it's getting everything set up that does. You use a mnemonic to ensure that you've got everything done. What's the difference between using your mnemonic that's been well memorized or a piece of paper that has the same things printed on it?


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## Carlos Danger (Jan 10, 2015)

Akulahawk said:


> For the most part, flying a plane (airliner) is very routine. All the prep work is done prior to takeoff and they follow a checklist.



This whole aviation : anesthesia thing is really overdone. There are some interesting conceptual similarities, I agree, but flying a plane and sleeping a patient are not the same thing. 

I sat in the left seat for many years with many different pilots, and I've never seen a checklist used during or immediately before takeoff, aside from checking the gauges just prior to pulling power, which is analogous to checking the monitor just prior to pushing induction drugs. The actual checklists are used earlier, during the pre-flight phase, which is analogous to my use of a mnemonic during room setup. 


Akulahawk said:


> You just admitted to using a checklist of sorts as well. It's not the mechanics of doing the deed, so to speak, that requires a checklist... it's getting everything set up that does. You use a mnemonic to ensure that you've got everything done. *What's the difference between using your mnemonic that's been well memorized or a piece of paper that has the same things printed on it?*



Timing.

There is nothing to be gained from using a written checklist immediately prior to routine induction of anesthesia.


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## jwk (Jan 10, 2015)

CANMAN said:


> I don't know if your post was directed at me, but I did not make the "real airway doctor" reference. I was replying to the OP who made that reference. Do I think a surgeon or someone doing anesthesia for a living should run through a checklist, of course not, and I never made such a statement. I was simply saying to the person who posted that I do not think you can judge someone's experience level or airway management competency based off if they use a checklist or not. My employer mandates it, regardless or your level of training, and we have more then one CRNA who still maintains their position as a flight nurse within our program. I am not sure what is up with the forum lately, but to me it seems like we have a few anesthesia providers on the board that feel like they have to prove superior knowledge and experience. I don't think anyone here has question those things in any of the posts I have seen.


I was replying to your statement that _"I couldn't disagree more and running through a checklist has nothing to do with how proficient at airway management a provider is.......", _as well as wondering about "real airway docs".  I'm not sure who a real airway doc is if it's not anesthesia folks.  Please note the last part of my reply as well - I'm all for checklists and algorithms to deal with relatively uncommon occurrences, including, among other things, airway management outside the OR.  RSI by paramedics in the field is a relatively uncommon occurrence - it's not done every day, or perhaps not even done every month or two, depending on the type of service. So, I think for the most part we're on the same page.  Checklists have their place - no doubt.  But going back to OR/anesthesia references, interestingly, the big checklist used in the OR, known as the "pre-incision time out" or even the WHO pre-op timeout, has NOT cut down on the peri-operative complications it was intended to reduce.  

People still make mistakes.  And all the checklists in the world still don't prevent people from making mistakes, whether it's operating on the wrong side, or intubating the esophagus instead of the trachea and not recognizing it.


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## Akulahawk (Jan 10, 2015)

Remi said:


> This whole aviation : anesthesia thing is really overdone. There are some interesting conceptual similarities, I agree, but flying a plane and sleeping a patient are not the same thing.
> 
> I sat in the left seat for many years with many different pilots, and I've never seen a checklist used during or immediately before takeoff, aside from checking the gauges just prior to pulling power, which is analogous to checking the monitor just prior to pushing induction drugs. The actual checklists are used earlier, during the pre-flight phase, which is analogous to my use of a mnemonic during room setup.


In other words, checklists are used, even mental ones, in aviation. Don't use a checklist and something gets overlooked and sometimes bad things happen. Also, because of the work done prior to takeoff, the pilot knows, by checking gauges and runway markers, that the takeoff is proceeding normally, and when it's necessary to reject a takeoff run. Also, sometimes the checklist that you don't see is affixed to the instrument panel and looks just like a small piece of plastic with about 5-7 lines of text on it.



Remi said:


> There is nothing to be gained from using a written checklist immediately prior to routine induction of anesthesia.


If the anesthetist didn't have that mnemonic memorized, then it might be a good idea to use a written checklist... and I'm sure you use a checklist of sorts before you get to the point where you're ready to induce someone into anesthesia, like making sure you know the patient's weight and BSA, going specifically over pre-induction risk assessments, and so on. I doubt you determine that stuff on the fly, 30 seconds before you induce someone.

Routine induction is also a somewhat different animal from the emergent induction. I would imagine that field providers aren't likely to be doing routine induction into anesthesia... it's going to be emergent inductions and for them, it's not a bad idea to have a checklist printed out and visible so that they can go right down the list and ensure that they have everything they're going to need.

Checklists are a good thing. How they're done depends upon the practitioner. You use a mental checklist (mnemonic) immediately prior to inductions to ensure you've not forgotten anything. Timing is irrelevant. You're using a checklist.

When running codes back in the day when we weren't using amiodarone for everything, I used a mnemonic to remember the drugs used. I'm still using a checklist... and I'd have a printed checklist handy to remember the dosages for those seldom-used drugs. Same thing. It's a checklist...


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## MonkeyArrow (Jan 10, 2015)

So I guess the real distinction here comes down to semantics. Is a checklist necessarily have to be a piece of paper that you physically put tick makes next to or does can it be a mental one too. In my previous post, I was referring to a checklist as a physical, piece of printed paper where you have to read off what it says or check off certain things on it in a certain order. That to me defines the limits of airway management as each patient is different, and yet, the checklist stays the same. Medicine is not a one size fits all deal.

However, I also did say that a "real airway doc" (I'm not sure why everyone else is putting this in quotes, but I'll do it too) is very well trained and knows what he is doing. Therefore, part of that proficiency is having a mental checklist memorized and not freelancing and doing procedures willy-nilly. A real airway doctor knows the algorithm and runs a checklist in his head, but he also knows how aggressive he needs to be and when to "deviate" from the checklist.


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## NomadicMedic (Jan 10, 2015)

I'm on my phone, so I can't get the citations, but "deviating from the checklist" is what kills people. I recently read a fantastic book about nuclear reactor accidents. Criticality accidents are when the reactor suddenly becomes hypercritical, and "runs away" from the operator. I think we can all agree that when operating a nuclear reactor, checklists to prevent these unplanned excursions are probably a good idea, because supercritical reactors are not a good idea. At all. Ever. 

In several criticality accidents, the operators, who were performing routine functions, decided to deviate from the checklist and perform operations that were not indicated. Most of the time investigators were unable to ask the operators why they perform these actions, because they were dead.

It can be assumed that the majority of the operators that control nuclear power generating stations were well-trained. Let's call them the "airway docs" of their field. They managed the criticality of the reactor every day, through normal periods and those periods that may have induced a bit of pucker. 

A false sense of security, complacency and dare we say, cockiness was what the NRC determined was the cause for many of the criticality accidents. The operators were well-trained, new the procedures inside and out, had checklists to follow… And disregarded the checklists for their own actions in periods of extreme stress. The exact time when a systemized checklist would be most useful. 

I don't know about you, but I'm certainly not too proud to follow a check list and mark off the boxes when I perform an RSI. And I would hope that the person who is performing then induction and intubating my mother, sister or daughter isn't either.


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## Akulahawk (Jan 10, 2015)

MonkeyArrow said:


> So I guess the real distinction here comes down to semantics. Is a checklist necessarily have to be a piece of paper that you physically put tick makes next to or does can it be a mental one too. In my previous post, I was referring to a checklist as a physical, piece of printed paper where you have to read off what it says or check off certain things on it in a certain order. That to me defines the limits of airway management as each patient is different, and yet, the checklist stays the same. Medicine is not a one size fits all deal.
> 
> However, I also did say that a "real airway doc" (I'm not sure why everyone else is putting this in quotes, but I'll do it too) is very well trained and knows what he is doing. Therefore, part of that proficiency is having a mental checklist memorized and not freelancing and doing procedures willy-nilly. A real airway doctor knows the algorithm and runs a checklist in his head, but he also knows how aggressive he needs to be and when to "deviate" from the checklist.


Done right, the checklist remains the same. The operator is free to select which technique to use and which drugs, but the checklist ensures that all is in place so the operator can go from primary option, to a backup option, to a rescue option and everything is right there and immediately at hand because you went through the checklist and ensured that all was available. Physical checklists could also be used/included in documentation because then you have some written "evidence" that you had your "stuff" with you and so on.


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## MonkeyArrow (Jan 10, 2015)

DEmedic said:


> I'm on my phone, so I can't get the citations, but "deviating from the checklist" is what kills people.


Sorry. I should have been more clear. I too am on my phone so I will attempt to keep this brief. I didn't mean deviate from the checklist as in break policy, but more like not be restricted to manage the airway with a BVM when a ET tube is indicated. If the checklist, let's say, goes in the order of BVM, ET, SGA, cric. I feel like you would have a hard time justifying a cric as your first attempt at gaining an airway in a XYZ pt., even though it was indicated, because you didn't try a less invasive means of securing the airway which could have worked, although it probably wouldn't have. This problem doesn't really exist without checklists, you acted based on your judgement and training providing care for your patients individual condition. However, a checklist, without deviating from it, I feel would force you to try airways that probably will not work. Damned if you do, damned if you don't. If you do, your not providing the optimal level of care to your pt. If you don't, you get grilled for why you deviated from the checklist. 

Of corse, this could also be a misunderstanding in our definitions of a checklist- supplies gathered vs. airway mgmt. algorithm like checklist


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## CANMAN (Jan 11, 2015)

Remi said:


> This whole aviation : anesthesia thing is really overdone. There are some interesting conceptual similarities, I agree, but flying a plane and sleeping a patient are not the same thing.
> 
> I sat in the left seat for many years with many different pilots, and I've never seen a checklist used during or immediately before takeoff, aside from checking the gauges just prior to pulling power, which is analogous to checking the monitor just prior to pushing induction drugs. The actual checklists are used earlier, during the pre-flight phase, which is analogous to my use of a mnemonic during room setup.



My program uses a checklist just prior to pulling power for a flight... It's a pilot vs. crew challenge.

End of the day:
-I think checklist have their place for use in airway management/RSI for field EMS provider
-I am required to use one per my employer so we do, and I RSI on the regular with CRNA's who have to run through the same checklist as me regardless of their higher level of training or daily practice. 
-Do I think running though a checklist makes you less of a provider, or can you evaluate said provider's knowledge because they use a checklist...NO


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