# Rsi



## MagicTyler (Aug 17, 2013)

Do you have the ability to RSI your patients? In my area this seems to be a golden goose that every medic seems to want, but the medical directors are very afraid. What is it like in your area?


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## VFlutter (Aug 17, 2013)

For those that do it would also be nice to know what initial training, continuing education, Q&I process, etc your company has.


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## Medic Tim (Aug 17, 2013)

We have RSI where I work, most medics can do it but not all. As of now there is little CE training though they are developing a new program and courses. 

We carry Morphine, Fentanyl, Midazolam and or diazepam, Roc. , sux. and ketamine.

I am over 2 hours to the nearest hospital and can have a chopper to my clinic in 45-50 min (if I am lucky)

I work at an Industrial oil Field plant in a clinic/first response setting.

I had RSI training in my medic program in the US and it is in most all Canadian programs I know of. Every RSI is QA's by the medical director. We are expected to attend classes and training on out own time and expense...... though as I mentioned earlier that is changing.


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## truetiger (Aug 17, 2013)

RSI is an option for any medic that has been cleared by the clinical director. Once a medic has competed their probationary period they then must go through an RSI class with the educator. Several CEU's related to RSI are available throughout the year. In addition to this, you must perform RSI in front of the medical director each year at a skills review. Every RSI is reviewed for QA. Capnography is mandatory. We have King airways, a quick trach device, and surgical airways as a back up.


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## Tigger (Aug 17, 2013)

Our medical director issues RSI cards to the medics that he has personally educated on the topic, allowing them to perform it. T

Here they use etomidate along with vecuronium and succinylcholine. Versed and Fentanyl are used for post procedure sedation. Given our transport times it is done fairly often. We only have 12 fulltime paramedics and a few part timers who are RSI cleared so everyone stays pretty in tune with the procedure and the medical director reviews each case. Many of them are done with the assistance of a flight crew but the medics are authorized to perform it alone.


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## NomadicMedic (Aug 17, 2013)

We have RSI in Delaware. All three counties have the ability, but our county does FAR more than anyone else. We are mostly rural and may have some significant transport times.

We also have an extensive, and I mean laborious, QI/QA procedure. One of the running jokes is, if you can get away without tubing someone, it's a good day because you won't have to do all the paperwork and go through the long, rigorous chart review procedure. It's a really good day if you perform the intubation, but your partner is up as the lead and he has to write the chart. 

Most medics in my system perform a couple of RSIs a year, with a total average between six and eight field tubes every year. We also are afforded the opportunity to attend OR sessions if we are not maintaining a sufficient number of field intubations or would like additional practice. 

I was taught RSI in my initial paramedic program and had to prove my RSI competency to each medical director that i worked under. (Three in Washington, one in Delaware) We have frequent RSI skill labs in continuing education and each RSI chart is scrutinized by other paramedics, administrators and the medical director. 

We use the standard RSI cocktail, lidocaine, atropine, succinylcholine, etomidate, Fentanyl, Versed and vecuronium. We're still trialing a video laryngoscope, but I expect that trial to be compleded soon and we'll make a final choice. I believe that VL will make a huge difference. (Yes, the plan is to use a video laryngoscope on every tube.)

I also had RSI in Washington state. From the attitude of the docs and providers, It seemed to be far less of a "big deal" there, then it is here. In Washington, if we needed to RSI a patient, we just did it. Here, it's looked at very differently, and a lot of paramedics are scared to perform the procedure. (And knowing some of the education that they have, rightly so.)

Some people here think we would be okay without RSI, and I tend to agree with them. However, it is a nice procedure to have in the toolbox when you need it. The main skill is not knowing how to RSI, but when not to. In the last few months I've called for RSI orders several times, and not used them because I elected not to take the patient's airway. 

RSI is a big responsibility, not one to be taken lightly. Any time you take a patient's airway, you should have some pucker factor. If you're blasé about an RSI, you need to rethink your position.


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## Aprz (Aug 17, 2013)

No RSI here. My RSI training from my paramedic program was initially "Ha! You'll never do that!" and then the instructor performed rapid sequence iteration clicking the powerpoint until it was no longer covering RSI. :[ Afterwards, I decided to research RSI and reviewed that part of the paramedic book on my own, and made a post on the forums about it here. One of the users, Linuss, also recommended that I read Manual of Emergency Airway Management, which I did read.


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## rmabrey (Aug 17, 2013)

We can.  Doctors dont care. Versed, Etomidate, Vec.


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## Jim37F (Aug 17, 2013)

I'm a Basic, what exactly is RSI?


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## VFlutter (Aug 17, 2013)

rmabrey said:


> Doctors dont care.



Care to elaborate on that statement? 

If I sacrificed 10+ years of my life to become a Physican I would certainly care about paramedics performing advanced procedures under my license.


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## NomadicMedic (Aug 17, 2013)

Jim37F said:


> I'm a Basic, what exactly is RSI?



RSI is "rapid sequence intubation", where a patient is sedated and paralyzed prior to intubation.


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## Aprz (Aug 17, 2013)

Or Rapid Sequence Indunction, which is a what I mostly see with non prehospital care textbooks and online websites.


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## Jambi (Aug 17, 2013)

DEmedic said:


> RSI is "rapid sequence intubation", where a patient is sedated and paralyzed prior to intubation.



And to add: it's important that it happens in that order.

(not saying this to DE, but just as an FYI in case anyone doesn't know.)


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## chaz90 (Aug 17, 2013)

rmabrey said:


> We can.  Doctors dont care. Versed, Etomidate, Vec.



You don't use a paralytic prior to intubation? I'm quite certain you're not using vecoronium before the tube...


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## rmabrey (Aug 17, 2013)

chaz90 said:


> You don't use a paralytic prior to intubation? I'm quite certain you're not using vecoronium before the tube...



Vec is optional but yes we can give it prior to intubating.


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## NomadicMedic (Aug 17, 2013)

This is a decent overview of RSI, for the poster that asked. http://emedicine.medscape.com/article/80222-overview

Definition of Rapid Sequence Intubation
A process that involves pharmacologically inducing unconsciousness and paralyzing the patient in a manner that facilitates tracheal intubation, while minimizing the risk of aspiration using application of cricoid pressure (traditional definition included this last point)
“Rapid sequence” refers to the fact that the induction agent and the neuromuscular blocker are given in quick succession, and are not titrated to effect

We actually refer to RSI as "DFI" (Drug Facilitated Intubation) in Delaware.


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## xrsm002 (Aug 18, 2013)

I've also hears it call PAI Pharmacologically Assisted Intubation


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## DesertMedic66 (Aug 18, 2013)

I honestly haven't heard of any county in CA doing RSI. I don't even know if its in our state protocols. 

I have talked to a good deal of medics in my area who have never heard of RSI before.


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## Aprz (Aug 18, 2013)

I believe I've read somewhere that sedated-only intubation without paralytics is bad.


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## Clipper1 (Aug 18, 2013)

Aprz said:


> I believe I've read somewhere that sedated-only intubation without paralytics is bad.



Intubation with only paralytics is bad. Sedation only is what many emergency situations need and can be successfully intubated without paralytics.

 Paralytics now are used only when needed and in the OR for obvious reasons with surgery. In the ICU the use of paralytics for intubated patients had fallen out of favor long ago with the exception of a few hard to ventilate patients or those on hypothermia protocol who will not stop shivering by other means.


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## MSDeltaFlt (Aug 18, 2013)

My state allows a DAI without paralytic protocol, but my 911 service does not.  The state will not allow us until we have complete coverage of capnography with backups for every county we serve.

And we keep growing acquiring some counties that don't have it.


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## Carlos Danger (Aug 18, 2013)

Clipper1 said:


> Intubation with only paralytics is bad. *Sedation only is what many emergency situations need* and can be successfully intubated without paralytics.



A field protocol that allows for intubation with sedation only is a bad idea, IMO. Many hold the view that sedation only is safer than sedation + NMB, but I respectfully and strongly disagree. 

If a patient is sedated deeply enough to allow intubation, they will not be protecting their airway adequately, will probably not be breathing adequately if at all, and they can still cough and gag and bite and retch and vomit when you start shoving things down their throat. How is that safer than using using paralysis, where the patient cannot cough, gag, bite, or retch, you have more predictable onset and much more reliable intubating conditions, vomiting is less likely as there is no skeletal muscle tone, and the jaw and head can manipulated at will? Bottom line is that paralytics make intubating easier and quicker, and anything you can do to make intubation easier and quicker will make it safer.

Of course there may be a rare, unusual situation where someone needs to be intubated in the field, yet NMB's are absolutely contraindicated. In that case, you do the best you can with just sedation, and thankfully those scenarios are rare. I do know of a flight program that was doing this and had good results with it, but still I do not think it should be a widespread practice. Personally I would not do sedation-only intubation in emergent, non-NPO patients as a routine practice.


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## SpecialK (Aug 18, 2013)

RSI is available to approximately 40-50 of our 300 Intensive Care Paramedics.  

They are selected based upon competence at a three part selection process involving 

(1) endorsement from their District Operations Manager stating they believe the Officer has ability to pass, 
(2) an hour long online exam testing knowledge of the Clinical Practice Guidelines, pharmacology (all medicines within ALS scope), core anatomy and physiology and core pathophysiology, and 
(3) a number of assessment stations around assessment, patient management, leadership, clinical decision making and airway/ventilation/failed intubation management; specifically
(a) Simulation – Each person will be a team leader for a scenario  involving a critical patient. These scenarios are not particular to RSI, but test ALS skills,  knowledge and decision making,
(b) Mini simulation – Each person  will be given a scenario with a patient that is not obviously time critical. These will test assessment, differential diagnosis and decision making, and 
(c) OSCEs – Each person will  undergo about six short skill  and/or knowledge assessments (referred to as OSCEs). These will last 5-10 minutes each  and are not scenario based. Examples of these OSCEs  could include demonstrating  a failed intubation drill, cricothyroidotomy, or answering  some questions relating to capnography.

If the Officer is successful at all components they are placed on the RSI course which is a learning package consisting of online workshops and some material on DVD plus practical.  It has been designed by the Clinical Director who is an Anaesthetist/Intensivist supported by the National Medical Advisor who is an Emergency Physician.

Each RSI or potential RSI must be debriefed with the Clinical Director or Medical Advisor.

Indication for RSI is GCS < 10 with airway or ventilatory compromise and most patients will either have traumatic brain injury or be post-cardiac arrest but others can be stroke, poisoning, DKA (noting a significantly altered level of consciousness with somebody who has DKA is very unlikely), postictal or status epilepticus etc.

Medicine regimen is fentanyl and either midazolam or ketamine and suxamethonium.  Post-intubation regimen is vecuronium, morphine and midazolam.  There is talk of moving to rocuronium only in 2014.

There is a limit of two attempts and you must be able to visualise vocal cords within 15 seconds of beginning laryngoscopy and intubate within 30 seconds. A bougie is mandatory.  Failed intubations are salvaged with an LMA.  

To date we have performed over 500 RSI with (my understanding) no surgical airway and near 98% success rate.

RSI can be done properly and safely in Paramedic hands provided it is a small, highly trained and very select group who get adequate ongoing exposure. 

These places that just tube people by shovelling midazolam into their drip until they are obtunded enough to accept a tube or just etomidate people into submission should be tried for crimes against humanity.


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## Craig Alan Evans (Aug 18, 2013)

We have been performing RSIs for the last 10-12 years. I can't remember exactly. Every RSI is reviewed by our team of medical directors and they give immediate feedback to the crew. We have every paramedic visit the OR annually sometimes every 2 years to get experience and guidance under an anesthesiologist.  So far the program has been very successful with no issues.


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## MSDeltaFlt (Aug 18, 2013)

Clipper1 said:


> Intubation with only paralytics is bad. Sedation only is what many emergency situations need and can be successfully intubated without paralytics.
> 
> Paralytics now are used only when needed and in the OR for obvious reasons with surgery. In the ICU the use of paralytics for intubated patients had fallen out of favor long ago with the exception of a few hard to ventilate patients or those on hypothermia protocol who will not stop shivering by other means.





Halothane said:


> A field protocol that allows for intubation with sedation only is a bad idea, IMO. Many hold the view that sedation only is safer than sedation + NMB, but I respectfully and strongly disagree.
> 
> If a patient is sedated deeply enough to allow intubation, they will not be protecting their airway adequately, will probably not be breathing adequately if at all, and they can still cough and gag and bite and retch and vomit when you start shoving things down their throat. How is that safer than using using paralysis, where the patient cannot cough, gag, bite, or retch, you have more predictable onset and much more reliable intubating conditions, vomiting is less likely as there is no skeletal muscle tone, and the jaw and head can manipulated at will? Bottom line is that paralytics make intubating easier and quicker, and anything you can do to make intubation easier and quicker will make it safer.
> 
> Of course there may be a rare, unusual situation where someone needs to be intubated in the field, yet NMB's are absolutely contraindicated. In that case, you do the best you can with just sedation, and thankfully those scenarios are rare. I do know of a flight program that was doing this and had good results with it, but still I do not think it should be a widespread practice. Personally I would not do sedation-only intubation in emergent, non-NPO patients as a routine practice.



Both of you appear to be saying the same thing.  You CAN intubate without paralytics.  If after giving the patient narcotics and sedatives the patient stops breathing and lises a gag reflex, why give a paralytic.  Although the paralytic needs to be drawn up regardless.  However, you had better NEVER paralize the patient without sedating them because thry'd be conscious.  And that'd be tantamount to torture.

Where people tend to get confused when intubating is they think that it is an all or nothing scenario.  That once you make the decision to intubate thst uou need to "hurry up and do it".  Thst when you perform the skill that is all you do.  When nothing could be further from the truth.  The decision to intubate is based off of your assessment.  But you don't stop assessing the patient.  You continue to assess the patient throughout the entire procedure that continues far beyond confirmation of proper placement and securing.

You don't hurry up and do this.  You slow your @$$ down and do it right.

There's a difference between giving a narcotic and treating pain.  There's a difference berween giving a sedative and sedating your patient.  And there is a huge difference between intubating and managing your patient's airway.

In my humble opinion, RSI should have sedatives as a requirement and paralytics as an option IF AND ONLY IF the patient does not need it.


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## Jambi (Aug 18, 2013)

SpecialK said:


> RSI is available to approximately 40-50 of our 300 Intensive Care Paramedics.
> 
> They are selected based upon competence at a three part selection process involving
> 
> ...



This brings a tear of joy to my eye...where do you live?


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## Medic Tim (Aug 18, 2013)

SpecialK said:


> RSI is available to approximately 40-50 of our 300 Intensive Care Paramedics.
> 
> They are selected based upon competence at a three part selection process involving
> 
> ...



I wish my system was like this



Jambi said:


> This brings a tear of joy to my eye...where do you live?



I could be wring but I think he or she is from Australia.


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## Carlos Danger (Aug 18, 2013)

MSDeltaFlt said:


> If after giving the patient narcotics and sedatives the patient stops breathing and lises a gag reflex, *why give a paralytic*.



Because NMB's make aspiration less likely and improve intubating conditions, making first-pass success more likely.

You don't know they've lost their gag reflex until you are in the back of the oropharynx with the blade. At that point if their reflexes are still intact, it may be too late because they can wretch and vomit pretty easily.

The RSI technique was developed not just to facilitate intubation - there are other, much gentler techniques if all you need to do is place a tube - but to minimize aspiration risk in high-risk patients. 

No question that the procedure shouldn't be rushed, but at the same time you really do need to minimize the time spent with the airway unprotected. That's really the whole point of the "rapid" sequence technique.


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## DrParasite (Aug 18, 2013)

my former hospital based EMS agency did RSI.... my current one doesn't.  The reasoning we don't is the same reason our orders from our medical control suck:we are urban and have short transport times, we have a lot of medics with high turnover so evaluating comptance is hard, and when it doubt, just load and go to the ER and the hospital will handle it.  We have a lot of doc who will only give M+T orders to sick patients, instead of having our crews treat aggressively.  I don't agree with it, but it's above my pay grade, 

Not for nothing, but RSI should be agency wide; either you call can do it or those that can't shouldn't be paramedics.  If the patient needs to be RSIed, it shouldn't be a gamble if the crew is certified to RSI or not.  and I have been one quite a few calls where the patient needed to be RSIed, and was RSIed successfully.


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## Rialaigh (Aug 19, 2013)

Just to play devils advocate I know some very smart and successful medics who treat aggressively who have had RSI in their protocols for years and have never in their career deemed it necessary to RSI a patient and have never had issues otherwise intubating the patients that need it.

It is a tool like everything else. Based on current (generalization) EMS education and provider competence I am not sure it is something that is +EV for EMS as a whole. 

I really applaud special K's agency


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## JPINFV (Aug 19, 2013)

DrParasite said:


> Not for nothing, but RSI should be agency wide; either you call can do it or those that can't shouldn't be paramedics.  If the patient needs to be RSIed, it shouldn't be a gamble if the crew is certified to RSI or not.  and I have been one quite a few calls where the patient needed to be RSIed, and was RSIed successfully.



Then there's the glass half full side. I'd rather take the gamble that the paramedic coming to me can RSI, but might not, than know that the paramedic can't RSI, despite having the skill to do so.


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## the_negro_puppy (Aug 19, 2013)

We have a trauma Doctor that works on a fly-car. They assist higher trained medics with RSI here


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## Clare (Aug 19, 2013)

The service SpecialK describes is the Order of St John New Zealand


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## Aprz (Aug 19, 2013)

Clipper1 said:


> Intubation with only paralytics is bad. Sedation only is what many emergency situations need and can be successfully intubated without paralytics.
> 
> Paralytics now are used only when needed and in the OR for obvious reasons with surgery. In the ICU the use of paralytics for intubated patients had fallen out of favor long ago with the exception of a few hard to ventilate patients or those on hypothermia protocol who will not stop shivering by other means.


I'm talking about initially, the use of only sedation without a paralytic prior to intubation. It's very obvious why using paralytics only without sedation is a bad idea, but not the other way around. When I start the HOWTO Rapid Sequence Induction (RSI) thread, I was also looking at other sources on how to RSI, and I read that sedation-only intubation, "Facilitated Intubation", was associated with  lower success rate, higher mortality rates in traumatic brain injury (TBI) patients, and a high incidence of hypotension, which would make sense why it didn't work out too well for patients with TBI. I don't know how for sure, but I suspect increase parasympathetic response and/or laryngospasm during laryngoscopy if paralytics prevent that better than sedatives (I don't know).


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## Clipper1 (Aug 19, 2013)

TBI might be the exception for prehospital which was the group studied. But that is not true for all medical patients.


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## Carlos Danger (Aug 19, 2013)

DrParasite said:


> Not for nothing, but RSI should be agency wide; either you call can do it or those that can't shouldn't be paramedics.



What is the rationale behind your "everybody or nobody" position?

Would you have those who do have the experience and judgement not be allowed to use it, just because others aren't as capable?


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## DrParasite (Aug 20, 2013)

Halothane said:


> What is the rationale behind your "everybody or nobody" position?
> 
> Would you have those who do have the experience and judgement not be allowed to use it, just because others aren't as capable?


As a patient, when i call an ambulance, I want an ambulance. If I need to be RSIed, and the paramedic crew can't do what is needed (but the other crew could have, if they were sent), then the service has done me a disservice.  Of course, we didn't know this until a paramedic arrived and determined that RSI was needed.

would you only allow some paramedics at an agency to intubate, because intubation rates suck prehospitally according to several studies?  What about needle decompressions?  What about d50?  maybe even 12 leads or direct admits to the cath lab? and then how do you select who gets the "full trained and can do everything" paramedics, and who gets the "everything but a potentially life saving skill?"

Or lets take the litigious concept: I need to be RSIed, but the crew you send to me can't RSI.... so I am going to sue your agency for sending a crew that couldn't help me in my time of need, when if they had sent me another one of their crews I would have had a much better outcome.  Think I can get a jury to feel sorry enough for your bad choices to award me a few million?


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## Aprz (Aug 20, 2013)

DrParasite said:


> As a patient, when i call an ambulance, I want an ambulance. If I need to be RSIed, and the paramedic crew can't do what is needed (but the other crew could have, if they were sent), then the service has done me a disservice.  Of course, we didn't know this until a paramedic arrived and determined that RSI was needed.
> 
> would you only allow some paramedics at an agency to intubate, because intubation rates suck prehospitally according to several studies?  What about needle decompressions?  What about d50?  maybe even 12 leads or direct admits to the cath lab? and then how do you select who gets the "full trained and can do everything" paramedics, and who gets the "everything but a potentially life saving skill?"
> 
> Or lets take the litigious concept: I need to be RSIed, but the crew you send to me can't RSI.... so I am going to sue your agency for sending a crew that couldn't help me in my time of need, when if they had sent me another one of their crews I would have had a much better outcome.  Think I can get a jury to feel sorry enough for your bad choices to award me a few million?


I dunno if you could successfully sue. It's kinda the same thing with tiered response with whether the ambulance should be sent code 2 or code 3, and if they should be BLS or ALS. I think it would better to only allow the ones who can do it do it, and the ones who can't do it, not be allowed to do it. Obvious if everyone could be trained in it, that would be awesome, and probably a selling point with an agency, but I think for now since it seems to be a difficult thing for paramedics, I don't see a problem with allowing only some to do it.


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## Clipper1 (Aug 20, 2013)

DrParasite said:


> As a patient, when i call an ambulance, I want an ambulance. If I need to be RSIed, and the paramedic crew can't do what is needed (but the other crew could have, if they were sent), then the service has done me a disservice.  Of course, we didn't know this until a paramedic arrived and determined that RSI was needed.
> 
> would you only allow some paramedics at an agency to intubate, because intubation rates suck prehospitally according to several studies?  What about needle decompressions?  What about d50?  maybe even 12 leads or direct admits to the cath lab? and then how do you select who gets the "full trained and can do everything" paramedics, and who gets the "everything but a potentially life saving skill?"
> 
> Or lets take the litigious concept: I need to be RSIed, but the crew you send to me can't RSI.... so I am going to sue your agency for sending a crew that couldn't help me in my time of need, when if they had sent me another one of their crews I would have had a much better outcome.  Think I can get a jury to feel sorry enough for your bad choices to award me a few million?



You can try to sue but it is doubtful you will get anywhere.

I want a truck with 2 Paramedics but get one with just 1 and an EMT because of staffing issues. Can I sue? Probably not.  

I want to go to the cath lab at the hospital 2 blocks further when I have chest pain but your protocol says "closest facility" which is where you take me. Can I sue? I could but you did what your protocols said. Your medical director probably had a reason for writing them.

I work for an EMS agency across town which allows me to RSI or do pericardiocentesis but moonlight at another which does not. Can I do my advanced skills "to save a life" when at the other agency? No. This has already be challenged in many cases.

Only about half the ALS agencies in the US do 12 Lead ECGs. Should a patient sue if he happens to have chest pain in the area where they do not have that ability?  Only about half of the states allow RSI. If you cross the state line and have expectations of equal care of what you have read about some of the best EMS agenices, what happens when you find out you not all are created equal?  

And, shouldn't all EMT-Bs be allowed to do glucose monitoring? Why should a patient have to wait for an ALS intercept just for a finger stick?

A doctor might have privileges to intubate had one hospital but has not been given that privilege at the hospital across the street. The person who has met the standards for intubation at that hospital will be called to intubate.

By your argument every doctor in a hospital should be neurosurgeons if the patient needed neurosurgery.

After reading the many, many posts on just this forum about how protocols differ from state to state, county to county, city to city and from one side of the street to the other with different agencies, some probably should be in court all the time.  But, just like any other health care profession and facility, only those qualified should be performing the skill. Only if it is a written mandate to have an RSI qualified Paramedic on every call would there be an issue.  This is seen by the expectations of a company promising an ambulance in 6 minutes or less.  Most of the time it is also the EMTs or Paramedics raising the questions rather than the public because they want more staffing or to be allowed to do things they have not be trained for and may not want to put forth the effort after being trained to maintain those skills. There have also been many examples of that which intubation proficiency is one good example. Should the patients also sue when intubation privilege is removed from the skillset? Or, since it can be argued a safety issue, do they have any grounds for the suit?


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## Carlos Danger (Aug 20, 2013)

DrParasite said:


> As a patient, when i call an ambulance, I want an ambulance. If I need to be RSIed, and the paramedic crew can't do what is needed (but the other crew could have, if they were sent), then the service has done me a disservice.  Of course, we didn't know this until a paramedic arrived and determined that RSI was needed.
> 
> *would you only allow some paramedics at an agency to intubate, because intubation rates suck prehospitally according to several studies?  What about needle decompressions?  What about d50?  maybe even 12 leads or direct admits to the cath lab? and then how do you select who gets the "full trained and can do everything" paramedics, and who gets the "everything but a potentially life saving skill?"*
> 
> Or lets take the litigious concept: I need to be RSIed, but the crew you send to me can't RSI.... so I am going to sue your agency for sending a crew that couldn't help me in my time of need, when if they had sent me another one of their crews I would have had a much better outcome.  *Think I can get a jury to feel sorry enough for your bad choices to award me a few million?*



To your second paragraph:

First of all, you are comparing apples and oranges. Pushing D50 or obtaining a 12-lead has very little in comparison to RSI, in terms of the training needed and the risk to the patient. If you can't see the difference between the gravity of RSI vs. that of obtaining a 12-lead, then I'm at a loss.

The important point you are missing is that all paramedics are simply not all the same in terms of training and experience and competency. If you haven't learned that reality yet, you will when you are more experienced.

If a medical director wanted to require his paramedics to have a certain number of year's experience before they could RSI, and a certain amount of time with the agency, and to complete a time-consuming training program first, I think that'd be pretty responsible and reasonable, and probably well in line with what the literature indicates is necessary for a successful RSI program. If he wanted to suspend RSI from individuals who don't meet certain continuing training or competency criteria, I think that's quite reasonable, too. These requirements would probably result in not all the paramedics at a given agency being able to RSI, but I don't know how you'd argue it's not a reasonable process or that it's not in the best interest of patients, or that it puts the agency at legal risk somehow.


To your last paragraph:

I'd like to see Wes weigh in on this, but I think there'd be a very slim chance you could successfully sue. If you could, it would set a precedent that every EMS agency and every hospital would essentially be responsible for following the same protocols and offering the same services, procedures, and interventions, because anyone who didn't do something that someone else did could be sued. Go to a hospital that doesn't offer the same procedure as another one? Sue 'em. Call EMS and they don't have the same drugs that another agency does? Sue 'em. Think that is good for patients? Or for the EMS profession?

Most importantly, order to successfully sue, you'd have to show damages resulting from the paramedic's action or inaction. I suppose it is plausible you could argue that damages _resulted from_ the paramedic's inability to RSI - rather than from the disease process - but that would be an uphill battle, I think. The EMS agency's lawyers would counter-argue that much of the literature shows that prehospital RSI is unsafe and doesn't improve outcomes (it is, in reality, inconclusive at best), and therefore having it in the protocols does more harm than good and this patient would very possibly have been even more seriously injured by it. Expert witnesses will explain that paramedics in general aren't good at RSI and even when they do it right, it doesn't improve outcomes.


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## Wes (Aug 20, 2013)

First of all, I'm not your lawyer, but I'm a lawyer.  (Subtle difference there, you know.)  If you'd like me to be your lawyer, I'll need a credit card number.

Generally speaking, EMS liability is a hard hurdle to reach. In Texas, EMS is actually covered under our version of the Good Samaritan law.  The appellate courts here have held that EMS is not a licensed health care profession, so we're covered under the statute.  (The one time that low EMS standards are helping us!)

So, under Texas law, you have to prove a willful act or gross negligence to prove a medic liable.  Hard hurdle to overcome.  To prove negligence, you have to prove the medic had a duty to act, that they breached the duty (IE, violating the standard of care), that the breach caused harm, and that the harm created damage.  So, you'd have to prove all of those things.  And for it to be gross negligence (the standard for EMS liabilty here in the Lone Star State), it's got to be pretty egregious.   So, I'd tend to lean against liability for the medic.

A slightly better bet would be a claim against the EMS medical director for not approving RSI.  But your chances on that are a crapshoot too.  Both sides will pull up every expert witness they can find.  Six or half a dozen there, especially since you never know what a jury would do.   My personal supposition is that RSI does not represent the standard of care.

In fact, a few years ago, there was a discussion about this very issue here in Austin.  Austin/Travis County EMS medics don't RSI, but the STAR Flight flight medics do.  There was a great deal of discussion as to whether the STAR Flight medics could carry RSI drugs if they were working overtime on a ground unit.  The decision was to not authorize them to carry RSI meds for the exact reason of liability and a uniform standard systemwide.

Final thought -- given the crappy state of airway education in general for EMS, I think there's a lot more potential for liability over failed RSI than there is for failure to authorize and allow RSI.


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## TransportJockey (Aug 20, 2013)

DrParasite, RSI is not standard of care so good luck. I think it should be a credentialed issue where not all medics have it. Just the best ones and the ones that can prove they know what they are doing


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## VFlutter (Aug 20, 2013)

DrParasite said:


> Not for nothing, but RSI should be agency wide; either you call can do it or those that can't shouldn't be paramedics.  If the patient needs to be RSIed, it shouldn't be a gamble if the crew is certified to RSI or not.



I strongly disagree. RSI is not a right inherently granted to you because you are a paramedic. Especially with current education standards. It is not a benign procedure, it is consider one of the most dangerous procedures in the ICU and has one of the highest mortality rates. Dr. Weingart makes a great point with this "License to Kill" lectures. I think most hospitals consider RSI related death up until 2 hours post procedure. Something you may not see. 

Also, they just took RSI out of our Critical Care PAs scope of practice. Not because they are not capable but because it is best practice for optimal patient outcomes. Now only CCPs and MDAs can do it. 

I am not saying RSI can not be done but to say that every paramedic should be able to it and if not they are not a "real" paramedic is rediculous.


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## Wes (Aug 20, 2013)

Someone once said that RSI is 2/3 of the lethal injection cocktail.   When you look at it that way, maybe not everyone needs to utilize it.

What we need to be teaching in addition to airway skills is airway decision making. But alas, critical thinking is in short supply while cookbook medicine is all too common. And don't even get me started on how little "live" practice we get prior to entering the field.  OR rotations are rapidly becoming a thing of the past and "Fred the Head" just isn't the same.

Sorry, didn't mean to go off on a tangent.


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## Carlos Danger (Aug 20, 2013)

Wes said:


> *
> Someone once said that RSI is 2/3 of the lethal injection cocktail.   *When you look at it that way, maybe not everyone needs to utilize it.
> 
> What we need to be teaching in addition to airway skills is airway decision making. But alas, critical thinking is in short supply while cookbook medicine is all too common. And don't even get me started on how little "live" practice we get prior to entering the field.  OR rotations are rapidly becoming a thing of the past and "Fred the Head" just isn't the same.



I never heard that saying but I believe it is technically accurate, and more importantly, is an excellent point.


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## NomadicMedic (Aug 20, 2013)

Or, you could work for an agency that strives for education, make sure that the paramedics are competent, has a stringent QA QI process and I could go on and on.

Not all paramedic systems are created equal. We have about 80 field paramedics in my system. All are trained to RSI. All of us have frequent opportunities to perform intubations, both in the field and in the OR. It's certainly not a skill to be taken lightly, but paramedics should be able to perform the skill, if certified and it's needed.

The ability to progress down the decision-making tree to the point where you're asking, "should I RSI this guy or not?" is the mark of a strong paramedic in our system. 

Just because you've seen some substandard paramedics, don't lump us all into that group.


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## truetiger (Aug 20, 2013)

If you're working in a a rural area with extended transport times, its absolutely necessary that you are proficient in not just RSI, but all of your skills. If not, you shouldn't be on a truck in a rural area.


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## TransportJockey (Aug 20, 2013)

truetiger said:


> If you're working in a a rural area with extended transport times, its absolutely necessary that you are proficient in not just RSI, but all of your skills. If not, you shouldn't be on a truck in a rural area.



Unless of course your state doesn't allow medics to RSI unless they are flight. I'm a very proficient rural medic who would love the opportunity to even try to initiate RSI in my system


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## Wes (Aug 20, 2013)

DEMedic -- couldn't agree more.  With appropriate education, both initial and continuing and proper clinical oversight, I believe there's a place for RSI.   I've got it in my toolbox and hope never to use it, but I know there is a patient population out there where RSI is going to be the ONLY thing that'll work.


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## DrParasite (Aug 20, 2013)

Wes said:


> Generally speaking, EMS liability is a hard hurdle to reach. In Texas, EMS is actually covered under our version of the Good Samaritan law.  The appellate courts here have held that EMS is not a licensed health care profession, so we're covered under the statute.  (The one time that low EMS standards are helping us!)


hmm, I have been told that because we receive a paycheck, the good sam law doesn't apply to us in NJ.  so while volunteers might be covered, those of us who are paid are not.





Wes said:


> So, under Texas law, you have to prove a willful act or gross negligence to prove a medic liable.  Hard hurdle to overcome.  To prove negligence, you have to prove the medic had a duty to act, that they breached the duty (IE, violating the standard of care), that the breach caused harm, and that the harm created damage.  So, you'd have to prove all of those things.  And for it to be gross negligence (the standard for EMS liabilty here in the Lone Star State), it's got to be pretty egregious.   So, I'd tend to lean against liability for the medic.


gross negligence, probably not.  what about simple negligence?


Wes said:


> A slightly better bet would be a claim against the EMS medical director for not approving RSI.  But your chances on that are a crapshoot too.  Both sides will pull up every expert witness they can find.  Six or half a dozen there, especially since you never know what a jury would do.   My personal supposition is that RSI does not represent the standard of care.


if, as an agency, the medical director doesn't approve RSI, so be it.  but if he only approves certain people?  and on a patient that could have benefited form RSI, and a non-RSI unit was sent, with negative consequences?  You don't think you could argue that simple negligence did occur?


Wes said:


> In fact, a few years ago, there was a discussion about this very issue here in Austin.  Austin/Travis County EMS medics don't RSI, but the STAR Flight flight medics do.  There was a great deal of discussion as to whether the STAR Flight medics could carry RSI drugs if they were working overtime on a ground unit.  The decision was to not authorize them to carry RSI meds for the exact reason of liability and a uniform standard systemwide.


that's system wide, which isn't what I am talking about.  it's not like half the Austin county Medics can't RSI, and the other half can.  System wide is system wide.  


Wes said:


> Final thought -- given the crappy state of airway education in general for EMS, I think there's a lot more potential for liability over failed RSI than there is for failure to authorize and allow RSI.


wait until intubation is taken out of the paramedic skill set at a result of this





Clipper1 said:


> I want a truck with 2 Paramedics but get one with just 1 and an EMT because of staffing issues. Can I sue? Probably not.


depends: if I need a paramedic unit, can the single person paramedic unit do less than a dual paramedic?  and is there any damages that result of being unable to do those procedures that having 2 medics would have permitted?





Clipper1 said:


> I want to go to the cath lab at the hospital 2 blocks further when I have chest pain but your protocol says "closest facility" which is where you take me. Can I sue? I could but you did what your protocols said. Your medical director probably had a reason for writing them.


where is the group that say "following orders isn't a justification for bad medicine?  Just look at the nuremburg war trials".  Actually, you probably could sue the agency, might even win.  probably wouldn't get anything from the paramedic.





Clipper1 said:


> I work for an EMS agency across town which allows me to RSI or do pericardiocentesis but moonlight at another which does not. Can I do my advanced skills "to save a life" when at the other agency? No. This has already be challenged in many cases.


the agency sets the standard.  if your agency won't allow you, than they won't allow you.  but the agency sets the standard agency wide, so no matter who shows up, it's a paramedic who can do all the skills that any paramedic can do.  essentially a paramedic is a paramedic is a paramedic, regardless of which paramedic unit for your agency shows up.



Clipper1 said:


> By your argument every doctor in a hospital should be neurosurgeons if the patient needed neurosurgery.


no: but every neurosurgeon should be able to do the same neurosurgery stuff, so if I call the on call Neuro, I don't need to worry about him or her not being able to do that procedure, and has to call someone else.





Halothane said:


> First of all, you are comparing apples and oranges. Pushing D50 or obtaining a 12-lead has very little in comparison to RSI, in terms of the training needed and the risk to the patient. If you can't see the difference between the gravity of RSI vs. that of obtaining a 12-lead, then I'm at a loss.
> 
> The important point you are missing is that all paramedics are simply not all the same in terms of training and experience and competency. If you haven't learned that reality yet, you will when you are more experienced.


they are both procedures, so yes, they are not apples and oranges.  has RSI saved people?  or benefited people?  are paramedics trained in performing RSI?

I know that no all paramedics were trained equally, or as experienced, and some are incompetent.  But a paramedic should be able to do paramedic skills, especially if that is the standard of care of a paramedic.  no matter which unit shows us, the interventions should be the same.  If you don't understand that, than I'm at a loss.


Halothane said:


> If a medical director wanted to require his paramedics to have a certain number of year's experience before they could RSI, and a certain amount of time with the agency, and to complete a time-consuming training program first, I think that'd be pretty responsible and reasonable, and probably well in line with what the literature indicates is necessary for a successful RSI program. If he wanted to suspend RSI from individuals who don't meet certain continuing training or competency criteria, I think that's quite reasonable, too. These requirements would probably result in not all the paramedics at a given agency being able to RSI, but I don't know how you'd argue it's not a reasonable process or that it's not in the best interest of patients, or that it puts the agency at legal risk somehow.


Based on your logic, he should be able to suspend D50 administration, or 12 lead transmissions, or needle decompressions, or intubation, on a per person basis, based on his beliefs that " don't meet certain continuing training or competency criteria."  although you can see the potential problems of having them still be a paramedic if they can't function 100% as a paramedic right?





Halothane said:


> I'd like to see Wes weigh in on this, but I think there'd be a very slim chance you could successfully sue. If you could, it would set a precedent that every EMS agency and every hospital would essentially be responsible for following the same protocols and offering the same services, procedures, and interventions, because anyone who didn't do something that someone else did could be sued.


not at all, but if damages were caused... 





Halothane said:


> Go to a hospital that doesn't offer the same procedure as another one? Sue 'em. Call EMS and they don't have the same drugs that another agency does? Sue 'em. Think that is good for patients? Or for the EMS profession?


huh?  each hospital can decide what it does; but if I call for an OB doc, they should be able to do OB doc stuff, not just 90% of what an OB doc can do.


Halothane said:


> Most importantly, order to successfully sue, you'd have to show damages resulting from the paramedic's action or inaction. I suppose it is plausible you could argue that damages _resulted from_ the paramedic's inability to RSI - rather than from the disease process - but that would be an uphill battle, I think. The EMS agency's lawyers would counter-argue that much of the literature shows that prehospital RSI is unsafe and doesn't improve outcomes (it is, in reality, inconclusive at best), and therefore having it in the protocols does more harm than good and this patient would very possibly have been even more seriously injured by it. Expert witnesses will explain that paramedics in general aren't good at RSI and even when they do it right, it doesn't improve outcomes.


So maybe no one should be RSIing, since it's so bad, it's unsafe and doesn't improve patient outcomes?  and if it's so bad, why do we even do it?


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## Wes (Aug 21, 2013)

Like I said, I was providing my answer on Texas law.  That's the state I'm admitted to practice as an attorney in.  I don't know the specifics and vagaries of other state's laws.  Simple negligence, at least in Texas, wouldn't factor in at all.  And ultimately, the question of any sort of negligence would be decided by a jury. Unfortunately, the legal issues as to EMS liability are very dependent on both specific facts and on state law, which makes it very hard to make generic rulings on EMS issues.


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## Clipper1 (Aug 21, 2013)

DrParasite;497 if I need a paramedic unit said:


> the same neurosurgery stuff,[/B] so if I call the on call Neuro, I don't need to worry about him or her not being able to do that procedure, and has to call someone else.they are both procedures, so yes, they are not apples and oranges.  has RSI saved people?  or benefited people?  are paramedics trained in performing RSI?
> 
> each hospital can decide what it does;* but if I call for an OB doc, they should be able to do OB doc stuff, not just 90% of what an OB doc can do.*
> So maybe no one should be RSIing, since it's so bad, it's unsafe and doesn't improve patient outcomes?  and if it's so bad, why do we even do it?



You are incorrect about all OB or all neurosurgeons. Not all have the same skill set. Most all can deliver babies but some might be competent to do high risk deliveries and advanced procedures like fetal scalp monitoring which is not mandatory in all hospitals. You should also check out what neurosurgeons do especially in EMS if your back goes out. Don't just pull one out of a list and expect him to do the same cutting. I also probably would not go to a Trauma Neurosurgeon to have disc surgery. Even the neurosurgeons step aside for other neurosurgeons to perform different skills. 

Not all EM doctors are the same either. Some have gotten their training to do extensive US in the ER.  Some have training to do the GlideScope or some other new intubation device while others might depend solely on DL while the GlideScope sits 3 feet away unused. 

There are also services which do not allow Paramedics to intubate by DL. They are still Paramedics. 

Two Paramedics would also be more ideal for RSI. One gives the medications and watches the monitor while the other maintains the airway preparing for DL. 

Somebody was talking about TX. I seriously doubt if there was any suits against these Paramedics directly since most states do have some protection statutes for EMS either by Good Sam extension or an immunity clause.

http://www.ems1.com/ems-products/ed...ocedure-gets-low-level-of-oversight-in-texas/

DrParasite, you have been an EMT-Basic for many years. Why haven't you taken the next step to being a Paramedic?


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## chaz90 (Aug 21, 2013)

Clipper1 said:


> Two Paramedics would also be more ideal for RSI. One gives the medications and watches the monitor while the other maintains the airway preparing for DL.



That's how we RSI every time. We require two paramedics for every RSI patient for exactly the reasons you describe. Typically the first medic will begin to get equipment out and park himself at the airway as the second calls in for RSI orders. As the first preoxygenates the patient, the second draws up and administers the drugs while watching the monitor and arranging the transition from nasal prong capnography to in line. When I've been the second medic, I've also started a timer on my watch after pushing Succs to keep track of how long the attempt is lasting and also to make sure we get the Versed, Fentanyl, and potentially Vecuronium onboard as soon as necessary. Having two people completely trained in the procedure makes a HUGE difference. I can't imagine trying to do everything with only an EMT that you don't know or don't work with often.


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## Carlos Danger (Aug 21, 2013)

DrParasite said:


> I know that no all paramedics were trained equally, or as experienced, and some are incompetent.  But a paramedic should be able to do paramedic skills, especially if that is the standard of care of a paramedic.  *no matter which unit shows us, the interventions should be the same*.  If you don't understand that, than I'm at a loss.



Look, you are entitled to your opinion and I'm not going to invest any more time into trying to change it.

But you should realize that you really have no backup for your claim. RSI is not even considered the standard of care in EMS, and most EMS agencies in the US don't even do it. Many EMS agencies that do, only credential some of their paramedics to do so because they feel it is unsafe to let everyone do it. If you are going to continue to believe you know more than those agencies' medical directors, attorneys, and risk management folks, so be it.  




DrParasite said:


> So maybe no one should be RSIing, since it's so bad, it's unsafe and doesn't improve patient outcomes?



Many medical directors have come to that exact conclusion. The literature is pretty clear that it is only helpful in very select situations and is often harmful.

I would actually not be surprised to see ETI itself start to go away before too long. It's already pretty clear that it doesn't improve outcomes. As the SGA devices improve and ETI training opportunities continue to go away, it might not be too long. 

But that's a whole other discussion.


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