# RSI: High-risk EMS procedure gets a low level of oversight



## VentMedic (Apr 20, 2008)

Saw this posted on another forum:

*High-risk EMS procedure gets a low level of oversight*

http://www.star-telegram.com/state_news/story/593026.html

By DANNY ROBBINS
Star-Telegram staff writer



> Not long after complaining of shortness of breath at her Quinlan home, Patricia Cannon was in a Hunt County ambulance heading north toward Greenville with a drug dripping into her veins capable of paralyzing every muscle in her body.
> 
> The drug, succinylcholine, was administered by a paramedic. The intent was for Cannon, thought to be suffering from a blood clot in the lung, to be immobilized while a breathing tube was placed in her windpipe.
> 
> But something happened along the way that prevented the tube from being inserted correctly. The job wasn't done until the ambulance delivered Cannon, 41, to the emergency room at Greenville's Presbyterian Hospital. By then, her condition had worsened considerably.






> An examination by the Star-Telegram found that at least two people in Texas have died and another has become permanently disabled after being deprived of oxygen during the procedure, known as Rapid Sequence Intubation.





> The situation also raises larger questions about EMS in Texas, illustrating what some believe is a state system that allows paramedics with minimal training to engage in increasingly invasive procedures.
> 
> "The elephant in the room is prehospital personnel have a difficult time managing airways," said Robert Simonson, director of emergency services at Methodist Dallas Medical Center and the medical director for CareFlite and six North Texas ground EMS providers. "And they get into particular problems when they paralyze patients. That is a very unforgiving thing."





> "You can become a paramedic in Texas with less than 700 contact hours, but it takes between 1,000 and 1,500 [to get a license] to cut hair," said Jay Cloud, an EMS instructor at San Jacinto College in Pasadena. "What's wrong with this picture?"
> 
> The bigger problem with intubations, according to many in EMS, is staying proficient, mainly because liability issues have made it increasingly difficult for most paramedics to work in hospital settings.



*much more at:*

http://www.star-telegram.com/state_news/story/593026.html


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## BruceD (Apr 20, 2008)

Although, not being a paramedic, not living in texas, and not having used RSI...

I'm a big believer that journalists should be neutral in their point of view and that they should stick to facts.

I very much dislike:



> "My gut feeling is that, for every one of these cases, there's probably a handful of others you never hear about," said Henry Wang, an assistant professor of emergency medicine at the University of Pittsburgh who has closely examined intubation by EMS personnel.


Because who cares about gut feelings?  My gut feeling is that people who give gut feelings to the newspapers are idiots. 
*'My spidey sense is tingling!! danger! Danger!'* We have the scientific method, use it, it is your friend.



> The most commonly used drug is succinylcholine, a short-acting paralytic that's also used when criminals are put to death by lethal injection.


Is this really the best method of describing succinylcholine?  It's also used all over the world in surgery should we tell those patients that their drug is the one used to kill people on death row?



> "I compare [RSI] to an M-16 -- extremely powerful ..


Wow, relating it again to something deadly?  This again from spiderman, err..our gut feeling professor.



> Particularly compelling were the events surrounding Cannon's death in May 2000, just 11 days after she gave birth to her first child.


Any death is a terrible thing.  Having this far down in the story is meant to invoke the tearing, knee jerk response.

I also believe that the star-telegram ignored the fact that this procedure is (should?) only be used on the sickest of sick patients...

arghhh... it goes on and on.

--
Sorry guys, not quite so much a comment on RSI as on the journalists of today....and now we return you to your regularly scheduled programming.


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## VentMedic (Apr 20, 2008)

Bruce,

Yes, the article is sensationalized, but who wants to read a boring medical article?   

What about the quotes you used that are from EMS professionals and Educators?   How is what is being said that much different from what people working in the field have commented on in the several threads we have had on education and RSI? 

Medicare has already spoken about its position on medical errors. Should EMS be exempt?   

Should Paramedics be exempt from any responsibility when it comes to mistakes or preventing them?  Why should they be viewed differently than other licensed HCWs?     They want the same responsibility as RNs and RRTs but don't want to maintain the initial and/or minimum education, competency and medical oversight standards.  How is that fair? 

Unfortunately, due to lack of proper education and training, there are those that will perform an advanced procedure because they can and not because they should.   We've seen this in the past with central lines.  

Whenever you accept the responsibility of performing advanced procedure, you should accept the responsibility of becoming competent and maintaining competency for that procedure.  Some, unfortunately, may not have even the background education to realize what is actually at stake with the procedure.  That may sound absurd but you can read for yourself the "nothing to it, no problem" posts in the RSI threads on the various forums. 

Any death is tragic if proper training could have prevented it.   If it takes sensationalized stories to get EMS Medical Directors to become more responsible for the proper education of Paramedics before they put their signature on the Protocol, so be it.

I have seen the results of RSI gone bad and it rarely has a good outcome.  Any, yes, it is hard to look at a familiy when you know it was a medical error and not the disease process that ended their loved one's life.


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## Flight-LP (Apr 20, 2008)

VentMedic said:


> ?
> 
> Unfortunately, due to lack of proper education and training, there are those that will perform an advanced procedure because they can and not because they should.   We've seen this in the past with central lines.
> 
> ...




These are the key points, I wholeheartedly agree...........

There were some strong points made in the article, any professional veteran in EMS can decipher whose opinion is significant and whose isn't. We all know Dr. Wang's view on Paramedic intubation period, let alone RSI. I think Bryan Bledsoe sums it best.............

"If you have a good medical director, somebody who's actively engaged and involved in EMS, you can kind of push the envelope," said Bryan Bledsoe, a Midlothian emergency physician and the author of several EMS textbooks. "The problem is a lot of these services have someone who just signs the chart." (i.e. AMR!)

This is key and is why my program's RSI performance is top notch. 100% QA / QI review, quarterly education and intubation requirements, and a solid protocol covering the procedure. "First attempt, best attempt" is a great attitude to live by. Transient hypoxia fails to meet this standard and is completely inexcusable. A couple points that I'd like to make about these two cases.....

1. AMR..........Enough said! Their clinical department in Texas has NEVER been a strong point, especially earlier this decade. Why those medics were even allowed near paralytics is beyond me.

2. Air Evac Lifeteam - Up until AEL merged the Critical Air crews into the system they did not have the best clinical training department. Their orientation was only 4 days long and little time was spent on their PAI protocol. AE 34 in Wichita Falls was new, the only helicopter AEL had in Texas, and was not properly regulated or managed initially. Critical Air on the other hand had an in depth training program that was closely monitored and evaluated new flight medics and nurses. That was lost when we lost our Texas protocols. Fortunately, AEL is currently very in depth and has somewhat raised their bar system wide, but in comparison to other Texas air and ground systems, it is still behind the curve. Unfortunately, that happens when you have a multi-state organization and seek CAMTS accredidation. You have to "universalize" the protocols.

While this article shows stupidity as evidenced by a lack of confirmation (ALWAYS confirm with ETCO2!), and it allows strong opponents of intubation to push their views, RSI in Texas isn't going anywhere. I still see a strong need for it when it is indicated and in the hands of people who know what they are doing and why they are doing it.

There are many who want to see "State" protocols throughout the country. Unfortunately for them it will never happen..................................


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## Flight-LP (Apr 20, 2008)

BruceD said:


> Is this really the best method of describing succinylcholine?  It's also used all over the world in surgery should we tell those patients that their drug is the one used to kill people on death row?



Actually the newspaper got that fact incorrect! They sure can write about opinions, but fail to make the grade when it comes to fact...................

Succinylcholine is NOT used during lethal injection. Pancuronium is, big difference!


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## BruceD (Apr 20, 2008)

VentMedic said:


> Bruce,
> 
> Yes, the article is sensationalized, but who wants to read a boring medical article?


True, but in our world of instant gratification and people knee jerking to everything they read, I don't know that this article is actually in the best interests of the public that all of you serve.  Case study is just a little bit above opinion on the scientifc scale...



> What about the quotes you used that are from EMS professionals and Educators?   How is what is being said that much different from what people working in the field have commented on in the several threads we have had on education and RSI?


Mostly because discussion within the group about how to better the profession is not bandied about in front of people with no medical experience to push a point of view and all sides can have their say, but I'm not really blaming them entirely, I'm willing to bet the 'reporter' (LOL) picked and chose quotes to place in the story.


> Medicare has already spoken about its position on medical errors. Should EMS be exempt?
> 
> Should Paramedics be exempt from any responsibility when it comes to mistakes or preventing them?  Why should they be viewed differently than other licensed HCWs?     They want the same responsibility as RNs and RRTs but don't want to maintain the initial and/or minimum education, competency and medical oversight standards.  How is that fair?


I'm sorry, of course responsibility should be taken and education should not just be when the person is learning their trade, but should continue throughout life.



> Unfortunately, due to lack of proper education and training, there are those that will perform an advanced procedure because they can and not because they should.   We've seen this in the past with central lines.
> 
> Whenever you accept the responsibility of performing advanced procedure, you should accept the responsibility of becoming competent and maintaining competency for that procedure.  Some, unfortunately, may not have even the background education to realize what is actually at stake with the procedure.  That may sound absurd but you can read for yourself the "nothing to it, no problem" posts in the RSI threads on the various forums.



You also have me there.

Sorry Vent, guess I too just had a knee jerk reaction to how this story was written.  Probably why I refuse to subscribe to newspapers, I hate the sensationalism.

Take care
-B


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## VentMedic (Apr 20, 2008)

Flight-LP said:


> Actually the newspaper got that fact incorrect! They sure can write about opinions, but fail to make the grade when it comes to fact...................
> 
> Succinylcholine is NOT used during lethal injection. Pancuronium is, big difference!



Actually Succinylcholine has been on the books as one of the paralytics that was used until the preferred 3 drug cocktail was accepted. 

Bruce,

I have been using using paralytics for intubation for over 20 years on Flight and specialty transport.  It is not something that should be taken lightly.  As Flight-LP pointed out, it takes continuing education and a solid protocol with excellent medical oversight.  

The journalists do take "quotes" and passionate stories to make their point.  Unfortunately the passionate stories do involve someone's loved one and if it was your family member it would be a big deal also.  You may also want to get the word out.   The recent Heparin stories can also be used as an example.  For those, more research found several flaws in the system and in the Heparin itself.  So, the sensationalized articles were not a waste.  They did spur a more thorough investigation than what might normally have taken place.  

MRSA re-emerged as a major story even though MRSA has been news for 25 years at least.  Yet, on some of the EMS forums it was still taken lightly and many show little knowledge about something that should have been included in a Basic class.  

Sensationalized journalism can bring mixed feelings.  The California EMTs thought the SacBee was picking on them with the numerous articles that  showed a weakness in their EMSA system that allowed serious felons to be certified and licensed.   The California EMTs will survive the articles and may be stronger in the long run.

Last weekend's San Francisco Chronicle article on slow EMS response times has made the national papers and received acknowledgement of some major politicians.   Some of the examples used in that article made me  while reading it but when taking the points as a whole, it did address some serious issues.

Don't apologize for expressing your opinion.  You also made very valid points and made me express my stance on the subject.  That's what makes a good discussion.


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## MedicPrincess (Apr 20, 2008)

Intresting.... I have been accused of being "scared" of RSI by some that consider themselves "agressive" airway managers.  I tend to use it as my last resort, as opposed to my first option, as I have seen done.  I am a big fan of the CPAP and inline neb tx....it was with an asthma pt that I choose that route, as opposed to RSI, that I was called a chicken to RSI..... and although I look at my Succs and Roc every shift, I tend to take that deep breath, and say that silent "Dear lord, please don't make me have to break these out today....but if I must, be there with me when I do it" prayer.....anyway....

In my old service, RSI was "standard issue" with your bag of tricks once you did your ride alongs after being hired as a medic.  Now the ride along times consisted of 1-20 shifts, with normally an FTO, but if an FTO was not available, any Medic'll do.  I had a new employee Medic with me I was supposed to be "training" only 3 shifts after I put on my patch... (another problem all together).  Either way, it was not uncommon for out of 50 transports, county wide, in a 24 hour period for 2-3 of those pts to have been RSI'd.  And often, there was more then one Medic that could be heard talking about how long its been since he HASN'T RSI'd someone on shift... vs. Me who can't remember when I've actually had to RSI someone.

Crossover to my new service.....RSI is a privledge granted to each Paramedic Individually by our medical director, only after completing his advanced airway course taught by him and then demonstrating your understanding of the material and skills covered.  He then often times is found "popping up" on calls, and seems to materialize out of no where either on scene or at back doors of our ambulances when we arrive at the hospitals with an RSI'd pt.  He then reviews the charts of, amoung others, every pt that is RSI's and has some (at least) face to face time with the Medic if he finds ANY irregularity or deviation from the protocols set forth.

We do however use sedation facilitated intubation.....and that is a skill any paramedic hired, and cleared to work the road, can pull out of their bag 'o tricks as necessary.  Again, though, our MD is often found "in the area" when it is used.  And for that we have Versed or Etomidate.


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## Jon (Apr 20, 2008)

I had the opportunity to hear Wang present his research just as his paper came out... it was at an "EMS Week" lecture series.

RSI WORKS... if you have a good QA/QI program, and the medics have lots of time intubating real patients... like doing an OR shift occasionally, and intibating lots of patients on duty... this is seen in aeromedical programs and CCT crews.

If the medic gets 2 tubes a year, should they even be intubating? Why not just drop a King LT-D (which any trained monkey, er chimp, could do).


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## MasterIntubator (Apr 21, 2008)

Just what we need. More leverage to take the tools some of us work so hard to have away. Without getting on a 10 page soap box, I wish I could have the newspaper write how, for the most part, intubation is NOT A DIFFICULT SKILL!  The dolt had the tube in, but WTF?? Can't even use basic skills to recognize a misplaced tube? What about oral landmarks? Should not have been a blind insertion, you either see it go in, or not! Then you check it. 

I just don't get it.


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## Ridryder911 (Apr 22, 2008)

Anybody else found this odd? 

_......" Dallas: Paramedics in a large system don't have enough opportunities to sharpen their intubation skills, according to medical director Paul Pepe_".....

Okay, let's see... hmm Pepe' the famous research who was lead author on the MAST trouser study, and famous pic on the last ACLS Text (holding a cell phone), now Medical Director can only say.. they don't have enough intubation opportunities to be sharp?... WOW! Millions of people, and they can't maintain their intubation skills?... Really, whom fault would that be.... maybe the medical director and education department? Okay, your department has nearly everyone a Paramedic and you flooded the ability to maintain skills.. so this was a good idea to still keep doing this? 

Again, not another rocket scientist dilemma. Reduce the number of Paramedics, and one will increase the number of skills.. just don't go overboard. Again, good ole common sense. 

R/r 911


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## Flight-LP (Apr 22, 2008)

He said that same crap when he was HFD'S medical director. He is a direct reason why Houston Fire's EMS is as crappy as they are. Load, go, get back in service. Minimal level of care to stretch the dollar as far as it can go................

But, yes, I found it humerous when they let him put his $.02 worth........................

And the MAST study is hilarious if read these days, to think some actually bought into that...............


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## MSDeltaFlt (Apr 22, 2008)

This apparently is becoming a very heated debate/discussion.  Just mention RSI on an EMS forum, yay or nay, and toes tend to get long.  This may be completely inappropriate, but this is where I stand.  

Those who do RSI and those who want RSI may be excellent airway managers; highly skilled and competent.  But can they guarrantee that for everyone in their service?  In some areas it is not likely.

A lot of people mention required skills, with continuing ed, and repeat skills, and QA/QI and the like.  Now QA/QI has synanyms.  They are "accountability" and "responsibility".  When it comes to RSI, or anything dealing with ABC's, iatragenesis has deadly consequences.  You must be held accountable for everything you do for a pt; good or bad.

Whenever you care for a pt, either by action or inaction, you must be willing to not only lose your job, but also lose your career.  If you are not willing, then you shouldn't even attempt it.

My humble 0.02


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## Rogue Medic (Apr 22, 2008)

I wrote a lot about this on my blog, Rogue Medic. RSI Problems - What Oversight?


The author of the Star-Telegram article actually did a lot of preparation for this article, including extensive interviews with Gene Gandy. While I do not agree with everything in the article, he did a good job of trying to present balanced information.
*
If the medics are not recognizing esophageal tubes it is primarily because their medical director is not providing competent oversight.*


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## BruceD (Apr 22, 2008)

Rogue Medic said:


> While I do not agree with everything in the article, he did a good job of trying to present balanced information.



Guess I missed the 'balanced' part


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## Rogue Medic (Apr 22, 2008)

He interviewed people who support and oppose RSI. He spent a lot of time talking with them. He selected what would appear to be pertinent bits from each. Even the title of the article points the finger where the blame should lie - the criminal lack of oversight by medical directors. 

While he does not take the position that I feel is appropriate, but he has spent months on this story to come up with a reasonable lay person view of RSI.

How can you say that it is not balanced? 

There are plenty of examples of a negative comments in the story. There are also plenty of positive mentions of RSI. In my opinion, most physicians would not have as balanced an approach to RSI. As a piece of journalism, this is something that appears to me to try to present a fair view of a poorly understood medical procedure.


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## MasterIntubator (Apr 23, 2008)

Hmmm....



> .....endotracheal intubation, a difficult skill under any circumstances,....


I don't buy it. 



> .......state system that allows paramedics with minimal training to engage in increasingly invasive procedures....



True.... negative light.



> ....prehospital personnel have a difficult time managing airways...



True... again, negative



> .....succinylcholine, a short-acting paralytic that's also used when criminals are put to death by lethal injection.



Did that really need to be part if the article?  Could have been worded different, related to freakin EMS.  ( and the next line does, but... come on )



> "I compare [RSI] to an M-16 -- extremely powerful in the hands of a master who's well-trained and gets a lot of practice, extremely dangerous in the hands of a beginner," said Wang. "Once you give the drugs, it is the point of no return. You must secure that airway."



What a violent comparison. Once you shoot an M-16, target is hit.  RSI, well... you have options.  How about BVM, alternate airway, surg airway....  Once again, shedding needless negativity.



> .........as long as 20 minutes and that the paramedic did not verify tube placement......



That is sad.  20 minutes is a long time.  Probably the medic's first time, his pucker factor is high, ego may have hit a high and he forgot to breathe for himself.  Can't knock that statement, it speaks volumes.



> ....it was the Hunt County EMS medical director himself who ultimately intubated Cannon correctly...



Know what that tells me?  It was not a complicated airway. B freakin VM!!

The story goes on.... it makes RSI look bad.  Nuff said.  Ohhh... does anyone have the stats on in-hospital intubations?  Bet it is just as interesting.


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## Rogue Medic (Apr 23, 2008)

> .....endotracheal intubation, a difficult skill under any circumstances,....



I agree with you. It usually is not difficult.



> .......state system that allows paramedics with minimal training to engage in increasingly invasive procedures....



Medics have more focused training. He seems not to grasped that. 

That medical directors allow bad medics to treat patients is a huge problem.



> ....prehospital personnel have a difficult time managing airways...



This one sure did. Actually, he seems to have had an easy time mismanaging the airway.



> .....succinylcholine, a short-acting paralytic that's also used when criminals are put to death by lethal injection.



And nitroglycerin is the explosive that Alfred Nobel used to make dynamite.

And adenosine, cardioversion, and defibrillation all stop the heart.

And Ativan, Valium, and Versed are all related to Rohypnol - the "date rape drug."

It is just a point of reference. It is true. Reporters look for something interesting to say to provide more information. I have used all of these examples myself. They are not inaccurate, but taken out of context can be misleading.



> "I compare [RSI] to an M-16 -- extremely powerful in the hands of a master who's well-trained and gets a lot of practice, extremely dangerous in the hands of a beginner," said Wang. "Once you give the drugs, it is the point of no return. You must secure that airway."



He was quoting Dr. Henry Wang, so this is not surprising. Dr. Wang is constantly doing airway research that is designed in a way that reinforces his biases. Is it intentional? I don't know.

He also quoted Gene Gandy and Dr. Bryan Bledsoe. If he wanted to present a purely negative piece about EMS, he would not have even talked with them.



> .........as long as 20 minutes and that the paramedic did not verify tube placement......



Please, put a positive spin on that and then claim you are providing balanced information. This was an execution.



> ....it was the Hunt County EMS medical director himself who ultimately intubated Cannon correctly...



I am disappointed that he had anything, that might be considered positive, to say about this medical director. How does a medical director have such a moron working for him and not know it? How does he allow the medic to continue without any discipline or retraining? That idiot medic is now "training coordinator." 

This kind of medical director is the real problem.

The article did not focus on the medical director as the cause of all this. I think that is wrong. Danny Robbins just came to different conclusions.

There are negative statements in an article about 3 airway errors that should never happen - NEVER. Well, duh! There will be some negative stuff in there.

If I wrote this, it would be far more negative. 

Two killings and one just brain damaged. You want to put a happy face on that? We definitely have the wrong priorities in EMS, when we want to have our Charlie Foxtrots portrayed in a better light, rather than improving the seriously flawed system that causes these problems.


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