# The Great Airway Debate...



## VentMonkey (Sep 4, 2016)

Alright all, this is officially my first thread so go easy on me if you will.

This on going "hot button" issue has come and gone many times on this site, I am sure, but instead of revamping a necrothread I felt the need to create a new one. First, I will ask some of the questions that have come to mind recently, then I will share my thoughts, and comments. I look forward to everyone's input as well, so here goes nothing...

_Do you feel advanced airway management (ETI) should disappear altogether in the prehospital setting? why or why not?
_
I don't think it should altogether, but that being said our level of training, and con-ed is severely lacking. I think advanced airway management should be reserved for certain patient populations only to include rural areas that permit RSI (e.g., ground services that have this capability). I also think that in general when I think advanced, only practioners that have, or seek this advanced training should be permitted, and if intubation is that important to you_, _then you will take the time to learn more about the importance of this procedure which includes anything from proper BLS techniques, when not to intubate, proper positioning, the RSI drug formulary, and what it is these drugs can, and cannot do. I also feel this is where the importance of vent management comes into play in the prehospital arena. Understanding that hand-bagging a patient for an extended period time is just BAD for these patients.

When it comes to who should be intubating, it's my belief that it should remain in the general paramedic scope to be taught, but there should be an exception to the rule that allows for us to utilize blind airway devices to secure their airway in the event that the patient is no more than, say, 10-15 minutes from the closest hospital if this is a straightforward arrest patient, and not one needing to be induced. Obviously, these devices are still excellent back up airways as well.

_Is CPAP/ BiPAP something that should be implemented in ALL BLS providers scope of practice? Why or why not?
_
Absolutely. This is a fairly safe, easy, but more importantly effective skill to perform on certain patient populations that with proper training, I don't see or have a problem with my tech setting this up, in fact I often showed them how if they were interested. This goes for breathing treatment IMO as well (disclaimer: I am from California so this isn't really accepted here). The turn around on these patient such as flash pulmonary edema, is to me, as remarkable as say Narcan, and Dextrose reversals; not always, but usually.

_Is the ventilator something that is being put into use in your service (I am more interested in ground 911 here, but all comers are welcome), and if so how much lee way do you have in terms of being able to make adjustments, or are you using basic setups such as the autovent? Do you feel that the ventilator is something that is ready to be added to the paramedic curriculum?
_
We don't do routine ground RSI here, however, my division does perform them, and has a specific ventilator protocol which includes parameters for certain patient populations. We don't use the autovent (thank goodness) anymore, and are actually in the market for an updated ventilator. 

I do think that basic ventilator management should be taught in the national paramedic curriculum if we are to continue providing advanced airway management. Then again, so should the RSI formulary, which I know can get combed over depending on the paramedic school you go to. I don't think what would be taught needs to be anything more than ABG basics, ventilator terminology, settings, and parameters. I do think it's important for all paramedics to understand that at the very least the tool comes with the (or at least should) "airway package". Don't get me wrong, by no means am I discounting the importance of proper BLS airway manuevers, but I don't feel we as medics should be so apprehensive with the vent. 

_Finally, do you place gastric tubes on all patients that you intubate? Do you feel that it's imperative/ takes away from the "gold standard" that is often seen with ETI?
_
I don't/ haven't, but am beginning to understand the importance that it serves, specifically in the patient who has been RSI-d. When we do perform RSI we are to place them in as well, as well as on the vent. I understand time constraints, but it really does defeat the purpose of calling it a "gold standard" of an airway without a gastric tube in place, and has forced me to make a conscious effort to place them on any, and every patient RSI-d, or who are intubated, and to be transported.

This is the general gist of how I feel. I assure you this is NOT a homework assignment, I'm just genuinely curious as to what side of the fence my fellow EMS-ers stand on this on going discussion. Like I said, all input is really appreciated as I know there are some people on this forum we could benefit to learn from so hopefuly y'all feel compelled to join this discussion. 
_
_


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## SeeNoMore (Sep 4, 2016)

1.I think there is clearly a role for advanced airway management in the pre-hospital setting.  I agree that advanced airway management should be performed by clinicians with a significant amount of education and exposure , and outcomes should be closely monitored. I think it is reasonable for  Flight / Critical Care teams and Paramedics in rural areas w/ extended transport times to utilize RSI if they prove capable of a very high first pass success rate and appropriate pt management generally.  I think it would be very reasonable to remove intubation from the general paramedic scope of practice.  

2. CPAP for all providers? Yes certainly. 


3. We do not use a vent at my ground per diem job though we RSI. This is an issue that has been discussed at length internally and there has been a push to purchase vents. I am a little unsure of adding vent management to the paramedic curriculum. I fear that spinning a few dials will be regarded as "understanding the vent". Then again, perhaps using some preset AC settings would be preferable to the general practice of aggressively hyperventilating patients. As per question 1 , I think it would be great for the teams that use RSI to have a vent. At least better than the autovent. 

4. We typically do place gastric tubes on all pt's we RSI.


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## SpecialK (Sep 5, 2016)

I think there is a role for both standard intubation (without medicines) and RSI in pre-hospital care.  Having said that, the only indication I can logically see for standard intubation is GCS 3 *and *ineffective breathing (which is also the only indication in the CPGs) although, even then if an LMA was in place and working well, and hospital was reasonably close, I wouldn't do it. 

Some ambulance services have removed endotracheal intubation on the basis it worsens outcomes as demonstrated in less than ideal quality studies.  This is true, there is significant risk associated with "badly" attempting to intubate somebody; for example long periods of laryngoscopy, multiple attempts, attempting it on somebody who has a GCS of greater than three without RSI.  All of the studies I am aware of have come from the United States, where large numbers of paramedics are able to intubate after, generally speaking, quite limited education, and may only intubate a very small number of people a year if that. 

In Australasia; intubation is limited to Intensive Care Paramedics who have many years of education and experience; the standard for a number of years now has been a Postgraduate certificate or diploma on-top of the standard university degree to reach this level.  The number of ICPs is also limited on the rationale of increasing the exposure these officers have to use their specific skills.  On-top of this, those ambulance services (such as St John, WFA, the QAS, and AV) who are doing RSI also further limit to a group of selected ICPs.  In Australia and Auckland, it is standard for HEMS to be crewed by a Doctor/Paramedic.  

I strongly believe RSI should not only be in the "rural" area; I have seen many patients in an urban area who've had falls from height, road crash, post-cardiac arrest or stroke, poisoning etc benefit from RSI.  You can be an hour from hospital, or two minutes, but if you have somebody with a severe traumatic brain injury for example who is all aggressive and fighty well doesn't really matter how close you are does it?

CPAP should absolutely be available; this seems to be standard in Australia.


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## VentMonkey (Sep 5, 2016)

Awesome input so far. It's nice to see and know what others are doing, and why they're doing what they do.

I hope to hear from others as well (any and all providers be it EMT, interns, medics, RN's, docs, CRNA's etc.)

I hope everyone has a safe and enjoyable Labor Day.


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## Carlos Danger (Sep 5, 2016)

My opinions on this issue are pretty much in line with the other posts so far in this thread.

There absolutely is a role for advanced airway management in the field, but I think it is pretty limited. The fact is, few patients really need intubation in the field, and those who do appear (according to what we are taught) to need it and receive it are statistically more likely to have a poor outcome. So we just aren't helping them, in most cases. 

Most of this research was done in urban areas, however, and I think that if you have long transport times (rural areas) and/or transport an unusual proportion of high acuity patients (HEMS, for instance), then the chances of encountering patients who do really need it are higher. So in those settings I think it is appropriate. The other advantage of limiting who does RSI is that the limited resources for ongoing training can be focused on a smaller group of paramedics.

CPAP? Sure. Great tool.

OG tubes? Not routinely. Some of the worst messes I've seen followed OGT placement. If someone has an elevated intragastric pressure, then disruption of the esophageal sphincter with the GT makes emesis more likely. And they can puke much faster than you can suction. And if they don't have an elevated gastric pressure - and especially if you already have the airway secured with an ETT - then you don't need to decompress their gut. I don't place them routinely in the field or the OR. Only if indicated for other reasons.


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## VentMonkey (Oct 22, 2016)

Thread bump...

So our program recently implemented ventilator placement for any, and all scene calls that are intubated. So far it seems to be going well. It frees up hands to perform other interventions. Obviously, it's much better for a patient than (inaccurately) squeezing air into their lungs, often incorrectly.

For any of the CCT/ HEMS people, with your service are you (paramedics) being trained on ventilator management as part of your initial new-hire training? Is it simply just learning how to dial in settings, or are you learning the ins and outs of vent management in the prehospital setting (ABG's, proper settings for different patient populations, formulas such as "Winter's Formula", etc.)? Do you feel it's that important, and if so, why or why not? Are the nurses at your service expected to be up on their ventilator knowledge as well?

I know some of the nurses I have come across, seem somewhat uneasy with vent management as most would say it's deferred to respiratory in the hospital.

I apologize if this is somewhat redundant, I am just genuinely curious what other paramedics think about prehospital vent management, and it's importance in relation to airway management in the field. Clearly, it isn't something that is emphasized in paramedic school, which I get, but for those who choose to go the critical care route, I cannot (IMO) stress the importance of learning proper prehospital ventilator management enough.

I still learn everyday, but can't help but feel that we as paramedics often stop once "the tube is in". This is sad, and to me further demonstrates why prehospital ETI should not be the norm for most paramedics in the field. 

If any paramedics, be it critical care, or not would like to dispute this, please feel free.


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## StCEMT (Oct 22, 2016)

I will throw my newbie $0.02 in.

1. No, there are obviously times it is necessary. I can think of a couple I have seen personally, however that is admittedly rare in the grand scheme of things compared to how many people I see per shift. But I have had the GCS of 3ish and a bloody mess of an airway and would definitely want anyone else like that intubated. That being said, I am also trying to read more lately on other times it truly is necessary vs I can get away with not doing it due to what I hear about poorer outcomes in some situations.

2. Absolutely. Both have helped many people avoid getting a tube. If I was on a BLS truck that was majority 911, I would definitely feel a lot better about that specific patient population knowing I had the ability to use CPAP. 

3. Our ALS trucks have vents. Partially due to the fact that we do a lot of transfers and so we will be the ones transporting vent patients in the city. In those cases, we just transfer them and have all their vent settings copied (or as close as we can get) to ours then an RT signs off on it after we watch them for 5 minutes. That being said, it is also available for patients we intubate in the field. The EMT would set that up while the medic takes care of the intubation. That is something I know I do not know a lot about beyond the basics and am trying to learn more on my own. The vent was in my curriculum though. Maybe just because the trucks where my class was had vents and they wanted us to know how to use those, but we all got to go over the vents and setting them up etc. I liked having that as part of my class, while the vents where I work are different it was easy to pick up.

4. The last few patients I saw tubed didn't get an NG tube. However, I wasn't running those calls. Personally, I probably would depending on the time I had from the hospital. Especially if it was someone who had been bagged for a prolonged period of time, a drowning, etc. That being said, Remi makes a good point as well. NG/OG tubes are one of those things I will just have to see for myself since they haven't been routine with anyone I have worked with that I know of.


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## VentMonkey (Oct 22, 2016)

StCEMT said:


> 4. The last few patients I saw tubed didn't get an NG tube. However, I wasn't running those calls. Personally, I probably would depending on the time I had from the hospital. Especially if it was someone who had been bagged for a prolonged period of time, a drowning, etc. That being said, Remi makes a good point as well. NG/OG tubes are one of those things I will just have to see for myself since they haven't been routine with anyone I have worked with that I know of.


This, I agree is subjective. Time permitting, I will place one, but it's definitely something that can wait until we get to the ED, as our main ED's we transport to have fairly short ETA's. Thanks for the feedback, @StCEMT .


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## StCEMT (Oct 22, 2016)

VentMonkey said:


> This, I agree is subjective. Time permitting, I will place one, but it's definitely something that can wait until we get to the ED, as our main ED's we transport to have fairly short ETA's. Thanks for the feedback, @StCEMT .


Same. I have....14? hospitals within the area I work, so my transports are not very long. It would definitely be a time permitting thing.


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## VentMonkey (Oct 22, 2016)

StCEMT said:


> Same. I have....14? hospitals within the area I work, so my transports are not very long. It would definitely be a time permitting thing.


We have two primary hospitals we land at with helipads. One being our Level 2, the other a cardiac/ neuro ED, so unlesss we're (>) 15 minutes flight time, I soon rather wait.

In regards to vent management, I am still hyper curious to see, and hear what other paramedics feel about this aspect of airway management in the prehospital setting. Why, or why not would one think it's relevant.


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## VentMonkey (Oct 23, 2016)

Though the title implies it is geared towards management of patients intubated, and placed on mechanical ventilation by the EM physician, I found this article by Dr. Weingart to be an excellent, and brief, tutorial for even prehospital providers placing their intubated patients on mechanical ventilation.

He appears to touch on all of the basics for proper initial ventilator management in the patient population, its importance, trouble shooting strategies, and things to consider.

http://emcrit.org/wp-content/uploads/2016/10/Mech-Vent-Article.pdf


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## Carlos Danger (Oct 23, 2016)

At this point in this discussion, I'm just going to throw out a few thoughts based in my experience and understanding.

1. That article by Dr. Weingart is an excellent, basic overview of initial ventilation strategies.

2. In a patient with healthy lungs (i.e. the healthy 25 year old who is intubated due to a head injury suffered during an MVC) during a short transport (say, <30 min), initial ventilation strategy probably has very little effect on outcomes. As long as you maintain normoxia and normocarbia and don't cause barotrauma by using 15ml/kg in an overweight patient (as I was taught to do in my initial paramedic training), little that you do probably matters. Just keep their Sp02 over 92 and their ETco2 between 28 and 35. And don't stress too much over it. 

3. Probably my biggest beef with the current trends in prehospital airway management is this: the avoidance of paralysis during the initial phases of management is completely unfounded. There is literally no downside to keeping these patients relaxed for the first hour or two of their management. It makes ventilation easier, and not having to deal with that frees up your hands and cognitive resources for other things. I find it a bit perplexing that the "progressive" folks who tend to endorse the "Roc rocks, and Succs sucks" approach tend to be the same ones who argue strongly against maintaining relaxation during transport. 

4. Early NGT placement has no proven benefit, and has actually been shown to increase the probability of emesis, most likely by disruption of the lower esophageal sphincter. Once you have an ETT in place it probably doesn't matter what you do as far as emptying the gut, but understand that it isn't an important intervention by itself.


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## VentMonkey (Oct 23, 2016)

Remi said:


> Probably my biggest beef with the current trends in prehospital airway management is this: the avoidance of paralysis during the initial phases of management is completely unfounded. There is literally no downside to keeping these patients relaxed for the first hour or two of their management. It makes ventilation easier, and not having to deal with that frees up your hands and cognitive resources for other things. I find it a bit perplexing that the "progressive" folks who tend to endorse the "Roc rocks, and Succs sucks" approach tend to be the same ones who argue strongly against maintaining relaxation during transport.


Goof stuff, @Remi; would you care to elaborate further on this statement? My dividing line for induction paralytic chosen would be an isolated increase in intra-ocular pressure having Rocuronium being the more favorable one of the two. Now, obviously many can argue that the majority of closed head injuries are at risk for an increase in their intraocular pressure based on the pathology of devastating insult within the cranial vault itself, however, for the majority of our patients (i.e., those without_ confirmed, and/ or isolated_ eye injury) they will receive Succinylcholine followed by proper sedation, and pain management. Given our flight times, there is no real reason to further inhibit a neurological exam needing to be performed at the receiving facility unless there are other predetermined factors that would dictate a patient receiving the longer acting paralytics either as a pre-, or post-induction agent.



Remi said:


> Early NGT placement has no proven benefit, and has actually been shown to increase the probability of emesis, most likely by disruption of the lower esophageal sphincter. Once you have an ETT in place it probably doesn't matter what you do as far as emptying the gut, but understand that it isn't an important intervention by itself.


I think the majority of people so far agree with this statement as well, including myself. Again, if time permits, and it doesn't seem like it will be, or pose any harm to the patient, I may placed one as a courtesy to our receiving facility. It will be placed eventually down the line, sometimes it's just easier to play nice, and act as part of the overall team in general.


Again, these are just my thoughts. While I can understand and appreciate some being apprehensive, or uncomfortable with this subject matter, I can't help but feel some degree of advanced respiratory knowledge is parallel with what is it paramedics are being taught in paramedic school. We are expected to be trained in airway management, so why just stop at proper tube placement, and confirmation? This just baffles me.


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## Carlos Danger (Oct 23, 2016)

VentMonkey said:


> Goof stuff, @Remi; would you care to elaborate further on this statement? My dividing line for induction paralytic chosen would be an isolated increase in intra-ocular pressure having Rocuronium being the more favorable one of the two. Now, obviously many can argue that the majority of closed head injuries are at risk for an increase in their intraocular pressure based on the pathology of devastating insult within the cranial vault itself, however, for the majority of our patients (i.e., those without_ confirmed, and/ or isolated_ eye injury) they will receive Succinylcholine followed by proper sedation, and pain management. Given our flight times, there is no real reason to further inhibit a neurological exam needing to be performed at the receiving facility unless there are other predetermined factors that would dictate a patient receiving the longer acting paralytics either as a pre-, or post-induction agent.



I don't mean that patients necessarily _should be _paralyzed for transport; just that there is no reason to avoid it. 

I know that many people view it almost as a weakness to keep patients paralyzed ("if you knew what you were doing with your vent settings and your sedation, you'd see that it just isn't necessary"), but after 15 years of vent transports in helicopters, fixed wings, and ambulances, as well as thousands of cases in the ICU and OR, I just don't agree that the disadvantages outweigh the advantages.


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## VentMonkey (Oct 23, 2016)

Remi said:


> I don't mean that patients necessarily _should be _paralyzed for transport; just that there is no reason to avoid it.
> 
> I know that many people view it almost as a weakness to keep patients paralyzed ("if you knew what you were doing with your vent settings and your sedation, you'd see that it just isn't necessary"), but after 15 years of vent transports in helicopters, fixed wings, and ambulances, as well as thousands of cases in the ICU and OR, I just don't agree that the disadvantages outweigh the advantages.


Yeah, I re-read the post after posting my reply, sorry about that. This is a hot-button issue currently in the critical care realm, or so it seems. Many promote less paralysis, and proper sedation/ pain management. This is what's being instilled almost anywhere I can think of, though I can appreciate, and know there are certain patient populations who may benefit from a longer acting paralytic such as respiratory failure patients who require rest from extreme muscle fatigue.

I don't know that I find it a weakness so much as a current trend. As an example, to go back to Dr. Weingart's article I posted earlier, he mentions favoring volume control assisted ventilations for the ALI/ ARDS folks, while others still emphasize more along the lines of PRVC. Though, perhaps because he is focused more on the initial settings in acute lung injured patients vs. the longer term respiratory care/ modes of ventilation needed to promote recovery, and SBT's. Nonetheless current trends, and keeping up to date with them can only benefit both the patient and the clincian, so again, I appreciate everyone's feedback.


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## Handsome Robb (Oct 23, 2016)

VentMonkey said:


> Though the title implies it is geared towards management of patients intubated, and placed on mechanical ventilation by the EM physician, I found this article by Dr. Weingart to be an excellent, and brief, tutorial for even prehospital providers placing their intubated patients on mechanical ventilation.
> 
> He appears to touch on all of the basics for proper initial ventilator management in the patient population, its importance, trouble shooting strategies, and things to consider.
> 
> http://emcrit.org/wp-content/uploads/2016/10/Mech-Vent-Article.pdf



SIMV 500VT 12RR Peep of 5 FiO2 1.0?




Sent from my iPhone using Tapatalk


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## VentMonkey (Oct 23, 2016)

Handsome Robb said:


> SIMV 500VT 12RR Peep of 5 FiO2 1.0?
> 
> 
> 
> ...


I LOL-d at this post pretty hard.


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## Tigger (Oct 24, 2016)

Handsome Robb said:


> SIMV 500VT 12RR Peep of 5 FiO2 1.0?
> 
> 
> 
> ...


Pretty much what our vent protocol is sadly. I am happy to have a vent for long transports, but I know next to nothing about vent management. I'm trying to educate myself, but am also hampered by the ParaPac which is fairly limiting. Tidal volume, frequency, 100% or 50% O2, and maximum inflation pressure are the only things I can set. I don't even know what to do with the max inflation pressure.


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## VentMonkey (Oct 24, 2016)

Tigger said:


> I don't even know what to do with the max inflation pressure.


While I am not familiar with this particular ventilator, nor am I an RT, I'm guessing it's an (mean) airway pressure reading/ alarm.

If so, most patients should not go above 30, however, certain conditions (e.g., ARDS, and/ or burn patients) may dictate slightly higher pessures.


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## StCEMT (Oct 24, 2016)

Tigger said:


> Pretty much what our vent protocol is sadly. I am happy to have a vent for long transports, but I know next to nothing about vent management. I'm trying to educate myself, but am also hampered by the ParaPac which is fairly limiting. Tidal volume, frequency, 100% or 50% O2, and maximum inflation pressure are the only things I can set. I don't even know what to do with the max inflation pressure.


Same vent I have. Want to learn more as well, because I just dont know enough to know how this vent is limiting. Well except with an assist setting, I had a transport who we couldn't put on that setting.


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## VentMonkey (Oct 24, 2016)

I posted this in another thread, but again, Eric's book is an excellent resource for paramedics at any level wanting to learn more about prehospital ventilator management.

He breaks it down in paramedic lingo so it's fairly easy to follow. I just got the second edition, and have perused through it. It has some updates from the first, but the first is also still a good starting point.

http://www.barnesandnoble.com/mobil...oks_00000000&2sid=Google_&sourceId=PLGoP62465


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## SeeNoMore (Oct 30, 2016)

I'd be curious to read this. I do advocate that all providers uss textbooks made for resp therapists and MDs/ critical care rns and are also are given quality education , clicnial time and testing. I think paramedics in particular should show that we are not second class providers through aggressive educational standards for ourselves.


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## GMCmedic (Oct 30, 2017)

I hate to see it happen but I think i am in favor of taking RSI away. Just watched one hell of a crap show from one of our medics while I was on the fire side.


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## Old Tracker (Oct 30, 2017)

I heard a rumor yesterday that Texas is considering doing away with RSI.  Time will tell.


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## TransportJockey (Oct 30, 2017)

Old Tracker said:


> I heard a rumor yesterday that Texas is considering doing away with RSI.  Time will tell.


Unless there's major state law changes the whole state cant just get rid of it as a while.


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## TransportJockey (Oct 30, 2017)

I am all in favour of making it a credentialed skill. Not every medic needs to be able to rsi. At my service only in charge certified paramedics and above can do it


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## DrParasite (Oct 31, 2017)

TransportJockey said:


> I am all in favour of making it a credentialed skill. Not every medic needs to be able to rsi. At my service only in charge certified paramedics and above can do it


I'd hate to have my family member call 911 for a serious medical condition, and have the ambulance show up with a crew that wasn't able to RSI, and have my family member need to RSI.  

In fact, if that happened, i would tell my lawyer that since RSI is the standard of care, the agency was negligent in not sending a fully capable ambulance crew.  probably have a decent shot of winning.


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## TransportJockey (Oct 31, 2017)

DrParasite said:


> I'd hate to have my family member call 911 for a serious medical condition, and have the ambulance show up with a crew that wasn't able to RSI, and have my family member need to RSI.
> 
> In fact, if that happened, i would tell my lawyer that since RSI is the standard of care, the agency was negligent in not sending a fully capable ambulance crew.  probably have a decent shot of winning.


There are entire states where RSI is not a ground paramedic skill.


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## DesertMedic66 (Oct 31, 2017)

DrParasite said:


> I'd hate to have my family member call 911 for a serious medical condition, and have the ambulance show up with a crew that wasn't able to RSI, and have my family member need to RSI.
> 
> In fact, if that happened, i would tell my lawyer that since RSI is the standard of care, the agency was negligent in not sending a fully capable ambulance crew.  probably have a decent shot of winning.


On the other hand how would you feel if you had a crew respond who butchered the RSI? 

Unless that agency has RSI in its protocols for all paramedics to use it will be really hard to get away with a claim of “standard of care”. If they elect that they want to give only certain paramedics the RSI skill then it would be safe to say that no RSI is the standard.


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## Carlos Danger (Oct 31, 2017)

DrParasite said:


> I'd hate to have my family member call 911 for a serious medical condition, and have the ambulance show up with a crew that wasn't able to RSI, and have my family member need to RSI.
> 
> In fact, if that happened, i would tell my lawyer that since RSI is the standard of care, the agency was negligent in not sending a fully capable ambulance crew.  probably have a decent shot of winning.


RSI is not the standard of care in EMS, and you would have no case at all on that basis.


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## DrParasite (Nov 1, 2017)

Remi said:


> RSI is not the standard of care in EMS, and you would have no case at all on that basis.


says you.... I know several agencies that do it..... that makes it the standard of care..... or at least I am pretty sure I can get a lawyer to make that case....


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## DrParasite (Nov 1, 2017)

DrParasite said:


> says you.... I know several agencies that do it..... that makes it the standard of care..... or at least I am pretty sure I can get a lawyer to make that case....


By the way, what is or is not the standard of care in anyone's opinion is irrelevant.... all that would become relevant is if an attorney could convince 12 people who weren't smart enough to get out of jury duty that it is the standard of care.... and I know enough shady lawyers who could pull that off.


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## DesertMedic66 (Nov 1, 2017)

DrParasite said:


> says you.... I know several agencies that do it..... that makes it the standard of care..... or at least I am pretty sure I can get a lawyer to make that case....


It makes it the standard for that agency but not EMS as a whole. If the agency that responds does not have RSI or decides to limit it to only a select number of paramedics then it is not the standard..


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## DrParasite (Nov 1, 2017)

sure, one agency doesn't meet the standard.... does 2? does 3?  How do you define standard?  if half the ALS agencies do RSI, does that make it the standard? Maybe that half meets the standard, and the other half is below standard?

Anytime you are cherry picking skills or treatment that am ambulance can perform (ambulance A can do it, but B can't, and it's pure luck if you get ambulance A or B), you are literally playing chance with patient's lives.  if RSI would have no impact on the patient's outcome, and it wouldn't matter, than I could see your point. 

But if I get ambulance B, and the patient dies, but if I had received ambulance A, who could have saved my loved one, well, I'm pretty sure I would have a pretty good negligence case.   After all, I only need to prove these four elements, from http://injury.findlaw.com/accident-injury-law/proving-fault-what-is-negligence.html:

Duty - The defendant owed a legal duty to the plaintiff under the circumstances;
Breach  - The defendant breached that legal duty by acting or failing to act in a certain way;
Causation  - It was the defendant's actions (or inaction) that actually caused the plaintiff's injury; and
Damages - The plaintiff was harmed or injured as a result of the defendant's actions.


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## DesertMedic66 (Nov 1, 2017)

DrParasite said:


> sure, one agency doesn't meet the standard.... does 2? does 3?  How do you define standard?  if half the ALS agencies do RSI, does that make it the standard? Maybe that half meets the standard, and the other half is below standard?
> 
> Anytime you are cherry picking skills or treatment that am ambulance can perform (ambulance A can do it, but B can't, and it's pure luck if you get ambulance A or B), you are literally playing chance with patient's lives.  if RSI would have no impact on the patient's outcome, and it wouldn't matter, than I could see your point.
> 
> ...


Show me where it states that RSI is that standard of care. 

If the medic is not able to RSI because they are not trained or not allowed by their system there is no duty to preform that skill and no breach of that duty.


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## DrParasite (Nov 1, 2017)

show me where it states RSI is NOT the standard of care.  And for the record, just because an agency doesn't do it isn't support that is isn't the standard of care, but rather support that that particular agency isn't meeting the standard of care.

As for your second statement, you're right, the individual has not..... the system/agency has. That is why standards exist, and if different ambulances (within the same system) can do different services, well, I would hate to get one of the ambulances that can't do a needed procedure out of dumb luck.


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## DesertMedic66 (Nov 1, 2017)

DrParasite said:


> show me where it states RSI is NOT the standard of care.  And for the record, just because an agency doesn't do it isn't support that is isn't the standard of care, but rather support that that particular agency isn't meeting the standard of care.
> 
> As for your second statement, you're right, the individual has not..... the system/agency has. That is why standards exist, and if different ambulances (within the same system) can do different services, well, I would hate to get one of the ambulances that can't do a needed procedure out of dumb luck.


Show me where open heart surgery is NOT the standard of care in EMS? You can’t just say show me where it’s not.


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## Bullets (Nov 1, 2017)

@DrParasite id say your NJ is showing. I dont know of an agency here that isnt RSIing


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## DrParasite (Nov 1, 2017)

DesertMedic66 said:


> Show me where open heart surgery is NOT the standard of care in EMS? You can’t just say show me where it’s not.


That's a strawman argument, and not a really good one, because I bet you can't show me any EMS system that is performing open heart surgery, so you have very little support to say that is in the standard of care.  

I can show you an entire state that has every ALS capable unit is able to RSI (Thank you @Bullets )

You are missing the important part: if your entire agency says "we aren't doing RSI", than that is their decision.  One could even argue that their "standard of care" is to not RSI.  

But when you have different ambulance crews having different capabilities, within the same system, where some can RSI and some can't, and it's plain old dumb luck if you get an RSI capable ambulance or not, than your agency has made the standard of care RSI.  

The individual medic isn't negligent; the agency is, because they failed to send an RSI capable ambulance to a patient that needed to be RSIed, and had they sent the appropriate ambulance with a crew meeting the agency's standard of care, no damages would have occurred.  

Let me try to make this even clearer:

Duty - The defendant owed a legal duty to the plaintiff under the circumstances; As the EMS agency of the area, I, the plaintiff, called 911 requesting a fully qualified medical professional to treat my loved one who was suffering a life threatening emergency.
Breach - The defendant breached that legal duty by acting or failing to act in a certain way; EMS agency failed to send a RSI capable ambulance.  They chose to send one that was not capable of RSI.
Causation - It was the defendant's actions (or inaction) that actually caused the plaintiff's injury; As a result of sending an ambulance that was unable to RSI, my sick family member was unable to receive the proper medical treatment.  Had they sent a fully trained ambulance crew, one that was capable of RSI, they would have received the appropriate care
Damages - The plaintiff was harmed or injured as a result of the defendant's actions. and as a result, my family member is no longer with us or suffered harm.
That is why it's always better to have one standard, across the board.  Either everyone at your agency can do it, or nobody; that's why it's the standard of care.


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## MackTheKnife (Nov 1, 2017)

DesertMedic66 said:


> Show me where open heart surgery is NOT the standard of care in EMS? You can’t just say show me where it’s not.


Can't prove a negative!


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## Qulevrius (Nov 1, 2017)

Orange Co, CA. RSI is taken out of ALS protocols by medical director. Waiting for the inevitable ‘oh it’s California, no wonder’ comeback.


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## DesertMedic66 (Nov 1, 2017)

Qulevrius said:


> Orange Co, CA. RSI is taken out of ALS protocols by medical director. Waiting for the inevitable ‘oh it’s California, no wonder’ comeback.


It’s not just Orange County. RSI is not in the state scope for paramedics.


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## Qulevrius (Nov 1, 2017)

DesertMedic66 said:


> It’s not just Orange County. RSI is not in the state scope for paramedics.



I knew for a fact it’s the case with OC. Saw LACoFD attempting intubation and failing, miserably...


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## TransportJockey (Nov 1, 2017)

DesertMedic66 said:


> It’s not just Orange County. RSI is not in the state scope for paramedics.


It's also not in the state scope in NM, and there are plenty of places in Texas where RSI is not allowed by some or all paramedics.


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## Carlos Danger (Nov 1, 2017)

DrParasite said:


> i would tell my lawyer that since RSI is the standard of care, the agency was negligent in not sending a fully capable ambulance crew.  probably have a decent shot of winning.





DrParasite said:


> By the way, what is or is not the standard of care in anyone's opinion is irrelevant.... all that would become relevant is if an attorney could convince 12 people who weren't smart enough to get out of jury duty that it is the standard of care.... and I know enough shady lawyers who could pull that off.



Well first, congratulations on 1) being part of the huge problem of overly-litigious people reinforcing the unfortunate practice of defensive medicine, which by some estimates cost our economy $100B a year, and for 2) formulating an argument based solely on the standard of whether or not you could use emotion to convince ignorant people of something that isn't true. Well done. Very rational and academic.

———————————————————————

First, as a paramedic, the only standard of care you will ever really be held to is whether you followed your agency's protocols and policies appropriately. The Bolam test that you refer to would likely only come into play if the paramedic were to deviate from protocol or policy, or in the unusual scenario where they clearly _should have_ deviated from protocol or policy but did not. In those cases the "reasonable professional" standard comes into play.

Second, you are mistaken in your belief that all it takes for something to become the standard of care is for it to be widely done. By that measure, thiamine, D50, and narcan could be argued to be the standard of care for unresponsive patients, because lots of places still do a coma cocktail. Lots of places also still backboard everyone who potentially suffered spinal trauma. Does that make backboards the standard of care? What about destination being determined by "mechanism of injury"? Very common still - so it that the standard of care?

Even if "widely done" is the metric that you choose to go by, it doesn't really help you because probably only about 50% (or less) of non-CCT ground paramedics in the US have RSI in their protocols. So are you now going to argue that the agencies employing roughly half of the paramedics practicing in the US are failing to meet the standard of care?

At the agency level, the medical director is primarily responsible for ensuring that protocols adhere to currently accepted standards of care. One of the main places that physicians and other independent practitioners get their standards from is the recommendations of their governing professional agencies. So which professional agency governing EMS physicians says that RSI should be universal among paramedics? Does ACEP say that? NAEMSP? No. What about the NAEMT? NREMT? Does the NHTSA curriculum say it? No, none of them do.

Another source of standards of care in a field is "practices which are widely accepted by experts in the field as being based on the best evidence available". So is universal RSI widely accepted by experts in the field? No. Some experts are very supportive of prehospital RSI, but in all my years of reading studies and articles and attending lectures and workshops on prehospital airway management and discussing and arguing about the topic over and over again, I've never heard anyone argue that, the way EMS exists in the US right now, RSI should be at the disposal of every paramedic everywhere. And even then, for every expert who is a proponent of prehospital RSI, there is another one who doesn't like it. So there's certainly no consensus among the experts in the field.

Finally, a true "standard of care" must by definition be the same everywhere. What's the right thing to do in one place is the right thing to do everywhere. But that presents some problems too. Do urban agencies with hospitals on every corner really need the same protocols as very rural agencies? What about resources? Does the small rural agency with no practical way to get OR time and who can't afford good airway trainers or VL's for every ambulance really have to have the same airway protocols as the agency in a wealthy suburb with several large hospital OR's and a paramedic program nearby to help with continuing training?

So to sum up, you are claiming that something is the standard of care which only appears in the protocols governing about 50% of paramedics, is not officially endorsed by any relevant professional agency, is not even close to being widely accepted by experts in the field, is supported by practically no evidence whatsoever and in fact has been found by many studies to be harmful to patients, can never be proven to have been beneficial in any specific instance, and for logistical reasons is very hard to implement in many locations. A malpractice defense attorney with someone like me as an expert witness would have a field day with your shady ambulance chasing lawyer.


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## DrParasite (Nov 1, 2017)

DesertMedic66 said:


> On the other hand how would you feel if you had a crew respond who butchered the RSI?


then I'd still call my attorney, just like if they butchered any procedure that resulted in harm to my family or loved one.





DesertMedic66 said:


> Unless that agency has RSI in its protocols for all paramedics to use it will be really hard to get away with a claim of “standard of care”.


You know what?  Your right.  I am revising my original statement to be in agreement with you: if an agency has RSI in their protocols, that is the standard of care.  What other people do is irrelevant, it's all based on what the agency's protocols are (your words, not mine)





DesertMedic66 said:


> If they elect that they want to give only certain paramedics the RSI skill then it would be safe to say that no RSI is the standard.


So certain paramedics aren't meeting the standard of care.... again, by your words, as the agency has RSI in their protocols, than that is the standard of care.  If the ambulance shows up and the paramedic can't RSI, but other paramedics in the system can, than that ambulance has failed to perform to the standard of care provided by that system.


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## VFlutter (Nov 1, 2017)

DrParasite said:


> .  If the ambulance shows up and the paramedic can't RSI, but other paramedics in the system can, than that ambulance has failed to perform to the standard of care provided by that system.



So every system that utilizes fly-cars is failing the standard of care? Just because HEMS/CCT has something that means ground medics must as well? Like we have discussed numerous  time on here before just because an intervention may be necessary does not mean that every single provider should be able to perform it. That is not failing to meet the standard of care. Not every physician in the ER is trained to the same degree. Some may have completed an ultrasound fellowship, others may critical care or anesthesia training. Each one may do a procedure that the other may not.


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## Chris07 (Nov 1, 2017)

Let's just do the California thing and cater to the lowest common denominator.

No RSI for anyone.

There, now all is well. People can now be screwed both on the ground and in there air. In the end, it's all about equality, right?


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## Carlos Danger (Nov 2, 2017)

Chris07 said:


> Let's just do the California thing and cater to the lowest common denominator.
> 
> No RSI for anyone.
> 
> There, now all is well. People can now be screwed both on the ground and in there air. In the end, it's all about equality, right?



No, it isn’t all about equality, it’s all about capability. What are you even talking about?


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## DrParasite (Nov 2, 2017)

Chase said:


> So every system that utilizes fly-cars is failing the standard of care? Just because HEMS/CCT has something that means ground medics must as well?


not at all.  nothing wrong with flycars, why would you say that?  an ALS/911 ambulance is an ambulance..... HEMS is different as are CCT units... most places don't don't HEMS units or CCT units on "routine" 911 calls (and by that, I mean they might go as a backup, but their primary role isn't as a 911 ALS ambulance).  you might even convince someone that no ALS ambulance crews can RSI, but only the flycar paramedics can.  That way you have a clear distinction (again, different roles and responsibilities within the system; all flycar paramedics, HEMS medics, and CCT medics can RSI; 911 ambulance paramedics can't is much different than some 911 ambulances can RSI, so you better hope you get lucky enough to get one if the procedure is needed)   





Chase said:


> Like we have discussed numerous  time on here before just because an intervention may be necessary does not mean that every single provider should be able to perform it. That is not failing to meet the standard of care. Not every physician in the ER is trained to the same degree. Some may have completed an ultrasound fellowship, others may critical care or anesthesia training. Each one may do a procedure that the other may not.


Physicians and paramedics are miles apart in terms of training.  Not even relevant to the topic at hand.


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## RocketMedic (Nov 2, 2017)

I can't RSI alone, and we're pretty medically progressive. I really don't see it as a dealbreaker


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## DrParasite (Nov 2, 2017)

sorry for the long post, but i wanted to make sure I covered everything in this long post


Remi said:


> Well first, congratulations on 1) being part of the huge problem of overly-litigious people reinforcing the unfortunate practice of defensive medicine, which by some estimates cost our economy $100B a year, and for 2) formulating an argument based solely on the standard of whether or not you could use emotion to convince ignorant people of something that isn't true. Well done. Very rational and academic.


what's that phrase?  don't hate the player, hate the game?   The system might be broken, but it does exist for a reason (like not sending a fully capable ambulance to an emergency).  and no, the whole ignorant people comment you made is just the way our court system is set up.  sorry you don't like it, maybe you should try serving on a jury and seeing what it's like?


Remi said:


> First, as a paramedic, the only standard of care you will ever really be held to is whether you followed your agency's protocols and policies appropriately. The Bolam test that you refer to would likely only come into play if the paramedic were to deviate from protocol or policy, or in the unusual scenario where they clearly _should have_ deviated from protocol or policy but did not. In those cases the "reasonable professional" standard comes into play.


We aren't talking about the individual paramedic, we are talking about the agency.... if the agency fails to send a fully trained crew, that's where the issue lies; the medic did nothing wrong.  please try to keep up with the topic at hand


Remi said:


> Second, you are mistaken in your belief that all it takes for something to become the standard of care is for it to be widely done. By that measure, thiamine, D50, and narcan could be argued to be the standard of care for unresponsive patients, because lots of places still do a coma cocktail. Lots of places also still backboard everyone who potentially suffered spinal trauma. Does that make backboards the standard of care? What about destination being determined by "mechanism of injury"? Very common still - so it that the standard of care?
> 
> Even if "widely done" is the metric that you choose to go by, it doesn't really help you because probably only about 50% (or less) of non-CCT ground paramedics in the US have RSI in their protocols. So are you now going to argue that the agencies employing roughly half of the paramedics practicing in the US are failing to meet the standard of care?


you're right.  that was why I amended my statement to be the agency's standard.  if your agency allows it's ground paramedics to RSI, but some aren't permitted to, than those paramedics are not following the agency's standard.  it's not an issue for the individual paramedics, it's for the agency that isn't sending a fully capable ambulance to a scene.





Remi said:


> At the agency level, the medical director is primarily responsible for ensuring that protocols adhere to currently accepted standards of care. One of the main places that physicians and other independent practitioners get their standards from is the recommendations of their governing professional agencies. So which professional agency governing EMS physicians says that RSI should be universal among paramedics? Does ACEP say that? NAEMSP? No. What about the NAEMT? NREMT? Does the NHTSA curriculum say it? No, none of them do.


fair point... which one says intubation should be universal among all paramedics?  let me ask an even more accurate question: which of those agencies says it's recommended to not have universal treatment capabilities among every ambulance?  I'll wait for you for you to show me that.





Remi said:


> Another source of standards of care in a field is "practices which are widely accepted by experts in the field as being based on the best evidence available". So is universal RSI widely accepted by experts in the field? No. Some experts are very supportive of prehospital RSI, but in all my years of reading studies and articles and attending lectures and workshops on prehospital airway management and discussing and arguing about the topic over and over again, I've never heard anyone argue that, the way EMS exists in the US right now, RSI should be at the disposal of every paramedic everywhere. And even then, for every expert who is a proponent of prehospital RSI, there is another one who doesn't like it. So there's certainly no consensus among the experts in the field.


yes, but what does your agency say?  do we like RSI?  if so, than everyone should be able to do it.  if we don't, than no one can.  That's the standard you should be looking at.





Remi said:


> Finally, a true "standard of care" must by definition be the same everywhere. What's the right thing to do in one place is the right thing to do everywhere. But that presents some problems too. Do urban agencies with hospitals on every corner really need the same protocols as very rural agencies? What about resources? Does the small rural agency with no practical way to get OR time and who can't afford good airway trainers or VL's for every ambulance really have to have the same airway protocols as the agency in a wealthy suburb with several large hospital OR's and a paramedic program nearby to help with continuing training?


I see you are really confused..... let me try to clear things up: should every ambulance on that rural agency be able to to the same interventions?  Should paramedic mike from rural agency A be able to intubate when it is clinically indicated, but paramedic bill can't?  so what happens when paramedic bill shows up for a patient which RSI is indicated, but he can't?  he has to request paramedic mike to respond, resulting in a delay of care, whereas if paramedic mike had been on the initial dispatch, they wouldn't be a delay.  





Remi said:


> So to sum up, you are claiming that something is the standard of care which only appears in the protocols governing about 50% of paramedics, is not officially endorsed by any relevant professional agency, is not even close to being widely accepted by experts in the field, is supported by practically no evidence whatsoever and in fact has been found by many studies to be harmful to patients, can never be proven to have been beneficial in any specific instance, and for logistical reasons is very hard to implement in many locations. A malpractice defense attorney with someone like me as an expert witness would have a field day with your shady ambulance chasing lawyer.


I'm pretty sure my ambulance chasing attorney would tear you to shreds on the witness stand, because you seem to have issues focusing your responses to the topic at hand. 

Ok, one last time: it doesn't matter what the experts say, or what other agencies do , or what your mother thinks about RSI.... If your agency lets some (ambulance) paramedics RSI, but not others, and I call 911 expecting a fully trained and capable ambulance paramedic to show up and treat in accordance to their agency's guidelines.  If that ambulance crew can't RSI, and has to call another ambulance to provide this procedure THAT IS LISTED IN THEIR PARAMEDIC PROCEDURES, delaying proper care, and resulting in a negative patient outcome, than I'm going to do 3 things: 1) call the agency asking why a properly trained crew wasn't sent 2) the local news to advise them that your agency is playing chance with people's lives, because not every paramedic ambulance is the same, and you need to actually request a fully trained ambulance crew who can do all the practices in their procedure book and 3) to my attorney, who will a) tear you to shreds and make you look like a fool on the witness stand and b) explain to the agency's attorney that sending only partially trained crews to some medical emergencies is a generally poor practice.

If you still don't get it, well, I give up, there is nothing further I can say or do, other than suggest you educate yourself on what the consequences are for failing to meeting standards.


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## DrParasite (Nov 2, 2017)

RocketMedic said:


> I can't RSI alone, and we're pretty medically progressive. I really don't see it as a dealbreaker


for clarification, is that you as an individual who is unable to RSI alone, or no paramedic at your agency can RSI without a second paramedic being present?


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## Chris07 (Nov 2, 2017)

Remi said:


> No, it isn’t all about equality, it’s all about capability. What are you even talking about?


I was attempting to be a smart ***.


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## Carlos Danger (Nov 2, 2017)

DrParasite said:


> If you still don't get it, well, I give up, there is nothing further I can say or do, other than suggest you educate yourself on what the consequences are for failing to meeting standards.



Look, the only standards you are beholden to is a defined list of interventions that someone else grants you permission to do, and can revoke permission for at any time. "See X, do Y", and as long as you follow those instructions, you are fine. You aren't really responsible to meet any true standard of care; you are just responsible for doing what you are told. Given that, I can see how you might have trouble wrapping your head around this issue. I on the other hand am an independent practitioner who practices  in one of the most litigious areas of medicine (OB), and have actual legal responsibility for (and formal education in) identifying and adhering to standards of care. So while I'm not a malpractice attorney, I have a pretty good idea what I am talking about when it comes to this because my livelihood requires me to actually adhere to it every single day. So you telling me to "educate myself" on this is laughable.

You started this whole thing claiming that anyone who doesn't RSI someone is failing to meet a fictitious standard of care. Then you changed that and said only agencies who don't RSI in a region or system where others do are failing to meet the standard. Finally, you moved the goalpost again to your current hypothesis, which is that if an individual paramedic doesn't do RSI while other paramedics in the same agency do, there is some failure to meet the standard of care.

I'm not going to argue over whose hypothetical lawyer would beat up the other guy's hypothetical lawyer. Instead, I'll lay this out objectively one more time:

There is no expert consensus that RSI should be the standard of care in the prehospital realm.
There is no statement out there by any professional authority (NAEMSP, ACEP) that says prehospital RSI is or should be considered the standard of care.
Routine prehospital RSI is not supported by the literature. Most studies indicate that it is actually more likely to harm a patient than to help them. (Which, BTW, might make it hard to argue that failure to use RSI was a causal factor in a poor outcome)
RSI is not universally performed. There are at least as many agencies that don't do it as there are agencies that do.
Adequate training in RSI (as defined by many experts in the field) is not available to every paramedic, probably not to a majority.
Without at least a couple of those things listed above, you simply cannot argue that a standard of care exists. Those things are, in fact, exactly how practices come to be accepted as the standard of care. You can hold your breath and stomp your feet and insist that it is, but you are still wrong.

Similarly, your assertion than every paramedic in an agency must be able to RSI or none of them should be able to is absolutely absurd, and is the opposite of what many consider a more responsible and manageable approach to prehospital RSI. It is perfectly reasonable for an agency to establish a basic standard of care (protocols) for every paramedic to follow, and then go on to credential some employees in additional skills once they have achieved certain levels of experience and/or received extra training. Lots of agencies do this in one form or another, because it is broadly recognized that training opportunities for RSI and other advanced skills are limited, and that gaining a certain level of basic paramedic experience before adding advanced skills probably makes sense.

Finally, if you are so convinced of this, *show me the case law*. If what you are claiming is actually true, it shouldn't be difficult to dig up examples of courts actually finding agencies negligent for violating the standard of care in airway management by only allowing some of their employees to RSI.


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## EpiEMS (Nov 3, 2017)

Stepping it back one level from the RSI debate...

I'm not somebody who can go around intubating whomever I see fit, but I'll say this: Intubation doesn't make the baseline paramedic skill set if I were to magically become the director of the system I'm in (assuming educational standards don't change, etc.).

Why? Because ETI offers no (neurologically intact) survival advantage most of the conditions where it is allegedly indicated (cardiac arrest, namely).

Where should EMS be performing ETI? Who in EMS should perform ETI?

A very limited number of circumstances - helicopter-based EMS and critical care-level EMS, sure, assuming their medics are getting enough OR time to be good at the skill and that there is QA/QI on every attempt.


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## VFlutter (Nov 4, 2017)

For those people whom are so adamant that RSI is the standard of care for EMS can you described a few situations where a) RSI is the only option for airway mangagment b) Lack of RSI would certainly result in serious harm or death and c) how often you actually encounter those situations in the field...

As I said before I am all for RSI. I think it is a fantastic tool to have when implemented correctly. But I don’t think you can make an argument that it is the standard of care and every medic should have it.


How many of you can quote your agency’s RSI statistics? How many have > 90% first pass and overall intubation success rate? Complication rates?

Like everything in medicine it’s risk vs benefit. It seems many people like to downplay the risk and over exaggerate the benefit.


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## Carlos Danger (Nov 4, 2017)

Chase said:


> For those people whom are so adamant that RSI is the standard of care for EMS can you described a few situations where a) RSI is the only option for airway mangagment b) Lack of RSI would certainly result in serious harm or death and c) how often you actually encounter those situations in the field...
> 
> As I said before I am all for RSI. I think it is a fantastic tool to have when implemented correctly. But I don’t think you can make an argument that it is the standard of care and every medic should have it.
> 
> ...



Those are good points but what really matters isn't how often a procedure is indicated or even how good we are at it, but how it actually affects outcomes. Lots of studies on prehospital intubation show really good success rates with RSI, but still associate the procedure with worse outcomes.

That realization is why we stopped focusing on just getting pulses back during CPR and instead started looking at neurologically intact discharge. It doesn't matter if high-dose epi gets pulses back more often if people are just going to die in the hospital, or have severe neurological impairment. Getting those pulses back might make us feel good, but it isn't ultimately helping the patient. Same with intubation: it might make us feel better to have a "secure" airway and maybe better blood gases, but if doing so doesn't actually improve the patient's chance of a favorable outcome, we probably shouldn't be doing the procedure routinely.


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## StCEMT (Nov 4, 2017)

@Remi, is there generally a significant difference pre/in hospital given that both providers are skilled? I've had a pt I didn't intubate because of the immediate risks just to have a doc do it shortly after and have to work an arrest. So does the who (assuming they're experienced) matter as much as the what (the act if intubating)?


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## Tigger (Nov 5, 2017)

DrParasite said:


> then I'd still call my attorney, just like if they butchered any procedure that resulted in harm to my family or loved one.You know what?  Your right.  I am revising my original statement to be in agreement with you: if an agency has RSI in their protocols, that is the standard of care.  What other people do is irrelevant, it's all based on what the agency's protocols are (your words, not mine)So certain paramedics aren't meeting the standard of care.... again, by your words, as the agency has RSI in their protocols, than that is the standard of care.  If the ambulance shows up and the paramedic can't RSI, but other paramedics in the system can, than that ambulance has failed to perform to the standard of care provided by that system.


Services in this area provide RSI as an option for providers. I cannot RSI a patient without another medic, because frankly I lack the experience needed do so. That will change when I can show a pattern of competency in managing airways over several years. I often work with an EMT, so either manage by another way or get another medic somehow. But sure, let's put providers that have no business independently providing a skill in a position where they have to just because of some arbitrary standard.


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## Carlos Danger (Nov 5, 2017)

StCEMT said:


> @Remi, is there generally a significant difference pre/in hospital given that both providers are skilled? I've had a pt I didn't intubate because of the immediate risks just to have a doc do it shortly after and have to work an arrest. *So does the who (assuming they're experienced) matter as much as the what (the act if intubating)?*



I don't know. That's the whole question. It certainly appears to have a bearing on outcomes, if you believe most of the studies.

For the record, I am not against prehospital RSI. I don't think it should be a routine paramedic skill primarily because 1) I don't think it is indicated as often as we think it is, and also 2) I think it is pretty clear that a lot of paramedics just don't have the clinical skill and judgment for such a critical intervention. I do think it has a place, though. We need some good prospective research to help show us when, how, and by whom it should be done.

We frequently talk about "the research" but what do we really mean when we say that? Well, over the past couple of decades there have been many retrospective analyses done on the outcomes of patients who were intubated in the field, vs. similar patients who were not intubated in the field. Probably 15 or so of these are what I would personally describe as "good" studies that really probably should be regarded as telling us something. Some of them were very large. What have these studies told us? The findings are not homogenous but with a pretty high degree of consistency, these studies show us two things: One, that using RSI, prehospital intubation success rates are pretty good (they were dismal before RSI became common). Placing the tube does not seem to be the problem. And two, patients who are intubated in the field have similar or worse outcomes than when like patients were not intubated in the field. Keep in mind that "not intubated" does not mean they didn't receive airway management. Also keep in mind that these are all retrospective studies that can show us relationships between interventions and outcomes, but do not indicate prehospital intubation actually causes worse outcomes. There has only been one large RCT done on prehospital intubation and that was in Australia, where the paramedics are trained differently enough from us here in the US that I don't think you could extrapolate findings from there to here anyway. This study did find some moderate improvements in functional neurological scores in the field-intubated group as opposed to the non-field intubated group, but these improvements were 6 months later, which really makes it impossible to attribute to when they were intubated. For all practical purposes, there were no differences in arrival condition or the overall clinical course between the groups.

Clearly, many agencies and individuals have chosen to simply ignore these studies when formulating their position on whether or not prehospital intubation should be routine. I can understand why, for the most part, though I don't really agree.

So, all that said, back to your question: why does it matter if a patient is intubated in the field by a paramedic, or a short while later by an ED doc? I think it is likely that the experience of the intubator matters more than we realize, in ways that we don't understand. Most of these studies were done on patients who were transported to tertiary centers, which means the receiving teams have a lot of experience with emergency airway management - a lot more than most individual paramedics get. So it could be there are subtle and even as-yet unidentified but important differences between the techniques used by people who intubate all the time, and those who don't, even if those who don't do everything correctly. If similar analyses were done on patients transported to community ED's, the differences in outcomes may not be so great. Another possibility is that there is something in the pathology of some TBI patients that makes them more susceptible to secondary injury very early after the initial insult than they are a little later.

What it all comes down to is that we really need to do the same kind of research in EMS that is done in other areas of medicine.


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## E tank (Nov 5, 2017)

StCEMT said:


> So does the who (assuming they're experienced) matter as much as the what (the act if intubating)?





It does within the confines of the hospital. It would stand to reason it would outside. Anesthesia folk are better than CC folk are better than ED folk (maybe) and nobody is better than ENT for a surgical airway. I don't need a study to establish that I'm more experienced and skilled at airways than an ED physician. But when I can't do it and an ENT breezes in, I'm out pretty fast.

ps....why is this script all frogged up?


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## StCEMT (Nov 6, 2017)

@Remi follow up then. I've seen you mention better success on first pass with paralytics. Do you think that intubation ought to be tightened up a bit more with who does it, but then for those that do intubate prehospitally use RSI? Instead of the wide range of who and how that we currently have....Maybe with something like discussed in this short podcast as an alternative. http://pjmed.libsyn.com/98-rapid-sequence-airway

Do any of the studies do a break down of overall status of injury/medical problem and vitals pre/post intubation? I don't doubt that actual managment/manipulation is definitely a part of it, but how much could be related to poor intubation prep? Ie. Rushing and not making sure the pt is properly preoxygenated and sitting at a safe BP before even touching the laryngoscope. Not that rushing is an excuse, but I have seen that in and out of the hospital first hand.

@E tank is that at first pass success, good outcome, or both? Guess I am just wondering if there comes a point where provider A can do it faster/easier than provider B, but the difference long term is none because both can competently manage the airway and beyond that is just a point of diminishing returns. This is probably more specific to your environment, I realize there is definitely a difference in ability between myself and an experienced ED doc.


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## E tank (Nov 6, 2017)

StCEMT said:


> is that at first pass success, good outcome, or both?




Not hard to get out into the tall weeds, is it? Outcome studies are great, but to have any relevance at all you need 100,000+ study subjects, which means you need big meta analysis efforts that don't exist (that I'm aware of).

The question really needs to be, in my opinion, does the tube go in the right place the first time? As simple as that sounds, it isn't so simple. Observational studies are raked with all kinds of biases as @Remi points out above (and see the latest go round on ETCO2 from this weekend) They're useless if not down right dangerous taken on their own and even meta analyses can be down right false if even one significant study has catastrophic flaws (I'm thinking of the European experience with perioperative beta blockade...google it if you're curious).

IMHO the reality is that these questions have to be answered at the local/state level where folks know their own people. They'll still be wrong some of the time.


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## VFlutter (Nov 6, 2017)

One caveat is that we should be focusing more specifically on "Definitive Airway _Sans Hypoxia_ and Hypotension on the 1st Attempt_" (DASHH-1A)._ I sometimes see people focus too much on first past success without mentioning the latter. Sometimes people miss the forrest for the trees and push an attempt for the sake of first past success at the cost of compensation. Although increased attempts have higher complication rates and worse outcomes but sometimes discretion is the better part of valor.


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## E tank (Nov 6, 2017)

Chase said:


> One caveat is that we should be focusing more specifically on "Definitive Airway _Sans Hypoxia_ and Hypotension on the 1st Attempt_" (DASHH-1A)._



That is an issue in anesthesia training programs with experienced preceptors literally at the elbows of the operators. It happens every July with CA-1's and SRNA's. If it happens there, good luck dealing with that in the field.


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## VentMonkey (Nov 20, 2017)

*“Attention To Detail”*

I was taking an ACLS refresher last week and went over the Kiwi-grip (figure 9) technique with a handful of paramedics. A couple of things stuck out in my mind:

1. Most of them still seemed unfamiliar with the Bougie, let alone the one provider/ one-handed method of insertion. This was a controlled environment mannequin with a grade 1 view you could easily go spelunking down. I think that an intubation with a Bougie regardless of the anticipated difficulty goes without saying.

2. (perhaps the most concerning) They seemed to still be caught up in the skill alone. No one took the time to set up the tube tamer underneath the head, have their equipment available, and anywhere that was at all times easily accessible to them, etc.

Until we approach advanced airway management with what I call the “IV approach” where we scout people’s airways religiously like some do with people’s veins; or learn what ramping entails, where and how the tragus should line up with the sternum, shoulder elevation placement, terms like RSA, and when that’s most applicable, set suction up, or learn the SALAD technique—what on earth are we doing with an endotracheal tube?

My short answer is: collectively, nothing good. 

There’s no foundation for advanced airway management among the majority of our field paramedics. I think many have been misled in thinking that the gold standard= an ETI rather than it equaling to prevent hypoxia until an ETI can be safely, and properly performed. 

Sadly many of my peers don’t seem to have any self-motivation for learning these things on their own, yet wonder why things go awry. I am sure blaming the equipment, or their partner, or whatever foolish arrogance they portray next time one fails at something that can often be prevented with self-motivated education, and reflection will further illustrate our overall competence as field providers...

...astonishing.


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## EpiEMS (Nov 20, 2017)

VentMonkey said:


> Until we approach advanced airway management with what I call the “IV approach” where we scout people’s airways religiously like some do with people’s veins



I have to ask...does anybody look at somebody as "less of a paramedic" because they used an IO rather than getting an IV in a critical patient? I think people see others as "lesser" when they use an SGA over ETI...
This goes back to culture - a macho culture, a culture of anecdotes...etc., no?


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## DesertMedic66 (Nov 20, 2017)

There are many issues with the way that intubation is taught. My college has one of the better medic programs in SoCal but our training on intubation was taught by another ground paramedic who has no extra training. We were shown what a bougie looks like and then never actually used it. There was never any talk about ramping or making sure all the axis align properly. Intubation was always considered the gold standard. 

Then when these new providers go out they receive no new training or information regarding intubation.


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## VentMonkey (Nov 20, 2017)

EpiEMS said:


> I have to ask...does anybody look at somebody as "less of a paramedic" because they used an IO rather than getting an IV in a critical patient?


On a critical patient where vascular access is absolutely pertinent? I hardly doubt it matters.

On a more personal note, the location of the IO, or even IV access can be more of an issue in-flight depending on the airframes cabin setup. Vascular access can always be re-established in-flight if absolutely necessary, though.


EpiEMS said:


> I think people see others as "lesser" when they use an SGA over ETI...


Yes, this is very much prevalent with many providers, namely the older “stuck in their ways” types; we all have these providers at our services.

For me, the blind airways become more about situational dependency, and whether or not the provider used _sound judgment_, or just blind sticks every airway without much critical thinking. Our local FD’s are slightly notorious for this.


EpiEMS said:


> This goes back to culture - a macho culture, a culture of anecdotes...etc., no?


It’s merely one of many examples of the egocentric culture that is EMS, yes.


DesertMedic66 said:


> There are many issues with the way that intubation is taught. My college has one of the better medic programs in SoCal but our training on intubation was taught by another ground paramedic who has no extra training. We were shown what a bougie looks like and then never actually used it. There was never any talk about ramping or making sure all the axis align properly. Intubation was always considered the gold standard.
> 
> Then when these new providers go out they receive no new training or information regarding intubation.


This is exactly the info I was looking for here. Our local JC’s paramedic program seems to put the same amount of “effort” into showing their students fundamentals surrounding advanced airway management. If you (the student) don’t even know what the list of fundamentals includes, you shouldn’t be allowed to proceed with invasive airway management.

I liken it to the foundation that a house is built upon. Without such a solid foundation, how sturdy is the house? Pretty simple logic, IMO. 

All in all, I still believe that the average ground paramedic has zero business performing endotracheal intubations, and the commonly displayed lackadaisical efforts and attempts often confirms such suspicions.


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## Tigger (Nov 21, 2017)

EpiEMS said:


> I have to ask...does anybody look at somebody as "less of a paramedic" because they used an IO rather than getting an IV in a critical patient? I think people see others as "lesser" when they use an SGA over ETI...
> This goes back to culture - a macho culture, a culture of anecdotes...etc., no?


I would like to say that this doesn't happen, but of course it does. I'd like to say that it doesn't matter to me, but subconsciously I think it is often the reason that people try one more attempt on just about anything.


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## VFlutter (Nov 21, 2017)

Tigger said:


> I would like to say that this doesn't happen, but of course it does. I'd like to say that it doesn't matter to me, but subconsciously I think it is often the reason that people try one more attempt on just about anything.



It drives me crazy me when we arrive on scene and get in the ambulance with a paramedic whom has attempted  drug assisted intubation multiple times and insists on "one more look" before we do anything. You called us for a reason, we have RSI and VL, let us use our tools. It does not make you less of a provider to defer to the more experience or better equipped person.


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## Tigger (Nov 21, 2017)

Chase said:


> It drives me crazy me when we arrive on scene and get in the ambulance with a paramedic whom has attempted  drug assisted intubation multiple times and insists on "one more look" before we do anything. You called us for a reason, we have RSI and VL, let us use our tools. It does not make you less of a provider to defer to the more experience or better equipped person.


It has not gotten quite to that point here. We've either got people with previous CC experience or younger people (like myself) who went through a solid program that was taught by the closest individuals we have to subject matter experts in the area. I am surprised to learn that many medic programs are taught by single instructors. My instructor only taught the topics she couldn't get someone who was truly awesome at teaching them to come in for. The guy that taught our airway portion teaches difficult airway classes on the side and actually knows how to educate as well. Maybe I'm just lucky...

But I will admit I will still look for an IV rather than jump to an IO because that is the silly expectation here. And some airway nightmares are affected by this attitude for sure, though we have not had that happen with RSI in the 15 years we've been doing it and we have internal documentation to back that up. 

I was pretty angry as a new medic to be told that I "must" intubate a cardiac arrest with a nightmare of an airway. An iGel would have been just fine for the bariatric patient down in a cluttered garage but no, we MUST tube all the patients. Of course it went "sideways" and while the patient was eventually intubated I am embarrassed to have been present for the procedure. The goal was purely to secure a tube, everything else be damned. Fortunately it was not a particularly viable patient but that attitude is anger inducing.


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## EpiEMS (Nov 21, 2017)

@Tigger @Chase
Certainly seems like you've seen what I'm describing - hard to put a word on it, I suppose, but I'd think machismo works.

How do we fix this issue? Better protocols?


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## Tigger (Nov 22, 2017)

EpiEMS said:


> @Tigger @Chase
> Certainly seems like you've seen what I'm describing - hard to put a word on it, I suppose, but I'd think machismo works.
> 
> How do we fix this issue? Better protocols?


Doubtful. Part of rolling out new protocols is learning who the old dogs are, and they just aren't going to change. Honestly there is a huge difference right around the 10 year mark here. Folks who have been doing it longer seem to be totally resistant to change and we'll just be better off when they're gone.


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## StCEMT (Nov 22, 2017)

Chase said:


> It drives me crazy me when we arrive on scene and get in the ambulance with a paramedic whom has attempted  drug assisted intubation multiple times and insists on "one more look" before we do anything. You called us for a reason, we have RSI and VL, let us use our tools. It does not make you less of a provider to defer to the more experience or better equipped person.


Had to do that a few times recently, the past few weeks I think have been at least two tubes and one cric by an MD shortly after arrival. Everything worked out, so no need for me to get bent out of shape about it.


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## TXmed (Nov 25, 2017)

Chase said:


> One caveat is that we should be focusing more specifically on "Definitive Airway _Sans Hypoxia_ and Hypotension on the 1st Attempt_" (DASHH-1A)._ I sometimes see people focus too much on first past success without mentioning the latter. Sometimes people miss the forrest for the trees and push an attempt for the sake of first past success at the cost of compensation. Although increased attempts have higher complication rates and worse outcomes but sometimes discretion is the better part of valor.



I just wanted to echo this statement.


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## CANMAN (Nov 25, 2017)

Chase said:


> It drives me crazy me when we arrive on scene and get in the ambulance with a paramedic whom has attempted  drug assisted intubation multiple times and insists on "one more look" before we do anything. You called us for a reason, we have RSI and VL, let us use our tools. It does not make you less of a provider to defer to the more experience or better equipped person.



That's unfortunate that situation even takes place once you arrive. Under our state protocols when we arrive on scene we are automatically the highest level provider's and all interventions will be performed by us. We generally don't encounter that problem too often. I get the customer service aspect, but in those situations have your crew attempted a courteous but stern "no we are here and going to take over now, you guys have done a great job thank you"?


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## Tigger (Nov 25, 2017)

CANMAN said:


> That's unfortunate that situation even takes place once you arrive. Under our state protocols when we arrive on scene we are automatically the highest level provider's and all interventions will be performed by us. We generally don't encounter that problem too often. I get the customer service aspect, but in those situations have your crew attempted a courteous but stern "no we are here and going to take over now, you guys have done a great job thank you"?


I’m glad that doesn’t happen here. N=a few but the “prestigious flight service” is far more likely to get themselves into a problem than many of the ground crews. Most of the mountain services have been or are soon to provide their own CCT and have providers with comparable experience and education to that of the flight crews. These folks are unfortunately not airway pros that many think they are, especially when we get two ICU nurses who “don’t really do airway” between the two. This is in stark contrast to the true CC practitioners that I encourtered in New England. It’s unfortunate that that isn’t the standard, but industry competition plays a role. 

When you’re over an hour by ground, at a certain point the helicopter is for expedited transport and sometimes it’s ok to admit that.


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## E tank (Nov 25, 2017)

CANMAN said:


> That's unfortunate that situation even takes place once you arrive. Under our state protocols when we arrive on scene we are automatically the highest level provider's and all interventions will be performed by us. We generally don't encounter that problem too often. I get the customer service aspect, but in those situations have your crew attempted a courteous but stern "no we are here and going to take over now, you guys have done a great job thank you"?



Scene control and command seems to be a hands off topic when it comes to medical control. It speaks to very weak leadership with regard to the medical direction of the local system. From the issues raised here to the perennial issue of fire not relinquishing medical control to the private or 3rd service ambulance crew, the physician/nurses in charge need to grow some cajones. A pi**ing match over a sick patient is a disgrace and it falls squarely in the lap of the medical director. It is a very frustrating situation that has existed for a very long time in a lot of jurisdictions.


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## CANMAN (Nov 25, 2017)

E tank said:


> Scene control and command seems to be a hands off topic when it comes to medical control. It speaks to very weak leadership with regard to the medical direction of the local system. From the issues raised here to the perennial issue of fire not relinquishing medical control to the private or 3rd service ambulance crew, the physician/nurses in charge need to grow some cajones. A pi**ing match over a sick patient is a disgrace and it falls squarely in the lap of the medical director. It is a very frustrating situation that has existed for a very long time in a lot of jurisdictions.



Totally agree! Like I said we didn't encounter too many issues, but if we did I felt 110% supported with inserting ourselves and taking over if it needed to be handled in that fashion and we would make up and worry about the PR fall out later once the patient was transported.


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## CANMAN (Nov 25, 2017)

Tigger said:


> I’m glad that doesn’t happen here. N=a few but the “prestigious flight service” is far more likely to get themselves into a problem than many of the ground crews. Most of the mountain services have been or are soon to provide their own CCT and have providers with comparable experience and education to that of the flight crews. These folks are unfortunately not airway pros that many think they are, especially when we get two ICU nurses who “don’t really do airway” between the two. This is in stark contrast to the true CC practitioners that I encourtered in New England. It’s unfortunate that that isn’t the standard, but industry competition plays a role.
> 
> When you’re over an hour by ground, at a certain point the helicopter is for expedited transport and sometimes it’s ok to admit that.



Sure I can understand that. It all depends where you're at and what services are available. While some of the ground crews we would interact with had RSI or DAI it was typically one provider and the difference in airway management experience between our provider's and those of the ground services was well known.


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## TXmed (Nov 25, 2017)

I can tell you in texas, most of the ground providers THINK theyre just as good at airway management as air medical providers. And they think that even as we rescue airway after airway from them.


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## RocketMedic (Nov 26, 2017)

I reckon there's a lot of 'expectations' in airway management that lead to negative outcomes because some people 'expect' that the tube _must_ be an ET tube; or that it will fail and that we shouldn't attempt ET intubation, or that the SGA will fail, or that _someone_ will take offense that _something_ wasn't done in a certain way. I think that this problem is worsened by closed cultures and competitive, masculine cultures that place a high value on task accomplishment. I think that it is worsened even more by non-holistic educational processes that boil intubation down to a "Mongo stick tube in Fred" 'skill' that is primarily taught to clear testing stations. On the other hand, there's also the opposite approach which is just as dangerous- the "we don't intubate here because we don't trust you to do it successfully" approach. I'd suggest that both the "tube at all costs" and the 'thou shalt ignore the existence of intubation' schools are both wrong. 


Worse, although I like, use and trust the current generation of SGAs with a _lot_ more airways than I did the old 37/41 Fr. Combitube duo I started with, I also find myself becoming less and less familiar with ET intubation, despite diligent efforts to practice and one of the company's more aggressive users of ET intubation. It's a lot like the introduction of GPS- it essentially killed universal compass/map/star reading for infantrymen and naval personnel as a core competency, because _who really does that every day when GPS is a thing? _Technological progress in airway management has not wholly removed the need for ET intubation yet, but it's come a long way, and we are seeing the results of that realignment now. If a college-going, EMTlifer like me who realizes this is still feeling the cobwebs, what about the average medic that doesn't care a lick about these things until they're staring at them?


But worst of all? I think that we have become _afraid_ of the ET tube. I think that a lot of providers from EMT to P to RN to MD hear so much about the evils and pitfalls of the tube that they become _afraid_ of the process and the methodology, to the point that discussions of airway management end not in "let's intubate them", but to "call that guy who is good at intubating people". Sure, we support it with scientific findings and studies and papers and the like, and we're _definitely_ not wrong to point out that intubation used to be too frequent, is dangerous, and is/was often poorly-done- but we're also forcing it into that role because we are deemphasizing it and expecting people to remember how to do it perfectly without realistic sustainment training (which no one wants to provide due to cost and effort required). Fear is contagious, and before you know it, you have two or three generations of providers who look at the ET tube as an object to be avoided unless in extremis, like the crike kit or levophed "leave-em'-dead" drips. These anecdotally-trained, risk-averse providers don't understand airway management beyond the skill and the basics of the equipment, and that means that most of them are either going to shove in an SGA and hope it works without an understanding of the underlying factors that determine that _or _they'll go in with the ET tube and muck about in airways trying to make Grandma into Fred's Head. Fear is not really a good teaching tool.


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