# Succinylcholine - Prehospital Abuse/Misuse



## Sugi (Jun 22, 2010)

I just want to be clear before posting this...

a) it is NOT ment to be offensive or bring any sort of disrespect to any one.
b) this is simply for a class discussion we are having, theoretical


I am currently working through my pharmacology class that is part of my paramedic program, and we were asked to start a discussion about certain topics. I chose to discuss RSI. Except here in Arizona, RSI is not a tool in toolset of a paramedic (except in Peoria), as Succinylcholine has been taken off (or not allowed in the first place) of all the rigs in the valley (again, except Peoria)

Speaking with an instructor who has been teaching medic students for the last... I believe 15 or 20 years, she said that the reason why we never had Succinylcholine is because, when this drug was introduced, paramedics from AZ went to parts of the country that were using Succinylcholine already, to try to get a feel for the drug, and its application, and had many many horror stories to tell..

Most of you should be familiar with Succinylcholine (and I refrain from referring to it as "sux" or "succs" per the advice and warning of said instructor, stating that this drug is dangerous enough that it demands respect, and should not be referred to in loose terms like "sux" or "succs"), however if you are not this drug is a paralytic. It is used when performing RSI.

Well, one of the things that was reported was that Succinylcholine was being used to essentially chemically restrain patients (drunk patients, mental disabilities, etc). So basically, because a patient was being unruly, or difficult, the attending paramedics were taking away this patients ability to breath.

Does anyone have any stories about these types of situations? I've contacted a few malpractice attorneys, and some medical directors in the area, however as Succinylcholine was not in the Phoenix valley (or only in the Phoenix valley for a short period of time, I'm not sure which), I was not able to pull up any situations like this.


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## firecoins (Jun 22, 2010)

Sorry, never heard of "succs" being used to restrain drunks.  Where did these paramedics go? The MDs would flip if it were used in any situation other than RSI.  The abusing medics would be gone.


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## 1badassEMT-I (Jun 22, 2010)

All I can say is wow......they would do jail time here for sure..... as for WV CCT Medics are the only ones here that able to RSI and I have not heard them doing anything else with other than RSI. But succs is not on trucks here other than CCT trucks. Also very rare a CCT Medic administer it as that is done in the ER by a Doctor... And the CCT Medic maintains it...but can do if needed.


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## SeeNoMore (Jun 22, 2010)

I think the issue is more proving whether pre hospital RSI is worth the risks. I have not heard of the issues you mention, but lots of dumb things get done so it would not really surprise me. Where I work, only flight medics use RSI.


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## TransportJockey (Jun 22, 2010)

Back in NM I believe there was one ground service with RSI (other than a service I used to run with that had a couple of CCT trucks), the rest didn't have it. Flight teams were generally the ones with RSI.


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## MrBrown (Jun 22, 2010)

Suxamethonium is a useful tool however, the evidence from our own prehospital RSI pilot program (since 2006) and provisional data from the Victorian RSI study shows it must be 

- *combined* with adequate analgesia (we use ketamine and fentanyl) and
- *restricted* to a selected group of Intensive Care Paramedics *and* to patients who require it.  The decision to use RSI or not is far more important than the psychomotor skill of administering the drugs.

We have consistently shown 95%+ success rates in our RSI program since 2006.


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## usalsfyre (Jun 22, 2010)

I have never heard of sux misused in this way. Given inappropritely to difficult airways, yes, but not to abuse a patient. 

Sux is a nasty drug, even for it's intended purpose however. Many side effects including hyperkalemia, malignant hyperthermia, ect. There are better paralytic choices out there.


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## reaper (Jun 22, 2010)

I have used it in RSI for years and have never seen nor heard of it being used in any way outside of RSI, in prehospital.

 RSI should only be used by educated and trained medics. As stated, it is not the use of it, it is the use of it at the wrong time. You must be educated on how to rate a pt for airway, prior to even thinking about RSI.

I truly believe that it is the best drug of choice for initial Paralytic. It is a short acting drug, which makes the side effects worth the risk. If you can not get the pt intubated, they can be assisted until it wears off. It normally only lasts 10 minutes. Most other paralytics on the market last from 30 minutes or longer. That is not what you want, if the airway is failed.


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## medic417 (Jun 22, 2010)

Perhaps they got confused with the sedative being used that is listed on the services RSI protocol.  Often the same sedative such as versed is used to chemically restrain people and for sedation for RSI.  

That or they have read some the idiotic practical joke threads on here where people laugh about hurting people so they decided it is ok to do so.


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## Aidey (Jun 22, 2010)

I've never heard of succs being used that way in real life. I've heard jokes made, and made them myself, but nothing realistic and nothing that was meant as a serious "I would do this" statement. I'm pretty sure our medical director would consider literally stick your head on a pole if that really happened. 

I wondered the same thing about the people mixing up* the sedative and paralytic since some places do have chemical restraint protocols. We do; using versed, but none of the other RSI drugs. 

*Not mixing up when they were administered, but mixing up when repeating the story.

Ok, I just had to eat my words, because right after I posted this I saw the link in the "Similar threads" box to the news report I posted on succs being used to assassinate a Hamas leader. So I rephrase, and say that I have never heard of it being used in EMS in such an inappropriate manner. 

Succs has it's benefits. I do wish that after we successfully intubated the pt using succs we were able to give a longer acting med. We do have Vec, but the problem we run into is that most of our transports are too short to fall into the Vec protocol, but succs isn't long enough when you add transport + hand off time + waiting for Respiratory to get there with more meds. I know from talking with docs in the ER they like it when we use Vec, and several have mentioned Rocuronium (sp?) as another one they would be happy with us using.


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## Flight-LP (Jun 22, 2010)

reaper said:


> I truly believe that it is the best drug of choice for initial Paralytic. It is a short acting drug, which makes the side effects worth the risk. If you can not get the pt intubated, they can be assisted until it wears off. It normally only lasts 10 minutes. Most other paralytics on the market last from 30 minutes or longer. That is not what you want, if the airway is failed.



I completely disagree respectfully, I absolutely despise Anectine and refuse to use it. The depolarizing effects and extracellular potassium shift isn't worth the additional aggrevation that it can produce. I prefer Zemeron or will just induce with Ketamine, Propofol, or Etomidate (whichever I have immediately available). Far less issues all around for a patient who is already compromised.


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## usalsfyre (Jun 22, 2010)

reaper said:


> I have used it in RSI for years and have never seen nor heard of it being used in any way outside of RSI, in prehospital.
> 
> RSI should only be used by educated and trained medics. As stated, it is not the use of it, it is the use of it at the wrong time. You must be educated on how to rate a pt for airway, prior to even thinking about RSI.
> 
> I truly believe that it is the best drug of choice for initial Paralytic. It is a short acting drug, which makes the side effects worth the risk. If you can not get the pt intubated, they can be assisted until it wears off. It normally only lasts 10 minutes. Most other paralytics on the market last from 30 minutes or longer. That is not what you want, if the airway is failed.



The "I can just bag them till it wears off" theroy is DANGEROUSLY flawed. If you have a patient whom airway success is in any serious dobut, you shouldn't be using a paralytic, period. If the pt can't be intubated, a EGD won't work and a crich is contraindicated, do you really expect to be able to bag them? If you don't have appropriate backup devices, you have no business doing RSI, and your medical director is negligent. You can't half-@$$ this procedure, if you wanna play, you gotta pay.

Sux was the choice for a longtime due to rapid onset, not short duration. However, non-depolarizers with a similar rapid onset have come along with a much better side effect profile.

Flight-LP, I agree, rocc is the bee's knees. Recently switched to it from sux and haven't looked back.


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## reaper (Jun 22, 2010)

usalsfyre said:


> The "I can just bag them till it wears off" theroy is DANGEROUSLY flawed. If you have a patient whom airway success is in any serious dobut, you shouldn't be using a paralytic, period. If the pt can't be intubated, a EGD won't work and a crich is contraindicated, do you really expect to be able to bag them? If you don't have appropriate backup devices, you have no business doing RSI, and your medical director is negligent. You can't half-@$$ this procedure, if you wanna play, you gotta pay.
> 
> *Never said, bag em till it wears off! But yes, it can work and does. Did you skip over the part of rating an airway, prior to even considering RSI? There are times that you will not get them intubated, after RSI, even with everything perfect. You damn well better know how to deal with this situation before hand. *
> 
> ...




Anyone that preforms RSI, should be well trained and educated in it's use and contraindications. We have a very high success rate, due to quality education and frequent airway training.


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## usalsfyre (Jun 22, 2010)

Reaper, I hve been doing RSI for many years as well, and have been to numerous classes on it. For the last 2 years I have consistently been doing 1-2 a month, so I've got a fair bit of exposure to the procedure. I am very familiar with the LEMON assesment and how to use it. I stand by what I said. If you are carrying sux for it's short duration, you're carrying it for the wrong reason. 

You are exactly right, if you end up in a failed airway, you better have a back up plan sooner rather than later. Trying to BVM an obese, bearded short necked COPD and CHF patient with a receding chin for the 7-12 minutes before the paralytic STARTS to wear off (you don't get complete reversal at that point) will likely not have a good outcome. Does your service have an alternative for predicted difficult airways? For instance NTI or etomidate only attempts?


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## reaper (Jun 22, 2010)

usalsfyre said:


> Reaper, I hve been doing RSI for many years as well, and have been to numerous classes on it. For the last 2 years I have consistently been doing 1-2 a month, so I've got a fair bit of exposure to the procedure. I am very familiar with the LEMON assesment and how to use it. I stand by what I said. If you are carrying sux for it's short duration, you're carrying it for the wrong reason.
> 
> You are exactly right, if you end up in a failed airway, you better have a back up plan sooner rather than later. Trying to BVM an obese, bearded short necked COPD and CHF patient with a receding chin for the 7-12 minutes before the paralytic STARTS to wear off (you don't get complete reversal at that point) will likely not have a good outcome. Does your service have an alternative for predicted difficult airways? For instance NTI or etomidate only attempts?




Yes, we carry NTI and Etomidate. Both are useless in a failed RSI. That is what I am talking about. You may have not had one happen yet, but it will. I have used a BVM to assist a Pt, until they were on their own. Yes, it is hard, but works fine, if done correctly. We carry succs for our own reasons, who are you to say it is the wrong reason? I am not arguing RSI with you. I am trying to let people know that they must be prepared to deal with the downfalls. They do happen.


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## mycrofft (Jun 22, 2010)

*Sux blowdarts...*

Like the old "...so I had to hit him with the E cylinder", it's part BS, and maybe a little life imitating braggadocio. A better subject would be "The Propagation Of Cultural Mores and Shibboleths Between EMS Workers Via Mythology".


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## Sugi (Jun 23, 2010)

So the general consensus is that

1. No ones ever heard of this type of misuse or abuse of a paralytic
and
2. If it were to happen, the medic in charge would be hung out to dry pretty quick.


Thats interesting... Im not sure how long ago the stories were from, so I definitely want to check back on that.

I appreciate all the input guys!


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## usalsfyre (Jun 23, 2010)

reaper said:


> Yes, we carry NTI and Etomidate. Both are useless in a failed RSI. That is what I am talking about. You may have not had one happen yet, but it will. I have used a BVM to assist a Pt, until they were on their own. Yes, it is hard, but works fine, if done correctly. We carry succs for our own reasons, who are you to say it is the wrong reason? I am not arguing RSI with you. I am trying to let people know that they must be prepared to deal with the downfalls. They do happen.



Reaper, I will agree to disagree with you on carrying sux.

The bigger point I'm trying to hit is if you don't think you can intubate *DON'T PUSH DRUGS THAT INTERFERE WITH THE PATIENTS ABILITY TO BREATHE!!!!! * If your looking at a patient with a poor LEMON assesment, you must have realistic options besides a full RSI sequence. For instance non-paralytic DAI, video laryengoscopy and NTI. In addition have real backups such as Combi/Kings and surgical crichothrotomy. A BVM and a prayer is not a backup, not to mention you still end up with an unsecured airway. But most importantly have the training to know when the clinical benefits of taking someones airway in an asture environment (compared to an OR) with a limited amount of help and resources far outweighs the risk. 

I have been involved in two failed RSIs. Looking back, with the experince and knowledge I have now, neither one of those patients should have been RSI'd with a paralytic. Both were cases of too little knowledge and too much agression.


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## Melbourne MICA (Jul 3, 2010)

*Nasty*

Sux - it's like a New Zealander saying six. (No offence to my cousins across the Tasman intended. PS the all whites were brilliant!!!). 

But six is the magic number. Six feet under for the pt if you mess with this little drug number and six steps to the front door of your branch if you think it's a cute toy with a cute name and treat it with anything but respect.

As for being used or useful to manage rowdy pts - ask the South American Indians who liked using paralytics on their blow dart tips just before they sliced off your head. 

Paralytics are NEVER used without sedation and analgesia.

We use Suxamethonium and Pancuronium with Midazolam and Fentanyl (Morph) in our RSI protocol.

MM

PPS To MYCROFT - Twaz brillig and the slithy toads did gyre and gimble in the wade, all mimsy were the borrogroves and the mome raths outgrabe. "I don't think we are in Kansas anymore Toto".


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## MrBrown (Jul 3, 2010)

Melbourne MICA said:


> Sux - it's like a New Zealander saying six. (No offence to my cousins across the Tasman intended. PS the all whites were brilliant!!!).



Yeah, but we don't have Ronaldo .... so no wonder we are now out of the World Cup.  I must say we have spent a fair amount of time infront of the telly at work watching the highlights of Ronaldo hmmmmmmm 



Melbourne MICA said:


> We use Suxamethonium and Pancuronium with Midazolam and Fentanyl (Morph) in our RSI protocol.



How much midaz are you using?  I am not so much concerned about the 1mg or so you give somebody who is traumatically brain injured with a GCS of 3 vs the amount you are going to have to pour into that catatonic asthmatic who is still conscious so he won't remember.

We used to use midazolam but now we use 1.5mg/kg of ketamine (unless the patient is traumatically brain injured or has neurogenic cause for coma with GCS < 10)

Mind you I am no anaesthetics consultant (one day......) but I hear that midazolam is great for wrecking people's blood pressure and other nasty things when given in any significant dose.

Although you *are* using sux too so it's probably only a small dose to give amnestic effect rather than any serious neuromusclar relaxation.

*Brown goes back to reading his anaesthesia textbook in an effort to obtain more knowledge


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## TomB (Jul 3, 2010)

I am aware of one situation where a rotor wing EMS service in AZ used an IM shot of succinylcholine to take down a patient who did not want to go to the hospital. I don't remember what was wrong with the patient. I only remember that he didn't possess decisional capacity (but he was agitated and adamantly refusing transport) and online medical control said, "Bring him in." I was surprised when I heard the story but I know the guy who did it and he's an awesome paramedic. In fact he's a nurse anesthetist now.


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## MrBrown (Jul 3, 2010)

TomB said:


> ....online medical control said, "Bring him in.".



Ah music to my ears ..... its no longer my *** on the chopping block


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## Melbourne MICA (Jul 3, 2010)

MrBrown said:


> Yeah, but we don't have Ronaldo .... so no wonder we are now out of the World Cup.  I must say we have spent a fair amount of time infront of the telly at work watching the highlights of Ronaldo hmmmmmmm
> 
> 
> 
> ...



(On the football - AH but what you showed was you don't need Ronaldo to be competitive. Beside look where it got Portugal? The guy score one goal in the whole tournament).

On the RSI stuff. RSI has been one of MICA's biggest successes in decades.

The sux is for tube placement in the traumatic or non-traumatic head injured pt with intact airway reflexes or trismus and GCS <10. Hence the need for paralysis. Its not for sedation. The Midaz and Fentanyl are for that (plus the fentanyl provides analgesia as well) - Paralytics and sedation are a hand and glove - never one without the other.

For the RSI we use Midaz 0.1mg/kg IV or half dose for age, low BP etc. We also add 8mg Panc after induction. In the HI trauma pt this is the key. The RSI is really for MAP control and therefore cerebral perfusion pressure control - None of those nasty spikes in BP (like when you stick a bloody big layryngo blade down the pts gullett without any paralysis on board which kills off more brain cells). You can cover secondary brain injury issues by controlling ventilation ETCO2/SPO2 etc after induction.

Sedation continues post intubation and Panc - Morph and Midaz infusion here 30and 30.

Your'e right about the Midaz trashing BP - most Benzos do when given in large IV doses. So there is a healthy 10ml/kg fluid load prior to the procedure. This covers both the Midaz hypotension side effect and also covers hypovolaemic issues - almost guaranteed in the multi-trauma pt.

We are only using Ketamine for analgesia in long bone fractures post Morph management - a trial at this stage. There's been no talk about using it for induction/sedation in our guidelines.

For the asthmatic pt who gets tubed - well if they are that far down the track i.e hypoxic - a late sign in severe asthma - then they need a tube and will need sedation to pass it. The hypoxic asthmatic is a stones throw from pushing up the daisies. We never paralyse an asthmatic - if you can't get the tube they are dead - no ventilations of their own. 

Having said this the preference is not to tube the asthmatic if avoidable as  management of the pt with a hyperinflated obstructed chest becomes problematic and dangerous. A pneumothorax is an easy complication of high pressure ventilation. It's also difficult to manage Co2 with ventilation measures in the asthmatic pt.

But life threat is life threat. Sedate to tube can certainly be lifesaving in such pts. I've seen it many times. The midaz is never an issue really.

Now I have to wait 4 more years for the Roos and Whites to play in the world cup but play they will. My tip for this one is Argentina or maybe Germany (if they beat them tonight).

Speaking of which, it's 20mins to kick off so I need to grab a beer and a chair and settle in.

MM


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## MrBrown (Jul 3, 2010)

I concur with most of your points here.  We have been trialing selected Intensive Care Paramedics with RSI for almost four years and have consistently achieved over 97% success so it's being rolled out nationally, still only to selected ICPs.

It is interesting you had not had significant problems with sedation only to intubate, we withdrew it about midway through the 00s because it was causing M&M to go up.


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## Melbourne MICA (Jul 3, 2010)

MrBrown said:


> I concur with most of your points here.  We have been trialing selected Intensive Care Paramedics with RSI for almost four years and have consistently achieved over 97% success so it's being rolled out nationally, still only to selected ICPs.
> 
> It is interesting you had not had significant problems with sedation only to intubate, we withdrew it about midway through the 00s because it was causing M&M to go up.



We did have early problems going back to the 1990's principally because we were not given the right tools for the job. For all pts where a drug assisted intubation was needed we only had Diazepam and Morph to do the job. Wow thanks for that. Guys were, funnily enough, having to give big doses and trashing BP's in the process. In my first head injured pt intubation attempt I needed just 20 and 20 of Morph and Diaz to place the tube. I was lucky. There wasn't even a mandatory pre - induction fluid loading in the protocol so no wonder the BP's were shredded. There was speculation we might lose drug assisted intubations altogether. The RSI HI pt trial saved us from that and we have never looked back since.

With Midaz and Fentanyl for our sedation only to intubate we have had no such problems. We always fluid load and the two drugs in combination are very effective. Our medicos I think sensibly limited drug assisted tubes to sedation only for certain pt groups such as severe respiratories. Besides you really don't see that many moribund asthmatics these days where we are and profoundly hypoxic pts like sick APO's and end stage COPD's you could knock over with a feather anyway. the guys assess very well and doses are carfeully titrated so overmedication is rarely a problem. The most difficult issue is of course choosing when you need to sedate to tube the pt.

As for the sedate to tube drugs we have measures to correct benzo/narcotic side effects; ventilation for resp depression, fluid loading/inotropes for hypotension, naloxone for narcotic overdose issues etc. There is a much wider margin of safety so a good move by our medicos as far as I see it. As for the RSI's - absolutely brilliant. Problems occur occasionally and we all make mistakes but such is the MICA standard overall our success rates are 97-99%. Not too shabby at all. 

Good education, good training, good audit, good review, good crews (and a fair bit of pride in your work to boot). Now if we could just get our organisation to stop cutting the rug from underneath us life might be a bit better still. 

MM


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## wyoskibum (Jul 5, 2010)

*The real reason.......*



Sugi said:


> Well, one of the things that was reported was that Succinylcholine was being used to essentially chemically restrain patients (drunk patients, mental disabilities, etc). So basically, because a patient was being unruly, or difficult, the attending paramedics were taking away this patients ability to breath.



I would use Versed or Etomidate before Suxs! ;-D

Seriously though, proper oversight and QA/QI would prevent such abuses.  The only reason why Medic don't have a skill/drug/etc... is that the Physician Medical Director does not want or support it.  Any other reason is just an excuse.

It could be a trust issue, as the PMD doesn't trust the Medics or it could be ignorance as not all PMD have emergency medicine backgrounds.


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## MrBrown (Jul 5, 2010)

Melbourne MICA said:


> Good education, good training, good audit, good review, good crews (and a fair bit of pride in your work to boot). Now if we could just get our organisation to stop cutting the rug from underneath us life might be a bit better still.



You must be referring to the days when you rolled around in Ford F-100s, before a Degree became mandatory and the hardest part of MICA was following Frank's diagrams on the whiteboard 

It sounds like you have a really good setup and we are in pretty much the same boat except we use ketamine and fentayl.  Fluid and adrenaline (inotropy) form part of other guidelines which are appropriate before we think about RSI (eg in APO) and not part of the RSI guideline itself.


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## LondonMedic (Jul 6, 2010)

Has someone mentioned 'sux races' as a way of brightening up a dull on-call? h34r:


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## Melbourne MICA (Jul 7, 2010)

*Sux Races?*



LondonMedic said:


> Has someone mentioned 'sux races' as a way of brightening up a dull on-call? h34r:



I shudder to think what you are referring to. Sux races - almost sounds like an oxymoron.

MM


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## Melbourne MICA (Jul 7, 2010)

*To be Frank*



MrBrown said:


> You must be referring to the days when you rolled around in Ford F-100s, before a Degree became mandatory and the hardest part of MICA was following Frank's diagrams on the whiteboard
> 
> It sounds like you have a really good setup and we are in pretty much the same boat except we use ketamine and fentayl.  Fluid and adrenaline (inotropy) form part of other guidelines which are appropriate before we think about RSI (eg in APO) and not part of the RSI guideline itself.



Arghh - those were the days. And yet most of the current MICA guys >5yrs all trained under Frank and we have had most of our greatest successes in the last 10yrs or so. That must say something about having to decode Franks' diagrams. He was a good stick and utterly devoted to his ambos.

MM


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## MrBrown (Jul 7, 2010)

Melbourne MICA said:


> Arghh - those were the days. And yet most of the current MICA guys >5yrs all trained under Frank and we have had most of our greatest successes in the last 10yrs or so. That must say something about having to decode Franks' diagrams. He was a good stick and utterly devoted to his ambos.
> 
> MM



I have seen some of his old "CP" (?) videos from MICA Stage 1 in 1993 on the DVD that John Till from AV is handing out.  They are bloody fantastic! Like being belted over the head with a lump of 4x2 with brilliance written on it.

One of my friends is at Monash so gets to work with him sometimes.

Oh we did have an interesting RSI job I should mention a while ago ... guy with a severed trachea and sternal/rib fractures after man vs horse.  Ick!


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