Dr Smith raises some interesting points, however I have to take issue with some of this presentation. It seems to me that the good doctors bias is showing. Whilst he happily includes the methodological flaws in the studies that are supportive of prehospital RSI, he does not consider the same troubles with the ones that are supportive.
For example, in one study that is reasonably widely quoted by opponents of RSI is: Wang et al, Out-of-hospital endotracheal intubation and outcome after traumatic brain injury, Ann Emerg Med 2004.
In this study Wang compares patient's who recieved prehospital intubation for head injury versus ER intubation. What is not mentioned anywhere in the study is how the airway management is carried out.
According to the Pennsylvania protocols that I have been able to access (at
http://www.dsf.health.state.pa.us/health/lib/health/ems/als_protocols-effective_07-01-07.pdf), Penn EMS does not have the option of RSI to achieve airway control. Therefore it would be reasonable to asusme that any patient intubated in Penn when this study was carried out either had it done cold, or with sedation alone. Now, how many people would assume the same of the tubes performed in the ER?
I would make a huge leap here and suggest that those who were intubated in the ER were tubed using RSI, which is clearly a very different matter than dropping a cold tube in someone who is so obtunded that they are all but dead anyway, or those that are intubated using sedation alone. I could be wrong, as Wang doesn't actually bother to let us know, however I am sure we would all be very surprised if the TBI patient in the ED just had a tube forced down or tons of sedation thrown onboard.
Wang also considers in his study that
any airway management in the field is the same as intubation, including cric, combi-tube, OPA, whatever. He even considers laryngoscopy as an intubation attempt! Wang also does some very interesting things with statistics (essentially he seems to think that paramedics lie about their attempts at tubing, so he just goes ahead and ups the numbers to what he reckons might be good!)
With such vague, poorly defined and patently ridiculous parameters along with bizarre fiddling with the stats, Wangs study is hardly worth the paper it is written on.
The San Diego study is also worth mentioning as it is also one of the cornerstones of the AntiRSI league's arguements. In this study the one thing that really comes across is, as Tony states, RSI done badly is bad. Desaturation, hyperventilation, failed intubations, low exposure all contribute to a poor outcome. Does this mean that the procedure done correctly is bad? No, just that the procedure (like all procedures) done
badly is bad.
I probably come across as a fervent supporter of RSI. I guess I am, as I am a medic that is authorised fairly liberally to RSI all manner of patients, and I have found that when done correctly by skilled and experienced operators, it is a godsend. Bear in mind that our medics are getting 3 or 4 tubes a week of various sorts, and average 1 RSI per week which is a far cry from Dr Smith's medics getting 3 a year.
However it is clear that there needs to be a lot more work done on the research front to confirm or deny the benefit. If it turns out from the studies that my service and others are doing that RSI is bad, so be it. However I think it is premature to be doing away with a procedure that is safe when done correctly and may still carry benefit (aside from making my life easier! ^_^ )
We need to compare apples with apples, as Wang (and others) clearly fail to do and not let those with agendas push our practice in a direction
they want it to go.
