OK, so your program wants to do RSI, but:
- Your medical director (apparently) isn't willing or able to design or teach the class.
- Your lead educator for this project will be someone who has only done the procedure himself a few times
- You don't even know if the paramedics at your service is any good at intubating
- You (apparently) aren't already training regularly in an OR, and don't know if you can get hands-on training in an OR
- Your paramedics are not already familiar with the basic adjuncts that you recognize are important to have, so they'll have to learn those at the same time that they'll be learning a critical new skill
What could possibly go wrong?
Agree 100% with Remi, and he pretty much highlighted all the points that need to be corrected before moving forward with an RSI program and education. Don't take this the wrong way, but chances are if your company doesn't even know some baseline first attempt success rates for it's current provider's, and judging off the information you have provided thus far, I would venture to say they're going to be pretty poor, or certainly not inline with tacking on an RSI program without some leg work. That leg work should be heavy on involvement from your Medical Director, and should establish clear guidelines for O.R. time, and skills assessment on a frequent basis. My program has quarterly requirements for live adult and pediatric intubations, as well as simulator intubations, and has bi-annual education and competency sessions we call WISER days. This past year we had a 96.7% first tube success rate across our entire system.
What are you guys currently using for rescue airways if you do not have training on the King Airway, and use of a bougie? Tossing RSI, along with new devices such as a bougie and King airways in the provider's laps all at one time I think is a terrible idea. That is alot to train everyone up on at one time, and also gives them 0 field time to gain experience with said tools before having to use them in a difficult airway or RSI gone bad scenario.
What is the plan going to be for ventilator management post RSI? Are you hand bagging 5 minutes to most of your ED's, in which case I would question if you even need RSI, or do you have extended transport times where the patient should be getting consistent rate/volume via a mechanical ventilator?
As far as protocols go, there are 10 ways to skin a cat, and maybe other provider's will have their opinions. Based on what has been posted I would make some changes personally. I agree with alot of FiremanMike's points, however would alter the cocktails, or at least give provider's some choices. Choices are great when you have high functioning provider's who are educated and can make solid decisions. I can understand why some places take more of a blanket approach. Based on my experience I am not a fan of Versed for induction. You typically need a hefty dose, and in alot of the population we are performing an RSI on it can put you in a hypotensive situation more often then not. Where I think it works well is in conjunction with Fentanyl for post RSI sedation with stable hemodynamics. Give provider's the option of Etomidate and Ketamine. We also ditched Succs in favor of just carrying Roc and Vec. We used to carry all three. For sedation we have Fentanyl, Versed, Propofol, Ketamine bolus and drip in our protocols. Without having this statement turn into a debate, I think the concept of "waking someone up" in a diffcult airway scenario is only appropriate for an O.R. type setting, where as previously described those patient's have been through pre op screening, and are generally stable for induction. If we make the decision to take someone's airway it's because it's indicated. Waking them up is going to put us in the same S sandwich we started with and put us no better off. If you can mask ventilate you DO NOT have an airway emergency and there is no shame in oxygenating and ventilating with a BVM on the way to the hospital if you cannot successfully intubate or place a rescue airway. If you are in a bad scenario where the patient needs an airway, you cannot establish one via ETT or rescue airway, and you cannot bag and maintain Spo2 of 90 or greater and ventilate then you go to a surgical airway and call it a day. Those are your choices in my opinion.
High flow nasal cannula for apneic oxygenation is a great thing, and I am glad a bunch of people on the board are doing it in the field. We still get crazy looks from MD's and Medics when we show up, RSI, and use that tool. It's our protocol for every RSI situation. Keep in mind it can assist you slightly with pre-oxygenation coupled with a non-rebreather, BVM, or whatever the situation indicates, however it's not going to increase your numbers once drugs are on board. It's designed to prolong your period of desaturation, and I think alot of people miss that concept.
TXmed, while I agree that focusing on oxygenation is extremely important, and ideally you want to start with the best numbers possible, sometimes clinically that just isn't possible. There are times where intubations occur with less then ideal sats or blood pressure because that is the best you can achieve given what is going on. To say we aren't going to proceed with intubation for a person who might be a trauma patient with a blood pressure of 80 systolic, or stop mid attempt is kinda silly in my opinion. Those number's are certainly going to guide my drug choices, or things we do in the preparation phase such as hyper elevating a morbidly obese person with crappy sats, but they aren't always going to prevent me from pulling the trigger on RSI if that's the best we have seen after some techniques which fail to improve the situation.
