RSI: Critical Decision Making (Advanced Provider response requested)

[usalsfyre]

Yes, I read it, but I was hoping you wouldn't mind doing a short case presentation on it, so we would get a more complete picture....

(Please keep in mind I may be wrong on some details, the cases in question happened about two years ago, six months apart. I haven't run into a case that's needed a crash airway since)

Case 1. 60ish year old male found in the ditch by ground EMS (no info further than that, the homeowner had literally walked out and found a strange, half nude man in the ditch) they had attempted intubation and were unable to as the patient had bitten the blade(no RSI). Narcan admionistered and found to be ineffective BVM was ineffective, only about every third or fourth ventilation was effective, as the patient was edentulous, bearded and had sunken cheeks. No signs of trauma were noted, patient was cold to touch and pale, unconscious and completely unresponsive, pupils were a 1 and fixed. Breath sounds were initially diminished to absent, abdomen was soft. Extrimities were intact. Pt was satting in the low 80s and headed downward, HR was in the 60s and headed down with the Sp02, but was hypotensive, systolic pressure in the 70s, per EMS this was the case from time of arrival. Were drawing up meds to intubate, when the SpO2 got to 75% and the HR 40 or so we aborted the full attempt, pushed 150mgs of succs and intubated quickly, lowest observed Sp02 was I believe 68% and lowest HR was 64. Sp02 and HR rose quickly after intubation, maintained in the high 90s and tachycardic respectively. Sedated with fent and a little bit of midz. In flight the patient received a liter of fluid and had dopamine started. Patient coded on arrival, CPR started, one shock delivered, and ROSC achieved. Was never able to follow up further than this as we were in a bit off a tiff with the receiving at the time, but I can't imagine him living.

Case 2. 19 YOM unrestrained driver ejected in a high speed MVC. Ground EMS packaged and was drawing up drugs to RSI on our arrival. Pt was unconscious, unrseponsive, trismus was noted, patient had vomit coming out from between his teeth, EMS was attempting to suction, but the trismus prevented it. Ground EMS had succs already drawn up, directed them to give it, achieved relaxation, suctioned appx 50-70mls of thick emisis out of his airway, passed a tube and ventilated. Pt sats remained in the 90s throughout this, pt had been on a NRB mask prior to our arrival so he was adequately prexoygenated. Sedated again with fent and midaz and passed an OG. Enroute patient remained adequately sedated and oxygenated. Was treated for a head bleed (don't remember the exact nature) and discharged to rehab a month or so later.

I agree, it is a great algorithm for difficult airways. I understand that in the field, critical thinking is important in the matters of life and death, but I was asking you if you had the ability to skip sedation based on established protocols for your program. I have never heard of such leniency for any non-physician provider.

My last job (HEMS) and my current job (regular ground EMS) both pretty much have photocopies of Dr. Walls guidelines (RSI, Crash, and Difficult and Failed) in their protocol books, the only change is that my current provider uses rocc instead of succs. I like options in airway managment, solely having an "RSI" protocol is why EMS fails at difficult airways. I also don't think every, or even the majority of EMS providers need to be doing RSI.

I worked with a few medics and nurses that thought whatever happened behind closed doors of the aircraft stayed in the aircraft, and got away with a lot (as long as it was "properly documented.")

I've worked with some of these, I assure I'm not one of them. What I do at any point affects what's down the road. I'll also say I've never actually had a medical director have a problem with treatments I've provided, it's always been their underlings. I have a reason for every treatment I provide. Most medical directors are very understanding of this, even if they suggest a different course the next time. The people I've seen get really hammered are the ones that do things "just because".

Reminds me of the two "cowboy" flight nurses from CALSTAR in February 2008 that got nailed to the cross.....

These two were actually cleared on any wrong doing by the state nursing board. You look at the minutes, and it seems to boil down to 1).a paramedic who lied multiple times 2.) the medical director's underling as above and 3.)an inaccurate coroner's report (I have no idea what this guy's motivation was, but he charted a jagged laceration well below the cricothyroid membrane as the cut for the cric). Several experts testified on the two nurses behalf.

Deeply unconcious as in code blue? :blink: I don't mean to be picky but Midazolam has not been proven to produce effective retrograde amnesia in any patient population (1,2,3,4). I hope neither of those patients remember being gagged by the cold laryngoscope blade.

I hope they didn't either. But as you can see, my partner and I truly believed in both cases it was a life-threatening situation.

I guess it all depends on how much you would want to put your license on the line. If :censored::censored::censored::censored: hits the fan, any medical director would cover their own butt first. Seen it happen, it's not pretty.

I was backed up by protocols and standard of care in both cases.

Sorry if this is disjointed, it was written over the course of 7 hours due to run volume :wacko: