Rsi

Can your service RSI?

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MagicTyler

MagicTyler

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Do you have the ability to RSI your patients? In my area this seems to be a golden goose that every medic seems to want, but the medical directors are very afraid. What is it like in your area?
 
For those that do it would also be nice to know what initial training, continuing education, Q&I process, etc your company has.
 
We have RSI where I work, most medics can do it but not all. As of now there is little CE training though they are developing a new program and courses.

We carry Morphine, Fentanyl, Midazolam and or diazepam, Roc. , sux. and ketamine.

I am over 2 hours to the nearest hospital and can have a chopper to my clinic in 45-50 min (if I am lucky)

I work at an Industrial oil Field plant in a clinic/first response setting.

I had RSI training in my medic program in the US and it is in most all Canadian programs I know of. Every RSI is QA's by the medical director. We are expected to attend classes and training on out own time and expense...... though as I mentioned earlier that is changing.
 
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RSI is an option for any medic that has been cleared by the clinical director. Once a medic has competed their probationary period they then must go through an RSI class with the educator. Several CEU's related to RSI are available throughout the year. In addition to this, you must perform RSI in front of the medical director each year at a skills review. Every RSI is reviewed for QA. Capnography is mandatory. We have King airways, a quick trach device, and surgical airways as a back up.
 
Our medical director issues RSI cards to the medics that he has personally educated on the topic, allowing them to perform it. T

Here they use etomidate along with vecuronium and succinylcholine. Versed and Fentanyl are used for post procedure sedation. Given our transport times it is done fairly often. We only have 12 fulltime paramedics and a few part timers who are RSI cleared so everyone stays pretty in tune with the procedure and the medical director reviews each case. Many of them are done with the assistance of a flight crew but the medics are authorized to perform it alone.
 
We have RSI in Delaware. All three counties have the ability, but our county does FAR more than anyone else. We are mostly rural and may have some significant transport times.

We also have an extensive, and I mean laborious, QI/QA procedure. One of the running jokes is, if you can get away without tubing someone, it's a good day because you won't have to do all the paperwork and go through the long, rigorous chart review procedure. It's a really good day if you perform the intubation, but your partner is up as the lead and he has to write the chart. :)

Most medics in my system perform a couple of RSIs a year, with a total average between six and eight field tubes every year. We also are afforded the opportunity to attend OR sessions if we are not maintaining a sufficient number of field intubations or would like additional practice.

I was taught RSI in my initial paramedic program and had to prove my RSI competency to each medical director that i worked under. (Three in Washington, one in Delaware) We have frequent RSI skill labs in continuing education and each RSI chart is scrutinized by other paramedics, administrators and the medical director.

We use the standard RSI cocktail, lidocaine, atropine, succinylcholine, etomidate, Fentanyl, Versed and vecuronium. We're still trialing a video laryngoscope, but I expect that trial to be compleded soon and we'll make a final choice. I believe that VL will make a huge difference. (Yes, the plan is to use a video laryngoscope on every tube.)

I also had RSI in Washington state. From the attitude of the docs and providers, It seemed to be far less of a "big deal" there, then it is here. In Washington, if we needed to RSI a patient, we just did it. Here, it's looked at very differently, and a lot of paramedics are scared to perform the procedure. (And knowing some of the education that they have, rightly so.)

Some people here think we would be okay without RSI, and I tend to agree with them. However, it is a nice procedure to have in the toolbox when you need it. The main skill is not knowing how to RSI, but when not to. In the last few months I've called for RSI orders several times, and not used them because I elected not to take the patient's airway.

RSI is a big responsibility, not one to be taken lightly. Any time you take a patient's airway, you should have some pucker factor. If you're blasé about an RSI, you need to rethink your position.
 
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No RSI here. My RSI training from my paramedic program was initially "Ha! You'll never do that!" and then the instructor performed rapid sequence iteration clicking the powerpoint until it was no longer covering RSI. :[ Afterwards, I decided to research RSI and reviewed that part of the paramedic book on my own, and made a post on the forums about it here. One of the users, Linuss, also recommended that I read Manual of Emergency Airway Management, which I did read.
 
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rmabrey said:
Doctors dont care.
Click to expand...

Care to elaborate on that statement?

If I sacrificed 10+ years of my life to become a Physican I would certainly care about paramedics performing advanced procedures under my license.
 
Or Rapid Sequence Indunction, which is a what I mostly see with non prehospital care textbooks and online websites.
 
DEmedic said:
RSI is "rapid sequence intubation", where a patient is sedated and paralyzed prior to intubation.
Click to expand...

And to add: it's important that it happens in that order.

(not saying this to DE, but just as an FYI in case anyone doesn't know.)
 
rmabrey said:
We can. Doctors dont care. Versed, Etomidate, Vec.
Click to expand...

You don't use a paralytic prior to intubation? I'm quite certain you're not using vecoronium before the tube...
 
This is a decent overview of RSI, for the poster that asked. http://emedicine.medscape.com/article/80222-overview

Definition of Rapid Sequence Intubation
A process that involves pharmacologically inducing unconsciousness and paralyzing the patient in a manner that facilitates tracheal intubation, while minimizing the risk of aspiration using application of cricoid pressure (traditional definition included this last point)
“Rapid sequence” refers to the fact that the induction agent and the neuromuscular blocker are given in quick succession, and are not titrated to effect

We actually refer to RSI as "DFI" (Drug Facilitated Intubation) in Delaware.
 
I've also hears it call PAI Pharmacologically Assisted Intubation
 
I honestly haven't heard of any county in CA doing RSI. I don't even know if its in our state protocols.

I have talked to a good deal of medics in my area who have never heard of RSI before.
 
I believe I've read somewhere that sedated-only intubation without paralytics is bad.
 
Aprz said:
I believe I've read somewhere that sedated-only intubation without paralytics is bad.
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Intubation with only paralytics is bad. Sedation only is what many emergency situations need and can be successfully intubated without paralytics.

Paralytics now are used only when needed and in the OR for obvious reasons with surgery. In the ICU the use of paralytics for intubated patients had fallen out of favor long ago with the exception of a few hard to ventilate patients or those on hypothermia protocol who will not stop shivering by other means.
 
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