RSI

[SpecialK]

G'day all

Been having a squiz around the internet and keen to see what other blokes are doing as part of your RSI programs as a bit of comparison to Australasia.

Specifically, I would like to know:

• Who is performing it? All officers at the appropriate level or is it restricted?
• Are you using the same tertiary institutions who deliver your initial education to also teach RSI? Is it part of your level-specific qualification or it is run in-house?
• What human factors principles and risk/error management strategies have you embedded as part of your programs? Are you working with others who may be on-scene during an RSI and/or assisting with one to achieve this; for example the police, fire brigade, other ambulance resources? helicopter or retrieval personnel?
• What ongoing education/CCE or exposure requirements do you have?
• How do you work in with others who might perform it before you arrive, or you might before they arrive? E.g. retrieval service or the HEMS team?
• What are your indications and contraindications?
• What are you using for general anaesthesia and neuromuscular blockade? Is it the same for all?
• Are you routinely using an intubating bougie?
• What are your backup options?
• How are you tracking/auditing your program?

All of the above are pretty well established down this end of the world but always plenty to learn.

Ta.

 

[Carlos Danger]

Hey SpecialK,

The first thing to know about EMS in the US is that the way EMS is regulated and delivered varies a lot from state to state, and also within states. EMS is only very loosely regulated at the federal level, and then each of the 50 states takes primary responsibility for regulation of EMS agencies and paramedic training, protocols, QA/QI, etc. Within each state, regulation is in most cases divided even further by county or region. In New York state, for instance, the state EMS office mandates basic regulations for EMS agencies, as well as minimum hours for paramedic training and continuing education, BLS protocols, and broad "minimums & maximums" for ALS protocols. However, the state is then divided into a handful of EMS regions, each with a regional EMS office that writes their regional ALS protocols and training requirements for things like RSI, and is responsible for enforcement of most EMS regulations. In California, my understanding is that it works pretty similarly, except that instead of a handful EMS regions, every county writes their own protocols and enforces EMS regulations. Other states don't have regional or county level offices and everything is directed by the state itself. In South Carolina, for example, the state writes the ALS protocols that every agency in the state follows. In still other cases, there is very little state or other regulation at all, and each individual EMS service writes its own protocols and training requirements. Some states don't allow their paramedics to RSI at all. Others leave it up to the county, region, or individual service.

It sound complicated, but all this really means is that as a paramedic, the agency that writes the protocols and training requirements that you follow and grants permission for "extra" skills (such as RSI) depends on where you live and work. But for the most part, paramedic practice is paramedic practice. EMS is regulated many different ways across the US and systems are designed very differently from place to place, but ALS protocols and educational requirements generally don't vary too much.

I think that background is important, because a big part of the answer to each of your individual questions is "it depends on where you are talking about". Some states, counties, or individual agencies have strict requirements and fairly in-depth training and QA/QI processes, while others do not. It depends on the regulations that the EMS agency is subject to, as well as the culture of the EMS agency and EMS community.

Who is performing it? All officers at the appropriate level or is it restricted?
Some places view RSI as a pretty standard paramedic skill and don't have any (or only minimal) training specific to RSI, and all the paramedics do it. Other places have separate training programs for it that take some time to complete, and only paramedics who have done that process are allowed to do it. Some places only allow supervisors or FTO's or the senior personnel to do it.

Are you using the same tertiary institutions who deliver your initial education to also teach RSI? Is it part of your level-specific qualification or it is run in-house?
In the US, most paramedic programs are taught at community colleges, which may or may not have a close affiliation with a tertiary hospital (most don't). So, most paramedics would get their initial airway training during their community-college based initial paramedic program, and then whey they go to work for an EMS agency, the agency may or may not have a separate RSI training program that the paramedic has to complete. If they do have a separate program, it might be something taught totally in-house by the EMS agency training staff or medical director, or it could be something more official put on by the county or regional EMS office or the community college.

What human factors principles and risk/error management strategies have you embedded as part of your programs?
This isn't really a part of EMS culture in the US yet, that I have seen. I hear people talk a little about it here and there, but it definitely is not a widespread, integral part of EMS education here.

What ongoing education/CCE or exposure requirements do you have?
Just like the initial training, it varies greatly. Common requirements are something like 5 intubations annually, and if you don't get them in the field, you have to go to an OR to get them. Some places require regular airway practice / protocol review sessions, and some places send their paramedics to the OR annually, no matter how many field intubations they do.

How do you work in with others who might perform it before you arrive, or you might before they arrive? E.g. retrieval service or the HEMS team?
Most of my experience is in HEMS and for most of my career, the ground agencies where I worked didn't have RSI in their protocols. So we would arrive, assess the patient, and do it if needed, usually in the ambulance before moving the patient to the helicopter. Once the ground agencies started doing it, it was usually not any kind of problem but I've definitely seen a handful of times where ego got in the way of good decision making.

What are your indications and contraindications?
Every place that I did RSI as a paramedic or flight nurse, we had broad criteria. "Inability to protect airway", "Inadequate respiratory effort", etc. Those are commonly seen phrases in the protocols.

What are you using for general anaesthesia and neuromuscular blockade? Is it the same for all?
It is not the same for all, it is dictated by protocol. Until recently, etomidate and succinylcholine were by far the most commonly used RSI drugs by ED's and EMS agencies in the US. In the past few years, ketamine and rocuronium have grown quickly in popularity. Some protocols also call for premedication with versed and/or fentanyl or morphine.

Are you routinely using an intubating bougie?
Personally, I've always only used a bougie when I needed it. Using it on every intubation has become popular in the ED/EMS community though, and is required by some protocols.

What are your backup options?
Most places have a supraglottic device of some sort (LMA, King, etc.) and some sort of surgical cric option. The specific devices and techniques are dictated by protocols.

How are you tracking/auditing your program?
Most EMS agencies that I'm familiar with do 100% audits for RSI encounters. The programs I worked for and the agency that I do some teaching with now has 100% medical director review for every airway call.

 

[Tigger]

• Who is performing it? All officers at the appropriate level or is it restricted?

Paramedics with two years in the system without any significant corrective action can apply to take the RSI course. My primary service is pretty small, so really it boils down the the training coordinator being comfortable with your care. At large services in the system you have to actually apply to clinical education and have a medical director's recommendation. New-to-the system paramedics cannot immediately RSI but can get a "waiver" to start the approval process if they have previous experience. Air medical can also of course RSI (both nurses and medics).

Are you using the same tertiary institutions who deliver your initial education to also teach RSI? Is it part of your level-specific qualification or it is run in-house?
My paramedic program (community college based but very affiliated with a hospital network) taught RSI but this is a relatively new development. That day was taught by the program's physician, who also happens to be my medical director. The RSI classes are taught by medical control physicians in conjunction with the agency's clinical educators. The hospital network's paramedic educators do not participate nor does the community college outside of the initial education class. It's a two day class with pre-class powerpoint, written test, practical test, and OR time.

What human factors principles and risk/error management strategies have you embedded as part of your programs? Are you working with others who may be on-scene during an RSI and/or assisting with one to achieve this; for example the police, fire brigade, other ambulance resources? helicopter or retrieval personnel?
Slowly the idea of using checklists is starting to come to fruition. My primary agency is usually the only ALS provider on scene so there is a limit to what we can accomplish with our co-responding volunteer agencies. In the city, the fire department has non-transporting paramedics who mostly cannot RSI. This has created a lot of issues as they have overall scene control and their medics can and do "overrule" the transporting paramedic from performing RSI. This month all paramedics will be required to take an "RSI Awareness" class to hopefully change this, I have my doubts.

What ongoing education/CCE or exposure requirements do you have?
You must take the RSI written exam every year as well participate in an RSI refresher with clinical education. Annual physician testing usually includes RSI as well. We are also implementing a minimum number of intubations per year to keep the privilege. If you don't have that, you can go to the OR. The EM physicians have worked with Anesthesia to find docs that are willing to have paramedics in the OR so the time is actually awesome.

How do you work in with others who might perform it before you arrive, or you might before they arrive? E.g. retrieval service or the HEMS team?
It is very unlikely that air-medical will beat us on scene. In the city, the fire paramedics are advised to not RSI anyone without another paramedic on scene and there are very few RSI qualified fire-medics anyway.

What are your indications and contraindications?
Indications are pretty broad. Airway protection, combative head injury, inadequate ventilation, etc.

The rules:
1. Can I get a good facial seal with the Bag-Valve-Mask?
2. Is the airway patent?
3. Do I think I can intubate this patient?

Absolute Contraindications
The known or suspected presence of any one of these selection features will contraindicate RSI:

1. Mallampati IV
2. Suspected or Known Mechanical Foreign Body in Airway
3. Suspected or Known Laryngeal/Tracheal Disruption or Fracture (as
   evidenced by expanding hematoma in neck, subcutaneous air in
   neck or altered anterior neck anatomy)
4. Suspected or Known Epiglottitis
5. Evidence of Significant Oral/Pharyngeal Angioedema
6. Significant Oral/Tracheal Burns
7. Presence of Airway Stridor for any reason
8. Known or Suspected Anterior Neck or Upper Chest Tumor, Recent
   Surgery or Bleeding
9. Significant oral facial hemorrhage or other fluid accumulation, such
   that airway landmark visibility will be severely compromised.
10. Cervical Rheumatoid Arthritis

What are you using for general anaesthesia and neuromuscular blockade? Is it the same for all?
The "standard" RSI is etomidate-succs-tube-fent and versed-vec or roc if needed.
We can also do ketamine-tube-sedate-paralyze as necessary. This is for respiratory patients and those with contras to succs. We cannot use Ketamine as post intubation sedation. The city has moved to Etomidate or Ketamine-roc-tube-fent/versed-paralyze as needed.

Are you routinely using an intubating bougie?
I do, but most do not. We recently got McGrath scopes and the city has King Visions, so that has lessened the need for the bougie.

What are your backup options?
Igels, Kings, Surgical Circh, BVM. Some services maintain nasal intubation which is not a backup but another option.

How are you tracking/auditing your program?
Every RSI is reviewed by clinical education, the hospital's paramedic educators, and a medical director.

 

[Tigger]

• Who is performing it? All officers at the appropriate level or is it restricted?

Paramedics with two years in the system without any significant corrective action can apply to take the RSI course. My primary service is pretty small, so really it boils down the the training coordinator being comfortable with your care. At large services in the system you have to actually apply to clinical education and have a medical director's recommendation. New-to-the system paramedics cannot immediately RSI but can get a "waiver" to start the approval process if they have previous experience. Air medical can also of course RSI (both nurses and medics).

Are you using the same tertiary institutions who deliver your initial education to also teach RSI? Is it part of your level-specific qualification or it is run in-house?
My paramedic program (community college based but very affiliated with a hospital network) taught RSI but this is a relatively new development. That day was taught by the program's physician, who also happens to be my medical director. The RSI classes are taught by medical control physicians in conjunction with the agency's clinical educators. The hospital network's paramedic educators do not participate nor does the community college outside of the initial education class. It's a two day class with pre-class powerpoint, written test, practical test, and OR time.

What human factors principles and risk/error management strategies have you embedded as part of your programs? Are you working with others who may be on-scene during an RSI and/or assisting with one to achieve this; for example the police, fire brigade, other ambulance resources? helicopter or retrieval personnel?
Slowly the idea of using checklists is starting to come to fruition. My primary agency is usually the only ALS provider on scene so there is a limit to what we can accomplish with our co-responding volunteer agencies. In the city, the fire department has non-transporting paramedics who mostly cannot RSI. This has created a lot of issues as they have overall scene control and their medics can and do "overrule" the transporting paramedic from performing RSI. This month all paramedics will be required to take an "RSI Awareness" class to hopefully change this, I have my doubts.

What ongoing education/CCE or exposure requirements do you have?
You must take the RSI written exam every year as well participate in an RSI refresher with clinical education. Annual physician testing usually includes RSI as well. We are also implementing a minimum number of intubations per year to keep the privilege. If you don't have that, you can go to the OR. The EM physicians have worked with Anesthesia to find docs that are willing to have paramedics in the OR so the time is actually awesome.

How do you work in with others who might perform it before you arrive, or you might before they arrive? E.g. retrieval service or the HEMS team?
It is very unlikely that air-medical will beat us on scene. In the city, the fire paramedics are advised to not RSI anyone without another paramedic on scene and there are very few RSI qualified fire-medics anyway.

What are your indications and contraindications?
Indications are pretty broad. Airway protection, combative head injury, inadequate ventilation, etc.

The rules:
1. Can I get a good facial seal with the Bag-Valve-Mask?
2. Is the airway patent?
3. Do I think I can intubate this patient?

Absolute Contraindications
The known or suspected presence of any one of these selection features will contraindicate RSI:

1. Mallampati IV
2. Suspected or Known Mechanical Foreign Body in Airway
3. Suspected or Known Laryngeal/Tracheal Disruption or Fracture (as
   evidenced by expanding hematoma in neck, subcutaneous air in
   neck or altered anterior neck anatomy)
4. Suspected or Known Epiglottitis
5. Evidence of Significant Oral/Pharyngeal Angioedema
6. Significant Oral/Tracheal Burns
7. Presence of Airway Stridor for any reason
8. Known or Suspected Anterior Neck or Upper Chest Tumor, Recent
   Surgery or Bleeding
9. Significant oral facial hemorrhage or other fluid accumulation, such
   that airway landmark visibility will be severely compromised.
10. Cervical Rheumatoid Arthritis

What are you using for general anaesthesia and neuromuscular blockade? Is it the same for all?
The "standard" RSI is etomidate-succs-tube-fent and versed-vec or roc if needed.
We can also do ketamine-tube-sedate-paralyze as necessary. This is for respiratory patients and those with contras to succs. We cannot use Ketamine as post intubation sedation. The city has moved to Etomidate or Ketamine-roc-tube-fent/versed-paralyze as needed.

Are you routinely using an intubating bougie?
I do, but most do not. We recently got McGrath scopes and the city has King Visions, so that has lessened the need for the bougie.

What are your backup options?
Igels, Kings, Surgical Circh, BVM. Some services maintain nasal intubation which is not a backup but another option.

How are you tracking/auditing your program?
Every RSI is reviewed by clinical education, the hospital's paramedic educators, and a medical director.

I would estimate there are close to 200 paramedics in the system.

 

[Handsome Robb]

@Tigger oropharyngeal burns are an absolute contraindication to RSI for you?

That may be the dumbest thing I've ever heard.


Sent from my iPhone using Tapatalk

 

[GMCmedic]

Who is performing it? All officers at the appropriate level or is it restricted?
All Paramedics are allowed to RSI
Are you using the same tertiary institutions who deliver your initial education to also teach RSI? Is it part of your level-specific qualification or it is run in-house?
A majority of local paramedics take the program at one of 3 community colleges, with one of those seeing over half of the new paramedics. RSI is taught in those programs with OR clinicals
What human factors principles and risk/error management strategies have you embedded as part of your programs? Are you working with others who may be on-scene during an RSI and/or assisting with one to achieve this; for example the police, fire brigade, other ambulance resources? helicopter or retrieval personnel?
We train all of our EMT's how to intubate on the dummy just so they know what we are doing and how we are doing it. We regularly work with our EMTs to refresh them on what drugs and equipment we need.
What ongoing education/CCE or exposure requirements do you have?
Once a month at staff meeting, all the medics go through intubation scenarios on the dummy head. we may have to intubated with a bougie or tomahawk, just depends on what the scenario is.

• How do you work in with others who might perform it before you arrive, or you might before they arrive? E.g. retrieval service or the HEMS team?

The director of our most frequently used HEMS service is also our director so we play nice very well.

• What are your indications and contraindications?

Pretty well the same as everywhere else. Our Medical Director trusts our judgement

• What are you using for general anaesthesia and neuromuscular blockade? Is it the same for all?

Ketamine, Fent/Dilaudid, Roc if needed, Nimbex if needed, Versed for ongoing sedation as well as maintenance doses of Roc.

• Are you routinely using an intubating bougie?

If I remember I have it. Ill use it on easy intubations to stay familiar and to give my EMT an opportunity to work with me on it,

• What are your backup options?

King airway, Surgical Chric

• How are you tracking/auditing your program?

Team leaders send all reports to the Medical director that reviews them all and provides feedback. By far the most common feedback is failure to use passive oxygenation which is new for us.

 

[TXmed]

Who is performing it? All officers at the appropriate level or is it restricted?
All flight medics and flight nurses have the ability to RSI and intubate.

Are you using the same tertiary institutions who deliver your initial education to also teach RSI? Is it part of your level-specific qualification or it is run in-house?
In house training done in the beginning by powerpoints and tests, then new hire it is done by regional educator on a HPS manikin in several scenarios, and finally done infront of your medical director on the HPS manikin.

What human factors principles and risk/error management strategies have you embedded as part of your programs? Are you working with others who may be on-scene during an RSI and/or assisting with one to achieve this; for example the police, fire brigade, other ambulance resources? helicopter or retrieval personnel? The flight crew operate as a team and therefore requires both in agreement for the procedure. We use DASH 1A guidelines. and while our 1st attempt success rate leaves alot to be desired our success with the DASH 1A guildlines are pretty decent. our response area has every thing from volunteer 1st responder, 3rd city service, to fire based EMS. most of which have the ability of RSI (although this puts us in a bad situation more than not).

What ongoing education/CCE or exposure requirements do you have?
Powerpoints, bi-annual training and skills performance in front of our medical director.

How do you work in with others who might perform it before you arrive, or you might before they arrive? E.g. retrieval service or the HEMS team?
This really depends on the service we respond with, some offer great teamwork and chemistry, others can offer hostility and aggression towards "dropping the tube" at all costs. For the most part we work well as we encourage a teamwork first environment. I also teach at a local paramedic school so whenever there is a student i recognize (or dont) i try to take it as a teaching moment, walk them through it, help them get the intubation, and follow up afterwards.

Im a hug fan of the vortex approach combined with teamwork. mainly because i believe that will bail you out of a bad situation more so than superior skill ( although skill is desired )

What are your indications and contraindications? same as everyone above me, no real contraindications just more use good judgment.

What are you using for general anaesthesia and neuromuscular blockade? Is it the same for all? we have the choice of etomidate, ketamine and versed to go along with succs, roc, and vec. although we usually choose ketamine and roc. and in some situations paralytic only.

sedation is ketamine, fent, vers, or morphine whichever.

Are you routinely using an intubating bougie? Although it is not required i personally use one everytime. I also practice with and without it.

What are your backup options? we can perform DL or VL, king, basic airway with BVM, needle or surgical cric

How are you tracking/auditing your program? every chart is reviewed at the base level no matter the call. any chart with an RSI procedure is reviewed by the regional educator.

 

[Tigger]

@Tigger oropharyngeal burns are an absolute contraindication to RSI for you?

That may be the dumbest thing I've ever heard.


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They've backed off that list fairly significantly and I doubt that it will be included in the guidelines. I did find it interesting that they went in such depth regarding contras. Our old medical director wanted us to have RSI but was militant about the protocol being followed to the T. But even he admitted during a refresher class that "significant" airway burns meant something more like airway destruction. I'm pretty sure with our new doc I could RSI someone by hitting them in the head with a brick and he would not care so long as there was some basic justification.

Also, no non-critical care service in Colorado can RSI patients under 13.

 

[RocketMedic]

SpecialK, Houston as a whole has some interesting and divergent policies.

Some agencies here (Waller County, GAAA, I think, and Fort Bend, Lake Jackson, Atascosita, etc) have RSI as an unrestricted medic skill, meaning every medic can do it. Interestingly, some of the smaller ones actually allow EMT-Intermediates or AEMTs to perform the intubation, under the supervision of a medic who pushes medications.

Other agencies (MCHD, Cypress Creek, Cy-Fair, ESD48, etc) do perform RSI, but require either two paramedics on-scene or an internally-designated and trained/certified "Critical care medic"/supervisor to be present and directly supervising. They do not have to be the actual laryngoscopist, but they do need to be there.

Houston Fire Department barely allows endotracheal tubes to be placed in the dead. Dallas Fire took those away years ago.

The honest answer is that any RSI program is only as good as its training and what tools are given to facilitate the intubation and manage everything post-intubation. I think a lot of places mis-emphasize the focus on the skill and forget about the thought process and patient presentation to get to that point.

 

[Tigger]

Some agencies here (Waller County, GAAA, I think, and Fort Bend, Lake Jackson, Atascosita, etc) have RSI as an unrestricted medic skill, meaning every medic can do it. Interestingly, some of the smaller ones actually allow EMT-Intermediates or AEMTs to perform the intubation, under the supervision of a medic who pushes medications.

Other agencies (MCHD, Cypress Creek, Cy-Fair, ESD48, etc) do perform RSI, but require either two paramedics on-scene or an internally-designated and trained/certified "Critical care medic"/supervisor to be present and directly supervising. They do not have to be the actual laryngoscopist, but they do need to be there.

We do a somewhat similar thing here. The RSI medic must be the one to push the medications but they do not have to intubate the patient provided they are willing to delegate that skill.

 

[dutemplar]

Who is performing it? All officers at the appropriate level or is it restricted?
All critical care paramedics capable of performing intubation are able to perform RSI.

Are you using the same tertiary institutions who deliver your initial education to also teach RSI? Is it part of your level-specific qualification or it is run in-house?
They come here educated and experienced. Formal in-house onboard training. Annual training includes trauma, resus, medical and I think they've rolled into a specific airway day as well. The annual training days are didactic and small group practical.

What human factors principles and risk/error management strategies have you embedded as part of your programs? Are you working with others who may be on-scene during an RSI and/or assisting with one to achieve this; for example the police, fire brigade, other ambulance resources? helicopter or retrieval personnel?
EMS is EMS here, other services do their thing and we do ours. Fire is actually Civil Defense under the Ministry of Interior, and completely different. Coast Guard does have some "special ops" but they are, more or less, EMTB. The military has some medics, but... The "state security" police has some medical, but... We run the helicopter service and although they are mostly staffed with permanent CCPs, there is some float back and forth as need arises.

What ongoing education/CCE or exposure requirements do you have?
Standard training, and I think they rolled out an annual day.

How do you work in with others who might perform it before you arrive, or you might before they arrive? E.g. retrieval service or the HEMS team?
We are the retrieval and HEMS.

What are your indications and contraindications?
They need an airway, and in our clinical judgement that's the best way to do it.

What are you using for general anaesthesia and neuromuscular blockade? Is it the same for all?
Generally speaking ketamine, fentanyl, mizadolam. Ketamine for continued sedation. Succinylcholine or rocuronium. Roc for followup.

Are you routinely using an intubating bougie?
Unless using the video, the CPG is to use a Frova so we can at least drop that through the cords and do some jet ventilation.

What are your backup options?
Video, LT, cric kit. All of which are required to be ready.

How are you tracking/auditing your program?
All RSI charts are automatically audited and the cases followed up on by the on-duty clinical manager.

 

[TXmed]

thought i would submit another answer as i recently started a new job.

Who is performing it? All officers at the appropriate level or is it restricted?

All flight nurses and medics have the ability to RSI and intubate

Are you using the same tertiary institutions who deliver your initial education to also teach RSI? Is it part of your level-specific qualification or it is run in-house?

My new flight program is hospital non-profit based. As such our protocols are the same as the hospital.

What human factors principles and risk/error management strategies have you embedded as part of your programs?

Several steps are mandatory. Video laryngoscope use is a requirement for adult intubations. We use the McGrath so it is easy to use as a DL if need be. Bougie use is a requirement. All RSI’s involve a paralytic no exceptions, unless of course you are not using RSI such as in cardiac arrest or peri-arrest states.

Are you working with others who may be on-scene during an RSI and/or assisting with one to achieve this; for example the police, fire brigade, other ambulance resources? helicopter or retrieval personnel?

We work with multiple ground crews and sending hospitals. While we encourage teamwork and working well together, the critical steps of RSI (intubation, med admin securing the et tube) have to be done by the flight crew.

What ongoing education/CCE or exposure requirements do you have?

Initial training is 1 day of OR/pedi OR time (I was able to get 10 intubations and 2 LMA’s, 2 of which were pediatric). Cadaver lab skill training once a year.

How do you work in with others who might perform it before you arrive, or you might before they arrive? E.g. retrieval service or the HEMS team?

I would like to say we work well with others who perform this but the fact is the majority of ground crews ive come across in texas do not perform this appropriately. They usually let the patient get super hypoxic, pound away at a difficult airway, or have poor decision making when to initiate RSI. The problems I have seen are NOT intubation skill issues they are decision making issues.

What are your indications and contraindications?

Same as everyone else. My new service is substantially more aggressive than my last HEMS service. But as such this service performs significantly more surgical crics.

What are you using for general anaesthesia and neuromuscular blockade? Is it the same for all?

Flight crew decision Etomidate,ketamine, or fent+versed. Succs or roc.

Are you routinely using an intubating bougie?

a bougie is mandatory, we also carry pedi-bougies

What are your backup options?

King tube, surgical cric, needle cric

How are you tracking/auditing your program?

All charts are 100% reviewed with monthly flight review with the MD.


One thing to note, and this is me bragging on behalf of my current service. We have carried a +95% success rate (with 100% success the past 4 months) for first pass intubations. This is something my MD is proud of. Several years ago their success rate was %80’s something he thought unacceptable no matter how bad of airways we see. So he changed the protocols for mandatory VL use, mandatory bougie use, and mandatory paralytic use. He attributes these changes as a reason for the increased success rates.

 

[CANMAN]

For sake of typing what most already have I will just toss in the specifics on my program...

-Both flight paramedics and nurses are both able to RSI and we normally switch/talk about who's up at the start of the shift.

-Mandatory first use/look with CMAC, and able to change up if needed to another blade. We currently only carry the CMAC 3 & 4 due to cost, but you can normally get by with those two for about 80% of the intubations we are performing. The CMAC 3 also works well (almost like a grandview) in some pediatric patients as well. We have been running VL for about 3 years, but didn't really see much of a change in our first tube success pass rates with implementation. Maybe like 1%.... We are currently sitting at 96.8% FTS rate.

-Bi-annual skills days with our medical director, quarterly O.R. time mandated if you don't get tubes in the field. 3 tubes a quarter for 12 live tubes a year minimum for every provider. First day of the new quarter if you don't have your intubations you're pulled off the schedule until you have them. O.R. time is paid as O.T. and we have about 3 hospital to pick from per region. Pediatric tubes can count into the mix, must have at least 2 pediatric live intubations per year.

-King LT airway, Surgical, Needle as backup.

-Bougie's available, provider choice to use them. I have one out for every intubation, but prefer not to use one each time. I reach for it in maybe 10% of my tubes.

-As with other's we interact with all types of ground crews, some with RSI, some without. If we arrive and patient needs RSI but hasn't been tubed then it is our intubation. State regs list us as higher level care and once we arrive the show is our's pretty much and have only ever gotten static from one ground provider in my career who had a new glidescope he wanted to use back in the day.

IFT we will not use our drugs unless we are doing the intubation as well. Program is fairly aggressive with airway management with 110% support from medical director. IFT we will often interface with the sending MD, discuss our thoughts on why the patient needs intubation for transport, and unless the sending MD insists on doing the intubation 90% of the time we will do our own intubations. On the off chance the MD wants to do it we will assist, but their team has to draw/admin drugs etc. On the really off chance they don't want to intubate the patient then we will have our MD speak with them, and the patient gets intubated or we don't leave. I find that once you throw out the "it's safer to do this here electively than emergently in the back of my aircraft" the MD's normally get on board. Alot of times they are just committed in other areas and want the patient gone/are short on time and you have to rope them back in to get on board with finishing the treatment and stabilization for transport. Alot of times they haven't even re-assessed the patient since calling for us initially. I will never voluntarily take someone to the aircraft for the purpose of intubating them to save on the customer relationship piece. HEMS is a business and huge on customer service, but I am not willing to compromise patient care and put us into a situation for badness to ensue in the aircraft. I know programs that do this, and you only need one time for that to go bad until you change your practice. That being said our referral hospitals have alot of confidence in our abilities and normally we have no issues.

 

[RocketMedic]

For sake of typing what most already have I will just toss in the specifics on my program...

-Both flight paramedics and nurses are both able to RSI and we normally switch/talk about who's up at the start of the shift.

-Mandatory first use/look with CMAC, and able to change up if needed to another blade. We currently only carry the CMAC 3 & 4 due to cost, but you can normally get by with those two for about 80% of the intubations we are performing. The CMAC 3 also works well (almost like a grandview) in some pediatric patients as well. We have been running VL for about 3 years, but didn't really see much of a change in our first tube success pass rates with implementation. Maybe like 1%.... We are currently sitting at 96.8% FTS rate.

-Bi-annual skills days with our medical director, quarterly O.R. time mandated if you don't get tubes in the field. 3 tubes a quarter for 12 live tubes a year minimum for every provider. First day of the new quarter if you don't have your intubations you're pulled off the schedule until you have them. O.R. time is paid as O.T. and we have about 3 hospital to pick from per region. Pediatric tubes can count into the mix, must have at least 2 pediatric live intubations per year.

-King LT airway, Surgical, Needle as backup.

-Bougie's available, provider choice to use them. I have one out for every intubation, but prefer not to use one each time. I reach for it in maybe 10% of my tubes.

-As with other's we interact with all types of ground crews, some with RSI, some without. If we arrive and patient needs RSI but hasn't been tubed then it is our intubation. State regs list us as higher level care and once we arrive the show is our's pretty much and have only ever gotten static from one ground provider in my career who had a new glidescope he wanted to use back in the day.

IFT we will not use our drugs unless we are doing the intubation as well. Program is fairly aggressive with airway management with 110% support from medical director. IFT we will often interface with the sending MD, discuss our thoughts on why the patient needs intubation for transport, and unless the sending MD insists on doing the intubation 90% of the time we will do our own intubations. On the off chance the MD wants to do it we will assist, but their team has to draw/admin drugs etc. On the really off chance they don't want to intubate the patient then we will have our MD speak with them, and the patient gets intubated or we don't leave. I find that once you throw out the "it's safer to do this here electively than emergently in the back of my aircraft" the MD's normally get on board. Alot of times they are just committed in other areas and want the patient gone/are short on time and you have to rope them back in to get on board with finishing the treatment and stabilization for transport. Alot of times they haven't even re-assessed the patient since calling for us initially. I will never voluntarily take someone to the aircraft for the purpose of intubating them to save on the customer relationship piece. HEMS is a business and huge on customer service, but I am not willing to compromise patient care and put us into a situation for badness to ensue in the aircraft. I know programs that do this, and you only need one time for that to go bad until you change your practice. That being said our referral hospitals have alot of confidence in our abilities and normally we have no issues.

I once interviewed at an AEL base in Altus, OK. Their stated preference was for patients to be pulled out to the helicopter and then intubated if the sending MD didn't want it and it was necessary.

 

[RocketMedic]

Houston-area busy urban/suburban EMS 911 ground service.

1) We can only RSI with a supervisor on-scene. We carry suxxs and roc, currently carrying pancuronium due to a shortage of roc; we also carry etomidate and ketamine for sedation. The supervisors receive some additional training in RSI (nothing really different than we have, but they are validated by the medical director) and carry Impact vents. The supervisors are technically "critical care medics", but that's kind of a hazy internal definition that doesn't really add much in practical terms. We can intubate without them on-scene for patients who don't need RSI, but they also usually come on critical calls, so that's not terribly common. Nasotracheal intubation is also authorized if needed. Any medic can push the drugs and perform the intubation, but a supervisor needs to be immediately present to RSI.

2) Our policy is to make the first attempt the best attempt. We have some very useful foam head bagels, Kingvisions, adult and pediatric bougies, direct laryngycopes and two different surgical crike kits along with the usual King LT.

3) I'm not sure what specific training the supervisors get, but they do a considerably higher number of RSIs than the P2s (us mere in-charges) get, because they are called to them more frequently than any transporting unit. As P2s, we don't have officially required sustainment training beyond a station airway head and Youtube. Opportunities are available but are not required. Clinical and education try to keep us up to speed but it is a work in progress.

 

[CANMAN]

I once interviewed at an AEL base in Altus, OK. Their stated preference was for patients to be pulled out to the helicopter and then intubated if the sending MD didn't want it and it was necessary.

Craziness, then again it is AEL.......Clearly their horrible safety record and poor decision making carries over to the clinical side of the house as well.

 

[Carlos Danger]

Craziness, then again it is AEL.......Clearly their horrible safety record and poor decision making carries over to the clinical side of the house as well.

What is so crazy about that?

 

[TXmed]

Craziness, then again it is AEL.......Clearly their horrible safety record and poor decision making carries over to the clinical side of the house as well.

I know some great clinicians that work for AEL. Also when i worked for them i never felt unsafe. If you wanna bash a particular flight service than you can start up a seperate thread for that.

 

[CANMAN]

What is so crazy about that?

Many things Remi. I am actually surprised that given your profession you wouldn't be on the same page.

1. HUGE liability aspect into recognizing the patient needs airway management and then removing them from a facility where there is a MD available. Everything goes well outside in the aircraft then sure no issues, but if that's not the case you bet your *** an attorney would have a field day with that. This isn't a trauma scene flight we are talking about, it's an IFT with a physician in that facility. Regardless of what we think/and may feel at the time, we as flight crew are a lower level of care and the sending MD is clearly in charge legally as far as EMTALA is concerned. You elect to go against them and remove a patient from their ED, or ICU, or whatever to do a procedure and it doesn't go well you think that is going to go well for the people involved? There are more judicious ways to go about accomplishing this task like linking your Medical Director and the sending MD up to speak and/or seeking an additional provider (if available) such as anesthesia to present the case to and or have at bedside to perform/assist/supervise if that makes the sending MD more comfortable.

2. We speak so frequently on this board about intubation, how to do it right, etc. I think we all agree that preparation and optimizing your conditions, patient, gear is the best approach for a safe and successful airway management scenario. So taking a patient from a hospital room that has space, optimal lighting, additional staff/hands, MD backup, possibly more equipment to manage unanticipated difficult airway, to move them to a vehicle which has a lack of all the above makes ZERO sense what so ever. Remi that would be like saying we know you typically do your induction either in the O.R. itself, or a small induction suite, but we disagree so lets move them to the loading dock or a vehicle to perform it instead. I can't think of a time where I haven't been able to bridge the gap and get the airway managed if that's what the patient indeed needs, and get it done in the facility, and leave with the sending MD not being too butt hurt over it, and guess what, they continue to call us! I can think of times where I know people from other programs, or have heard stories of "well we are in a rush so lets just take the patient to the aircraft and tubed them there" and it goes badly, and then they end up walking right back into the same ED they came from. You don't think the MD is going to be more pissed at that point?

We can agree to disagree on this topic if that's what it comes to. As far as the AEL stuff Txmed, I am sorry if those comments upset you. I didn't say they don't have some great clinicians working for them, but the facts are the facts and they do have a poor safety record. I also question the judgement of anyone who feels like the above mentioned practice is safe and in the best interest for the patient as well and that's the "standard practice". Seems to me that there could be more time spent educating referral facilities (outreach) the concerns and operational challenges in HEMS and why we may want to tube when MD's don't, and less time worrying about pissing off a sending MD and risking profit margins......

What is so crazy about that?

 

[Carlos Danger]

Many things Remi. I am actually surprised that given your profession you wouldn't be on the same page.

It is probably very poor practice to routinely violate the orders of referring physicians. However, there are exceptions to every rule. My opinion on this is based on the assumptions that 1) the patient really does need to be intubated, i.e. we aren't doing it just because we like to tube people, and 2) reasonable attempts have been made to gain the support of the referring doctor, but 3) we've reached a point where spending further time trying to convince does not appear to be in the best interest of the patient. I've never personally encountered such a scenario, and I would think it pretty rare across the board, but I also don't doubt it has happened to someone before and that it will again.

Since you brought up the liability aspect of it, let's keep in mind what a fickle mistress "liability" is. If a bad outcome follows a scenario such as this and a suit is filed on behalf of the patient, you will likely be named no matter what you did or didn't do (as will the referring MD, the receiving MD, your medical director, and everyone's employers), even if your decisions clearly seemed like the right thing to do in the view of many folks. Who gets dismissed from the suit and whose insurance ends up paying depends on what the lawyers, after gathering all the evidence during discovery, think they can hash out in terms of placing blame. If the case were to go to trial (which is really uncommon), whether you are found personally at fault will come down to whether what you did appears to have been intended to provide for the best interests of the patient, and whether others with the same training and licensure would have acted similarly. If the answer to both of those is "yes", then whether you violated protocol or a referring doctors order will matter little. Whether your state board chooses to censure you somehow is a separate matter and depends on whatever their rules and procedures are. But generally speaking, you are ALWAYS in the most legally defensible position possible if you can just make a good argument that what you did seemed at the time to be the best thing for the patient. Having followed the applicable protocols and rules and orders is a good thing to have on your side of course, but even that doesn't necessarily shield you from a suit and liability. You can get called on the carpet no matter what, so the best policy is always just to do what seems like the right thing for the patient.

Lets say there is a substantial transport delay because you weren't comfortable taking this patient without them being intubated first, and that the patient ends up with a bad outcome. Could your decision to delay transport possibly be pointed at as the cause of the bad outcome? Sure it could. Would that go anywhere? I don't know. It depends. Hopefully not. Maybe. The point is, again, that liability is a hard mistress to keep happy. My feeling is that we are best off just not trying. Follow policies and protocols as much as possible, try to get guidance from your medical director in tricky situations, and document well - but above all just do a good job for your patients, and don't worry so much about getting sued.