RSI

[GMCmedic]

@Remi youre last line there is perfect.

It is pretty common for us a ground service to do things we feel the referring hospital should have done. It is usually just minor things, most commonly it is a critical access in our hospital system where the ER doctors do not have much experience with critical patients. Our Medical director has our back in those situations. We get called to do intubations for them fairly regularly.

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[TXmed]

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......

But you have not stated any facts. I have read reports on crashes by many providers ie: AEL,PHI, air methods, AMRG, REACH etc. But the reality is these larger companies spend more time in the air than most local flight services. So you must look at rotor time vs number of bad/potentially bad instances, you also must take into account number of landings/responses to scenes or previously unapproved LZ's as these offer more dangerous elements in the critical phases of flight.

I can say for a fact AEL follows a substantial amount of safety protocols such as a baldwin RA, great amount of OCC oversight, autopilot use, and most importantly the 51% rule. i worked for them for just over 2 years and was never questioned on why i turned down a flight.

Every one of the national services i named above has their bad apples and less than stellar bases, but to generalize them into the whole company is ridiculous. You thinking you have used facts to suggest that AEL is unsafe or provides below average clinical care is stupid on your part.

 

[CANMAN]

But you have not stated any facts. I have read reports on crashes by many providers ie: AEL,PHI, air methods, AMRG, REACH etc. But the reality is these larger companies spend more time in the air than most local flight services. So you must look at rotor time vs number of bad/potentially bad instances, you also must take into account number of landings/responses to scenes or previously unapproved LZ's as these offer more dangerous elements in the critical phases of flight.

I can say for a fact AEL follows a substantial amount of safety protocols such as a baldwin RA, great amount of OCC oversight, autopilot use, and most importantly the 51% rule. i worked for them for just over 2 years and was never questioned on why i turned down a flight.

Every one of the national services i named above has their bad apples and less than stellar bases, but to generalize them into the whole company is ridiculous. You thinking you have used facts to suggest that AEL is unsafe or provides below average clinical care is stupid on your part.

For lack of derailing the entire thread I am not going to get into an entire debate about AEL. If you worked there for 2 years and felt safe doing it that's great. Bottom line is 5 fatal accidents in the last decade, that's a fact and easily researchable. Like I said you can have your opinion and I will stick with mine. Will leave it at that.

 

[babymedic842]

Special K,
We are currently performing it in the area where I work. I work in the US and the area is still mostly volunteer fire departments/rescue squads but very few, if any left at all, don't have paid EMS, if not full time per diem. We are currently on our 3rd year with the program in place and are seeing our 2nd set of changes from the original coming out sometime in the near future.

• Who is performing it? All officers at the appropriate level or is it restricted?: As of right now, and for the indefinite future it is restricted. Before you can even become eligible for the course your agency has to be part of the program, which few are, and you have to be recommended by your agency medical director. After that in order to meet the requirements you have to have at least 5 years experience as a Paramedic, Completion in a recognized advanced airway course, minimum 10 ETI over that 5 years, no documented esophageal intubations (This rules you out of the program for life), and work a minimum amount of hours in the system itself. From my understanding most of these requirements are guidelines and each provider can be examined on a case by case basis to determine if they are eligible for the course. The only guidelines that I have not heard of them granting exceptions for are the 5 year experience requirement, and the no lifetime esophageal intubations.
• 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?: While a majority of the Paramedic Programs in the area do teach RSI as part of their curriculum, all training is handled at an agency level with the Medical Director usually teaching the lectures. We are required to go through our regional facility for our practical and written examinations, but most of the training is taking place 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?: We are mostly working alone as an agency. Originally the program required a 2nd Paramedic on scene in order to RSI a patient, we have since adopted a criteria for single provider RSI based on our QA/QI on the program which takes into account patient's mental status, respiratory status, and inability to manage the airway effectively with less invasive methods. As of right now we have 2 flight services in our area, and 1 of them is able to take over patient care in the even we have performed RSI, and the other is not.
  
• What ongoing education/CCE or exposure requirements do you have?: In order to maintain our status, we have to attend a minimum of 4 hours CME on RSI itself annually as well as have a minimum of 12 ETI per year. If the year ends and we only have 10, we are allowed to perform a skills exam in front of a certified instructor to maintain our status.
  
• 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 rule is generally, with exception to HEMS of course, that the provider who performs the procedure accompanies the patient to the hospital.
  
• What are your indications and contraindications?: Indications are Respiratory Failure (Inability to Breathe, Hypoxia, Restlessness, Anxiety, AMS, Shallow Tachypnea, Tachycardia, Diaphoresis, Hypercarbia), Loss of Airway Reflexes, Anticipated Deterioration, Severe Trauma Patients who are AMS, Combative, Hypoxic, and Patient's who Cannot Maintain Their Airway. Our contraindications are Cardiac Arrests, Severely Obtunded Patients, Disfiguring Facial Trauma, Airway Burns, Neck Trauma, Spinal Cord Injury, Patients you do not believe you can successfully intubate. The reason I was given for patient's with airway burns being a contraindication (which I know in my area is a topic of debate among providers) was the occurrence of hyperkalemia. Also we were told informally by my service medical director, nothing on paper of course, that if the patient needs to be intubated and RSI was the only way to accomplish that, you know where that was headed. Of course as long as there is a good outcome I don't think they would be too upset at our actions, but on the other side...So there is some provider discretion if the patient doesn't fall within the on paper criteria, we just have to make sure that we are able to successfully intubate them.
  
• What are you using for general anaesthesia and neuromuscular blockade? Is it the same for all?: Right now we are using Etomidate, Succinylcholine (or Rocuronium if that is contraindicated), Versed, Fentanyl and Vecuronium. We have a new update that will be coming out shortly, where we will be getting ketamine.
  
• Are you routinely using an intubating bougie?: Provider discretion. I've never used a bougie, I don't know many providers who have, and the proliferation of video laryngoscopes have kind of pushed it to the back of everyone's minds.
  
• What are your backup options?: Backup options are Video System, if we didn't use that initially which most of us do, King Airway, or BVM.
  
• How are you tracking/auditing your program?: All cases are reported immediately to the county, they are examined by the Doctors in charge of the Program, and any remediation is generally administered within 2-3 days. The program itself will look at the cases individually to determine where changes can be made to improve patient care, or remove unnecessary steps. We historically have seen updates out of the program once a year. Due to the relatively low number of participating agencies and providers, our 2016 numbers were something like 30 cases that year.

 

[RocketMedic]

Where is this at? Sounds rural and New Englandish

 

[RocKetamine]

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.

While I'm sure it has happened before (or they wouldn't ask that question) the chance of that actually happening is incredibly low. For the most part the physicians at smaller facilities that AEL will usually transfer out of will agree with what the flight crew has in mind 95% of the time. If not, you get on the phone and have them speak to a medical director which will take care of the other 4.9%.

It's obviously not good practice to go against what the sending physician orders, but at the same time you need to do whats best for the patient. After talking to a med director and the patient is in obvious need of an airway, intubating en route to the receiving might be the best place. However, it's not the preferred location at all.