The Great Airway Debate...

[Qulevrius]

Orange Co, CA. RSI is taken out of ALS protocols by medical director. Waiting for the inevitable ‘oh it’s California, no wonder’ comeback.

 

[DesertMedic66]

Orange Co, CA. RSI is taken out of ALS protocols by medical director. Waiting for the inevitable ‘oh it’s California, no wonder’ comeback.

It’s not just Orange County. RSI is not in the state scope for paramedics.

 

[Qulevrius]

It’s not just Orange County. RSI is not in the state scope for paramedics.

I knew for a fact it’s the case with OC. Saw LACoFD attempting intubation and failing, miserably...

 

[TransportJockey]

It’s not just Orange County. RSI is not in the state scope for paramedics.

It's also not in the state scope in NM, and there are plenty of places in Texas where RSI is not allowed by some or all paramedics.

 

[Carlos Danger]

i would tell my lawyer that since RSI is the standard of care, the agency was negligent in not sending a fully capable ambulance crew. probably have a decent shot of winning.

By the way, what is or is not the standard of care in anyone's opinion is irrelevant.... all that would become relevant is if an attorney could convince 12 people who weren't smart enough to get out of jury duty that it is the standard of care.... and I know enough shady lawyers who could pull that off.

Well first, congratulations on 1) being part of the huge problem of overly-litigious people reinforcing the unfortunate practice of defensive medicine, which by some estimates cost our economy $100B a year, and for 2) formulating an argument based solely on the standard of whether or not you could use emotion to convince ignorant people of something that isn't true. Well done. Very rational and academic.

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First, as a paramedic, the only standard of care you will ever really be held to is whether you followed your agency's protocols and policies appropriately. The Bolam test that you refer to would likely only come into play if the paramedic were to deviate from protocol or policy, or in the unusual scenario where they clearly should have deviated from protocol or policy but did not. In those cases the "reasonable professional" standard comes into play.

Second, you are mistaken in your belief that all it takes for something to become the standard of care is for it to be widely done. By that measure, thiamine, D50, and narcan could be argued to be the standard of care for unresponsive patients, because lots of places still do a coma cocktail. Lots of places also still backboard everyone who potentially suffered spinal trauma. Does that make backboards the standard of care? What about destination being determined by "mechanism of injury"? Very common still - so it that the standard of care?

Even if "widely done" is the metric that you choose to go by, it doesn't really help you because probably only about 50% (or less) of non-CCT ground paramedics in the US have RSI in their protocols. So are you now going to argue that the agencies employing roughly half of the paramedics practicing in the US are failing to meet the standard of care?

At the agency level, the medical director is primarily responsible for ensuring that protocols adhere to currently accepted standards of care. One of the main places that physicians and other independent practitioners get their standards from is the recommendations of their governing professional agencies. So which professional agency governing EMS physicians says that RSI should be universal among paramedics? Does ACEP say that? NAEMSP? No. What about the NAEMT? NREMT? Does the NHTSA curriculum say it? No, none of them do.

Another source of standards of care in a field is "practices which are widely accepted by experts in the field as being based on the best evidence available". So is universal RSI widely accepted by experts in the field? No. Some experts are very supportive of prehospital RSI, but in all my years of reading studies and articles and attending lectures and workshops on prehospital airway management and discussing and arguing about the topic over and over again, I've never heard anyone argue that, the way EMS exists in the US right now, RSI should be at the disposal of every paramedic everywhere. And even then, for every expert who is a proponent of prehospital RSI, there is another one who doesn't like it. So there's certainly no consensus among the experts in the field.

Finally, a true "standard of care" must by definition be the same everywhere. What's the right thing to do in one place is the right thing to do everywhere. But that presents some problems too. Do urban agencies with hospitals on every corner really need the same protocols as very rural agencies? What about resources? Does the small rural agency with no practical way to get OR time and who can't afford good airway trainers or VL's for every ambulance really have to have the same airway protocols as the agency in a wealthy suburb with several large hospital OR's and a paramedic program nearby to help with continuing training?

So to sum up, you are claiming that something is the standard of care which only appears in the protocols governing about 50% of paramedics, is not officially endorsed by any relevant professional agency, is not even close to being widely accepted by experts in the field, is supported by practically no evidence whatsoever and in fact has been found by many studies to be harmful to patients, can never be proven to have been beneficial in any specific instance, and for logistical reasons is very hard to implement in many locations. A malpractice defense attorney with someone like me as an expert witness would have a field day with your shady ambulance chasing lawyer.

 

[DrParasite]

On the other hand how would you feel if you had a crew respond who butchered the RSI?

then I'd still call my attorney, just like if they butchered any procedure that resulted in harm to my family or loved one.

Unless that agency has RSI in its protocols for all paramedics to use it will be really hard to get away with a claim of “standard of care”.

You know what? Your right. I am revising my original statement to be in agreement with you: if an agency has RSI in their protocols, that is the standard of care. What other people do is irrelevant, it's all based on what the agency's protocols are (your words, not mine)

If they elect that they want to give only certain paramedics the RSI skill then it would be safe to say that no RSI is the standard.

So certain paramedics aren't meeting the standard of care.... again, by your words, as the agency has RSI in their protocols, than that is the standard of care. If the ambulance shows up and the paramedic can't RSI, but other paramedics in the system can, than that ambulance has failed to perform to the standard of care provided by that system.

 

[VFlutter]

. If the ambulance shows up and the paramedic can't RSI, but other paramedics in the system can, than that ambulance has failed to perform to the standard of care provided by that system.

So every system that utilizes fly-cars is failing the standard of care? Just because HEMS/CCT has something that means ground medics must as well? Like we have discussed numerous time on here before just because an intervention may be necessary does not mean that every single provider should be able to perform it. That is not failing to meet the standard of care. Not every physician in the ER is trained to the same degree. Some may have completed an ultrasound fellowship, others may critical care or anesthesia training. Each one may do a procedure that the other may not.

 

[Chris07]

Let's just do the California thing and cater to the lowest common denominator.

No RSI for anyone.

There, now all is well. People can now be screwed both on the ground and in there air. In the end, it's all about equality, right?

 

[Carlos Danger]

Let's just do the California thing and cater to the lowest common denominator.

No RSI for anyone.

There, now all is well. People can now be screwed both on the ground and in there air. In the end, it's all about equality, right?

No, it isn’t all about equality, it’s all about capability. What are you even talking about?

 

[DrParasite]

So every system that utilizes fly-cars is failing the standard of care? Just because HEMS/CCT has something that means ground medics must as well?

not at all. nothing wrong with flycars, why would you say that? an ALS/911 ambulance is an ambulance..... HEMS is different as are CCT units... most places don't don't HEMS units or CCT units on "routine" 911 calls (and by that, I mean they might go as a backup, but their primary role isn't as a 911 ALS ambulance). you might even convince someone that no ALS ambulance crews can RSI, but only the flycar paramedics can. That way you have a clear distinction (again, different roles and responsibilities within the system; all flycar paramedics, HEMS medics, and CCT medics can RSI; 911 ambulance paramedics can't is much different than some 911 ambulances can RSI, so you better hope you get lucky enough to get one if the procedure is needed)

Like we have discussed numerous time on here before just because an intervention may be necessary does not mean that every single provider should be able to perform it. That is not failing to meet the standard of care. Not every physician in the ER is trained to the same degree. Some may have completed an ultrasound fellowship, others may critical care or anesthesia training. Each one may do a procedure that the other may not.

Physicians and paramedics are miles apart in terms of training. Not even relevant to the topic at hand.

 

[RocketMedic]

I can't RSI alone, and we're pretty medically progressive. I really don't see it as a dealbreaker

 

[DrParasite]

sorry for the long post, but i wanted to make sure I covered everything in this long post

Well first, congratulations on 1) being part of the huge problem of overly-litigious people reinforcing the unfortunate practice of defensive medicine, which by some estimates cost our economy $100B a year, and for 2) formulating an argument based solely on the standard of whether or not you could use emotion to convince ignorant people of something that isn't true. Well done. Very rational and academic.

what's that phrase? don't hate the player, hate the game? The system might be broken, but it does exist for a reason (like not sending a fully capable ambulance to an emergency). and no, the whole ignorant people comment you made is just the way our court system is set up. sorry you don't like it, maybe you should try serving on a jury and seeing what it's like?

First, as a paramedic, the only standard of care you will ever really be held to is whether you followed your agency's protocols and policies appropriately. The Bolam test that you refer to would likely only come into play if the paramedic were to deviate from protocol or policy, or in the unusual scenario where they clearly should have deviated from protocol or policy but did not. In those cases the "reasonable professional" standard comes into play.

We aren't talking about the individual paramedic, we are talking about the agency.... if the agency fails to send a fully trained crew, that's where the issue lies; the medic did nothing wrong. please try to keep up with the topic at hand

Second, you are mistaken in your belief that all it takes for something to become the standard of care is for it to be widely done. By that measure, thiamine, D50, and narcan could be argued to be the standard of care for unresponsive patients, because lots of places still do a coma cocktail. Lots of places also still backboard everyone who potentially suffered spinal trauma. Does that make backboards the standard of care? What about destination being determined by "mechanism of injury"? Very common still - so it that the standard of care?

Even if "widely done" is the metric that you choose to go by, it doesn't really help you because probably only about 50% (or less) of non-CCT ground paramedics in the US have RSI in their protocols. So are you now going to argue that the agencies employing roughly half of the paramedics practicing in the US are failing to meet the standard of care?

you're right. that was why I amended my statement to be the agency's standard. if your agency allows it's ground paramedics to RSI, but some aren't permitted to, than those paramedics are not following the agency's standard. it's not an issue for the individual paramedics, it's for the agency that isn't sending a fully capable ambulance to a scene.

At the agency level, the medical director is primarily responsible for ensuring that protocols adhere to currently accepted standards of care. One of the main places that physicians and other independent practitioners get their standards from is the recommendations of their governing professional agencies. So which professional agency governing EMS physicians says that RSI should be universal among paramedics? Does ACEP say that? NAEMSP? No. What about the NAEMT? NREMT? Does the NHTSA curriculum say it? No, none of them do.

fair point... which one says intubation should be universal among all paramedics? let me ask an even more accurate question: which of those agencies says it's recommended to not have universal treatment capabilities among every ambulance? I'll wait for you for you to show me that.

Another source of standards of care in a field is "practices which are widely accepted by experts in the field as being based on the best evidence available". So is universal RSI widely accepted by experts in the field? No. Some experts are very supportive of prehospital RSI, but in all my years of reading studies and articles and attending lectures and workshops on prehospital airway management and discussing and arguing about the topic over and over again, I've never heard anyone argue that, the way EMS exists in the US right now, RSI should be at the disposal of every paramedic everywhere. And even then, for every expert who is a proponent of prehospital RSI, there is another one who doesn't like it. So there's certainly no consensus among the experts in the field.

yes, but what does your agency say? do we like RSI? if so, than everyone should be able to do it. if we don't, than no one can. That's the standard you should be looking at.

Finally, a true "standard of care" must by definition be the same everywhere. What's the right thing to do in one place is the right thing to do everywhere. But that presents some problems too. Do urban agencies with hospitals on every corner really need the same protocols as very rural agencies? What about resources? Does the small rural agency with no practical way to get OR time and who can't afford good airway trainers or VL's for every ambulance really have to have the same airway protocols as the agency in a wealthy suburb with several large hospital OR's and a paramedic program nearby to help with continuing training?

I see you are really confused..... let me try to clear things up: should every ambulance on that rural agency be able to to the same interventions? Should paramedic mike from rural agency A be able to intubate when it is clinically indicated, but paramedic bill can't? so what happens when paramedic bill shows up for a patient which RSI is indicated, but he can't? he has to request paramedic mike to respond, resulting in a delay of care, whereas if paramedic mike had been on the initial dispatch, they wouldn't be a delay.

So to sum up, you are claiming that something is the standard of care which only appears in the protocols governing about 50% of paramedics, is not officially endorsed by any relevant professional agency, is not even close to being widely accepted by experts in the field, is supported by practically no evidence whatsoever and in fact has been found by many studies to be harmful to patients, can never be proven to have been beneficial in any specific instance, and for logistical reasons is very hard to implement in many locations. A malpractice defense attorney with someone like me as an expert witness would have a field day with your shady ambulance chasing lawyer.

I'm pretty sure my ambulance chasing attorney would tear you to shreds on the witness stand, because you seem to have issues focusing your responses to the topic at hand.

Ok, one last time: it doesn't matter what the experts say, or what other agencies do , or what your mother thinks about RSI.... If your agency lets some (ambulance) paramedics RSI, but not others, and I call 911 expecting a fully trained and capable ambulance paramedic to show up and treat in accordance to their agency's guidelines. If that ambulance crew can't RSI, and has to call another ambulance to provide this procedure THAT IS LISTED IN THEIR PARAMEDIC PROCEDURES, delaying proper care, and resulting in a negative patient outcome, than I'm going to do 3 things: 1) call the agency asking why a properly trained crew wasn't sent 2) the local news to advise them that your agency is playing chance with people's lives, because not every paramedic ambulance is the same, and you need to actually request a fully trained ambulance crew who can do all the practices in their procedure book and 3) to my attorney, who will a) tear you to shreds and make you look like a fool on the witness stand and b) explain to the agency's attorney that sending only partially trained crews to some medical emergencies is a generally poor practice.

If you still don't get it, well, I give up, there is nothing further I can say or do, other than suggest you educate yourself on what the consequences are for failing to meeting standards.

 

[DrParasite]

I can't RSI alone, and we're pretty medically progressive. I really don't see it as a dealbreaker

for clarification, is that you as an individual who is unable to RSI alone, or no paramedic at your agency can RSI without a second paramedic being present?

 

[Chris07]

No, it isn’t all about equality, it’s all about capability. What are you even talking about?

I was attempting to be a smart ***.

 

[Carlos Danger]

If you still don't get it, well, I give up, there is nothing further I can say or do, other than suggest you educate yourself on what the consequences are for failing to meeting standards.

Look, the only standards you are beholden to is a defined list of interventions that someone else grants you permission to do, and can revoke permission for at any time. "See X, do Y", and as long as you follow those instructions, you are fine. You aren't really responsible to meet any true standard of care; you are just responsible for doing what you are told. Given that, I can see how you might have trouble wrapping your head around this issue. I on the other hand am an independent practitioner who practices in one of the most litigious areas of medicine (OB), and have actual legal responsibility for (and formal education in) identifying and adhering to standards of care. So while I'm not a malpractice attorney, I have a pretty good idea what I am talking about when it comes to this because my livelihood requires me to actually adhere to it every single day. So you telling me to "educate myself" on this is laughable.

You started this whole thing claiming that anyone who doesn't RSI someone is failing to meet a fictitious standard of care. Then you changed that and said only agencies who don't RSI in a region or system where others do are failing to meet the standard. Finally, you moved the goalpost again to your current hypothesis, which is that if an individual paramedic doesn't do RSI while other paramedics in the same agency do, there is some failure to meet the standard of care.

I'm not going to argue over whose hypothetical lawyer would beat up the other guy's hypothetical lawyer. Instead, I'll lay this out objectively one more time:

• There is no expert consensus that RSI should be the standard of care in the prehospital realm.
• There is no statement out there by any professional authority (NAEMSP, ACEP) that says prehospital RSI is or should be considered the standard of care.
• Routine prehospital RSI is not supported by the literature. Most studies indicate that it is actually more likely to harm a patient than to help them. (Which, BTW, might make it hard to argue that failure to use RSI was a causal factor in a poor outcome)
• RSI is not universally performed. There are at least as many agencies that don't do it as there are agencies that do.
• Adequate training in RSI (as defined by many experts in the field) is not available to every paramedic, probably not to a majority.

Without at least a couple of those things listed above, you simply cannot argue that a standard of care exists. Those things are, in fact, exactly how practices come to be accepted as the standard of care. You can hold your breath and stomp your feet and insist that it is, but you are still wrong.

Similarly, your assertion than every paramedic in an agency must be able to RSI or none of them should be able to is absolutely absurd, and is the opposite of what many consider a more responsible and manageable approach to prehospital RSI. It is perfectly reasonable for an agency to establish a basic standard of care (protocols) for every paramedic to follow, and then go on to credential some employees in additional skills once they have achieved certain levels of experience and/or received extra training. Lots of agencies do this in one form or another, because it is broadly recognized that training opportunities for RSI and other advanced skills are limited, and that gaining a certain level of basic paramedic experience before adding advanced skills probably makes sense.

Finally, if you are so convinced of this, show me the case law. If what you are claiming is actually true, it shouldn't be difficult to dig up examples of courts actually finding agencies negligent for violating the standard of care in airway management by only allowing some of their employees to RSI.

 

[EpiEMS]

Stepping it back one level from the RSI debate...

I'm not somebody who can go around intubating whomever I see fit, but I'll say this: Intubation doesn't make the baseline paramedic skill set if I were to magically become the director of the system I'm in (assuming educational standards don't change, etc.).

Why? Because ETI offers no (neurologically intact) survival advantage most of the conditions where it is allegedly indicated (cardiac arrest, namely).

Where should EMS be performing ETI? Who in EMS should perform ETI?

A very limited number of circumstances - helicopter-based EMS and critical care-level EMS, sure, assuming their medics are getting enough OR time to be good at the skill and that there is QA/QI on every attempt.

 

[VFlutter]

For those people whom are so adamant that RSI is the standard of care for EMS can you described a few situations where a) RSI is the only option for airway mangagment b) Lack of RSI would certainly result in serious harm or death and c) how often you actually encounter those situations in the field...

As I said before I am all for RSI. I think it is a fantastic tool to have when implemented correctly. But I don’t think you can make an argument that it is the standard of care and every medic should have it.


How many of you can quote your agency’s RSI statistics? How many have > 90% first pass and overall intubation success rate? Complication rates?

Like everything in medicine it’s risk vs benefit. It seems many people like to downplay the risk and over exaggerate the benefit.

 

[Carlos Danger]

For those people whom are so adamant that RSI is the standard of care for EMS can you described a few situations where a) RSI is the only option for airway mangagment b) Lack of RSI would certainly result in serious harm or death and c) how often you actually encounter those situations in the field...

As I said before I am all for RSI. I think it is a fantastic tool to have when implemented correctly. But I don’t think you can make an argument that it is the standard of care and every medic should have it.


How many of you can quote your agency’s RSI statistics? How many have > 90% first pass and overall intubation success rate? Complication rates?

Like everything in medicine it’s risk vs benefit. It seems many people like to downplay the risk and over exaggerate the benefit.

Those are good points but what really matters isn't how often a procedure is indicated or even how good we are at it, but how it actually affects outcomes. Lots of studies on prehospital intubation show really good success rates with RSI, but still associate the procedure with worse outcomes.

That realization is why we stopped focusing on just getting pulses back during CPR and instead started looking at neurologically intact discharge. It doesn't matter if high-dose epi gets pulses back more often if people are just going to die in the hospital, or have severe neurological impairment. Getting those pulses back might make us feel good, but it isn't ultimately helping the patient. Same with intubation: it might make us feel better to have a "secure" airway and maybe better blood gases, but if doing so doesn't actually improve the patient's chance of a favorable outcome, we probably shouldn't be doing the procedure routinely.

 

[StCEMT]

@Remi, is there generally a significant difference pre/in hospital given that both providers are skilled? I've had a pt I didn't intubate because of the immediate risks just to have a doc do it shortly after and have to work an arrest. So does the who (assuming they're experienced) matter as much as the what (the act if intubating)?

 

[Tigger]

then I'd still call my attorney, just like if they butchered any procedure that resulted in harm to my family or loved one.You know what? Your right. I am revising my original statement to be in agreement with you: if an agency has RSI in their protocols, that is the standard of care. What other people do is irrelevant, it's all based on what the agency's protocols are (your words, not mine)So certain paramedics aren't meeting the standard of care.... again, by your words, as the agency has RSI in their protocols, than that is the standard of care. If the ambulance shows up and the paramedic can't RSI, but other paramedics in the system can, than that ambulance has failed to perform to the standard of care provided by that system.

Services in this area provide RSI as an option for providers. I cannot RSI a patient without another medic, because frankly I lack the experience needed do so. That will change when I can show a pattern of competency in managing airways over several years. I often work with an EMT, so either manage by another way or get another medic somehow. But sure, let's put providers that have no business independently providing a skill in a position where they have to just because of some arbitrary standard.