Versed as a sole RSI agent

[mso_kirk]

We've been fighting with our medical director for years to get RSI protocols. He's resisted the whole time, despite the fact that every single ALS agency around us now has it. In any case, he recently signaled that he would relent and allow us to have RSI protocols. But what he's come up with has sort of thrown me for a loop. He says he won't give us Anectine because of liability issues and because of concerns expressed by local anesthesiologists. He says he'll allow us to use Versed to intubate patients, and he says it's safer since we carry romazicon that we can use to reverse it if we can't get the tube.

I'm curious if there are any other agencies out there that are using or have used Versed as a sole intubation agent. I've read several accounts from people saying that Versed doesn't knock them down far enough, and I also have concerns about our doc's assertion that romazicon can "easily" reverse them. I used Anectine in my old department for years, and the worst I ever had to worry about was bagging them for 5 minutes if I couldn't get the tube.

Thoughts?

 

[Veneficus]

We've been fighting with our medical director for years to get RSI protocols. He's resisted the whole time, despite the fact that every single ALS agency around us now has it. In any case, he recently signaled that he would relent and allow us to have RSI protocols. But what he's come up with has sort of thrown me for a loop. He says he won't give us Anectine because of liability issues and because of concerns expressed by local anesthesiologists. He says he'll allow us to use Versed to intubate patients, and he says it's safer since we carry romazicon that we can use to reverse it if we can't get the tube.

I'm curious if there are any other agencies out there that are using or have used Versed as a sole intubation agent. I've read several accounts from people saying that Versed doesn't knock them down far enough, and I also have concerns about our doc's assertion that romazicon can "easily" reverse them. I used Anectine in my old department for years, and the worst I ever had to worry about was bagging them for 5 minutes if I couldn't get the tube.

Thoughts?

Understand it? Yes. I worked at a service that did that about 8 years ago.

Agree with it? Partially

Ability to change it? None.

Versed in the right dose will sedate somebody enough to pass a tube. It is called sedation facilitated intubation. There is a thread around here somewhere on it. I can't find it on search.

But the long and short of it is, that it looks to me like your Med director doesn't want to give you RSI for whatever the reason, so is basically allowing for conscious sedation.

It'll work and you probably won't ever need more than 30mg of versed. More probably between 14-20mg.

I do not agree with giving EMS Romazicon. It is not a simple or benign reversal agent. The use of it or even the suggestion of it being used to reverse the benzo from a failed tube attempt doesn't appreciate the sequele of doing that.

I hope your medical director will speak with anesthesia about using romazicon for such purposes. Especially on patients who will likely need to be intubated later.

 

[Smash]

Thoughts?

Yes, I've had at least 3 thoughts today, thanks for asking!

In relation to this, I think it is a dumb idea. RSI needs to be done properly or not at all. Versed only isn't an RSI protocol, it's a protocol for death by semi-lethal injection, hypotension and messed up airways.

Why doesn't the Medcial Directory trust his medics?

EDIT: Sorry, I'm posting while caffiene deprived: romazicon? Who on earth carries flumazenil these days? Strange.

 

[Veneficus]

In relation to this, I think it is a dumb idea. RSI needs to be done properly or not at all. Versed only isn't an RSI protocol, it's a protocol for death by semi-lethal injection, hypotension and messed up airways.

Why doesn't the Medcial Directory trust his medics?

Wow, that is a strong statement!

Conscious sedation is used for all kinds of procedures, especially on kids, it is a relatively safe and widely accepted practice.

The use of a neuromuscular blocker is so lesser doses of the anesthetic agents are needed. It is not required.

I agree with you it is not the optimal way, but "semi-lethal injection" may be a bit extreme.

I have used it, and the drop in BP isn't that dramatic in my anecdotal experience.

It might not be a lack of trust in the medics, but the lack of desire to commit to the proper oversight of such a program.

Of course if they still have romazicon on the truck, it may be complete lack of interest on the medical director's part.

 

[mso_kirk]

Smash -

I don't know why we have romazicon. It was in the protocols for years before I was hired. Our MPD is of the opinion that if we carry any benzos that we have to have it. It's never been used to my knowledge. BTW, I appreciate the input of everyone so far. This is stuff I can take back to the doc.

 

[Smash]

I have sedation only as an option in my protocols as well, used it a number of times last year. The trouble comes when that is the only option for drug assisted airway management. Messing around with versed only in head injured patients for example is somewhat less than optimal, and can potentially add to catastrophic outcomes.

 

[Outbac1]

We have it for conscious sedation to facilitate intubation and/or to keep the pt from fighting the tube. However we only have 10mg of it. From the research I've done we should have 30mg available. I haven't had to use it yet for that but a coworker had a problem with it the other day. They had a GCS 3 pt who had vomited several times and then trismused. They tried 8mg of versed to try and relax the jaw enought to get a tube. It didn't work. The pt woke up briefly and told them off. Then went unc again. Pt survived inspite of themselves.

Versed is not the right drug for trismus and in low doses not normally sufficient for intubation. I've been present many times in the ER when it was used for reductions and it worked quite well. We don't carry Flumazenil.

Our MD is also not fond of field RSI. In a discussion with him a couple of years ago he expressed concern that anouther area that does do it has an unusually high number of field crycs to compensate for failed intubation attempts. Now that we have the King Airway perhaps he will reconsider.

I am convinced there is a place for field RSI, but I am not convinced it should happen as often as it does. Some medics just do not take the time to assess the pt properly for how difficult the intubation will be. Then they rush and sedate and paralyse then can't get the tube. Just because you can doesn't mean you should.

Hopefully your MD will give you enough versed to work with. Consider it a step towards RSI.

 

[MrBrown]

Oh good lord Brown is mortified somebody is once again considering the butcher shop half arsed ghetto Parathinktheyare approach of sedation only intubation.

For a number of years we had midazolam facilitated intubation and it was withdrawn after increase in mortality rate, adverse patient outcomes (like secondary brain inury due to hypovolaemia and increased ICP) and generally poor form.

We now have proper anaesthesia and paralysis based RSI with fent, ketamine, suxamethonium, vecuronium, electronic capnography and all that other good stuff.

 

[Melclin]

I can't be arsed pulling up endnote right now so I just googled some links. If needs be PM me and I'll send you the papers/more detail on our RSI protocols etc.

http://onlinelibrary.wiley.com/doi/10.1111/j.1742-6723.2006.00850.x/abstract
-Argues against prehospital intubation in trauma (head injury) with the use of sedatives only. This was based on data from the trauma registry showing poorer outcomes with SFI in TBI. Suggest trial of proper RSI.

http://onlinelibrary.wiley.com/doi/10.1046/j.1442-2026.2002.00382.x/abstract
-Earlier HEMS based successful RSI trial.

http://www.ncbi.nlm.nih.gov/pubmed/21107105
-THE RSI trial. Very successful. Early success saw the TBI RSI rolled out to other forms of hypoxic brain injury.

I had the privilege to speak briefly with Stephen Bernard who was largely responsible for these trials. I asked him if he thought our superior education (compared to the states) had anything to do with the success of our trial. He surprisingly disagreed and said the most important thing was close medical oversight and a good relationship between the medical oversight and the paramedics for training and QA/QI purposes. It doesn't sound like you have that.

The literature says do RSI and do it right.

Vene,
I think there is a difference between the average procedural sedation and the prehospital intubation of a multitrauma pt. The Victorian trauma registry agrees. You'd have to agree that 25mg of midaz in a TBI pt with dicey BP is pushing it safety wise when there is a clearly better option.

 

[MrBrown]

You'd have to agree that 25mg of midaz in a TBI pt with dicey BP is pushing it safety wise when there is a clearly better option.

The better option is to give Brown the 25mg of midaz so that when Brown wakes up we will have skipped to the end and found out how the patient did without all the hard work involved

 

[Melclin]

The better option is to give Brown the 25mg of midaz so that when Brown wakes up we will have skipped to the end and found out how the patient did without all the hard work involved

I thought you had shotgun on the special K, Bro. Stop camping the induction drugs dude.

 

[Veneficus]

Vene,
I think there is a difference between the average procedural sedation and the prehospital intubation of a multitrauma pt. The Victorian trauma registry agrees. You'd have to agree that 25mg of midaz in a TBI pt with dicey BP is pushing it safety wise when there is a clearly better option.

I think proper RSI is a better option in all cases, not just multisystem trauma.

I wasn't arguing for it, only expressing that I have used sedation facilitated intubation, and that it can work.

But like I said earlier, I don't think the OP is part of the most up to date system. (or even in the 21 century system) As evidenced by not only the idea that romazicon would be an acceptable reversal if a tube failed, but having romazicon available prehospital at all.

 

[mso_kirk]

I think proper RSI is a better option in all cases, not just multisystem trauma.

I wasn't arguing for it, only expressing that I have used sedation facilitated intubation, and that it can work.

But like I said earlier, I don't think the OP is part of the most up to date system. (or even in the 21 century system) As evidenced by not only the idea that romazicon would be an acceptable reversal if a tube failed, but having romazicon available prehospital at all.

We are admittedly not the most up to date system. :sad: We have tiny volunteer agencies surrounding us that have much more advanced protocols than we do. We still have to call in to ask permission to give certain drugs like Lasix for pulmonary edema and narcs for pain control, and we don't even carry drugs like Pitocin, beta blockers, or mag sulfate (these are standards on all other drug boxes in the region). I don't know if it's so much that our MPD doesn't trust us, it's more that he has virtually no experience in emergency medicine as he's a GP. He is very gun shy about giving us new tools or drugs that he's not familiar with. Yes, we've been looking at replacing him, but so far we've been having trouble finding another local doc to take over.

 

[Melclin]

You've gotta hit the literature. Its clearly in support of your position and, importantly, very beneficial to your patients.

Its pretty hard to argue with a hardcore lit review and a well made argument about raising the level of pt care to be in line with the rest of the developed world.

How well educated are the paramedics in your system? Are they willing to be involved in the professional development and on going oversight that an RSI program requires? Do they have the educational foundation to make it feasible?

 

[Veneficus]

We still have to call in to ask permission to give certain drugs like Lasix

Unless you have a very long transport time this is probably a good idea.

and narcs for pain control,

This is not a good idea

and we don't even carry drugs like Pitocin, beta blockers, or mag sulfate (these are standards on all other drug boxes in the region).

I don't think you should compare your system advancement with other agencies around you, but rather compare what you have to your patient needs. A bunch of drugs is not superior to highly capable providers able to effectively serve their patients.

I don't know if it's so much that our MPD doesn't trust us,

I don't think it is usually a matter of trust, but a matter of involvement. Many medical directors in the US want to spend as less time as possible with EMS duties. The pay is usually symbolic and the assumed risk very high. You cannot blame the medics in a system for the lack of incentive to the medical director.

it's more that he has virtually no experience in emergency medicine as he's a GP.

I really wish people would quit thinking that an Emergency Medicine doctor is the only physicians who understand or know how to deal with emergencies. I'll say it again, many senior physicians who exclusively do emergency, even in large centers were trained prior to the specialization of emergency medicine. They are not less capable. Sorry, this is a pet peeve of mine.

He is very gun shy about giving us new tools or drugs that he's not familiar with. Yes, we've been looking at replacing him, but so far we've been having trouble finding another local doc to take over.

If he does not have the interest, help him by presenting the research and make your own case as opposed to asking for stuff and hoping he will take it upon himself to do the research. It is hard to say "no" to an overwhelming body of evidence. It is easy to say "no" to a request.

 

[mso_kirk]

Veneficus -

Sorry if it's a pet peeve of yours, but in our case the doc is the first to admit he doesn't feel comfortable with emergency medicine because of his GP specialty. When we first floated the RSI protocol his comment was, "Guys, you have to understand I haven't intubated anybody or anything since medical school 20 years ago." We get those sort of comments a lot, and it results in him having to run things by a bunch of other physicians before he'll agree to anything. Since we have a bunch of turf-conscious docs at the local hospital who don't hide the fact that they don't really care for paramedics, we rarely get anything new because they'll tell our MPD that we shouldn't have it. This is our primary problem. And we have presented him a mountain of evidence supporting RSI over the past 5 years. He'll look at it and say, "Wow, that's pretty strong evidence...let me look in to this." A week later he'll come back and say, "I talked with one of the anesthesiologists over coffee yesterday and he told me paramedics shouldn't be doing RSI. He thinks I'm crazy for even letting you intubate." And then the conversation is over for a few months until we find something else to present him, and then it just repeats itself. :wacko:

As to the Lasix question, we typically have transport times of over 1 hour, and we also have no CPAP.

 

[Melbourne MICA]

What are we good for?

Veneficus -

Sorry if it's a pet peeve of yours, but in our case the doc is the first to admit he doesn't feel comfortable with emergency medicine because of his GP specialty. When we first floated the RSI protocol his comment was, "Guys, you have to understand I haven't intubated anybody or anything since medical school 20 years ago." We get those sort of comments a lot, and it results in him having to run things by a bunch of other physicians before he'll agree to anything. Since we have a bunch of turf-conscious docs at the local hospital who don't hide the fact that they don't really care for paramedics, we rarely get anything new because they'll tell our MPD that we shouldn't have it. This is our primary problem. And we have presented him a mountain of evidence supporting RSI over the past 5 years. He'll look at it and say, "Wow, that's pretty strong evidence...let me look in to this." A week later he'll come back and say, "I talked with one of the anesthesiologists over coffee yesterday and he told me paramedics shouldn't be doing RSI. He thinks I'm crazy for even letting you intubate." And then the conversation is over for a few months until we find something else to present him, and then it just repeats itself. :wacko:

As to the Lasix question, we typically have transport times of over 1 hour, and we also have no CPAP.

Perhaps it has something to do with his medical license being on the line if screw ups by staff wind up in the coroners court? Sounds like his conservative approach has a lot to do with that scenario. Is it also something to do with funding for training and education as well? Money and trouble - two good ways to make a Doc nervous!

MM

Saving face also has a lot to do with peer credibility as well.

 

[MrBrown]

Perhaps it has something to do with his medical license being on the line if screw ups by staff wind up in the coroners court? Sounds like his conservative approach has a lot to do with that scenario..

*Brown goes off to find something to hit the dead horse with "Paramedic registration" written on it.

Oh wow that was exertious, time for a bit more ketamine

For now here rapid sequence intubation is only for selected, specially upskilled Intensive Care Paramedics and at last count they average just over one RSI per Officer per week. Each must be followed up with a debrief by the regional Medical Advisor or Medical Director. In time was with other things it will most likely open up to all Intensive Care officers but for now we are being judicious and taking small steps. Our RSI guideline is (if Brown may say so) fairly advanced by the looks of things so its probably a wise idea.

Some sparky two bit Parathinktheyare who got thier Paramedic certification out the Weet Bix box should hardly be trusted with a drip and bag of fluids let alone suxamethonium/

 

[Veneficus]

the hard truth

Veneficus -

Sorry if it's a pet peeve of yours, but in our case the doc is the first to admit he doesn't feel comfortable with emergency medicine because of his GP specialty. When we first floated the RSI protocol his comment was, "Guys, you have to understand I haven't intubated anybody or anything since medical school 20 years ago." We get those sort of comments a lot, and it results in him having to run things by a bunch of other physicians before he'll agree to anything. Since we have a bunch of turf-conscious docs at the local hospital who don't hide the fact that they don't really care for paramedics, we rarely get anything new because they'll tell our MPD that we shouldn't have it. This is our primary problem. And we have presented him a mountain of evidence supporting RSI over the past 5 years. He'll look at it and say, "Wow, that's pretty strong evidence...let me look in to this." A week later he'll come back and say, "I talked with one of the anesthesiologists over coffee yesterday and he told me paramedics shouldn't be doing RSI. He thinks I'm crazy for even letting you intubate." And then the conversation is over for a few months until we find something else to present him, and then it just repeats itself. :wacko:

As to the Lasix question, we typically have transport times of over 1 hour, and we also have no CPAP.

I was thinking how best to address this.

I think your medical director has made a sound clinical decision in the best interest of both the patients and system. Probably not what you wanted to hear.

If one of my friends who was a medical director and came to me seeking advice on if he should permit his paramedics to RSI people, I would only have to ask a few questions and probably not have to reply.

Q: "How many paramedics do you have?"

Q: "How many of them get at least 12-15 tubes a year to maintain proficency on the road or supervised in the OR?"

Q: "Are you comfortable enough with intubation to oversee the extensive QA and oversight this program will require to be successful?"

Q: "Are you willing to devote the time and effort in education and oversight for one of the most intricate EMS procedures known?"

Q: "You realize that the endgame of a failed tube and crash airway will result in the need for an immediate surgical airway?"

Q: "Are you comfortable are with that?"

Because if you are in for a penny, you are in for a pound on this one.

In all fairness, it sounds like this medical director recognizes his limitations. He is rightfully concerned about allowing RSI, and in all truth your replies haven't convinced me it is a good idea and I have nothing to lose by saying it should be allowed.

Depending on the answers to these questions I might even say you medical director is being extremely generous letting your service intubate at all. But I cannot speak for your answers.

LIke I said, probably not the support you are hoping for. But it sounds like it was a wise decision since I agree with what was said about physician involvement and oversight being the key to success.

 

[mso_kirk]

Perhaps I'm not explaining our demographics and circumstances well enough, but it probably doesn't matter in the long run. The person we have to convince is the doc, not the people here.

We are a busy municipal department that runs over 6000 ALS calls per year in an all career department. The reason that I was comparing us to surrounding agencies is that we have tiny volunteer departments surrounding us that run 100 calls a year that have protocols 100 times more advanced than ours (including RSI and even things like placing central lines) that we don't have. In my mind, clearly we have the need and our paramedics certainly have the knowledge base and education. In fact, we've trained most of the paramedics in these outlying areas.

In any case, we may have a trump card, so to speak. My chief advised me today he has a lead on a new doctor in town who has expressed interest in taking over the medical oversight role. Apparently he's a former medic and has already expressed concern at what our protocols are lacking. I guess if you can't get the top guy to give you what you want or need, you fire him and replace him with somebody who will.