On Fri Feb 17, 1995, DAVID G. WARD wrote:
> >Are you concerned that RSI will be used
> >inappropriately (too often), or are you concerned about the
> >situation where intubation is still not successful even
> >after proper RSI?
> Absolutely. In pur present situation, we have little control over
> training and QA in our EMS. Short staffed and over worked (how unique)
> pediatric training has received the short stick. Too many diagnostic
> mistakes in lesser conditions lead me to have less than faith.
This is unfortunate. Making no judgments on the
pre-hospital care providers that you deal with, it is true
that standards of training and performance vary from state
to state (and even within states). You also need to admit
that proficiency between providers (both in- and
pre-hospital) varies wildly.
> >The reason I ask is that I want to understand where the
> >concerns in the in-hospital medical community lie. Is it
> >just that paramedic's aren't sufficiently trained to handle
> >RSI and the complications / side-effects, or is it because
> >it is occuring in an isolated environment (outside of your
> I'm not an anesthesiologist,
Nor do I play one on the Internet... :-)
> but my understanding (go ahead burn me) is that
> they are trained, retrained, supervised directly in a way that makes street
> scene RSI out of control of everyone except the individual on doing the
Of course. That's the whole focal point about pre-hospital
care. It's the issue that always feeds the RN vs. Paramedic
flame wars. "In the street, no one can hear you scream." (my
apologies to "Alien"). There is no overhead paging for
help. There is nobody down the hall. It's loud, dirty, often
dark and always less than ideal conditions.
Besides your partner, there is no backup (don't get me
started about systems that don't run two Paramedics on a
truck). This may be a good argument for not doing RSI in the
However, I think that the good EMS systems can implement RSI
correctly. I know many Paramedics that can intubate far
better than most EP's and many anesthesiologists
(IMHO). It's all a matter of practice. For a system that
implements RSI, each use should be QA'ed. That will be the
best way to deter providers that are too eager to "play with
the new skill". I'm sure you find many young residents that
are all too eager to do a lumbar puncture on every kid with a
sniffle. Its all a matter of proper instruction and
Regarding the failure to intubate even after RSI, we would
do what you would do. Bag. Bag. Bag.
> Of lines placed in the field, I find about 25% "out" on arrival in the ED. IO
> access is less successful. Since the EMS has pushed drugs through these "out"
> lines by the time they arrive, how are we to get the RSI agents on board?
This is bad. This would not be acceptable in the system that
I work in. You also need to understand that we need to move
the patient quite a bit to get them to your door, and lines
do get pulled out. If I had 25% of my lines falling out you
could be sure that I would start carrying duct tape. I've
never done an IO before (but then, I'm a new medic), so I
don't know how hard they are to keep in. It is an optional
skill here in Mass. Maybe you could help your pre-hospital
providers by showing them better / more successful ways of
doing IO's. I don't know of any medics that claim to do them
What I'm waiting to hear is stories from systems that do
have pre-hospital RSI. I want to hear about situations where
RSI was useful, and where intubation without RSI was not
possible. I also want to hear stories about problems with
RSI in the field. This is where we can start making more
informed judgments about the usefulness of this technique.
Thanks for taking the time to respond.
PS. I'm leaving OSF next week. If you want to mail to me
directly, use "[log in to unmask]" or
"[log in to unmask]". As of right now, both are active
and will be for some time to come.
John Rousseau, NREMT-P Internet: [log in to unmask]
Open Software Foundation UUCP: uunet!osf!rousseau
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Cambridge, MA 02142 http://riwww.osf.org:8001/~rousseau