EMS World

OCT 2015

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AIRWAY MANAGEMENT Gene: Rapid sequence intubation, or rapid sequence induction and intubation (RSI), and delayed sequence induction and intuba- tion (DSI) are techniques that can be life- saving. When your patient cannot protect his airway, endotracheal intubation is the preferred method for airway management, but if there is a gag reflex, you will have to sedate and paralyze him to accomplish that. Not all EMTs are allowed to practice RSI. Some states prohibit it, others restrict it, and many medical director physicians do not trust their medics to do it and therefore do not allow it. Jason: There's a reason for that. Many air- way studies have been done in systems that, like the paramedic above, aren't really pre- pared to do RSI well. As a result, many of them showed harm, particularly in patients who would have done well, such as those with head injuries. The medicine isn't dif- ferent out there in the field, so if these are patients we would intubate in the hospital without harm, there's clearly something at play besides the mere location of intuba- tion. Fortunately, newer data from New Zea- land shows that a good system can not only match hospital outcomes, but exceed them. 1 Kelly: Fun fact: Louisiana added RSI to the paramedic scope of practice based in large part on a proposal I drafted for our EMS certification commission in 1999. I wrote it following a call in 1997 that threatened to spiral out of control much like this one. I was 12 minutes from a rural hospital with a nonbreathing patient in a "can't intubate, can't ventilate" situation. As I prepared to do a surgical cricothyroidotomy—not in our scope of practice at the time—I dis- tinctly remember thinking, Boy, it sure was fun being a paramedic. I wonder what I'm going to do next. Fortunately, with a little creativity and a lot of luck, I managed to nasally intubate the patient instead, and a week later I had an RSI protocol on our medical director's desk. It took two years to percolate through the EMS bureaucracy, but eventually RSI was added to the Louisiana paramedic scope of practice. In researching that proposal, I encoun- tered a few eye-openers. First, relatively few EMS agencies that had RSI had an increased airway training requirement, and second, my own agency's intubation success rates sucked. Companywide, our first-pass suc- cess rate was 74%, but when you eliminated two medics, it jumped to 96%. Those two medics missed over half their intubation attempts and were the first medics we tar- geted for remedial training. And therein lies the problem with RSI: While it may make intubation easier in certain instances, the person wielding the laryngoscope has to have some serious airway chops before you even consider the procedure. You must consider the potential efficacy of the procedure based not upon the airway skills of your best medic, but those of your worst medic. I factored that consideration into my proposal to the state, and when we implemented RSI we had a yearly live intu- bation quota to meet, 24 hours of additional airway management training, and a clinical contract with a local teaching hospital to get our medics the additional live intuba- tion attempts as needed. In my opinion, agencies that utilize RSI must have more rigorous CQI, alterna- tive rescue airways and mandatory airway refresher training with a live intubation requirement. That becomes even more of a necessity given the low threshold for intuba- tion proficiency in recent paramedic curricu- la. Five successful intubations does not make you competent, it makes you dangerous. Gene: The key to successful RSI is plan- ning, preparation and practice. Planning involves education and training beyond simply being familiar with the techniques. It involves having set routines that crews will practice. The "pit crew" approach is excellent. If it works for NASCAR, why wouldn't it work for EMS? 50 OCTOBER 2015 | EMSWORLD.com 1601 W. Deer Valley Road, Phoenix, AZ 85027 • www.knoxbox.com • info@knoxbox.com Knox ® MedVault ® Drug Locker P r o t e c t y o u r D e Pa r t M e n t, S ta f f a n D I n V e n t o r y • neW – Two Sizes Available • Know Who Accessed Narcotics & When • neW – WiFi Remote Administration • Narcotic Access Control & Accountability 800-552-5669 • knoxbox.com r e D u c e e x P o S u r e t o n a r c o t I c S t h e f t For More Information Circle 31 on Reader Service Card

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