Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

RSI Problems – What Oversight?

In High-risk EMS procedure gets a low level of oversight,[1] an article in the Star-Telegram, Danny Robbins writes about problems with airway management in EMS, specifically RSI (Rapid Sequence Induction, sometimes referred to as Rapid Sequence Intubation). Danny Robbins is a reporter who has won a bunch of awards, does his homework, and puts out a balanced piece of journalism. For one thing, he seems to recognize the problem as one of oversight more than skill.

It appears that the AP (Associated Press) has picked up the story and there are abbreviated versions of it turning up all over Texas. The rest of the country may add to the commotion. There is a pretty good Interactive graphic: RSI with the story. One of the other papers to pick up on the AP redistribution is the Houston Chronicle in their abbreviated story Health officials question high-risk intubation procedures. Ordinarily, I would not mention the derivative story, but they have a comment section at the end of the article that is interesting. EMS1.com also has the story and a comment section.

The Interactive graphic: RSI is a bit misleading without the rest of their course to explain the steps and the importance of all parts of the procedure. There are two problems that I have with it. On the slide for RSI step 3, the suggestion that cricoid “Pressure prevents stomach contents from entering the airway,” is not accurate. Dr. Bryan Bledsoe, interviewed in this article, wrote about the shortcomings of Sellick’s Maneuver, or cricoid pressure on EMS1.com. Sellick’s Maneuver — Not the Panacea We Thought.

Then on the slide for RSI step 6, the CO2 (carbon dioxide) detector is, in my opinion, not appropriate for RSI. There should be a requirement for waveform capnography for all RSIs. The plastic piece stuck on the end of the tube contains some litmus paper that changes color to indicate the presence of an acid – carbon dioxide. It loses its ability to change color, react to CO2, in the presence of moisture.

Breathe in some dry air and when you breathe out, it will be moist. If you have ever seen a couple fogging up a car, exhaled moisture and cool night air are the reasons for the condensation on the windows. For another example of this, take a color change CO2 detector, open the package and breathe through the detector. Don’t worry, you won’t be ruining anything of value. How many breaths does it take until the litmus paper stops changing color? In my experience, these detectors fail on real patients – due to moisture – at ridiculously high rates.

If you wish to monitor CO2, use waveform capnography. A site that explains this in a lot of detail is Capnography for Paramedics. Waveform capnography is capable of providing far more than just information about tube placement. If the patient has a sudden change in cardiac output, waveform capnography will spot that before any other assessment method will. The patient regains a pulse, the CO2 increases significantly. The opposite is true if the patient arrests. Having trouble differentiating between CHF and asthma, or emphysema? Waveform capnography can be a tremendous help.

But let me just offer my modest opinion. Anyone intubating without waveform capnography is asking for trouble. There are very few exceptions. The printout from waveform capnography is more trustworthy than any other method of confirming placement. Including direct visualization. If anything bad happens to the patient, produce a couple of printouts of good CO2 numbers and you can be certain that the tube was not in the esophagus at the times the recordings were made.

Or you can use some other method and try to explain that the tube must have moved after it was placed correctly. Almost always this is what medical professionals, in an effort to be accurate, call a lie. Without any form of documentation it is easy to claim that some form of magical intervention caused the tube to move. “Winged monkeys sighted over ambulance after successful intubation. On arrival at the hospital the tube was found to be in the esophagus. News at 11.”

Read this excuse of the paramedic “training coordinator” for AMR (American Medical Response), who committed the one most unforgivable sin of airway management – he did not recognize that the tube was in the wrong place.

The paramedic, Jeffrey Dektor, stated in a deposition that he made two attempts to intubate Cannon, the second time with the ambulance stopped at a parking lot.

He testified that he believed his first attempt was successful but tried again with a larger tube when he noticed that Cannon’s oxygen saturation levels continued to decline. During that attempt, he said, the tube became dislodged.

Asked why he didn’t use any form of carbon dioxide monitoring, even though it would have been available on the ambulance, he replied: “I cannot state why I did not.”

Twenty minutes passed from the time of Dektor’s first attempt until Cannon was successfully intubated at Presbyterian Hospital, records show.[2]

The medical director did not have any problems with this. There are not words strong enough for such indifference. How can a medical director be complacent about a medic who cannot recognize a misplaced tube? Another way of describing a misplaced tube is a suffocation device.

Everybody seems to put the blame on the medic. The medic was doing what he was taught by the medical director. The medical director probably mentioned the end tidal CO2 device, but perhaps did not stress it enough and clearly did not do enough continuing education. The biggest problem with this infrequently performed skill is the lack of competent oversight.

Robert Kowalski, who was the hospital’s director of emergency medicine as well as Hunt County EMS medical director at the time, confirmed in his deposition that he was the physician who finally intubated Cannon.

He stated repeatedly during the deposition that the matter did not cause him any concern.

Kowalski, who now lives in Cadillac, Mich., said recently he doesn’t remember the case well enough to discuss its details.

“It was not a paramedic we had problems with, I can tell you that, because I know the [paramedics] we had problems with, and he wasn’t one of them,” he said.(article)

So, this is not one of the bad medics Dr. Robert Kowalski continues to allow to treat patients, in spite of his knowledge of their danger to patients. This abuse of a patient’s airway was an action that Dr. Robert Kowalski did not have a problem with. Should we blame the medic or the medical director. This is another example of the dangerous Medic X that I wrote about here, here, here, here, and here. Not that I have an opinion on this mistreatment of patients by medical directors.

Dr. Robert Kowalski knows the medics he has problems with, but only seems to know that he did not identify this medic as one of the problem medics. Did Dr. Robert Kowalski know any of his good medics? Did Dr. Robert Kowalski have any good medics?

EMS personnel work in an environment that can be noisy, bumpy, and distracting. Waveform capnography helps you to deal with those problems that interfere with a good assessment. To not use waveform capnography is very bad risk management. To not have a problem with not using waveform capnography is beyond reckless.

There are courses that do an excellent job of teaching medics, nurses, and doctors to use RSI safely. RSI is a tool. A tool can be misused by any tool. RSI is not dangerous. A poorly planned for RSI is dangerous. A poorly trained for RSI is dangerous. Unskilled people performing RSI is dangerous.

Having well trained people, with excellent oversight, perform RSI is not dangerous.

Probably the best known of the courses to teach all aspects of airway management from BVM to RSI is SLAM (Street Level Airway Management). Their courses are not cheap.When it comes to airway management, there is no such thing as cheap. If you do not pay to train your people well (doctor, nurse, medic) you will end up paying more for it in the end. They also have a book available on their site and elsewhere. Danny Robbins interviewed one of their instructors , Gene Gandy, for the article.

The issue of whether RSI should be practiced by ground EMS was underscored by the Cannon lawsuit, which charged that American Medical Response never retrained the paramedic who attempted to intubate Patricia Cannon even after the company, based in Greenwood Village, Colo., became aware of the facts of the case.(article)

When I make a mistake, which happens more often than I would like, I follow up by doing what I can to avoid making that mistake again. According to this article, AMR (American Medical Response) apparently does not see inexcusable mistakes that kill patients as any kind of a problem. It is unfortunate that there were no criminal charges brought against AMR and their medical director – Dr. Robert Kowalski.

Poor performance of RSI is an indication of poor medical oversight. RSI is a tool. As a tool, it can be used properly, or it can be misused. If it is allowed to be misused, that is the fault of the medical director. How can anyone say that the liability should be placed anywhere else?

That is plenty of writing for now.

Other posts about this:

More RSI Oversight

Misleading Research

Intubation Confirmation

More Intubation Confirmation

RSI, Intubation, Medical Direction, and Lawyers.

RSI, Risk Management, and Rocket Science

My other posts on OLMC requirements and Medic X are:

OLMC (On Line Medical Command) Requirements Delenda Est

OLMC for President!

OLMC = The Used Car Dealers of EMS?

OLMC For Good Medics

Fun with explosives – NTG.


^ 1 RSI procedure gets low level of oversight in Texas
The Star-Telegram article is no longer maintained at their site, but EMS1.com has what I believe is the full article on their site. This was published in various abbreviated formats by various news organizations. The abbreviated articles usually were attributed to AP or some other news organization, rather than to Danny Robbins.
High-risk EMS procedure gets a low level of oversight at JEMS.com

Now apparently only available at Free Republic.

^ 2 All quotes are from the same article. The current link I am using is High-risk EMS procedure gets a low level of oversight at JEMS.com



  1. Once properly placed, I have found that the taping of certain EMT’s hand to the tube/patient provides the best defense against those damned winged monkeys and their tube-dislodging shenanigans. 😉

  2. Sometimes the best way to secure the tube is to keep your hand on the tube and the upper lip through the entire transport. Sort of a pinch between the cheek and gum, so to speak.Of course, you have to be able to put the tube in the right place to begin with.


  1. […] RSI Problems – What Oversight?, I briefly wrote about medical oversight problems. In the article, High-risk EMS procedure gets a […]

  2. […] Research Wed, 23 Apr 2008 04:11:00 +0000 By Rogue Medic 5 Comments In my last post, RSI Problems – What Oversight? I quoted from an article by Danny Robbins High-risk EMS procedure gets a low level of oversight. […]