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

- Rogue Medic

Comment on Irresponsibility and Intubation – The EMS Standard Of Care


I wrote about the petition to protect paramedic incompetence in Irresponsibility and Intubation – The EMS Standard Of Care

Nathan Boone responded with the following comment

You’re forgetting about the rural medic out there.


No. I am not.

Are you suggesting that bad airway management for a longer period of time is less harmful than bad airway management for a shorter period of time?


Where we are with our patients for more then a hour, not 5 mintues.


The harm from incompetent airway management does not depend on distance from the hospital. Intubation even kills patients in the hospital.

You may believe that the efficacy of voodoo is directly related to the distance from the hospital, but it appears to be only your belief that increases.

Voodoo does not work, regardless of the distance from the hospital.

If the paramedic cannot manage an airway, the paramedic should not be permitted to intubate.

Sometimes air- craft isn’t available if its raining or on another call.. You want us to use a bvm and take chance of filling the patients stomic up for over a hour.. Yes we can be extremely careful and do everything in our power not to fill the stomic but there’s some patients out there who have difficult airways where bagging can be extremely difficult and or impossible.


Give incompetent paramedics dangerous tools to try to manage difficult airways because of distance? Wouldn’t it be better to try to make them competent – or to limit intubation to competent paramedics?

Intubation and BVM (Bag Valve Mask) are not the only forms of ventilation.

Rsi does save patients in rural areas, we need intubations..


Maybe. Maybe not. Maybe RSI kills more patients than it saves.

Actually, what I mean to write is, Maybe paramedics using RSI kill more patients than they save.

If you want to claim otherwise, prove it with high-quality research.

Unless you can provide high-quality research, your plastic airway religion is just another alt-med scam.

If your patients are important, then you need to demand that we find out what is best for the patients.

Do I believe that Rsi is risky and their is some medics out there who would rather make the patient more hypoxic then before until they give up and go to a secondary airway..absolutely.. But to take it away from Rural Medics when we can have anything to burn patients to anaphylactic reactions and to take our ONLY definitive airway;away from us..


You seem to think that RSI (Rapid Sequence Induction of anesthesia) becomes less risky the farther you are from the hospital.


Incompetence for a longer period will be expected to cause more harm.

Sometimes the incompetence of the paramedic doesn’t kill the patient.

Trauma patients were significantly more likely to have misplaced ETTs than medical patients (37% versus 14%, P<.01). With one exception, all the patients found to have esophageal tube placement exhibited the absence of ETCO2 on patient arrival. In the exception, the patient was found to be breathing spontaneously despite a nasotracheal tube placed in the esophagus.[1]


The patient clearly did not need intubation.

As with the crash of Trooper 2 in Maryland, the survival of the patient for hours in the woods, in the rain, following the helicopter crash that killed all of the other healthy people on board, was clear evidence that there was no reason to send this patient to the trauma center by air.

The same argument was provided by people, including Dr. Thomas Scalea, the head of Shock Trauma – If you don’t let us have our toys, people will die![2]

The rate of helicopter transport of trauma patients was dramatically cut.

That was almost a decade ago and we are still waiting for the dead bodies.

I expect that the same failure of prophesy will occur, when incompetent paramedics are prevented from intubating.

I expect that the fatality rate will decrease, when incompetent paramedics are prevented from intubating.

I think you’re out of your mind.


Many religious fanatics do.

In the city, I can maybe defend you. But the studies need to be done out in the sticks as well. I believe that we should have to go outpatient surgery every year or 2 or have number set of how many we need in that time period successfully to keep our skills sharp..


Every year or two?


You don’t want to be taken seriously, do you?

This is something that requires a lot of skill and practice, so I get just a tiny bit, every other year. Trust me with your life.

After a Rsi and I have no one in the back but myself for over an hour.., I can place the patient on a vent and care for my patient. If RSI is taken away. I loose the capability to monitor my patient, and would be more focused on bagging my patient, or making sure the secondary away isn’t failing and I’m filling the stomic on the vent, because it can happen.


It is just a staffing issue.

That is different.

Competence isn’t needed when you are in the back by yourself.

Why are you opposed to competence?

Where is a single reasonable argument that intubation improves outcomes?

Where is a single reasonable argument that rural paramedics have an intubation success rate that is above 95%?

Even 95% means that some of your patients don’t end up with a properly placed endotracheal tube. What do you think happens to them?

Does your EMS agency have a better than 95% intubation success rate?

If you can’t manage at least 95%, why do you believe you can manage intubation?

Is each intubation on video, or do they just believe whatever you tell them?

If you want to be taken seriously, these are just some of the essential points to address.

This is not a new topic. You might also read the series below:

In Defense of Intubation Incompetence – Part I

In Defense of Intubation Incompetence – Part II

In Defense of Intubation Incompetence – Part III

How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part I

How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part II


[1] Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768 [PubMed – indexed for MEDLINE]

Free Full Text PDF

[2] Helicopters and Bad Science
Thu, 09 Oct 2008
Rogue Medic


Irresponsibility and Intubation – The EMS Standard Of Care


There is a petition to save EMS intubation, but it claims to be a petition to save patients. The petition is not to save patients.

Image source
Details here and here.

The petition states that its intent is to protect patients, but it does not provide any evidence. It only makes the same claims that every other quack makes to promote his snake oil.

We are worse than homeopaths, because homeopaths do not actively harm patients by depriving patients of oxygen, as we do when we intubate.

We are the quack, witch doctor, homeopath, horseshit peddlers Dara O’Briain is describing.


Today we are possibly facing the removal of the most effective airway intervention at our disposal as paramedics, endotracheal intubation.[1]


Most effective?

There is some evidence that intubation can be – in limited situations, by highly trained, competent people – beneficial. There is also plenty of evidence that intubation is harmful. It is easy to kill someone by taking away the patient’s airway.

Most effective?


This petition does not mention evidence, so it has no credibility when it comes to claims of whether intubation is effective. This petition expects us to believe in a faerie tale of magical improvement with intubation. This petition wants us to clap for Tinkerbell, because If we believe hard enough, it just might come true. Grow up.

Please sign this petition so that these patients have a chance to live[1]


Prove that requiring higher standards for intubation would take away a patient’s chance to live.

Prove that intubation improves outcomes.

This is a petition to keep standards low for paramedics.

This petition does not mention competence, or even what is involved in competence, because this petition is opposition to competence.

This is the Protect Incompetent Paramedics from Responsibility Petition.

Responsibility is for professionals. In EMS, we reject responsibility.

We are more concerned with whether our shoes are shiny, than whether we are harming, or helping, our patients. The reason EMS exists is to improve outcomes for patients.

We don’t deliver competent care, but only the appearance of competence. We are medical theater, putting on a fancy show. The TSA (Transportation Security Administration) is the same – all appearance and no substance.

Most effective? Maybe intubation is the most effective theater.

The outcomes of our patients are affected, but we refuse to learn if we are helping, harming, or doing equal amounts of harm and help.

We actually oppose learning. We are willfully ignorant – and proud of our defiant stand for ignorance.

How much hypoxia do we cause in our attempts to place the so called gold standard? The actual gold standard is helping the patient to protect his own airway, but who cares what’s best for the patient? Not those who sign the petition.

How much vomiting, and aspiration, do we cause?

How much airway swelling do we cause?

How many airway infections do we cause?

How much harm do we cause?

We don’t know. We don’t care. We oppose attempts to find out.

We are EMS and we believe that our actions should be protected from examination, because we are beautiful and unique snowflakes who demand our participation trophies without doing real work required to be competent.

Go ahead, snowflakes, demonstrate your incompetence by signing the petition, because this protect intubation petition is really a protect incompetence petition.

If we want to continue to intubate, and we want to improve outcomes for our patients, we need to demonstrate that intubation by EMS provides significant benefit and which patients are most likely to benefit. We can’t do that because we don’t care enough about our patients.

Brian Behn has a different reason for not signing the petition for low standards – Why I am Not Signing The Petition About Intubation.

Dave Konig also comments on the petition for low standards – Is ET Intubation Joining Backboards In Protocol?


[1] Allow paramedics to continue to save lives with endotracheal intubation!
Anthony Gantenbein United States
Petition site


The cricoid cartilage and the esophagus are not aligned in close to half of adult patients


Cricoid pressure has been used to keep the stomach contents in the stomach, and out of the airway, since Dr. Brian A. Sellick wrote about it in 1961.[1] The problem is that the evidence does not show that it works.

This study looked at cervical CT (Computed Tomography) scans to see what anatomic relationship exists between the cricoid ring and the esophagus in a group of patients with some sort of reason to have a neck CT. These are people with necks that may have some abnormalities, but they do give us some information on whether cricoid pressure should be expected to work and how cricoid pressure would be expected to malfunction. About half of the CTs showed masses displacing the esophagus or cricoid ring and were excluded.

Lateral esophageal displacement was seen in 49% (25/51) of the CT images. Of those displaced, 92% were displaced leftward and 8% were displaced right-ward. When present, the length of displaced esophagus relative to the midline of the cricoid was 3.3 mm ± SD 1.3 mm (range 1.4 mm to 5.7 mm).[2]

Of the patients without masses displacing the anatomy, half of patients still did not have the esophagus directly alinged behind the cricoid ring.

Based on anatomy and common sense, an assumption has been made since Sellick introduced the technique of cricoid pressure in 1961: the esophagus lies directly posterior to the cricoid. While this relationship has been assumed to be true in the majority of the population, we have identified some degree of lateral esophageal displacement in 25 of 51 subjects.[2]

The displacement is not large, but how much displacement is required for it to be significant?

The purpose of cricoid pressure is to prevent gastric contents from entering the airway (and maybe to improve glottic view), but does it work? This study only looked at the anatomy, but we have other reasons for doubting the efficacy of cricoid pressure from other studies.

FIGURE 2 Computed tomography of the neck and line drawing demonstrating 1.5 mm of leftward lateral esophageal displace-ment. AJ = anterior jugular vein; C = carotid artery; Cr = cricoid cartilage; E = esophagus; IJ = internal jugular vein; SCM = stern-ocleidomastoid muscle; Th = thyroid gland; VB = vertebral body.[2]

Although there is only 1.5 mm displacement, would pushing straight back on the cricoid ring obstruct that esophagus?

However, previous reports of its failure to prevent regurgitation have never been explained adequately. Its use has also been associated with serious complications including distorted laryngeal view, increased difficulty with intubation, laryngeal trauma, cricoid fracture, and esophageal rupture.

Distorted laryngeal view?

All inadequately studied procedures should encourage caution.

A maneuver that makes it even harder to place an endotracheal tube should have received much more examination in the first four decades of use.


[1] Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia.
Lancet. 1961 Aug 19;2(7199):404-6. No abstract available.
PMID: 13749923 [PubMed – indexed for MEDLINE]

[2] The cricoid cartilage and the esophagus are not aligned in close to half of adult patients.
Smith KJ, Ladak S, Choi PT, Dobranowski J.
Can J Anaesth. 2002 May;49(5):503-7.
PMID: 11983669 [PubMed – indexed for MEDLINE]

Page with link to Free Full Text Download in PDF format from Springerlink.

Smith KJ, Ladak S, Choi PT, & Dobranowski J (2002). The cricoid cartilage and the esophagus are not aligned in close to half of adult patients. Canadian journal of anaesthesia = Journal canadien d’anesthesie, 49 (5), 503-7 PMID: 11983669


How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part II


Continuing from Part I,

Do we accurately report errors and success with pediatric RSI (Rapid Sequence Intubation/Induction)?

Should we trust our memories?

The leading indications for tracheal intubation were a failure of oxygenation (22 subjects) or ventilation (20 subjects), followed by head injury (17 subjects), seizure (16 subjects), apnea caused by infection (12 subjects), and altered mental status (11 subjects). None of the 114 subjects died in the ED; 5 died during the corresponding hospitalization.[1]

There is good variety among the patients studied, so there should not be any claims that this just looked at other pediatric patients. This appears to be representative.

All but 1 subject were tracheally intubated by the fifth attempt (1 required 9 attempts) in the ED.

. . . .

No rescue methods, eg, laryngeal mask airways, were used for any subject and no surgical airways were performed.[1]

1 required 9 attempts

That is so unreasonable, that it distracts us from the rest of the sentence –

All but 1 subject were tracheally intubated by the fifth attempt

5 intubation attempts are not considered to be unreasonable.

A patient doesn’t require 9 attempts. The patient is abused by 9 attempts by doctors who refuse to manage the airway by other means.

Taking 5 attempts, without switching to other means, is similarly unreasonable. The difference appears to be that the tube coincidentally ended up in the trachea in 5 moves or less.

Original image credit.

Hold onto this nut, while I take a shot at that intubation.

But you’re bind – and a squirrel!

But nothing – I can probably intubate in fewer than 9 attempts.

Well, we don’t know about that particular patient, but we do know that 31% of patients had more than one adverse effect.

52% intubation success on the first attempt. I could almost make an argument that there are two holes, so the probability is 50-50 regardless of training, but that is not the way probability works. that is just the appearance – if we were to judge a book by its cover. Let’s not be that foolish.

In their defense, some of these unsuccessful intubations were right mainstem intubations, which are providing some oxygenation and ventilation and (if correctly identified) only need to have the tube pulled out a small distance. A mainstem intubation is significantly less of a problem than an esophageal intubation.

Seventy subjects (61%; 95% CI 52% to 70%) experienced at least 1 adverse effect during RSI, and 35 (31%; 95% CI 23% to 40%) experienced more than 1.[1]


61% at least 1 adverse effect.

31% more than 1 adverse effect.

The depth of desaturation was available for 29 of the 38 subjects with an episode identified during RSI. Among these 29 subjects, 22 (76%) had desaturation to below 80% and 10 (29%) to less than 60%.[1]


10 patients had desaturation to 59% or less.

They give this as 29%, but that is 29% of the patients who desaturated. These are actually 9% of all RSIs.

One out of every 11 patients had SpO2 drop to 59% or less.

While hypoxia alone is not harmful, these patients had other medical problems that would probably not do well in the presence of hypoxia.

I usually have to tie a patient down and place a pillow over the airway to drop their sat into the 30s, 40s, or 50s.

Did anyone hit the 20s?

We don’t know, but if we assume that they hit 60% and stopped, we are lying to ourselves. Less than 60% does not include 60%. Also, this is not a PaOO2 of less than 60 torr, which also indicates hypoxia, just a much milder hypoxia.

An SpO2 of 59% or less is an adorable little Smurf, but this is not a cartoon and I don’t like Smurfs.

Was there any other bad news?

4 patients with some hypotension, 4 patients with some bradycardia, and 2 patients with some CPR.

How much of this would have been avoided by a maximum number of intubation attempts (2?, 3?) before requiring use of an extraglottic airway?

We did not identify any occurrences of aspiration, pneumothorax, or pneumomediastinum for any subject.[1]

That is some good news.

Focused review of the written record revealed marked variation in the documentation of important aspects of the RSI process, as well as notable discrepancies with findings from video review.[1]

Is anyone surprised that the documentation of these adverse events is more optimistic than what really happened?

There is more to write about this, because this is an important paper, so there will be at least a Part III.


[1] Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.
Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR.
Ann Emerg Med. 2012 Sep;60(3):251-9. Epub 2012 Mar 15.
PMID: 22424653 [PubMed – in process]

Free Full Text from Annals of Emergency Medicine.

There will probably be a podcast by David H. Newman, MD, and Ashley E. Shreves, MD. covering this paper, but the current issue podcasts usually do not get posted until a few weeks after the current issue. Annals Podcast page.

Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, & Mittiga MR (2012). Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Annals of emergency medicine, 60 (3), 251-9 PMID: 22424653


How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part I


Which patients cause most of us the most anxiety?


Which patients do most of us least want to injure?


What skill do we tend to brag about as if we are much better than our actual success rates?

IVs, 12 lead ECG interpretation, and even driving are up there for EMS, but the biggest exaggeration is probably for intubation.

Combine all of these and move to the ED (Emergency Department) and the skill most inaccurately represented as positive may be pediatric intubation.

Is this because we unintentionally remember only some of our errors in managing pediatric airways?

An article in the current Annals of Emergency Medicine suggests that the errors reported are much lower than the actual number of errors during pediatric RSI (Rapid Sequence Intubation/Induction).

These studies likely underreport the frequency of both first-attempt failure and adverse effects because of voluntary self-reporting or the limitations of chart review. Our clinical experience and quality assurance efforts suggested that failed first attempts and adverse effects occur more commonly than reported for pediatric emergency patients undergoing RSI.[1]

Are they right?

The goal of our study was to accurately and thoroughly describe the process, success, and safety of RSI for patients in a busy pediatric ED. Using video review, we specifically sought to determine the frequencies of first-attempt success and adverse effects for patients undergoing RSI in a pediatric ED.[1]

The video does not lie – at least it is less motivated to lie.

Video review was the primary source for all study data; if a data point was unavailable or unclear from the video, it was obtained from the medical record or consensus review. If not recorded in the medical record, the data element was considered missing for that subject.[1]

None of the doctors reviewed their own patients.

In this ED, critically ill or injured patients are managed in one of 4 resuscitation bays by a designated team, which includes emergency physician and nurse team leaders, a pediatric or emergency medicine resident, several bedside nurses, and a respiratory therapist. The physician team leader is either board certified in pediatric emergency medicine or a second- or third-year fellow in pediatric emergency medicine. For critically injured patients, the team also includes a general surgery resident, a surgical fellow or attending surgeon, and providers from anesthesiology and critical care. During the study period, no standard protocol for the practice of RSI was in place and video-assisted laryngoscopy was not routinely performed.[1]

These should be the calmest, coolest, most collected of the people intubating children, so the tendency to unintentionally under-report errors may be least with these doctors.

In other words, we should expect that other hospitals, and especially EMS, should be much more stressed out and much less accurate in their reporting of errors.

The primary outcome was success of intubation with the first attempt, which included all insertions of the laryngoscope blade with the intent to intubate, even when there was no insertion of the tube, but they do not explain how they determined intent.

If I place the laryngoscope in the airway, how does anyone know what my intent is?

If I am holding the tube in my hand, this may just be a reasonable way to be prepared for an unexpectedly easy intubation, even though I had not been intending to place the tube. This is much more likely to be the case when the patient has not received RSI medications. The best reason for taking a look without the intent of intubating is before the RSI drugs are given, because the main reason to look first is to see if there is something that would make RSI especially dangerous in this patient.

If I take a look in the airway and decide that intubation with RSI is not the best way to manage this patient’s airway, is that a failed attempt. According to this study – only if I have pushed RSI drugs.

However, suppose that I have pushed RSI drugs and notice something I had not noticed earlier. If I take a look after pushing the RSI drugs, but place an extraglottic airway, that is a failed attempt. If I never use the laryngoscope, that is not a failed attempt, but it is also not an intubation. This does not appear to have been the case for any patients, but it is a good idea to be prepared to use Rapid Sequence Airway.[2],[3]

Our secondary outcome was the occurrence of adverse effects, measured as the number of patients with video evidence of 1 or more adverse effects during RSI.2, 16 [1]

Unfortunately, they had to rely on statements about the adverse events, except for the obvious (such as CPR), in order to recognize adverse events, because they did not have continuous records of the information on the monitors.

If the patient has an adverse event, but nobody notices or it is corrected without comment, the adverse event did not happen, at least as far as this study is concerned. RSI-related adverse events are unlikely to resolve spontaneously, so that should not affect the outcome, but a nurse, or doctor, could easily correct something and not state it out loud, especially if the people working together are accustomed to communicating without stating the obvious.

Here is the way they dealt with these limitations –

We attempted to identify the following adverse effects with only video review: nonairway intubation, inadequate paralysis (vocalization, biting, or general movement at the first attempt), vomiting, and endotracheal tube obstruction. The following adverse effects were identified with the aid of the medical record: mainstem bronchial intubation (confirmatory chest radiograph), aspiration (foreign material visualized in the airway or a combination of vomiting and new infiltrate on chest radiograph), pneumomediastinum, pneumothorax, and dental/oral injury.[1]

In Part II I will discuss the results. Some are good. Some are not so good.


[1] Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.
Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR.
Ann Emerg Med. 2012 Sep;60(3):251-9. Epub 2012 Mar 15.
PMID: 22424653 [PubMed – in process]

Free Full Text from Annals of Emergency Medicine.

There will probably be a podcast by David H. Newman, MD, and Ashley E. Shreves, MD. covering this paper, but the current issue podcasts usually do not get posted until a few weeks after the current issue. Annals Podcast page.

[2] Rapid Sequence Airway (RSA)–a novel approach to prehospital airway management.
Braude D, Richards M.
Prehosp Emerg Care. 2007 Apr-Jun;11(2):250-2.
PMID: 17454819 [PubMed – indexed for MEDLINE]

[3] Rapid sequence airway vs rapid sequence intubation in a simulated trauma airway by flight crew.
Southard A, Braude D, Crandall C.
Resuscitation. 2010 May;81(5):576-8. Epub 2010 Feb 18.
PMID: 20171002 [PubMed – indexed for MEDLINE]

Average time to secure the airway was 145 s shorter in the RSA group (95% CI: 100.4-189.7). Lowest oxygen saturation was 4.8% higher (95% CI: 2.8-6.8) in the RSA group. During RSI, FC placed a back-up airway 47% of the time.

Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, & Mittiga MR (2012). Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Annals of emergency medicine, 60 (3), 251-9 PMID: 22424653


What should be the rules for safe drug administration – Part III

I mentioned and the right time in Part I and the right dose in Part II.

Karen Sugarpants commented that there are at least ten rights. This isn’t about a number, but about what is right for the patient. As long as we understand the pharmacology of what we are giving and we are reassessing our patients, we should do what is right for each of our patients.

We are taught 10 rights at my college:
Just thought you’d be interested.

What about the right frequency?

In How to Torture Patients, that is the problem. The long-lasting paralytic is being given with a sedative that is not even close to long-lasting.

And nothing is being given for pain.

CombatDoc commented –

Of 3% of patients given fentanyl that became hypertensive, could it be possible that they were under medicated?

Changes in vital signs should always encourage reassessment, especially when we are giving a variety of medications. An improvement in vital signs does not necessarily mean that the patient is getting better, or that we are doing a good job medicating the patient. We need to reassess to try to figure out what we are doing right, or what we are doing wrong that is coincidentally producing better looking numbers on the monitor.

If the patient is experiencing extreme stress, we should find out what is going on.

I have said for years, since Vec and Roc have been added to ambulances with the RSI protocols, EMS needs a long acting sedative or dissociative that is safe to use with hypotension. Versed is good when hypotension is not an issue and Ativan with Fentanyl is adequate with hypotension but, Ketamine or Propofol is better.

Vec is vecuronium (Norcuron), Roc is rocuronium (Zemuron), Succs is succinylcholine (suxamethonium in Commonwealth countries, brand name Anectine) and RSI is Rapid Sequence Induction/Intubation.

There are many possible medication combinations that will work for the chemically paralyzed patient. If we have used RSI to intubate, we will assess (and continually reassess) placement of the tube. Why do so many of us not reassess what we are doing with medications?

Why should we give a drug that lasts a long time with a drug that wears off quickly?

Part of the right frequency should be the right combination.

Another right. I think I took it to eleven. 😳

It is easy to remember the different duration of different drugs in an environment that is not stressful. When treating a patient who has just been emergently paralyzed and intubated as just the preparation for everything else, the environment can be stressful. Reassessing can remind us of things we have forgotten, but maybe we should avoid these reminders by being better prepared with combinations that go together. Similar onset. Similar duration of effect.

That is not even considering the very real problem of the patient’s pain. What are we giving for pain?

We have Succs for the intubation and in all reality if we had the proper meds for long term sedation we would not need to use our Vec but, medical directors would rather give us half the tools for patient care than allow us to properly treat the patient. Makes no sense to me that I can use a long acting paralytic but, not a short or long acting sedative that is appropriate for patient condition.

Protocols have some big problems. One is that the people who write them often do not have to follow them. Often, the paramedics involved in writing protocols are members of the QA/QI/CYA committee and may have agenda that do not place patient care anywhere near the top of the list.

There are dramatic differences among protocols in different systems. Some use the protocol as a ceiling, above which no medic may rise, regardless of whether there is a dominus vobiscum from the online medical command permission physician. Protocols that discourage recognizing and treating this patient’s condition, rather than treating this patient as if all patients should be made to fit the protocol.

Kelly Grayson writes about this in his excellent Meditations on Being an EMS Cowboy, which is not just relevant to EMS.

At least, that’s the theory. All too often, the protocols are written in such a way that the strongest medic is forced to lower his level of care to that of the weakest paramedic. The protocols provide a ceiling of care, rather than a floor. So it occasionally becomes necessary to decide, in the best interests of the patient, when to deviate from said protocol.

Highlighting is mine. Unfortunately, we cannot use tools we do not have. We are always going to be limited to what is practical to put into a drug bag/box, but we should have drugs that play well together. Just because drugs are compatible in the same IV line, does not mean that they work well for the patient.


Does RSI Protect Against Aspiration of Stomach Contents

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

One of the reasons we use RSI (Rapid Sequence Induction/Intubation) is to protect the airway from aspiration of stomach contents, blood, debris, and other things that might make their way into the lungs and make the patient’s already very bad day, very much worse.

Does RSI protect against aspiration of stomach contents?

We are presented with a patient who appears to need airway management.

You believe that tracheal intubation to isolate the respiratory from the gastrointestinal tract is considered to be the optimum method to prevent aspiration in at-risk patients. Limiting the time that the airway is unprotected during the induction of anesthesia is intuitively advisable and the practice of rapid sequence induction (RSI) with cricoid pressure is widely accepted as the standard of care in this setting.1 [1]

When the word intuitively is used in a medical journal, that is a bad sign. The concerns about protecting the airway for anesthesia are minor concerns compared to those faced by EMS in the much less controlled prehospital environment.

As you contemplate the intervention, you wonder what evidence is available to measure the impact of RSI on the incidence of aspiration, how it should best be performed, and what is its risk-to-benefit profile.[1]

Certainly, we should have considered this before beginning RSI, but this is a way of involving us in the care of a patient. I imagine Theodoric of York pausing during an intubation to ponder this. Naaaah!

Does this –


Image credit.


protect against this?


Image credit.

A search of the available research (2007) was performed and –

It was readily apparent that any conclusions addressing the primary question would be inadequately supported due to the limited number of studies, most of which were retrospective in nature. As well, the working definition of RSI used by researchers was variable and many of its component parts were of unproven or questionable merits.[1]

This is not a review of whether EMS should use RSI, but of the evidence that RSI works in the ideal environment of the OR (Operating Room).

For the purpose of our review and discussion, we defined RSI as it would be conventionally carried out by practicing anesthesiologists. The technique evaluated includes preoxygenation, rapid administration of predetermined doses of both induction and paralytic drugs, concurrent application of cricoid pressure, avoidance of bag and mask ventilation, and direct laryngoscopy followed by tracheal intubation.[1]

How many of us avoid the use of BVM (Bag Valve Mask) ventilation for preoxygenation?

If we have paralyzed the patient’s muscles to prevent stomach contents from being propelled out of the stomach, haven’t we also paralyzed the muscles that may prevent oxygen from entering the stomach?

If we are using BVM ventilation before giving paralytics, and some of that oxygen is forced into the stomach by BVM, aren’t we providing more pressure to propel stomach contents into the airway?

Can cricoid pressure decrease the amount of oxygen that enters the stomach by positive pressure ventilation?

However, a number of factors make it difficult to employ aspiration as the outcome variable in studies assessing the impact of RSI. Aspiration is rare and very large numbers of patients would need to be studied to assess the impact of RSI on its occurrence.[1]

Is aspiration rare because RSI works to protect against aspiration?

Is aspiration rare regardless of RSI?

For practical reasons, surrogate outcomes, such as ease or success of intubation with RSI, are the most commonly reported, with successful tracheal intubation being the single most common outcome reported in clinical evaluations of RSI protocols.[1]

Surrogate endpoints are great for the initial assessment of a treatment, but do not tell us what we need to know about whether what we are doing is actually helping patients, is of no benefit to patients, or is harmful to patients.

We need to do better than just following some old wives’ tales from a time when far less was known about patient care.

Further, many of the reports assessing RSI outcomes are simulations of RSI conducted in healthy elective populations who may not be representative of the cohorts of patients typically subjected to RSI.[1]

In EMS, we should not be treating many healthy patients.

EMS is supposed to be providing not elective airway management, but necessary airway management.

Following our analysis of the literature it was apparent that there was no evidence available that would allow the following question to be answered: “Does RSI reduce either the incidence or the adverse consequences of aspiration during emergency airway management?” In fact, there is no study, randomized, controlled, blinded, or otherwise, that measures the impact of any intervention on the incidence of aspiration, nor is there likely to be a statistically meaningful study conducted on this issue.[1]

This seems to prevent the study of RSI for aspiration prevention by anesthesiologists, but maybe it is still something that EMS can examine.

We are fortunate in that our patients tend to be much more nauseated by us. At least they tend to vomit on us, or around us, much more often than they do around others (maybe oncologists or gastroenterologists see more vomit than EMS).

Can we show that the attempts to prevent aspiration are more than just placebo?

How rare is aspiration in EMS?

How many patients might benefit from RSI to prevent aspiration?

Do we want to know if we are harming our patients?


[1] No evidence for decreased incidence of aspiration after rapid sequence induction.
Neilipovitz DT, Crosby ET.
Can J Anaesth. 2007 Sep;54(9):748-64. Review.
PMID: 17766743 [PubMed – indexed for MEDLINE]

Link to Abstract and Free Full Text PDF Download from Can J Anaesth

Assuming that the incidence of aspiration during emergency surgery is 0.15%,13 a strategy that would simply reduce the incidence by 50% would require a study of approximately 50,000 patients to confirm that benefit (one-tailed hypothesis for improved outcome, α = 0.05, β = 0.20). Thus, the strength of any recommendation favouring the use of RSI for the prevention of aspiration would be Grade D.[1]

All we need to understand about the evidence grading system is that D is bad. The grades do not go any lower than D. D includes expert opinion, which is the least reliable evidence that should ever be considered. Expert opinion is what is behind one of the worst abuses of patients – the Standard Of CareI’m doing it because everyone else is doing it, not because there is any good reason to believe it is good for the patient.

Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation … Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way:

Science is the belief in the ignorance of experts.Richard Feynman.

Neilipovitz DT, & Crosby ET (2007). No evidence for decreased incidence of aspiration after rapid sequence induction. Canadian journal of anaesthesia = Journal canadien d’anesthesie, 54 (9), 748-64 PMID: 17766743


Comments from drastic on Intubation Improvement

In If We Were Really Serious About Intubation Quality, I wrote –

If We Were Really Serious About Intubation Quality – we would require that each medic be intubated by a different medic at least once a month.


In response, drastic wrote a few comments.

The risks of intubation are such that we only perform it when it is likely to prevent someone from dying. When people are so sick that the risk of them dying is greater if we do nothing than if we intubate. Every single procedure carries a risk and intubating people who don’t need it is reckless!


People are intubated for elective procedures in controlled settings, so I do not accept the life or death requirement. There are several videos of awake intubation for, demonstration purposes, available.[1],[2]


I agree that something may need to be done but I don’t think this is the answer.


We can always discuss other possibilities. What is most important is that we eliminate the routine poor mangement of airways that is so common in so many places.

In Australia we have a tiered system. The paramedics trained to perform intubation (MICA paramedics) are likely to perform it often and as such are well practiced. If non Mica paramedics were trained in intubation they would not need to do it enough to maintain the skill. MICA Paramedics in Australia achieve an almost 100% success rate with intubation, without needing to intubate each other.


In the US, we tend to have a view that more medics are better, but let me rephrase that –

Less experience is better.

We have some places where half a dozen US paramedics will show up to treat a single uncomplicated patient.

US paramedic is the equivalent title to the Australian MICA paramedic, but usually without the equivalent experience, probably without the equivalent education, yet still with the authorization to intubate. In intubation studies, US paramedics have success rates that vary from 52%[3] to 95.5%.[4]

The highest success rates are in tiered response systems, not in the everybody on the truck is a medic systems.

I responded with a request for information about success rates and drastic replied with –

Here is one paper giving MICA flight paramedics a 97% success rate.



While we expect that flight crews will have excellent intubation success rates, that is not always the case[5]

Here is another giving MICA paramedics a 97% success rate, and also reporting on better patient outcomes after paramedic intubation when compared to in hospital intubation..



This is the paper I began to write about on Thursday.[6],[7] I was fortunate in being able to obtain a copy from drastic. Thank you.

This is a study of some excellent intubation by ground paramedics using RSI (Rapid Sequence Induction/Intubation) and deserves a lot of attention. 97% success rates. Zero unrecognized esophageal intubations. Zero crichothyrotomies. I will be writing a lot more about this.

What are they doing right that so many others are not (based on published studies)?

The results of another very recent study with a larger sample size were presented at the Student Paramedics Australasia Conference a couple of weeks ago and cited an even higher success rate, but i don’t think it has been published yet.


I would love to see that paper, when it is available.

I agree with you that training and skills maintenance is required, however I feel that a change to the system – ie introducing an intensive care ambulance tier – would be more effective and safer for employees than intubating each other (as demonstrated by the success of MICA). Personally I don’t care how amazing my colleagues are at intubation. There is no way I would have it done to me for no reason. I would be risking infection, trauma, hypoxia, and more. It seems like a bit of a pointless debate though, as I can’t see it passing ethics.


If we have an unacceptably high rate of infection, then we need to fix the infection rate, not hope that there is no evidence of infection until after the patient is in the ICU.

If hypoxia is a problem during a stable intubation in a controlled environment, then maybe we should not permit intubation on sick people in far less controlled environments. Ditto trauma.

I do not see ethics as a problem. We treat patients with things that have absolutely no evidence of benefit, but we claim that we cannot study them also because of ethics. I wonder if there are people in medicine who understand ethics.


Look at the numbers from intubation research. Almost all of the studies demonstrate a level of skill that a chimpanzee could be trained to provide.

Which intubation research is this?


The study in footnote [1] is the study that shows the worst numbers I have seen, both ground crew and flight crew success rates, but there are plenty of other studies. The studies showing high success rates are the ones that are hard to find.

I should add, that while I am opposed to you in this particular facet, I agree completely with your attitude. Skills maintenance is so important and it is our responsibility to ensure that we are competent at the skills we claim to hold.


I think that there are a lot of people with a similar attitude. They think that my suggestion is too aggressive, but they do realize that it is our responsibility (as well as the responsibility of our medical directors and QA/QI/CYA departments) to provide the highest quality intubation practical.


[1] EMCrit Podcast 18 – The Infamous Awake Intubation Video
January 27, 2010
Article and video

[2] Awake Endotracheal Intubation
Dr. Michael Bailin

[3] Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed – indexed for MEDLINE]

Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (PreHospital Intubation)

[4] Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.

[5] Prehospital intubations and mortality: a level 1 trauma center perspective.
The same as footnote [1] above.

Of the 203 patients, 115 (57%) were transported by air, and within that group, 94 (82%) were properly intubated in the field, and 21(18%) were not. Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (P < 0.001 compared with patients transported by air).

Even though the flight crew success rate was dramatically better than the ground EMS intubation success rate, it is still unacceptably low. What is the difference between the flight crews with 82% intubation success and the ground crews with 95+% intubation success or the flight crews with 95+% intubation success?

[6] Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.
Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, David, Taylor, Smith K, Patrick I, Edington J, Bacon A, Rosenfeld JV, Judson R.
Ann Surg. 2010 Dec;252(6):959-65.
PMID: 21107105 [PubMed – indexed for MEDLINE]

[7] Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury – Summary
Rogue Medic