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

- Rogue Medic

RSI, Intubation, Medical Direction, and Lawyers.

There has been a discussion of the article High-risk EMS procedure gets a low level of oversight[1] on TexasEMT.com. The forum on RSI (Rapid Sequence Induction or Rapid Sequence Intubation) has been very active. It presents a variety of views, including mine.

One of the physician/medics on the list included some posts from another site. The posts provide a lot of good evidence for the safety of RSI. I will eventually review a lot of the intubation research. There will be special places for the examples of research from Dr. Wang and Dr. Yealy that are discouraging good airway management.

The gist of the discussion between me and another person has been the level of medical director responsibility. He does not see the problem with medical directors as serious.

I see bad medical direction as the essence of airway problems.

His most recent post finishes up with this statement.

So, if you’re right, and failed tubes are the fault of bad medical directors, then the studies quoted above represent incontrovertable evidence of excellence in medical direction. After all, a 95% success rate and only 3 surgical airways in over 1500 attempts shows that they clearly have in-touch doctors.[2]

The 95% success rate refers to intubation success. The airway management success rate was 99.7% and it improved with the addition of capnography.[3]

I agree with him. The problem is that these are only some of the systems that intubate. Dr. Wang and Dr. Yealy will find you places with much lower success rates.

The bigger problem is that systems with poor intubation success rates are not hard to find. While we should be encouraging the excellent systems, where is the outrage at the incompetence of systems that do far worse?

If you are Dr. Wang or Dr. Yealy, looking at paramedics in Pennsylvania where every town that has its own traffic light needs to have its own paramedics, why correct the problem of too many ALS services, too many medical directors, and too many bad medical directors? Instead, use this situation to justify criticism of paramedics’ intubation skill.

Why are we not gathering pitchforks and torches and demanding better than the bad airway management encouraged by Dr. Henry Wang, Dr. Donald Yealy, Dr. Robert Kowalski, Dr. S. Addison Beeson, Dr. Cynthia Simmons, Dr. Paul Pepe, Dr. Robert Simonson, Dr. Frankenstein, . . . .

“If you have a good medical director, somebody who’s actively engaged and involved in EMS, you can kind of push the envelope,” said Bryan Bledsoe, a Midlothian emergency physician and the author of several EMS textbooks. “The problem is a lot of these services have someone who just signs the chart.”(article)

Just signing a chart, or just looking at flagged charts, is not medical oversight. These service should not have ALS unless they have a real medical director.

“I’ll say this flat out: There is no excuse for a misplaced tube,” said William E. Gandy, an EMS educator in Tucson, Ariz., who is known nationally for his expertise in airway management. “We have the means to verify that a tube is in the right place. There’s no excuse for not verifying.”(article)

Can anybody make a good case that he is wrong?

I can’t.

Who is responsible for these three cases of, not RSI problems, but intubation confirmation problems?

All of these cases were problems with the confirmation of the placement of the endotracheal tube – not with the use of the medications to paralyze the patient.

Very basic stuff for an ALS airway.

While it is difficult to know how widespread such problems might be, many familiar with EMS issues say the incidents that reach the legal system are likely just the tip of the iceberg.

R. Jack Ayres, an Addison attorney who holds a paramedic’s license and has long been involved in EMS at the state and local levels, said he knows of at least 50 cases in which botched intubations caused death or disability.(article)

People have been saying that this is only a matter of 3 cases.

People have been saying that this is a matter of only RSI problems.

They don’t know what they are talking about. If you have a system that has the ability to check exhaled CO2, (carbon dioxide), but people don’t check exhaled CO2,, then this is a huge problem.

Each of these cases would have been prevented by simply checking exhaled CO2,, and placing an alternative airway if the medic could not get the tube in the right place.

How difficult is it to teach that you check CO2, continuously on every intubated patient?

How hard is it to make sure, as medical director, that this is done on every intubation?

If you show up at the emergency department and you do not have a device for checking exhaled CO2,, nobody notices?

Allen was intubated seven minutes before the helicopter landed at the United Regional Health Care center in Wichita Falls, according to records. The tube became dislodged before she was treated in the emergency room, the records indicate.

Both the flight nurse and the paramedic acknowledged in depositions that they did not use carbon dioxide monitoring, even though it was available.

The medical director for Air Evac’s Wichita Falls base at the time was S. Addison Beeson, a Tulsa emergency physician. She did not respond to messages from the Star-Telegram.(article)

It isn’t as if you sneak into the emergency department with these patients and nobody notices. Intubated patients are high priority patients. They require extra staff and equipment.

None of the nurses, doctors, techs, respiratory therapists, janitorial staff, . . . notice this?

One problem is that it isn’t much better in the emergency department. When I bring in a patient with waveform capnography attached, the first thing that staff will tend to do is pull the tubing, because it is “in the way.” Would they go into the ICU (Intensive Care Unit) and do the same? There is a lot more stuff “in the way” in the ICU.

One reason for this is that, in the ICU, more stuff is considered better care. More EMS stuff, even though it is helping EMS to provide a higher level of care than than the emergency department, is viewed as just “in the way.”

What doctor, nurse, or respiratory therapist throws away the best method of confirming tube placement without using it?

OK, that is a bit unfair. I have never seen a respiratory therapist do this. The respiratory therapists are often as interested in this as in any other new gadget, and they understand its value. Why don’t the doctors and nurses? OK, still a bit unfair. It is only some doctors and nurses that do this, but why do any do this? If you do not know what it is, ask before removing it. Hmm, this pin is “in the way” on this hand grenade, better remove it.

What is extremely rare is that the doctor, or nurse, will use the waveform capnography to check tube placement. Instead, they will be running circles around themselves to use all sorts of inferior methods of confirming placement. They will completely ignore the most reliable method of confirming placement.

This is wrong.

This is where EMS learns to not use capnography, or the slightly-better-than-useless color change device.

“If they don’t use this stuff in the hospital, why do we have to use it?”

Clearly, anyone who would say this, does not understand patient care and should not be intubating. In EMS there are too many of these idiots. The medical directors, the essence of airway problems, do not seem to do a good job of removing them.

Simonson said records he has reviewed at CareFlite show that the air medical service regularly has to “bail out” ground EMS crews that fail to intubate paralyzed patients.(article)

So, they couldn’t intubate the patient. This happens. Did they use an alternative method of managing the airway?

That is what matters.

None of these cases in the article were about RSI, they were about airway management.

There are places where the medics have no clue about airway management, but are allowed to intubate. Is this acceptable? Should this be acceptable?

What kind of person knows that his people cannot manage an airway, but allows them to intubate (RSI or no RSI)?

Dr. Simonson goes on to say:

Simonson said he has come to believe that RSI “needs to go away” when it comes to ground EMS. To that end, he has removed it from the protocols of all but two of the units under his direction because, he said, only those units had the necessary experience.(article)

Has he taken intubation away from the inexperienced ground services?

Has he done anything to educate them, to improve their experience level?

With only a few sentences out of hours of comments, it is difficult to determine what his approach is.

The problem remains a failure of the most important part of airway management in three cases. The problem was not with the medications that cause temporary paralysis (RSI).

Here are the reasons, given by the medical directors for two large cities, for not using RSI.

Arlington: Short transportation times and the inability to train a large number of paramedics are cited by Cynthia Simmons, the local medical director for the city’s ambulance provider, American Medical Response.(article)

In other words, the medical director can’t train a large number of medics in advanced airway management.

Dallas: Paramedics in a large system don’t have enough opportunities to sharpen their intubation skills, according to medical director Paul Pepe.(article)

He used to be medical director for the state of Pennsylvania, home of Dr. Wang and Dr. Yealy. What kind of illogic is this? If the medics in a large system “don’t have enough opportunities to sharpen their intubation skills,” who does?

What kind of medical oversight do they have that keeps them lacking in “sharp?”

Bad airway management, RSI or not, is a reflection of the quality of the medical director.

Other RSI/airway/tube confirmation posts of mine:

RSI Problems – What Oversight?

More RSI Oversight

Misleading Research

Intubation Confirmation

More Intubation Confirmation

RSI, Risk Management, and Rocket Science

Footnotes:

^ 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 TexasEMT.com Forum Index » Open EMS/EMT Discussion » RSI

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

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