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

- Rogue Medic

RSI, Risk Management, and Rocket Science

This is the way that RSI (Rapid Sequence Induction, or Rapid Sequence Intubation) starts out. An impressive presentation. Usually by means of a PowerPoint presentation.

Sometimes there will be problems that cannot be handled in the normal fashion.

Competent preparation includes the ability to bail out, such as the use of rescue airways, as necessary.

When that preparation is not handled competently, even the rescue airway is not really available to the less-than-prepared.

The search for the highest level person to take the fall for the superiors becomes the focus of the aftermath. Those who create the environment that encourages this failure rarely suffer any significant consequences.

Why should I use the example of the Challenger (STS-51-L), January 28, 1986?

Unreasonably optimistic claims of safety.

Irresponsible oversight.


The blame is focused away from the dominant cause.

NASA claimed that the reliability of the Space Shuttle was so great that the risk of an accident was 1/100,000 flights. With this kind of reliability, they could fly twice a week for a thousand years with only one serious failure. The Rogers Commission found that even a 1/100 flight accident rate was unreasonably optimistic.

NASA was claiming that the missions were more than 1,000 times safer than they had any reason to believe. Did they learn from this and improve? Dr. Richard Feynman wrote his own appendix to the findings of the Rogers Commission.

If a reasonable launch schedule is to be maintained, engineering often cannot be done fast enough to keep up with the expectations of originally conservative certification criteria designed to guarantee a very safe vehicle. In these situations, subtly, and often with apparently logical arguments, the criteria are altered so that flights may still be certified in time. They therefore fly in a relatively unsafe condition, with a chance of failure of the order of a percent (it is difficult to be more accurate).

Official management, on the other hand, claims to believe the probability of failure is a thousand times less. One reason for this may be an attempt to assure the government of NASA perfection and success in order to ensure the supply of funds. The other may be that they sincerely believed it to be true, demonstrating an almost incredible lack of communication between themselves and their working engineers.

And he concluded with:

For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.[1]

After all, everyone was watching their performance, how could they continue to make bad decisions that resulted in deaths?

February 1, 2003. Columbia (STS-107). 17 years and only 88 flights later.

“It’s just a flesh wound.”

Not a laughing matter, but the way that NASA has handled risk assessment has been one big example of what not to do. In some places, medical oversight of RSI appears to be following a similar path, just on a much lower budget.

The advantage of hindsight, and the opportunity to second-guess decisions made since February 2003, permeates these observations. All of them were, however, written prior to the launch of STS-114.[2] It is also important to recognize that the behaviors and attitudes described here were not chance occurrences that were observed only once or twice, but that emerged numerous times throughout the Task Group’s interaction with NASA. The intent of these observations is to help NASA leadership identify and rectify these concerns. We will address four main areas: rigor, risk, requirements, and leadership.[3]

How does a medical director not know that medics are not using waveform capnography to assess placement of endotracheal tubes?

A. They use it. I just know.

B. I follow up with the hospital staff to find out what they saw as good and bad about the packaging and care of unstable patients, especially RSI patients.

C. We can’t afford waveform capnography. We use something “just as good.”

D. What’s waveform capnography?

Only one of these is an acceptable answer.

Imagine if you had a device that could monitor the patient’s ECG (ElectroCardioGram) and 12-lead ECG, NIBP (Non-Invasive Blood Pressure), pulse oximetry, and waveform capnography. All with the ability to store the records for dozens of patients, so they can be recovered, or transferred to other media, later.

Printer problem? No problem. Can you say accountability?

Now imagine that you can use waveform capnography to prove that the ETT (EndoTracheal Tube) was not in the esophagus.

If a medical director is responsible for the oversight of paramedic intubation and is not using waveform capnography, there is a serious lack of understanding of risk management.

“We can’t afford waveform capnography.”

Show a lawyer the evidence that the tube was not in the esophagus – a waveform capnography recording from just after the tube was placed, repeated recordings while en route, and another recording just prior to moving the patient to the hospital stretcher – the lawyer will realize that there is no money to be made from this EMS organization.

When that is not the case, it is just your word against an expert witness. An expert witness is someone who gets paid a lot of money (something you claim not to have) to go all over the country to testify that the patient care was incompetent. There are a lot of very persuasive, charming expert witnesses. They make a lot of money. They are good at convincing juries that the patient care was incompetent. Juries love hearing that a simple device, although expensive, was available, but not used. The medical director decided the patients’ lives were not worth this much. Or the EMS agency made that decision and the medical director did not have enough sense or integrity to challenge the medical orders of the EMS agency.

Is waveform capnography idiot-proof?

Nothing is idiot-proof, especially in EMS, but waveform capnography is as close as you are going to get to idiot-proof in airway management.

If EMS is to be improved, we need to get more medical directors who understand risk management and waveform capnography.

This should not even be a topic for debate. There is no valid argument against waveform capnography.

If you cannot afford waveform capnography, then you cannot afford to intubate.

If you decide that intubation should be done anyway, you do not deserve any compassion when your actions result in disability and/or death.

Idiocy is not a valid excuse.


For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.[4]

If you prefer, you may substitute God for the term nature.

All of the images used are in the public domain.

Some other posts about this:

RSI, Intubation, Medical Direction, and Lawyers.

RSI Problems – What Oversight?

More RSI Oversight

Misleading Research

Intubation Confirmation

More Intubation Confirmation


^ 1 Report of the Presidential Commission on the Space Shuttle Challenger Accident (Also known as The Rogers Commission Report)
Volume 2: Appendix F – Personal Observations on Reliability of Shuttle
by R. P. Feynman

^ 2 STS-114

^ 3 Return to Flight Task Group Final Report 8/17/05
A.2 Observations by Dr. Dan L. Crippen, Dr. Charles C. Daniel, Dr. Amy K. Donahue, Col. Susan J. Helms, Ms. Susan Morrisey Livingstone, Dr. Rosemary O’Leary, and Mr. William Wegner.
Page 188
http://www.nasa.gov/pdf/125343main_RTFTF_final_081705.pdf This is an automatic download.
If that does not work, or you do not want to download the file, try:

^ 4 The same as footnote 1



  1. Poor medical direction is a huge problem with airway management. Especially aggressive airway management. Not just from the department OMD but the doctors in ER you are going to. If they can’t intubate and rely on us or the OR to do it how can we trust them over the radio with our patients? The other problem I see in my area is training. We have to take a regional RSI class that goes through drugs and protocols and then we have to take a city difficult airway class that goes over proper use of our “toys”. The ILMA and the King airway to be exact. These classes have been far apart ( my DA class was in Dec. and I still haven’t had the Regional class.)and without follow up instruction. This causes us to not have our drugs yet and we have issues with the equipment because we got the quick overview and then they waited a couple months gave us the toys and that was it. We have had to retrain ourselves. How are we supposed to be progressive and agressive managers of care when we get poor training and no back up from our admin and OMD? Frustrating and very dangerous to say the least.

  2. Gertrude,I agree with a lot of what you write. I am not familiar with some of the acronyms you use DA and OMD (Online? Medical Direction). On Line Medical Command (OLMC)is something I have written about here, here, here, here, and here. Some might say that my criticism of OLMC goes just a bit too far. :-)I also wrote about the influence of OLMC on RSI in the links listed at the end of this post.The difference between a good RSI program and the rest is mostly found in the oversight provided by the medical director.How much of the research on RSI looks at this?

  3. DA meaning difficult airway and OMD meaning operational medical director. The MD that oversees our department. I don;t think that much research looks at medical direction for RSI. They just look mainly at outcomes of patients.

  4. I become creative when presented with acronyms. :-)So many acronyms in EMS are regional.To evaluate outcomes, without looking at the skill of the providers, is a mistake. To look at a bunch of different systems, see a variety of skill levels, and not look for the factors that could lead to such a wide distribution of results only demonstrates that few performing airway research have any kind of a clue about how to improve airway management. We need for medical directors to be more aggressive in oversight and to be more familiar with airway management quality.


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