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

- Rogue Medic

More RSI Oversight

RSI (Rapid Sequence Induction, sometimes referred to as Rapid Sequence Intubation) is sedating and paralyzing a patient to assist with intubation. The intubation doesn’t change. The patient who was moving, biting down, agitated, or . . . is no longer able to move – or breathe. Unless EMS breathes for the patient.

In RSI Problems – What Oversight?, I briefly wrote about medical oversight problems. In the article, High-risk EMS procedure gets a low level of oversight,[1] there was a description of one of the unrecognized esophageal tubes and the response to this. I am reprinting the comments of the paramedic “training coordinator” for AMR (American Medical Response).

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.(article)

He did not think the tube was in the wrong place, but was going to put in a bigger tube apparently to bring up the patient’s oxygen saturation, or to keep it from dropping.

Hmmm. If the patient’s sat is dropping, why do you think it is because of tube size?

If you put a 6.0 mm tube in a 300 pound patient you can still move enough 100% oxygen (because that is what we use) to keep the patient’s sat up. You might have to work a little bit more and keep the respiratory rate up to make up for the extra resistance of the tube.

Of course, the real problem with putting an itty-bitty 6.0 mm tube in somebody that large is that you won’t get any kind of cuff seal in the trachea. So, maybe the problem was that he used a tube that was so small that he could not get the cuff to act as a seal in the trachea.

Why would he be using a tube that is so inappropriately small? Was he using a formula to calculate the size of the tube?

If he feels that During that attempt, he said, the tube became dislodged, perhaps he doesn’t understand that the original tube needs to come out for the new tube to go in.

He thinks changing tube size is going to improve oxygen saturation, but doesn’t think that the tube might be in the wrong place. He knows when the tube became dislodged, but never did anything to correct it?

Is he so good that his patients will survive without oxygen?

Since this patient did not survive, I guess we know the answer to that.

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.(article)

He cannot say why he did not check tube placement.

He should have been checking, not once, not twice, but continually on every intubated patient.

This didn’t just happen.

How did the medical director – Dr. Robert Kowalski not know about this?

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

Clearly, Dr. Robert Kowalski doesn’t know anything about oversight of airway management.

Is there a more dangerous airway incompetence than not continuously confirming tube placement?

These are things that should be done on every intubated patient, RSI or not.

This is probably not the first time that this has happened.

How does the medical director remain oblivious to this?

Chart review is not a real form of quality control/quality assessment/quality improvement. It is just CYA.

Chart review is just a way of enjoying creative fiction. Do all medics honestly document their care, or lack of care?

If the medical director is only looking for certain things on charts, he is going to see those things on the chart, because medics are capable of learning.

If he were to train them to actually do what they document, that would be something good.

If he is using chart review and they are honestly documenting their lack of airway management, how does he justify that?

This medic had so many blatant errors on this call. This can’t be his first Charlie Foxtrot. He obviously has practiced to arrive at this level of destruction.

In each of the cases examined by the Star-Telegram, records show that EMS personnel failed to use the rudimentary tools that are standard for checking whether breathing tubes are in the proper place.(article)

This is the part of the article that few people seem to have noticed.

It does not matter if RSI was used for the cases in the article. The problems that killed two patients and severely damaged the brain of another patient were problems that are problems even without RSI.

Any time an endotracheal tube is placed the location of the tube must be confirmed by multiple methods and reconfirmed continually. Only an idiot doesn’t do this.

A medical director who has medics who regularly do not do this is just letting the medics kill people.

How many patients were intubated without RSI and did not have tube placement confirmed.

It is possible to put the tube in the wrong place. As long as you check placement and keep checking, this should not be a serious problem. If you never manage to get the tube in the right place, there are several alternatives that even non-medical people should be able to place correctly. They just are not as effective at manging the airway, but are adequate if the tube cannot be correctly placed quickly.

If you do not check placement and the tube is in the wrong place you are a killer.

If you are the medical director and you should know that your medics do not check placement of tubes you too are a killer. As a medical director, you just kill more people.

Other posts about this:

RSI Problems – What Oversight?

Misleading Research

Intubation Confirmation

More Intubation Confirmation

RSI, Intubation, Medical Direction, and Lawyers.

RSI, Risk Management, and Rocket Science


^ 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.


DC Fire and EMS – making everyone happy.

The changes at DC EMS are making at least a few people less than happy. Dave Statter at STATter 911 writes Major change in the structure of DC Fire & EMS Department. Civilian EMS workers will become sworn, uniformed members of department. He has an update today – Unity sparks disharmony.

While I do not know how things operate in DC as far as who is in the ambulances, there are some pretty nasty accusations that fly both ways in the comment section of the articles. If anyone knows how things work there I would love to learn more about it. Reading the comments does not really tell me anything, except that some people on opposite sides of the “debate” cannot make cohesive arguments.

What I do know about DC is not impressive. If there is one place that has protocols that exemplify the problems I have with OLMC (On Line Medical Command) requirements and poor physician oversight, DC is it. It appears that almost all ALS (Advanced Life Support) treatment requires a non-rebreather mask and high flow oxygen, an IV, and an ECG monitor.

This is their protocol for PVCs (Premature Ventricular Contractions) – those funny looking beats that should not generally be treated. The authors of the comments on STATter 911 are probably experiencing more than a few PVCs as they write their tirades.

Adult Cardiac Emergencies:
Premature Ventricular Ectopy (PVC’s)

All Provider Levels

1. Refer to the Patient Care Protocols.

2. Provide 100% oxygen via NRB, if respiratory effort is inadequate
assist ventilations utilizing BVM with 100% oxygen.

3. Place the patient in position of comfort. If evidence of poor
perfusion is present place the patient in shock position.

4. Initiate advanced airway management with Combi-tube if
respiratory effort is inadequate.

Note Well: EMT-I and EMT-P should use ET intubation.

5. Establish an IV of Normal Saline KVO or Saline lock.

Note Well: An ALS Unit must be en route or on scene.

II. Advanced Life Support Providers

1. Attach EKG monitor and interpret rhythm.

2. If possible, obtain 12 lead EKG.

It goes on to the typical reflexive bad reaction to PVCs – lidocaine. OK, maybe amiodarone would be more typical, but both are a bad idea for PVCs of unknown origin. Is this the normal, walking around rhythm of the patient?

Why the high flow oxygen? ACLS certainly does not encourage that.

Apparently, if it is ALS, you need at least a mask in DC.

Looking at protocols on their site kept causing my browser to freeze up. Whether it is on my end, their end, or something else, if your browser has problems there don’t be surprised.

They are hiring Paramedic/FireFighters at $48,731- $69,998/year.

I couldn’t find information on the non-fire fighter medic jobs, so I don’t know what the difference in pay is. This does appear to be a system that needs a lot of work. The outside experts have recommended fixes, but the city just seems to like to pay them to come in, make recommendations that will be ignored, and go away with a lot of city money.

Hey, DC people throwing around money – Call me!