Ideas for RSI eduction

[Doczilla]

I mean look at the components of the score also. Not useful if they're paralyzed.

 

[medicaltransient]

I don't think AEL parallelizes everyone they RSI. No it's not intended for the paralyzed pt.

 

[RocketMedic]

This entire venture seems to be steeped in failure. Medicaltransient, what area are you discussing here? To be honest, it sounds like you're trying to justify what's already being done, and it sounds sketchy as heck.

 

[medicaltransient]

This entire venture seems to be steeped in failure. Medicaltransient, what area are you discussing here? To be honest, it sounds like you're trying to justify what's already being done, and it sounds sketchy as heck.

Thanks for your encouragement RocketMedic and I will cease the project immediately.

 

[medicaltransient]

How do you guys prepare and administer Ketamine?

 

[EMSComeLately]

How do you guys prepare and administer Ketamine?

For us, it's diluted with 9ml NS before ivp.

 

[SeeNoMore]

I'm not sure if people really understand the RASS. In any event OP, if you do go ahead with this without OR time and a doc involved, I'd suggest you all work to support each other. I'd use scenario training with no hand holding. Make sure people are able to explain why they want to RSI , what med doses (and draw them up), verbalize a checklist, perform the intubation several times (different blAdes, video, bougie) and manage the patient afterwards. Go over pre and post RSI hypotension and other management issues. Good luck.

 

[TXmed]

I don't believe OR time is a must for this type of education, RSI has alot more components then just ET success rates.

 

[chaz90]

I don't believe OR time is a must for this type of education, RSI has alot more components then just ET success rates.

I don't think anyone would argue that ETI itself is the only important part of RSI. I think you'd be hard pressed to argue it isn't vital though. The best decision making processes, appropriate medication administration, and pre-oxygenation doesn't mean much if your successful first pass intubation rate is only 50%...

 

[TXmed]

But there are other ways to increase ET success without OR time. VL, bougie, practice on manikens, and some cadaver training. If you can get OR time that is great but Its not a must.

 

[chaz90]

Real, live (or dead in some cases) intubations on human beings with varying anatomy and physical characteristics matters much more than intubations on Fred the Head. Mannequin practice has its place, but it doesn't replace real intubations or skill competency check off by an expert in the OR.

As much as the actual act of intubating a few patients an hour in the OR is worth your time, having an anesthesiologist or CRNA who manages airways for a living critique your technique is invaluable. I'd go so far as to say that if your program doesn't have access to an OR for initial skills verification and retesting/practice as needed, you shouldn't establish a RSI program. One of the scariest things about some paramedics having access to RSI is the prospect of people who may not have intubated a real patient in two or three years pulling the trigger on an RSI and realizing they're over their head when it comes to a live patient.

 

[TXmed]

Manikins are important for developing technique and muscle memory. If it was required to have OR time as a skills check off then 90% of the programs in Texas wouldn't have RSI

 

[jwk]

Manikins are important for developing technique and muscle memory. If it was required to have OR time as a skills check off then 90% of the programs in Texas wouldn't have RSI

Intubating the same mannequin 50 times does absolutely nothing to teach you about varying airway anatomy. Getting one-on-one training on real patients in the OR from someone with expertise is invaluable. Mannequins are a poor substitute. I've been involved with EMS airway training off and on for years - invariably, the medics and students I've had in the OR would agree there is no comparison.

 

[TXmed]

I'm not saying OR time isn't great to have. But in my opinion it is not a must have for a successful education program.

 

[CANMAN]

Manikins are important for developing technique and muscle memory. If it was required to have OR time as a skills check off then 90% of the programs in Texas wouldn't have RSI

You're missing the point. Intubating Fred the Head will develop the same technique and the same muscle memory each and every time is what we are saying. Obviously in real life every airways isn't the same, so why would you train that way? There is also a lot more to benefit from OR time then just sinking a tube. I guarantee if you went to an OR regularly your technique would improve 10 fold and you will realize that your technique probably wasn't that great to start with.... I certainly did, and I felt like I was fairly strong in airway management when I first started hitting the OR compared to some of my coworkers in both knowledge, number of live intubations, etc.

12 intubations a year to maintain a 90% success rate, where you are still missing 10% of your tubes. Most field medics now a days are lucky to get half of that. RSI service or not. Dedicated OR time for an RSI program is an invaluable resource.

 

[Carlos Danger]

I can see both sides of this.

On one hand, I think the only way to get REALLY good at something is to do it frequently for a long period of time, under different conditions and with different challenges. And the only place you can reliably practice airway management multiple times a day, on any day, is the OR. Manikins are good for practicing the gross procedure of intubation and the entire sequence of doing an RSI - and that stuff is important - but they simply aren't realistic enough to provide the type of practice you get on real patients. In the OR you can drop LMA after LMA and ET tube after ET tube in patients of all shapes, sizes, and ages. You can see how different drugs and combinations of drugs and dosages effect the patient. You can practice different ways of positioning. Masking a fat face is different from a skinny face, and someone with teeth is different than someone without. You just can't replicate masking a bearded 350#er with sleep apnea or intubating a 70 year old diabetic with a stiff, brittle cervical spine.

On the other hand though......while I think there are a lot of glaring weaknesses in prehospital airway management and I do not think RSI should be a standard paramedic skill, the fact is that success rates for intubation are actually really high with prehospital RSI, and I don't know that the amount of time paramedics spend in the OR has ever been shown to have much bearing on that. Most paramedics who do go to the OR only go once or twice a year and might get a handful of tubes each time. But that's not nearly enough time to develop the type of skill and comfort level with airway management (not just airway intubation) that I think we would ideally have if we are going to be paralyzing sick people out in the field with little or no backup.

So I think OR practice is critically important in order to learn how to be a really skilled and confident all-around airway manager. But when it just comes to pushing some sux (or roc ) and then dropping a tube, I honestly don't know that it really matters that much.

 

[RocketMedic]

"Waaaaa I wanna RSI people on an organizational level despite lacking literally all of the prerequisite support for it!"

 

[Tigger]

Manikins are important for developing technique and muscle memory. If it was required to have OR time as a skills check off then 90% of the programs in Texas wouldn't have RSI

So how do you decide someone is competent then? Most of the skills that EMS provides are practiced in a clinical setting prior to the provider being cut loose. While there are some exceptions (crichs among others), this is an elective procedure. There is no excuse not to test for competency and that is done on live patients in a controlled setting.

 

[RocketMedic]

Do you even have an organizational culture that would take the training seriously?

 

[medicaltransient]

There will be a test for competency and not every one will be clear to do RSI. We have a great bunch of guys and most of us are older guys. Thanks again for the input.