Rsi

[Wes]

First of all, I'm not your lawyer, but I'm a lawyer. (Subtle difference there, you know.) If you'd like me to be your lawyer, I'll need a credit card number.

Generally speaking, EMS liability is a hard hurdle to reach. In Texas, EMS is actually covered under our version of the Good Samaritan law. The appellate courts here have held that EMS is not a licensed health care profession, so we're covered under the statute. (The one time that low EMS standards are helping us!)

So, under Texas law, you have to prove a willful act or gross negligence to prove a medic liable. Hard hurdle to overcome. To prove negligence, you have to prove the medic had a duty to act, that they breached the duty (IE, violating the standard of care), that the breach caused harm, and that the harm created damage. So, you'd have to prove all of those things. And for it to be gross negligence (the standard for EMS liabilty here in the Lone Star State), it's got to be pretty egregious. So, I'd tend to lean against liability for the medic.

A slightly better bet would be a claim against the EMS medical director for not approving RSI. But your chances on that are a crapshoot too. Both sides will pull up every expert witness they can find. Six or half a dozen there, especially since you never know what a jury would do. My personal supposition is that RSI does not represent the standard of care.

In fact, a few years ago, there was a discussion about this very issue here in Austin. Austin/Travis County EMS medics don't RSI, but the STAR Flight flight medics do. There was a great deal of discussion as to whether the STAR Flight medics could carry RSI drugs if they were working overtime on a ground unit. The decision was to not authorize them to carry RSI meds for the exact reason of liability and a uniform standard systemwide.

Final thought -- given the crappy state of airway education in general for EMS, I think there's a lot more potential for liability over failed RSI than there is for failure to authorize and allow RSI.

 

[TransportJockey]

DrParasite, RSI is not standard of care so good luck. I think it should be a credentialed issue where not all medics have it. Just the best ones and the ones that can prove they know what they are doing

 

[VFlutter]

Not for nothing, but RSI should be agency wide; either you call can do it or those that can't shouldn't be paramedics. If the patient needs to be RSIed, it shouldn't be a gamble if the crew is certified to RSI or not.

I strongly disagree. RSI is not a right inherently granted to you because you are a paramedic. Especially with current education standards. It is not a benign procedure, it is consider one of the most dangerous procedures in the ICU and has one of the highest mortality rates. Dr. Weingart makes a great point with this "License to Kill" lectures. I think most hospitals consider RSI related death up until 2 hours post procedure. Something you may not see.

Also, they just took RSI out of our Critical Care PAs scope of practice. Not because they are not capable but because it is best practice for optimal patient outcomes. Now only CCPs and MDAs can do it.

I am not saying RSI can not be done but to say that every paramedic should be able to it and if not they are not a "real" paramedic is rediculous.

 

[Wes]

Someone once said that RSI is 2/3 of the lethal injection cocktail. When you look at it that way, maybe not everyone needs to utilize it.

What we need to be teaching in addition to airway skills is airway decision making. But alas, critical thinking is in short supply while cookbook medicine is all too common. And don't even get me started on how little "live" practice we get prior to entering the field. OR rotations are rapidly becoming a thing of the past and "Fred the Head" just isn't the same.

Sorry, didn't mean to go off on a tangent.

 

[Carlos Danger]

Someone once said that RSI is 2/3 of the lethal injection cocktail. When you look at it that way, maybe not everyone needs to utilize it.

What we need to be teaching in addition to airway skills is airway decision making. But alas, critical thinking is in short supply while cookbook medicine is all too common. And don't even get me started on how little "live" practice we get prior to entering the field. OR rotations are rapidly becoming a thing of the past and "Fred the Head" just isn't the same.

I never heard that saying but I believe it is technically accurate, and more importantly, is an excellent point.

 

[NomadicMedic]

Or, you could work for an agency that strives for education, make sure that the paramedics are competent, has a stringent QA QI process and I could go on and on.

Not all paramedic systems are created equal. We have about 80 field paramedics in my system. All are trained to RSI. All of us have frequent opportunities to perform intubations, both in the field and in the OR. It's certainly not a skill to be taken lightly, but paramedics should be able to perform the skill, if certified and it's needed.

The ability to progress down the decision-making tree to the point where you're asking, "should I RSI this guy or not?" is the mark of a strong paramedic in our system.

Just because you've seen some substandard paramedics, don't lump us all into that group.

 

[truetiger]

If you're working in a a rural area with extended transport times, its absolutely necessary that you are proficient in not just RSI, but all of your skills. If not, you shouldn't be on a truck in a rural area.

 

[TransportJockey]

If you're working in a a rural area with extended transport times, its absolutely necessary that you are proficient in not just RSI, but all of your skills. If not, you shouldn't be on a truck in a rural area.

Unless of course your state doesn't allow medics to RSI unless they are flight. I'm a very proficient rural medic who would love the opportunity to even try to initiate RSI in my system

 

[Wes]

DEMedic -- couldn't agree more. With appropriate education, both initial and continuing and proper clinical oversight, I believe there's a place for RSI. I've got it in my toolbox and hope never to use it, but I know there is a patient population out there where RSI is going to be the ONLY thing that'll work.

 

[DrParasite]

Generally speaking, EMS liability is a hard hurdle to reach. In Texas, EMS is actually covered under our version of the Good Samaritan law. The appellate courts here have held that EMS is not a licensed health care profession, so we're covered under the statute. (The one time that low EMS standards are helping us!)

hmm, I have been told that because we receive a paycheck, the good sam law doesn't apply to us in NJ. so while volunteers might be covered, those of us who are paid are not.

So, under Texas law, you have to prove a willful act or gross negligence to prove a medic liable. Hard hurdle to overcome. To prove negligence, you have to prove the medic had a duty to act, that they breached the duty (IE, violating the standard of care), that the breach caused harm, and that the harm created damage. So, you'd have to prove all of those things. And for it to be gross negligence (the standard for EMS liabilty here in the Lone Star State), it's got to be pretty egregious. So, I'd tend to lean against liability for the medic.

gross negligence, probably not. what about simple negligence?

A slightly better bet would be a claim against the EMS medical director for not approving RSI. But your chances on that are a crapshoot too. Both sides will pull up every expert witness they can find. Six or half a dozen there, especially since you never know what a jury would do. My personal supposition is that RSI does not represent the standard of care.

if, as an agency, the medical director doesn't approve RSI, so be it. but if he only approves certain people? and on a patient that could have benefited form RSI, and a non-RSI unit was sent, with negative consequences? You don't think you could argue that simple negligence did occur?

In fact, a few years ago, there was a discussion about this very issue here in Austin. Austin/Travis County EMS medics don't RSI, but the STAR Flight flight medics do. There was a great deal of discussion as to whether the STAR Flight medics could carry RSI drugs if they were working overtime on a ground unit. The decision was to not authorize them to carry RSI meds for the exact reason of liability and a uniform standard systemwide.

that's system wide, which isn't what I am talking about. it's not like half the Austin county Medics can't RSI, and the other half can. System wide is system wide.

Final thought -- given the crappy state of airway education in general for EMS, I think there's a lot more potential for liability over failed RSI than there is for failure to authorize and allow RSI.

wait until intubation is taken out of the paramedic skill set at a result of this

I want a truck with 2 Paramedics but get one with just 1 and an EMT because of staffing issues. Can I sue? Probably not.

depends: if I need a paramedic unit, can the single person paramedic unit do less than a dual paramedic? and is there any damages that result of being unable to do those procedures that having 2 medics would have permitted?

I want to go to the cath lab at the hospital 2 blocks further when I have chest pain but your protocol says "closest facility" which is where you take me. Can I sue? I could but you did what your protocols said. Your medical director probably had a reason for writing them.

where is the group that say "following orders isn't a justification for bad medicine? Just look at the nuremburg war trials". Actually, you probably could sue the agency, might even win. probably wouldn't get anything from the paramedic.

I work for an EMS agency across town which allows me to RSI or do pericardiocentesis but moonlight at another which does not. Can I do my advanced skills "to save a life" when at the other agency? No. This has already be challenged in many cases.

the agency sets the standard. if your agency won't allow you, than they won't allow you. but the agency sets the standard agency wide, so no matter who shows up, it's a paramedic who can do all the skills that any paramedic can do. essentially a paramedic is a paramedic is a paramedic, regardless of which paramedic unit for your agency shows up.

By your argument every doctor in a hospital should be neurosurgeons if the patient needed neurosurgery.

no: but every neurosurgeon should be able to do the same neurosurgery stuff, so if I call the on call Neuro, I don't need to worry about him or her not being able to do that procedure, and has to call someone else.

First of all, you are comparing apples and oranges. Pushing D50 or obtaining a 12-lead has very little in comparison to RSI, in terms of the training needed and the risk to the patient. If you can't see the difference between the gravity of RSI vs. that of obtaining a 12-lead, then I'm at a loss.

The important point you are missing is that all paramedics are simply not all the same in terms of training and experience and competency. If you haven't learned that reality yet, you will when you are more experienced.

they are both procedures, so yes, they are not apples and oranges. has RSI saved people? or benefited people? are paramedics trained in performing RSI?

I know that no all paramedics were trained equally, or as experienced, and some are incompetent. But a paramedic should be able to do paramedic skills, especially if that is the standard of care of a paramedic. no matter which unit shows us, the interventions should be the same. If you don't understand that, than I'm at a loss.

If a medical director wanted to require his paramedics to have a certain number of year's experience before they could RSI, and a certain amount of time with the agency, and to complete a time-consuming training program first, I think that'd be pretty responsible and reasonable, and probably well in line with what the literature indicates is necessary for a successful RSI program. If he wanted to suspend RSI from individuals who don't meet certain continuing training or competency criteria, I think that's quite reasonable, too. These requirements would probably result in not all the paramedics at a given agency being able to RSI, but I don't know how you'd argue it's not a reasonable process or that it's not in the best interest of patients, or that it puts the agency at legal risk somehow.

Based on your logic, he should be able to suspend D50 administration, or 12 lead transmissions, or needle decompressions, or intubation, on a per person basis, based on his beliefs that " don't meet certain continuing training or competency criteria." although you can see the potential problems of having them still be a paramedic if they can't function 100% as a paramedic right?

I'd like to see Wes weigh in on this, but I think there'd be a very slim chance you could successfully sue. If you could, it would set a precedent that every EMS agency and every hospital would essentially be responsible for following the same protocols and offering the same services, procedures, and interventions, because anyone who didn't do something that someone else did could be sued.

not at all, but if damages were caused...

Go to a hospital that doesn't offer the same procedure as another one? Sue 'em. Call EMS and they don't have the same drugs that another agency does? Sue 'em. Think that is good for patients? Or for the EMS profession?

huh? each hospital can decide what it does; but if I call for an OB doc, they should be able to do OB doc stuff, not just 90% of what an OB doc can do.

Most importantly, order to successfully sue, you'd have to show damages resulting from the paramedic's action or inaction. I suppose it is plausible you could argue that damages resulted from the paramedic's inability to RSI - rather than from the disease process - but that would be an uphill battle, I think. The EMS agency's lawyers would counter-argue that much of the literature shows that prehospital RSI is unsafe and doesn't improve outcomes (it is, in reality, inconclusive at best), and therefore having it in the protocols does more harm than good and this patient would very possibly have been even more seriously injured by it. Expert witnesses will explain that paramedics in general aren't good at RSI and even when they do it right, it doesn't improve outcomes.

So maybe no one should be RSIing, since it's so bad, it's unsafe and doesn't improve patient outcomes? and if it's so bad, why do we even do it?

 

[Wes]

Like I said, I was providing my answer on Texas law. That's the state I'm admitted to practice as an attorney in. I don't know the specifics and vagaries of other state's laws. Simple negligence, at least in Texas, wouldn't factor in at all. And ultimately, the question of any sort of negligence would be decided by a jury. Unfortunately, the legal issues as to EMS liability are very dependent on both specific facts and on state law, which makes it very hard to make generic rulings on EMS issues.

 

[Clipper1]

the same neurosurgery stuff,[/B] so if I call the on call Neuro, I don't need to worry about him or her not being able to do that procedure, and has to call someone else.they are both procedures, so yes, they are not apples and oranges. has RSI saved people? or benefited people? are paramedics trained in performing RSI?

each hospital can decide what it does; but if I call for an OB doc, they should be able to do OB doc stuff, not just 90% of what an OB doc can do.
So maybe no one should be RSIing, since it's so bad, it's unsafe and doesn't improve patient outcomes? and if it's so bad, why do we even do it?

You are incorrect about all OB or all neurosurgeons. Not all have the same skill set. Most all can deliver babies but some might be competent to do high risk deliveries and advanced procedures like fetal scalp monitoring which is not mandatory in all hospitals. You should also check out what neurosurgeons do especially in EMS if your back goes out. Don't just pull one out of a list and expect him to do the same cutting. I also probably would not go to a Trauma Neurosurgeon to have disc surgery. Even the neurosurgeons step aside for other neurosurgeons to perform different skills.

Not all EM doctors are the same either. Some have gotten their training to do extensive US in the ER. Some have training to do the GlideScope or some other new intubation device while others might depend solely on DL while the GlideScope sits 3 feet away unused.

There are also services which do not allow Paramedics to intubate by DL. They are still Paramedics.

Two Paramedics would also be more ideal for RSI. One gives the medications and watches the monitor while the other maintains the airway preparing for DL.

Somebody was talking about TX. I seriously doubt if there was any suits against these Paramedics directly since most states do have some protection statutes for EMS either by Good Sam extension or an immunity clause.

http://www.ems1.com/ems-products/ed...ocedure-gets-low-level-of-oversight-in-texas/

DrParasite, you have been an EMT-Basic for many years. Why haven't you taken the next step to being a Paramedic?

 

[chaz90]

Two Paramedics would also be more ideal for RSI. One gives the medications and watches the monitor while the other maintains the airway preparing for DL.

That's how we RSI every time. We require two paramedics for every RSI patient for exactly the reasons you describe. Typically the first medic will begin to get equipment out and park himself at the airway as the second calls in for RSI orders. As the first preoxygenates the patient, the second draws up and administers the drugs while watching the monitor and arranging the transition from nasal prong capnography to in line. When I've been the second medic, I've also started a timer on my watch after pushing Succs to keep track of how long the attempt is lasting and also to make sure we get the Versed, Fentanyl, and potentially Vecuronium onboard as soon as necessary. Having two people completely trained in the procedure makes a HUGE difference. I can't imagine trying to do everything with only an EMT that you don't know or don't work with often.

 

[Carlos Danger]

I know that no all paramedics were trained equally, or as experienced, and some are incompetent. But a paramedic should be able to do paramedic skills, especially if that is the standard of care of a paramedic. no matter which unit shows us, the interventions should be the same. If you don't understand that, than I'm at a loss.

Look, you are entitled to your opinion and I'm not going to invest any more time into trying to change it.

But you should realize that you really have no backup for your claim. RSI is not even considered the standard of care in EMS, and most EMS agencies in the US don't even do it. Many EMS agencies that do, only credential some of their paramedics to do so because they feel it is unsafe to let everyone do it. If you are going to continue to believe you know more than those agencies' medical directors, attorneys, and risk management folks, so be it.

So maybe no one should be RSIing, since it's so bad, it's unsafe and doesn't improve patient outcomes?

Many medical directors have come to that exact conclusion. The literature is pretty clear that it is only helpful in very select situations and is often harmful.

I would actually not be surprised to see ETI itself start to go away before too long. It's already pretty clear that it doesn't improve outcomes. As the SGA devices improve and ETI training opportunities continue to go away, it might not be too long.

But that's a whole other discussion.