I am so happy over all of the discussion comments so far I have another to post. So as a mentor for the local College Paramedic program I walked out of the class with a burning question on my mind. How well do you all think the current National standard of teaching in either CCEMTP or NREMTP prepare Paramedics in the field for performing the skill of RSI. I write this though as a man who can show the scar of a RSI gone bad which cost me temporary suspension of the priveledge followed by remediation and now finds me as a preacher of strength to those who like me fall from grace and need a shoulder to lean on to get back up. I ask this as it seems to me what I see of young providers just fresh in doing the skill seem to be walking on water not realizing the true depth below them until the misstep occurs. Is there any cutting edge training ( I already took the difficult Airway Course and found it phenominal) that can be utilized to make us to the level of " the pros". I cant wait to see your thoughts.

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From his comments above, it seems that Dr. Grabinsky disagrees.



Scott Lancaster said:

I believe the cardiac arrest issue is settled, especially in the EMS realm - no need to keep beating that dead horse. 

"...not everything that is medically proven inside the hospital has to be studied outside to see if it looses efficacy once an invisible property line is crossed." 

 

How is asking for proof of positive correlation between in-hospital and out-of-hospital efficacy "hard to prove a negative?"

Mr. Waller

 

I just have a couple of things to say. First it is obvious you must have a ton of time on your hands  to sit around the station and argue with one of the most respected trauma  anesthesiologists in the country, which directly correlates with the probability that you probably don’t handle too many critical airways. I am sure you and your training officer are satisfied with your success rates at placing your favorite rescue multi-lumen esophageal tracheal airway of choice. I am also pretty sure he is much more at ease with you placing a rescue airway device rather than the risk, as you put,  of performing such a high risk procedure such as as ETI, RSI, BNTI…etc. That being said…… you sir need to remember your place on the EMS food chain which is:  when a paramedic proponent (from one of the most respected EMS services, with the one of the top ETI rates in the country for over 40 years)   like Dr.  Grabinsky speaks…you should open your ears and absorb what he is saying. You can go on quoting ACLS ECC guidelines all day long…but remember the AHA, self admitted by the AHA, has always angled its certification courses to the lowest common denominator, which are  clinicians that can’t handle the responsibilities of advanced procedures like ETI and RSI so they  preach the skills with the  lowest  risk, lowest stress, and the easiest to comprehend.  So go on preaching ACLS this and AHA study that, with your love of rescue airways and your ACLS card in hand, you may be better suited in a less stressful level of certification, maybe  EMT-RA (rescue airway) ?  In closing , you should be careful on discussion boards like this because the more you open your mouth on this subject,  the more embarrassed I am for you and your “advanced” ALS  fire department truck on your profile.



Ben Waller said:

Repeating the words "gold standard" does not define what a "gold standard" is.

It does not define what a "gold standard" is supposed to be.

 

It does not provide any evidence for using a device, drug, or procedure in specific circumstances.

 

Most importantly, it does not tell us whether or not a specific device, drug, or procedure is a case of "the cure is worse than the disease".

 

In the case of CPR, the device indeed does not compromise CPR - especially if you don't take it out of the wrapper and interfere with CPR while trying to insert it into the patient.  Patient benefit is about outcomes, not techniques.  Where is the evidence that ETT improves to patient outcomes - or benefits cardiac arrest patients at all?

Mr Waller

 

Internet died during last post

 

….I would like to add that I find it hard to believe , even with all your cool instructor certs you have so neatly listed on your profile,  you have the huevos’ to argue with a world renowned anesthesiologist (which last time I checked, is essentially an airway physician)  on what the gold standard airway management device is…….short sighted  and disrespectful.  Hilton Head must be proud.

 

Mike,

Respectfully, you made several false assumptions in your statement, and you based your entire post on a logical fallacy - the Appeal to Authority.   From that link: "An Appeal to Authority is an argument from the fact that a person judged to be an authority affirms a proposition to the claim that the proposition is true."

 

In other words, no one's position is proven correct because of who the person is, the position that person has, or that person's credentials.   Positions must stand on three elements in order to be valid - they most be logical, they must be factual, and in medicine, they must be supported by evidence.  Part of proposing evidence is a definition of terms.  When we're talking about a "Gold Standard", that term was undefined as the good doc used it.  I asked for a definition - and it took some digging before someone else came up with a three-part definition - two of which are completely subjective.

 

I did not attack anyone in any way - I questioned positions, proposed alternatives, and asked for a definition.  If we get to a position in EMS where no one can question a physician, then we're going to create more problems than the ones we solve.

 

The "cool rescue truck" in my avatar was in fact an 3rd-Service EMS rescue truck that I operated at a previous employer.

 

I don't stand on anything I list in my profile, I ask for evidence and compare it to other evidence.

I also understand that the goal of a lot of RSI research is "Place the ET tube", not "Improve patient outcomes".  That leaves a big hole in some of that evidence when the ultimate goal is (or should be) improving patient outcomes.

 

I don't place a lot of advanced airways in my current position - I am that training officer to which you referred, apparently in the mistaken belief that it is someone else.  However, I've placed plenty of ET tubes orotracheally, nasotracheally, and via RSI during previous stops in high-volume EMS systems.  That doesn't make me an expert, but it does give me real-world field experience in the topic.

 

I quoted no ACLS guidelines, in fact, I just compared airways, ease of placement, and discussed different patient populations with different airway needs.

 

I don't "sit around the station" and post on internet forums.  I do that on my own time. 

 

I also didn't conduct a personal attack.  You did.  Respectfully, it would be more positive and helpful if you asked a few questions first instead of posting a rant based on mistaken assumptions.

 

Here is more evidence that ETT is NOT always the "Gold Standard", even if that is defined as "the best we can do with what we have" or something like it.



mike said:

Mr. Waller

 

I just have a couple of things to say. First it is obvious you must have a ton of time on your hands  to sit around the station and argue with one of the most respected trauma  anesthesiologists in the country, which directly correlates with the probability that you probably don’t handle too many critical airways. I am sure you and your training officer are satisfied with your success rates at placing your favorite rescue multi-lumen esophageal tracheal airway of choice. I am also pretty sure he is much more at ease with you placing a rescue airway device rather than the risk, as you put,  of performing such a high risk procedure such as as ETI, RSI, BNTI…etc. That being said…… you sir need to remember your place on the EMS food chain which is:  when a paramedic proponent (from one of the most respected EMS services, with the one of the top ETI rates in the country for over 40 years)   like Dr.  Grabinsky speaks…you should open your ears and absorb what he is saying. You can go on quoting ACLS ECC guidelines all day long…but remember the AHA, self admitted by the AHA, has always angled its certification courses to the lowest common denominator, which are  clinicians that can’t handle the responsibilities of advanced procedures like ETI and RSI so they  preach the skills with the  lowest  risk, lowest stress, and the easiest to comprehend.  So go on preaching ACLS this and AHA study that, with your love of rescue airways and your ACLS card in hand, you may be better suited in a less stressful level of certification, maybe  EMT-RA (rescue airway) ?  In closing , you should be careful on discussion boards like this because the more you open your mouth on this subject,  the more embarrassed I am for you and your “advanced” ALS  fire department truck on your profile.



Ben Waller said:

Repeating the words "gold standard" does not define what a "gold standard" is.

It does not define what a "gold standard" is supposed to be.

 

It does not provide any evidence for using a device, drug, or procedure in specific circumstances.

 

Most importantly, it does not tell us whether or not a specific device, drug, or procedure is a case of "the cure is worse than the disease".

 

In the case of CPR, the device indeed does not compromise CPR - especially if you don't take it out of the wrapper and interfere with CPR while trying to insert it into the patient.  Patient benefit is about outcomes, not techniques.  Where is the evidence that ETT improves to patient outcomes - or benefits cardiac arrest patients at all?

Nathan said:

We've all heard the whole "Gold Standard" think.  I too have yet to see hard evidence that backs that up.  Im not saying it doesn't seem superior in some cases.  Im just saying that there are other airways that, depending on the situation such as available manpower and prioritizing other tasks, ETT usually ends up closer to the middle than the top of the list.


Well, it's hard to sum up 100+ years of anesthesia and critical care and (somewhat fewer years of) emergency medicine literature in an internet post.  :)  The very first non-surgical tracheal intubation was in 1858, according to Wikipedia, so there's a lot of material out there--the 20-page airway chapter in my EM text has 142 endnotes, much of it from EM-specific literature; the 41-page "tracheal intubation" chapter in my procedure book lists 164 (and unlike the EM text, there is literally nothing in that chapter except tracheal intubation--LMAs and supraglottic devices are in the "basic airway" chapter and mechanical ventilation is its own chapter). 

That said, ETI is only the treatment of choice for the short- and medium-term ventilation of the critically ill pt. Clearly, LMA is equivalent in some surgical settings, BIADs appear to be superior in OHCA, and in the long term you'll get a tracheostomy.

In any case, it's not surprising that there are few schools teaching RSI, since it's not part of the NSC and not even an option for providers in many states (thereby reducing motivation to go above and beyond). One of the simulation centers here offers an EMS difficulty airway course which includes use of the difficult airway manikin, but I've never taken it.

"That said, ETI is only the treatment of choice for the short- and medium-term ventilation of the critically ill pt."

 

Excluding CPAP?  CPAP is a great tool for short-term ventilation of many critically ill respiratory patients and it has given us a tool that has replaced a lot of nasotrachael ETIs.

 

Here's additional discussion on the ETI for EMS topic.  It's an opinion-based article, but it should make us all think about alternatives.

Yeah, I forgot about CPAP/BiPAP. :) I can probably find some more qualifiers to throw into this sentence if I think about it a while:

That said, ETI is only the treatment of choice for the short- and medium-term mechanical ventilation of the critically ill pt who has failed non-invasive therapy.

Think of short-term as the first day or 2, not the first hour or 2. Does that change your answer a bit?

Nathan said:

But why is it the only "treatment of choice"?  What is that based on?  I can think of some reasons for the long term but for the short term??  I guess that depends on the definition of short term..

dr-exmedic said:

Yeah, I forgot about CPAP/BiPAP. :) I can probably find some more qualifiers to throw into this sentence if I think about it a while:

That said, ETI is only the treatment of choice for the short- and medium-term mechanical ventilation of the critically ill pt who has failed non-invasive therapy.

"Think of short-term as the first day or 2..."

 

In EMS terms, that's not short term, it's almost forever.  :-)

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