I recently read an article about the controversy over Rapid Sequence Intubation (RSI) in Texas. This is quite a disturbing article to me. Any paramedic in any state should be able to determine when RSI needs to be performed and be able to successfully perform the procedure.

Following is the article I speak of. After the article, I provide some of my personal thoughts. I urge all readers of this article to comment with your personal thoughts. My curiosity sometimes gets the best of me, that's why I desire others to read this article and post your thoughts. My point of this article is to get feedback from other medics, especially educators to try and understand why medics in Texas are facing this controversy. You'll understand what I am getting at after the article below.

RSI Could Threaten Texas Tradition
At least two people in Texas have died and another has been permanently disabled after being deprived of oxygen during Rapid Sequence Intubation (RSI). The incidents detailed in court records stemming from lawsuits, may indicate a much wider problem. "My gut feeling is that, for every one of these cases, there (are) probaly a handful of others you never hear about," said Henry Wang, an assistant professor of emergency medicine at the University of Pittsburgh. "I compare (RSI) to an M-16 - extremely powerful in the hands of a master who's well-trained and it takes alot of practice, extremely dangerous in the hands of a beginner," said Wang. "Once you give the drugs, it is the point of no return. You must secure that airway."

The RSI debate has been raging nationally for years, and some states have limited the procedure in the prehospital enviroment, paticularly for gound EMS. Texas has followed a different path, leaving RSI decisions to the physicians who serve as local EMS medical directors. Although Texas' approach to EMS, known as delegated practice, has long been considered a necessity because of the state's size and diversity, it may be put to the test by RSI.

Forth Worth Star - Telegram, April 20, 2008
Reference: Best Practices In Emergency Medicine

Personal Thought:
First off, Mr. Wang's statement above "paticularly for gound EMS" is a complete turn off to me. I have worked with countless medic's and nurse's both on the ground and in the air. A well trained medic is a well trained medic regardless if he/she is on the ground or in the air. Same story for nurse's.

The difference here is I am assuming from Mr. Wang's comment is having a nurse onboard in the air makes the difference although the article did not specifically state this. I have also listed a couple of other areas of weaknesses Mr. Wang may have been referring to below.

Limiting RSI on the ground but not in the air? I assume this is due to having virtually unlimited access to equipment for the air ambulance versus the ground units or maybe because an RN is onboard the air unit. I know from experience the air crews train more extensively than do the ground crews, have better equipment and access to better medications.

I feel Mr. Wang's comments need some backing or should I say more clarification. It appears that Mr. Wang has more confidense in air crews than ground crews. To me, that's a slap in the face. I have worked with as many awesome ground medics as I have air medics.

I am quite sure Mr. Wang did his home work on this topic but did not clarify why the ground medics are at the point of controversy versus the air medics. Once again, I am assuming several factors. All are easily corrected with persistant training. 1 through 3 below are what I would assume may be the reasons Mr. Wang feels more strongly about air crews versus the ground crews. Heck who knows, maybe Mr. Wang is on the side of all medics but I don't feel he is by his rather strong comments.

Why Would Air Medics Be More RSI Favorable Than Ground Medics (via Mr. Wang)?
    1. Better equipment
    2. More training
    3. RN onboard the air unit (I am just assuming this is a point that Mr. Wang did not clarify)

Mr. Wang should have clarified his reasoning and provided more proof to go with his article. It's very difficult to determine his stance with RSI with ground medics versus air medics.

My problem with the controversy over RSI is really quite simple. Acutally, let me back up a bit here. I have personally performed many RSI procedures. Knock on wood with a 100% success rate. This goes for all of my ground medics with the ground services I ran for years as well. This is due to strong, committed and adequate training. I budgeted my training to allow for extra training sessions covering RSI.

The problems here can be easily identified by anyone who has been a medic for years. Mr. Wang should help clarify the problems medics face and why the RSI controversy exist to the proper agencies and help us get the point across. Please see my thoughts below!

• Equipment plays a major role

Ground units do not have the more sophisticated equipment as do the air units. This is because air units have more adequate funding than do ground services. Directors on the ground deal with hospital administrators, county commissioners, medical directors and many others dealing with budgets for equipment. Save the money. Don't get me wrong, as a director with many years under my belt, I do understand the budget. I also understand the concept for what we medics stand for. "We are here to save lives!"
• Lack of the same medications as air units

Air units have more medications than ground units. This is due to training and cost factors.
• Training or Lack There Of

Training is the problem with low RSI success rates. I am a bit distraught in this area. Training being the biggest problem can be easily corrected in my opinion. Directors need to take a stronger stance in the training arena. Fight for the training budget, I did. Be persistent with obtaining the money needed to keep your medics trained in RSI procedures. Write policies and procedures that include a strong dedicated training process. I always included my EMT's with RSI training. As we know, the strong EMT helps make a strong compotent medic. Continual RSI training is even more important in the rural medic setting such as Texas in the article above. I have ran both rural and big city systems. I was even more aggressive in the area of RSI training with my rural medics than I was with my city medics.

Summary
In the world of EMS, money holds our systems back in many cases. This includes bugets for training, equipment and so much more. Money is a huge part of what makes a good service versus a bad service. I have witnessed this both ways. Why would agencies wonder why something like RSI success rates are low? It's very simple! It's all in the training and equipment. Service directors need to take a strong stance with this issue. Don't allow government agencies or any other entity decide what a medic can or can't do pertaining to RSI training. It's the training! Fight for more money, better equipment and higher levels of training.

I have sat many times in front of hospital administrators, county commissioners and other agencies fighting for my EMT's and paramedics. We love to save lives. To save lives we need money. Why would or should we be limited or forced to stop performing a procedure like RSI due to lack of money for training or equipment? Why should we have service directors that do not know or understand how to get their EMT's and paramedics the money they need to train and save lives?

Money and training are the issues at hand, not incompotent medics! Paramedics need to form an informational society or agency of our own to get these problems noticed. People like congressman or other goverment agencies that do not know what is or is not obtainable in our work need to learn. We need our own group that can partake in studies of our own starting at the ground level, like equipment and training for instance.

Another problem is physicians at the upper levels of making policies for what medics can and can't do. These upper class physicians are as concerned about budgets as they are training. Can't we find the funding needed for better equipment and more adequate training? Yes we can, it takes knowledge and persistence beginning with our field personnel lead by our services directors.

As the author of this article, some good feedback would be greatly appreciated. I may be looking in the wrong direction or maybe I have too much confidense in our paramedics today but I feel the problem with the low success rate pertaining to RSI is more lack of training than anything else. In my years of being a paramedic, I have had the pleasure of working with some of the worlds best medics as far as I am concerned. We are all the same as paramedics, we train to save lives, we live to save lives. Why should we allow people to tell us we can't perform or limit a procedure we have trained so hard to perform. Why is it budgets should limit the training needed to save a life? What do you think?

Phillip Sampson
EMS Prime
http://emsprime.com