Rapid sequence intubation should be done oNLY in an OR by an aneasthesiologist. Plain intubation in the field can be argued, I favor an LMA as I have seen too many EMT’s mess up an airway beyond retrieval with repeated attempts to intubate which wastes time and slows transport. Most pts can be adequately bagged, and an LMA is almost idiotproof.
Giving succ in a moving ambulance is stupid beyond belief.
Hopefully they would have secured the airway before they hit the road.
The hypoxic clenching patients in the ER might tend to disagree with you. ;'P
The problem here is not the intubation problems or the RSI, it is the failure to recognize that the tube is not in place, either initially or when it later became dislodged. The whole point of RSI is to put the patient down quickly, but BRIEFLY, while you intubate. The drugs should be chosen to wear off quickly so that if there is a problem with the intubation you can bag the patient until the drugs wear off, and at worst you are back to where you started within minutes.
These paramedics failed to recognize and address the problem of hypoxia, and that is a major failure. In addition to the clinical measures that should be used to verify tube placement, where the heck was the pulse oximetry? I don't know why any ambulance service would not be requiring its continuous use in all respiratory patients. It is the one thing that would have clearly let the paramedics know there was a problem with the tube. Maybe the patient didn't look blue or there was too much noise to properly assess breath sounds, and it seemed like the patient's chest was rising...but if that Pulse Ox is dropping, you have to know there is a problem.
That long time of UNRECOGNIZED hypoxia is the problem, not the actual intubation.
Just my 2 cents,
O2
What really gets me excited about RSIs now is a new tool called the McGrath laryngoscope. Have you heard of it? It's a digital camera with the lens at the end of the blade. The thing is AMAZING. I first saw it in action when we were having trouble securing the airway of a patient in CCU who was in severe respiratory distress and the ED MD could not, for some reason, visualize the vocal cords with a standard laryngoscope. We were getting ready to do an emergency cric on the patient when the anesthesiologist shows up at the last second, whips out a McGrath laryngoscope, and slips a 7.5 down just as neat as you please. He totally saved the day!
He showed me how the McGrath works. He says it had saved a lot of patients from getting "criked" since he started using it. My hospital evidently saw its potential benefits, too. Now our ED, OR, and CCU each have McGraths as standard equipment in our difficult airway kits and it has become the tool of choice, with only a few exceptions where the blades are not long enough.
And here's the real kicker: the guy who invented it wasn't even in the medical profession. McGrath was an engineering student in the UK, and IIRC his capstone project was to invent something. He looked for an opportunity to invent something that would benefit people, and somehow decided to try and improve intubation techniques.
Mr. McGrath came to America last year to assess the effectiveness of his invention, and he actually visited my hospital a few months back. We showed him the statistics r/t before and after getting his laryngoscope. The contrast was stunning. The MDs and anesthesiologists also presented the areas where the McGrath was not effective (longer airways and hyper-morbidly obese patients. He took notes. A few months later, we got new McGrath blades that incorporated his revisions to accomodate the problem patients.
A friend of mine who is an anesthesiologist told me that Mr. McGrath was totally blown away about the effectiveness of his brainchild. She said that McGrath was one of the most self-effacing, humble, genuinely nice people she has ever met. I don't think that McGrath will ever realize how many lives will be saved by his invention. I think there's a special place in heaven for the guy.
But I digress from the subject.
From my particular point of view as an Emergency RN, I have found that even a bad airway is better than no airway at all. At least it's a start. And if a patient is in cardiopulmonary arrest in the field, then an emergency airway should be obtained. LMAs are good, but the rationale that intubation is preferable if it can be done safely is, IMO, a sound one.
There is variation among regions regarding the skill of medics. I think that it would be a good thing to assess the training and skill of each ALS medic and to provide enhanced training for those medics who do not demonstrate proficiency in securing an emergent ETT in field conditions. Maybe providing the McGrath would improve things. Anyway, that's my long-winded response. Have a great day, Doc. Cheers! /Gunner