My thoughts, as a doctor providing pre-hospital care at motorcycle
races.
In an ideal world we would all get lots of experience in RSI and
regularly re-train/re-validate. This is in reality increasingly
difficult unless your work directly leads to you being exposed to
suitable cases. Theatre based RSI is an option but with the
increasing use of the LMA this is much less frequently performed. It
also represents cases that are very different to those encountered
pre-hospital.
This leads to the conclusion that manequin based training has to be
used to some degree and has benefits of newer manequins being able to
simulate difficult airways.
It is entirely artificial to give a fixed number of RSI cases
required. Some operators require little repeat training, while
others will remain poor no matter how many intubation's they have
performed eg the year 4 anaesthetic SHO we wish would never come to
our resus. This recommendation comes as a concern as it may be used
against us if a patient suffers an adverse outcome as a result of our
intervention.
This is balanced by the only case that I know of relating to to RSI
pre-hospital. It was published in the MPS casebook about 2 years
ago. In short, the case found against the doctor(s) at boxing
ringside who did not intubate a boxer with a significantly impaired
GCS. He had an adverse neurological outcome. The case found that he
should have been intubated and awarded damages accordingly.
All of this means that risk-benefit of any RSI should always be
considered, which should be what we do anyway. Anyone performing RSI
should be able and prepared to proceed to advanced airway techniques/
rescue techniques. From an ethical point of view it would be
desirable for those asking you to perform a pre-hospital service to
provide resources to train/re-train in procedures that are
infrequently performed. It would appear to be more efficient to
cover several rarely performed procedure at regional study days or
equivalent. Experience gained at other training courses should also
be taken into account. I have concerns that recommendations such as
those raised will lead to those involved in seeing high acuity cases
having a requirement to be trained in ACLS, APLS, ATLS, MOET, STAR,
PHTLS, advanced airway course... Where does it end?
When we encounter a case that we need to intervene with we do so on a
risk-benefit decision. This relates to the individual involved and
their level of training. It can not be compensated for by any
number of certificates.
Alistair Murray
SpR Emergency Medicine
Dublin
On 15 Sep 2007, at 08:43, Jel Coward wrote:
> Hi all
> Been quiet around here and something has been on my mind for a
> while....
>
>
> Despite being overseas I choose to receive the the EMJ still.
>
> I think most of you will know that I fundamentally a GP and was
> quite involved with pre-hospital care in the UK until I left in 2001.
>
> I now work in a rural area, not that rural by Canadian standards
> but still 2.5 hours from a DGH type hospital, along a road that is
> treacherous ( the Sea to Sky Highway - locally known as the Sea to
> Die Highway) and which is often closed due to snow and/or MVC's.
>
> The GP's here run the Emergency Department and we deal with
> whatever comes in - there is no 'bypass' - and we provide all the
> care for a very large area.
>
>
> Now to what has been on my mind.
>
> I have followed slightly the move towards certifying intubation for
> pre-hospital care doctors in the UK. My reading (and my
> recollection may be incorrect) is that if a doc hasn't done x
> number of intubations in time period y and hasn't been signed off
> then the proposal is that they shouldn't be allowed to do it.
>
> I don't intubate often. Probably much less often than most members
> of this list. When I do it is most often in our small emergency
> dept which is staffed by a single nurse. (we always try to get
> other nurses/docs in when time allows of course).
>
> I work a 1 in 3 in our rural community and there is no provision to
> backfill me if I were to want to go and grab a few tubes in the city.
>
> The expectation of my hospital colleagues in the city is that I
> will intubate when necessary. Indeed, I have only ever heard here
> of a GP being criticised by a hospital doctor for _not_ intubating.
>
> An example, a pre-teenager bumps his head, brief loss of
> consciousness perhaps, story is not clear, maximum duration 10
> secs. Marked ante and retrograde amnesia. And a tempo-parietal
> bump on the right side ( you know where this is going now). So
> yes, a fairly typical extradural haematoma story ensues over
> perhaps the next hour. Perhaps then this child becomes more and
> more obtunded. Transport is awaited and might be in the form of a
> rotary air ambulance with ALS type paramedics. Patinent becomes
> bradycardic, say around 40, resps become not so regular. Mannitol
> given. All the usual guff going on whilst he just gets worse and we
> can add in a bit of trismus and vomiting for good measure.
>
> There is great fear in these situations - what if I attempt this
> paediatric intubation and something goes wrong? what if I don't
> attempt it, I am almost certain that something will go wrong?
>
> That fear, for me at least, is best managed by the thought 'what do
> I think is the best thing for this person?'
>
> But...
> What if I don't have my number of requisite intubations? And don't
> have my certificate? (we don't have a requirement but I pose the
> question as if in the UK)
>
> This is not intended as a challenge to what is proposed in the UK.
> It is just something that is in my mind that intrigues me greatly
> and I think probably disturbs me a little. I don't pretend to know
> or think I know the answer to this particular conundrum. I do
> think that the drawbacks of certification systems should be fully
> explored. I think and hope they will be because one of the people
> involved I remember as a dear colleague and friend who is a great
> champion of pre-hospital care.
>
>
> Thoughts?
>
> --
> Jel
> PS - this is therapy for Jel :)
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