> 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.
As I understand it from elsewhere, the MPS casebook presented a rather abridged version of what happened. There were several issues around this: the oxygen ran out (there was only one cylinder); the patient was not bagged once the oxygen ran out; there was a long transfer to a neurosurgical centre when the patient should have been taken to the nearest A and E department etc. Although not intubating was mentioned what was said in the judgement was that the doctor had failed to ensure that there were adequate facilities to deal with problems and should have permitted the match to go ahead.
> 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.
However, from a medicolegal point of view you are potentially getting yourself into a tricky situation if you have intubation equipment but are not up to speed with intubating. Once you have the equipment you are acknowledging that you may need to intubate. If you do that but fail to ensure either that you are of a reasonable standard yourself or that someone else present is, it looks a bit tricky. Again, I come at it not from the point of view of whether I'd do something I wasn't really competent at if it was necessary but whether if I thought it was a real possibility that I'd need to do it I should be competent.
I agree about the problem with the large numbers of courses. However, by its nature emergency care involves a wide range of skills. What will get interesting is when the number of juniors gets cut across the board and there simply are not enough people on site with certain skills. To me it seems that for emergency care to work, we probably do need to spend a fair amount of our daylight hours in skill maintenance which may need to be outside the ED. (It is a bit of a problem that the same consultant contract applies to a dermatologist with no on call; a cardiothoracic surgeon; and an emergency physician when the ways of working are so different.
Matt Dunn
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