Vic wrote:
The only formula that should be in your head
> is "Must I do this now to get the best outcome, or is it better for the
> patient for someone else to do it later?" That question alone is difficult
> enough to make, without other distractions.
> 

I think the point about 'without distractions' is perhaps a large part of 
what is driving my exploration of this.

Pre-hospital care is challenging  - probably part of the reason we do it.

The challenges can be almost overwhelming.

To secure an airway and facilitate ventilation is not that infrequently, 
essential.

In a difficult environment as an an infrequent intubator I need to be as 
focussed as possible on what I am doing - and not on the fact that my 
'ticket' expired last month.  Adding that distraction is very likely to 
worsen my performance - and detract from my care. Which poses the question 
'is the existence of that certificate a good or bad thing in that circumstance.

The question might be extended to 'and what if docs stop doing pre-hospital 
care because of requirements that are too difficult to meet?'  - and 
perhaps also to 'what about the patient that dies for want of a secured 
airway'.

Yes - nice to have an anaesthetic/surgical team on hand everywhere.   The 
reality is that we don't have that.  Whatever is done we must be careful 
not to downgrade the care provided for want of certificates.

Another approach to this might be to say 'hey, perhaps we need to improve 
advanced airway care in the pre-hospital setting.  Let's make it easy for 
pre-hospital docs to get more training by funding something like the AIME 
course (or others, AIME is Canadian, I think) and by building a cadre of 
willing anaesthetists who are happy to be called up by those docs and offer 
them sessions where they can intubate'.  And leave out the certification. 
I think a lot of pre-hosp docs are self motivated (mainly volunteer) and 
would dearly like to avail themselves of such opportunities.

Not sure what is 'right' here - good to discuss - other thoughts?

> Vic Calland
> Rapidly becoming an "old fogey" of Pre-hospital Care
> 

You always have been me 'ol matey!


Jel



> -----Original Message-----
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]] On Behalf Of Jel Coward
> Sent: 15 September 2007 08:43
> To: [log in to unmask]
> Subject: RSI in the pre-hospital setting
> 
> 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?
>