I agree with Vic.
I am one of those who does do more than 20 prehosp RSI's
in a year (26 in 2006), mostly for combatative HI's. The
problem as you have quite correctly stated is a
combination of appropriate training, but then maintainance
and then "quality assurance". Its easy for the anaesthetic
hosp docs as you can often discuss a case next day, and of
course you're doing RSI's certainly on a weekly basis on
an emergency list. The problem of course is what to do as
a GP. The evidence on skill decay will say that you need
to do something at least once a month (once you reach an
appropriate standard), so that equals obviously 12 RSI's a
year. Probably 6 could be done on a simulator, but that
still leaves 6 on the road. But what is "appropriate
training". The only prehosp RSI courses I know of are part
of MAGPAS initial traiining and of course HEMS London. Ron
Walls does a EMS RSI course in the states, as well as a EP
and Anaesthetic airway course
(http://www.theairwaysite.com/wordpress). I did the EP one
in 2002 and is definately the best airway course I have
done, (ive done the SAVE and UK emergency airway courses).
I do think anaesthetists over play the "what if"
scenarios, and I say that as an anaesthetist, but as
always its a risk-benefit thing, for Jel its different,
and I suspect if you went on one of Ron Walls' courses
then you would definately feel more confident and have a
"qualification" to speak of, but the skill maintainence is
the issue. As for GP's in the UK, as long as people are
happy to devote the time to learning the skill and
maintainence, I personally think that RSI and appropriate
triage are two of the best skills a doctor can bring to a
scene. Its not about what you are but what you do that
makes the difference - 10 years ago they wouldn't let
anyone without an FRCA do an RSI in hospital alone - now
we have paramedics doing RSI prehosp, what matters is good
training, good CPD and good quality assurance - how to
provide that is the issue.
The other barrier is of course appropriate monitoring!
Rob
On Sat, 15 Sep 2007 10:41:43 -0700
Jel Coward <[log in to unmask]> wrote:
> 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?
>>
>
>
>
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