Episode 14 - Questions and Answers
Questions and Answers
Released
December 2023
Hosts
John Hill
Scott Wildenheim
Caleb Ferroni
Ray Pace
Links
www.prehospitalparadigm.com/podcast/ask-a-podcast-question
Episode Videos
The End of Year Grab Bag Episode - Part 1
The End of Year Grab Bag Episode - Part 2
The End of Year Grab Bag Episode - Part 3
Happy Holidays
Episode Audio
Show Notes
This episode features viewer / listener questions to the podcast team
Question 1
Do you see RSI becoming a standard in the UH EMS protocol?
Answer
NO
We believe this is asking is this going to become the standard of care. It is already standard for the participating departments
Protocol features both drug assisted airway (standard airway protocol for everyone) this features the protocol to allow paramedic providers to use ketamine or fentanyl and midazolam to assist with airway placement. and a proper RSI protocol.
DAI (Drug Assisted Airway) Ketamine or Fentanyl and Midazolam - available to all paramedics
RSI (Rapid Sequence Intubation) Ketamine and Rocuronium - available to select trained departments and paramedics
There is already a standard RSI protocol for participating departments
The musts;
must have 3 providers on the truck, two of which are RSI trained paramedics
must have video laryngoscopy with direct laryngoscopy backup along with supraglottic backups
must have special training and authorization from the medical director. This will include in-person validation of skills as well as quarterly re-validation.
The shoulds;
The department must be willing to pay and maintain this program
The department should already be adept at intubation, the tools and drugs do not make you better. This proficiency needs to be in place before undertaking the process.
The medical director and the chief must agree that the process is needed
A full time department
Lookback on call for preceding years, how may times would it likely have been NEEDED?
Is it needed? drug assisted airway usually gets the job done. The cases where its absolutely needed are few and far between. It can be beneficial in these rare cases.
Question 2
What can a Paramedic do to prepare for a field RSI?
Prepare to fail - have the backup plan scribed before the attempt. The first attempt needs to be the best attempt
Training
The setup and prep make or break the success of the event
Take the airway on YOUR time
The rapid part of RSI does not mean hurry up and do a thing. It is in reference to the speed of the sequence of which the patient is induced then paralyzed. Nothing in the procedure should be fast, haphazard, or rushed. The process must be methodical and then the induction and paralytic delivered when the patient and the environment is optimized for the procedure.
Use the protocolized checklist in the protocol
Question 3
When would you use different analgesics?
Caution - this is entirely subjective and there is nuance - No right answer, many people may answer this differently.
Here are some things to think about;
is it a trauma case or medical case?
is the trauma case in shock or not?
Medical cases - flank pain, specific protocol add of ketorolac
Medical case - ACS - specific protocol use of fentanyl
Non-penetrating eye trauma - specific protocol use of tetracaine
Other medical pain
Is the patient opioid dependent, opioid acclimated, or on a narcotic recovery program
Things to consider with any case
What has worked in the past
Suspected source of pain
Age
Renal status
Side effects of the medication
Synergistic effects of multiple agents
Can you use non-pharmacogical methods to help improve pain
Set appropriate expectations - can help but will not complexly relieve pain
Can always give more, don't need to start with huge dose
LISTEN TO THE PODCAST and formulate what makes sense or what works best for you.
Question 4
How do we do the things enroute safely that are needed to be done when balancing rapid transport and intervention on stroke patients? (Paraphrased)
Discuss processes with partner before shift
Discuss enroute to call
Whoever is in charge can announce to the patient (and partner what the plan is)
IV's
Bring sharps containers close to you if doing IV's during transport
Develop routine with partner
Engineer the setup of the truck to facilitate interventions during transport
Buy or source self sheathing IV catheters
Work from bag rather than shelf (stay belted)
Manage time better. Stop the truck enroute once set up during transport, immediately resume transport once IV established
Discuss processes with partner before shift
Whoever is in charge can announce to the patient (and partner what the plan is)
Discuss enroute to call
12 Leads
Proper skin prep
Shut off inverters move device away from source of 60 cycle interference
Do 12 leads in house / bedside
Buy good electrodes
Propper placement
VAN
Can be done enroute for sure, doctors do it walking to the CT scanner all the time
The Protocols
Episode Shorts
From The Episode
Scott and Dr. Hill discuss duration of action for hydromorphone
Ray describes the EMT level assesments for stroke
Scott almost took his dogs meds this am
Dr. Hill discusses his personal experiances as a patient with analgesics