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