As an anesthesiologist and a medical director of an ambulance service that participates in the education and training of EMTs and paramedics, I read with great interest your original research article ˙Focus on RSI: Does training in the OR create an optimal RSI program?Ó (MarchJEMS).
The OR paramedics attempted to intubate one-third more patients (22 patients) than manikin-only trained paramedics. It wouldn_t seem possible that one group would randomly respond to more patients in respiratory distress. An interesting follow-up would be to see what number of patients required urgent intubation by ED physicians on arrival.
In the results section, there_s confusion in the numbers: The OR paramedics performed 90 RSI attempts on 70 patients, and the non-OR paramedics performed 55 RSI attempts on 48 patients. That_s a total of 118 patients, not 115, as the initial sentence states. Both groups were unable to intubate three patients (67 of 70, 45 of 48 non-OR). That_s six patients who were unable to be intubated.
The last paragraph of the results section states: ˙The first attempt success rates and second attempt success rates did not differ between the two groups.Ó This is a more appropriate comparison of the two groups versus the sum total of all attempts. This represents the fact that both groups completed a paramedic training program that included airway manikin training and OR intubation rotation, as well as their work-related field intubations. Ultimately, most of the training for RSI is didactic-based: choice of the appropriate patient, medical necessity and airway assessment; medications; induction and paralytic agents; and difficult airway algorithms for those patients unable to be intubated and possibly ventilated.
If the theory is that didactic lecture with manikin simulation is sufficient training for RSI or even intubation, it would require utilizing paramedics who have never intubated a human before. As an anesthesiologist and an educator, that_s not who I want responding to my airway emergency.
Deborah Smith, MD, NREMT-P
Authors Cynthia Kelmenson, MD; Josh Salzman, MA, EMT-B; Kent Griffith, RN, EMT-P; Koren Kaye, MD, FACEP; & R.J. Frascone, FACEP, respond:The overall number of patients included in this retrospective review was, in fact, 118, not 115, as was published in the original article. We apologize for the error. Taking this into consideration, the overall intubation success rate in the first sentence of the results section should read 95% (not 97%), and there was a total of six patients (three from the OR-paramedic group and three from the non-OR paramedicgroup) who were unable to be intubated.
In response to the question of unbalanced RSI attempts between the OR paramedic and non-OR paramedic groups, we noticed a trend over the course of the study period in which RSI attempts as a whole declined steadily. The non-OR paramedics began working in this system after the initial 12 paramedics were trained in 1999, and we believe the difference between the groups can be attributed to the general decrease in RSI cases for this service over the study period.
The last paragraph of the results section looks more in-depth at differences that may have existed between the two groups. However, we believe it_s still important to examine the overall success rate between groups in relation to the number of attempts. Consistent with the standard reporting for airway management in the literature, we reported overall, first- and second-attempt success rates, and compared them between groups as appropriate. Ideally, the overall success rate would match the first attempt success rate, but in the real world, this often isn_t the case. Additional attempts at securing an airway lead to the problems Dr. Smith discusses in her response, particularly hypoxia. Reporting overall success rate by attempt can help raise red flags about individual paramedics or groups of paramedics who have large differences between their success rates by attempt.
Dr. Smith_s letter also comments on ˙the fact that both groups completed a paramedic training program that included airway manikin training and an OR intubation rotation as well as their work related field intubations.Ó If the reference is in regard to initial paramedic training, there_s no guarantee all the paramedics actually participated in an OR rotation. Educational research conducted by one of the authors (Salzman J) using FISDAP has shown inconsistency among training programs with regard to the utilization of OR rotations for endotracheal intubation training.
Regardless, the purpose of this study was to examine paramedics with similar RSI training experiences, with the exception of the OR rotation. As with all retrospective studies examining a specific variable, limitations are many and were documented in the discussion section. We encourage readers to keep this in mind as they review the information presented and decide whether to make changes to their programs based on this study.
William Ott_s byline was omitted from the AugustJEMS feature, ˙The Threat of Hackers.Ó
In the August Case of the Month (˙Cardiac Injury: Severe blunt chest trauma leads to cardiac arrestÓ), the vital stat oxygen saturation on non-rebreather mask should have read 98% rather than 9%.JEMS
The Body Electric
Thanks to Keith Wesley for ˙Hands On Defibrillation: Are gloves necessary during defibrillation?Ó (June, Jems.com; read it atwww.jems.com/wesley). I found it really helpful. Once, during resuscitation of a male with an implantable defibrillator in refractory V-tach, the patient_s defibrillator kept going off. Another paramedic on the job said he had been shocked as well. Normally, I would_ve told him it was rubbish, and he must have felt something else, but I was leaning against him when it happened and felt a nibble too. This is probably not really that relevant as it_s an untested, unrepeated anecdote, but I won_t be touching anyone who_s being defibbed, gloves or not.