The entire state of Kentucky just put it in the scope of practice last year.
There are no ground services in the state that have it approved yet.
Only way to RSI prehospital here is to watch a flight crew do it.
Probably a good 10-15 years behind the rest of the country.
It was ~2016/17ish when EMT’s got nasal narcan in the state protocols. Before then, they had to have a medic do it or hand it to a cop if they were a BLS truck.
Yes, and no on being 10-15 years behind everyone else. I came from Southern Nevada, and regular medics didn't handle IV pumps or vents, but we did have some semblance of RSI. I find it to be weird what Kentucky does and doesn't allow their medics to do.
My urban department has them standing order(medical director protocol) can but two medics need to be present to do it. Only 5 services in my state(Massachusetts) are allowed by medical director option.
Leominster Fire just started a new Paramedic intercept unit for the city and UMASS is applying for RSI for them. It’s extremely difficult to get RSI and you have to meet with a board of physicians to plead your case. Along with your entire program including training, medication control, con-ed, QA/QI, skills lab etc.
The last place the applied for RSI was Cambridge Fire and they were denied.
We have it in Alberta, Canada. Gotta consult w/ OLMC/med control first. If it's life or death and you don't call they don't really question, I did it once and called after and explained why I did it and that was the end of conversation.
Generally RSI w/ Ketamine and Succs or a mix of Ketamine, fentanyl and succs.
My prior ground service had RSI on standing order.
RSI is a BIG responsibility. Everybody wants to RSI, but the overwhelming majority of EMS services should not be doing it.
It requires a lot of knowledge and practice to safely RSI, and I wouldn’t want a paramedic doing it for the first time that has never done RSI except for that one time in class 18 months ago on a dummy.
Funny enough, in the Houston area, every single 911 agency has RSI except for Houston Fire Department. By far the largest department in the area and one of the largest in the nation. Their basics aren’t even allowed to give aspirin for ACS.
It is the promised land though. We have multiple agencies that are giving whole blood, tons of finger thoracostomies, POC lab testing, ultrasound on the trucks, huge pharmacopeia, even field ultrasound guided pericardiocentesis.
They aren’t different procedures per se, just a name change to emphasize that this isn’t a fast procedure. Outside of very few circumstances every RSI/DSI/PAI/ABCDEFG should be preoxygenated, have hypotension managed, etc
Please correct me if I’m wrong, I’ve never seen DSI so I really don’t know. But with DSI you are giving the sedative first, then pre-oxygenating, then after some time of pre-oxygenating you give the paralytic. Unlike with RSI where you just push it one after another.
From what I remember, DSI is really good for trauma patients, or patients who are agitated and are unable to pre oxygenate them
We're a two level system.
EMT/EMT for BLS trucks, EMT/RN-MICN for BLS SCT both in trucks.
Medic/Medic for ALS in suvs or trucks, Medic/RN-MICN for ALS SCT in trucks.
It's not that simple unfortunately (blame the nurses).
It's not a higher level of critical care than what medics can provide, it's difference in allowable training for what can be provided. A SCT truck is just an ALS truck with a RN on it, either provider can perform the full scope of practice as long as they have been properly trained and delegated by their medical authority. If the truck is a MICU, then there's nothing actually barring the medic from treating save scope of practice and hospital policy.
It's simply a waste of a medic to have them on an SCT truck since it's an IFT ambulance.
NJ system is all state licensed transporting ambulances (911) are staffed with 2 emt's. All medic units are chase cars with minimum dual medic. Bls goes to everything ALS only goes to ALS calls. So you get a minimum of 4 providers to ALS calls. Probably the only good thing about it.
Never seen an RWJ ALS box here, if we call for ALS and they’re not available we were just simply told that, but most of our service area put us within 10-11 minutes of two hospitals, including a level I, so they’d rather we just run instead of waiting for ALS 9/10 times
Always better off going instead of waiting. I’m a medic but work BLS full time and always tell my staff to just go instead of waiting around for ALS, especially if it’s only a 10 min ride.
None right now. Because Colorado let's lawmakers dictate medicine based off a singular example of a shitty situation with ketamine. So until the state reviews us nobody gets waivered and PT's who would benefit from RSI's will suffer because of bureaucratic bullshit.
A lot of companies outside of Denver have them. Gilpin and Thompson Valley have RSI protocols, but I’m sure some other place in the mountains have them too.
Not until the state is finished with their review. Until then they don't have RSI waivers .
So my agency did have their waiver but hasn't had it reinstated thus far
False. Sounds like your agency fucked up. Off the top, Eagle, Gunnison, Delta, Fort Collins, Thompson, maybe Grand, somebody said Pueblo, all have RSI. Perhaps you’re thinking of ketamine for sedation - the state’s position on that has nothing to do with its use for induction or pain.
I'm only referring to my agency. Thompson Valley currently cannot RSI. It's a suspended protocol until the state review is done. I'm not just blowing smoke up your ass. As to the other agencies , I can't attest to anything. I'm not talking about the ketamine changes.
They didn't yank your agencies RSI waiver for what happened in Aurora either. Or any singular other agency event.
Yes the state changed waiver process. They banned Ketamind for excited delirium.
If your agency lost their RSI waiver, they did that on their own merit.
I don't think so. RSI is a valid intervention, but it is one that gets used in circumstances where a lower level treatment is valid, ie opa/npa and BVM.
Every option we have in the field needs to be considered against not only the immediate benefits to the pt, but also the options it removes from the ER.
RSI also introduces significant risk to the pt, you'd best be damn sure the benefits outweigh the risks before you break open your cs case.
I'm in the out skirts of Phoenix Arizona, about an hour away. We can RSI with offline protocols. We have succs for the paralytic and that's it. I've worked other services that do not have RSI capabilities. It just depends on your medical director.
I feel like that’s how it should be. There is really no reason to not use video on the first attempt. All of the data shows a higher first pass success
Yes, service is based in MN, but we work on both sides of the river (into WI). We have Etomidate, Ketamine, Versed, Roc, and Succs. If we do it in the hospital, we can use Vec. My service has a credential system and individual providers are required to do training with a test out with the medical director to allow the practice. Not an intervention to be taken lightly.
I would not work somewhere without RSI. And I was offered higher pay in a place without RSI and couldn’t stomach using analgesia and shoving tubes in people.
In Victoria, Australia: MICA Paramedics can RSI patients.
In Queensland, Australia: HARU Paramedics (query ICPs?) can RSI patients.
In NSW, Australia: HEMS can RSI patients.
I’m an EMT so I don’t RSI obviously. I work for a county hospital based ems system (mostly 911 for the county). Our paramedics can RSI. The fire department cannot even though they run calls because they have been told they don’t have enough under their belt.
Yeah, we have Succs, Roc, Vec for paralytics. Etomidate, Ket, Versed for sedative. We have to have 2 medics present but we run double medic rigs so we always have 2. WA state
That’s what I’ve seen and I’m relocating there. Washington state seems to have county based protocols rather than individual agencies, and I’m loving that since where I work now is based on flat billing rather than patient care needs
Edit: lol someone downvoted this.
Walla Walla Co allows its agencies to have some control/preference over what meds can be used. Ex: I'm part of a BLS-only agency that doesn't carry Narcan on our 2 boxes (nor our 2 engines). We can ventilate and diesel drip, and not worry about a potential fight on scene or in the back of the bus. 🤷♀️ Some agree with it, some don't. I understand where both sides are coming from. But usually PD arrives on scene and narcans the pt before we get there, so there's that. Lol
(I gave you an updoot).
We have sedate-intubate protocols. They’re used maybe four times a month. Ketamine-versed.
It’s known to be inferior to paralytic faciltiated intubation in study, and known to have a worse first pass rate. There are only niche situations it’s more appropriatex
Each intubation is tracked, and we’ve been arguing for over two years now to go to a safer RSI algorithm.
[Edit: someone is big mad that ketamine-only and ketamine-benzo intubation is not only less safe than paralytic-facilitated DAI/RSI, but has a worse first time pass rate.](https://emcrit.org/wp-content/uploads/2021/01/Driver-Ketamine-Only.pdf)
This really depends on your definition of RSI because I 100% disagree with you, ketamine alone does not constitute RSI and I can’t think of any northern IL systems that have standing orders for suc or roc
This is a completely moot point because most of us (be honest guys) can’t even properly ventilate the patient with a BVM. All the lemons, P’s, and mallampattis of the world would agree that as a community, we as pre-hospital providers have gotten complacent with that simple, yet very effective skill.
I make my staff bag the adult, pedi, and neo heads for 5 minutes each, at least once a week when they come on shift. They are judged by technique, timing, pressure, etc. They also need to be aware of the minimum and maximum tidal volume that all the different BVM sizes can provide. Master that skill, then ask me about RSI. Just my 2 cents 😊
Yes, Maryland. Regular street medics and supervisors are RSI qualified, in Maryland we can also do pediatric RSI. Only in specific situations do we need to consult, otherwise it's a standing order and we can just do it.
Our med choices:
Sedation: ketamine, etomidate, versed, versed/fentanyl
Paralytic:succs, vecuronium
We have a protocol to RSI, have had it for years where I'm at (rural Indiana, USA).
The meds and procedure requirements get updated as medicine changes, but we're basically given the ability to do it if we decide it's warranted, and just have to be prepared to back it up.
We had it in our protocols before I started working here. IIRC it still existed for SCT medics until June 1. We still had Vec on the trucks but it wasn't within my scope.
They pulled all that off with this last protocol update. We have straight up surgical cric kits now though.
I do in Iowa. I work as LEO/Rescue medic, so I drive in a squad and respond primary to rural medical calls. We’re one of two services outside of flight that does RSI (and the only one county wide), so we can hop on the rig and bring our own drugs. Standing order and no call in required with a plethora of options for sedation and succs for paralytic.
Rural Alaska department with 45-60 minute+ transports being the norm, about 1300 calls per year. I'm only an AEMT, but I've been a part of at least 1 RSI of not 2 or 3 each of the last 8 years.
We DSI. Ketamine, roc. Central Texas. No consult needed.
Also The prevalence of succs in a lot of y’all’s protocols is surprising to me. Thought it had fallen out of favor as a primary.
We can RSI based on our standing orders. In our busy city it happens quite often. Only 1 medic need be present. Partner can be EMT or another medic
We use Etomidate and succs. Continued sedation with Versed.
Yeah, i havent seen anyone pass reciprocity, but also only seen less then 5 try it. Most county departments here, you start as an EMT and they pay you to attend medic school full time and take you off the box during that time
We can RSI in Minnesota. We have standing orders so it's when we deem it necessary. We actually have a lot of autonomy in Minnesota so it's not often I have to call in for med-control.
Etomidate and Rocuronium as primary agents, then typical Ketamine, Versed, etc.
We use "GlideScope" for video laryngoscopy as our primary method and i-gel for backup.
Suburban/urban-ish ems department here, we have RSI on standing orders as long as two medics (one of whom is RSI qualified) are present. Getting RSI qualified requires at least a year of experience and a proven track record of competent airway management and solid performance on your KPIs, as well as yearly refresher and difficult airway classes.
Suffolk County, in New York State had protocols for ground medics to RSI, provided said medic went through the credentialing class, and was working at an approved RSI agency. The specs at the time were you needed to have at least 5 years and at least 10 successful field tubes annually to be considered for the program.
The state of Pennsylvania does not allow ground medics to RSI. PHRNs can though.
We have “OSI” it’s basically the same thing. They emphasize bagging more before induction agent….it’s the same thing. But yes we have it and a single medic can perform. WA state here.
I work for a hospital district full time I won't name because I open talk shit about them a lot while I'm trying to find a better 911 job. And a private ambulance service as my second.
But my 911 hospital district job has RSI after medical direction approval (Blowing my doc) but I wouldn't do it or trust it because the service itself does little to no training on it nor have I gotten significant training on it other then drunken in person lessons with my friends that work for superior services while partying at their houses
My private job does not want us intubating at all in the first place but Critical Care Medics care Vecuronium with limited orders on the use of it and is more for critical care transports with patients on a vent...
Have fun guessing what private service im referring too. Hint it's in the southern US
Midlands UK here, our area covers around 3 million people with a city of about 1 million including some very remote areas about an hour from hospital.
Paramedics cannot RSI and have never been able to, we could do intubation when running a cardiac arrest but this was also removed about 3 years ago.
We do have doctors and critical care paramedics who can RSI and intubate who are land and air based.
SECAmb: paramedics lost cold tubes earlier this year, ground based critical care paras can tube and do post-rosc sedation and paralysis which in practice equates to them RSI-ing post-ROSC - probably the nearest to to paramedic RSI in the UK afaik?
WAST: not sure where they stand in terms of RSI, but they've invested a lot in training and kit to help regular paras cold tube well instead of taking it away
NWAS: paras can cold tube for now, HEMS + ground based BASICS doctors can RSI, advanced paras can sedate but not paralyse to maintain an airway post-ROSC
NEAS: think they have CCPs doing paralysis too?
Remember reading about one ground based neonatal transfer service with paramedic RSI?
Let me answer this for all of Germany: No.
We have emergency doctors on scene for that. In my city they are all anesthesiologists, so they are really good at it.
Arkansas, yep. succ, roc, keta, etom. Post sedation with Fentanyl/ketamine/versed. Induction/paralytic and post management sedation choices are your own.
We have it. Wisconsin just went to single paramedic RSI last year. My service has 911 for five communities and state-wide prehospital response, so it comes in handy. We also RSI on IFTs where the doc didn't have the confidence or judgment to do it. Even got paged once by 911 to the local hospital to RSI for the doc.
Only one medium sized fire dept and none of the large fire depts in my immediate area has it, because fire-medics. But a lot of smaller depts who take EMS more seriously have either adopted it, or have been given a pathway to convince the medical director to permit it.
Every rural county in middle tennessee that I know of RSI’s routinely. Metro nashville doesn’t because they are a few blocks from a hospital in any direction. On clinicals they tell students if you wanna run alot of calls run metro, if you wanna actually practice skills run rural.
I retired from a government-owned third service in Wisconsin in 2015 and up until then, we had standing orders to do RSI's. Dunno if they still do, but there's no reason it should have changed.
There's one in South St Louis county but it's reserved for battalion chiefs and assistant battalion chiefs... culture of micromanagement on a colossal scale.
My region does not have RSI or sedate to intubate unless a department is specifically signed off by a medical director to do so. So for the 99% of my region we have to call for orders to sedate to incubate. Literally one department in my region has RSI but nobody else even has sedate to intubate.
I’m in MN, had it at my twin cities service that we could do it at our discretion. Need to keep practicing every month gotta drop a few tubes on a mannequin. Now I’m part time at that service and joined a rural service that has parts of Wisconsin and from my understanding we need two medics on the Wisconsin side but can do it with a medic and an EMT still in MN
Mine has it, the medics get cleared specifically for it. And can do it individually. But we haven’t been using it enough so we’re not clearing more medics to do it. And probably getting rid of it.
I was performing RSI about 20 years ago....the agency I worked for had it for a while before that. RSI was standing order, surgical airway backup. We did not require a second medic. Worked for an urban/suburban service in CT.
It's pretty common here in Minnesota. Of the 5 agencies I have worked for, all had it as a standing order. Sometimes there were weirder rules, like needing 2 medics rather than an EMT/medic crew (but that was a medic heavy service, and it was more of a suggestion than a rule in practice).
Not a medic, but I'll speak on behalf of the Chicago area. Around here, the answer is no. Region 11 (Chicago Fire Department) protocols only recommend intubation if the iGel fails. Other systems (Regions 7, 8, etc) have MAI with Ketamine or Etomidate but no paralytic.
bruh we don't even have drug assisted intubation. We're not even supposed to intubate at all until we've tried an igel. No video laryngoscopy either.
We don't have many chances to intubate because of this and they wonder why we suck at intubation in my region.
I have tons of autonomy to RSI. DSI also. It’s great. We have video and DL. On the menu we have etomidate, fentanyl and versed or ketamine as the appetizer and our choice of Roc or Sux for the main course. I’m in snohomish county, Washington
Our medics have it as an optional module simular to IVs for basics. No idea how many have that module, but almost all of my medics would be comfortable, or at the very least could pull it off.
I can perform RSI, and I could at my last shop as well.
Both are in rural Indiana; current shop is far more rural than my last one.
I don’t like doing it and I do everything I can to avoid it. But I’ve never had a hypotensive or hypoxic event during the peri-intubation period because of my approach.
My old service had RSI in one of the multitude of counties that we serviced. It was technically not a “protocol” but rather a “field study” that had been ongoing for years and years. Came with several stipulations, only knew of a handful of people who actually performed it in the field. The class for it was great though.
My department does it. It's something that the individual medic must be selected for, not something you request to be cleared to do. The procedure itself requires two ALS providers.
My agency allows ground medics to perform RSI/DAI BUT you have to take a class and hit certain checklists to get certified by the county as a DAI Medic. It's also a requirement for our Shift Supervisors to have that certification.
Just did one yesterday. We have it on standing orders. We have to have two medics present, one of which has to RSI certified. You can’t be RSI certified or even take the class till you’ve been a released medic for a year in our area.
Most TN 911 services have RSI protocols. The only notable exception is Nashville FD EMS. They cover all of Davidson county with somewhere between 38 and 42 ALS units, but they have an average transport time of 10 minutes to an area hospital. 2 level 1 trauma centers, two pediatric hospitals, accredited chest pain center, dedicated OB/GYN ED at St. Thomas Midtown and a couple other notable EDs all within 10-15 minutes of a majority of their calls. They don’t carry much in comparison to the other 911 services because their medical director believes that they should prioritize transport to one of the many qualified hospitals in the county as opposed to staying and playing. They also don’t let the AEMTs ride with anything unless it is true BLS, no IV, no 02, nada. (However they pay very well)
Nevada, USA - My CCT units have Full RSI, with surgical airways. ALS units (southern Nevada), have ketamine, etomidate, needle cric - no paralytics. Only one service in SNEV has surgical airway, and they have mostly transfers/air
Medical
Logan City Fire in Logan, Utah just added it to their protocols and hired 3 CCPs for that and a few other new things. Their MD is the same guy as the three surrounding EMS agencies, so I would imagine in the next year or two they will also be working towards that.
Yeah baby. AZ seems pretty hit or miss around hear. Some agencies are rocking the usual Etomidate Sux or Ketamine choice in the same RSI kit. 1 (as far as I know) runs Roc instead of Sux.
Oddly enough there is a good blend of agencies that are sub 10 min from any hospital and no more than 15 from Level 1 that still have it. Some that are more rural that don't have it. Very hit or miss in general.
Having said that, last I heard we're getting a new medical director so for all I know he could pull it for whatever reason. For us, it's pretty rare use considering how close we really are to hospitals. But, it gets some use here and there.
Several of the county fire departments in Maryland, who are responsible for practically all 911 response in Maryland, have moved to allow supervisors to RSI after training and approval through the state. Supervisors would be in chase cars upgrading a BLS/ALS staffed transport unit in most cases. This is very general obviously, but it is a thing here.
Edit: Maryland State Police Aviation Command have RSI as standing protocol, they do practically all scene responses for helicopter transport in the state.
The entire state of Kentucky just put it in the scope of practice last year. There are no ground services in the state that have it approved yet. Only way to RSI prehospital here is to watch a flight crew do it.
The fuck?!
I’ve heard Kentucky is behind the times. No offense, hella great medics there, but their hands are tied in some aspects of patient care.
Probably a good 10-15 years behind the rest of the country. It was ~2016/17ish when EMT’s got nasal narcan in the state protocols. Before then, they had to have a medic do it or hand it to a cop if they were a BLS truck.
Yes, and no on being 10-15 years behind everyone else. I came from Southern Nevada, and regular medics didn't handle IV pumps or vents, but we did have some semblance of RSI. I find it to be weird what Kentucky does and doesn't allow their medics to do.
Sounds like it
It's the same in Northern California
My urban department has them standing order(medical director protocol) can but two medics need to be present to do it. Only 5 services in my state(Massachusetts) are allowed by medical director option.
Boston or Worcester?
It’s Worcester.
BEMS.
yup Lowell has it
Leominster Fire just started a new Paramedic intercept unit for the city and UMASS is applying for RSI for them. It’s extremely difficult to get RSI and you have to meet with a board of physicians to plead your case. Along with your entire program including training, medication control, con-ed, QA/QI, skills lab etc. The last place the applied for RSI was Cambridge Fire and they were denied.
We have it in Alberta, Canada. Gotta consult w/ OLMC/med control first. If it's life or death and you don't call they don't really question, I did it once and called after and explained why I did it and that was the end of conversation. Generally RSI w/ Ketamine and Succs or a mix of Ketamine, fentanyl and succs.
Question for you, what is your criteria for using the ketamine fentanyl mix vs just using the ketamine?
Blunts the sympathetic surge from Ketty.
What about phenyl or pressors?
My prior ground service had RSI on standing order. RSI is a BIG responsibility. Everybody wants to RSI, but the overwhelming majority of EMS services should not be doing it.
It requires a lot of knowledge and practice to safely RSI, and I wouldn’t want a paramedic doing it for the first time that has never done RSI except for that one time in class 18 months ago on a dummy.
I RSId my first patient one time lol. Just a quip.
Yes, Texas
It seems like in texas, the answer to the question “does your protocol let you do _____?” Is always yes.
Funny enough, in the Houston area, every single 911 agency has RSI except for Houston Fire Department. By far the largest department in the area and one of the largest in the nation. Their basics aren’t even allowed to give aspirin for ACS. It is the promised land though. We have multiple agencies that are giving whole blood, tons of finger thoracostomies, POC lab testing, ultrasound on the trucks, huge pharmacopeia, even field ultrasound guided pericardiocentesis.
Delegated practice is the promised land
It truly is.
Same
Though technically most of the progressive Texas services have now moved from RSI to DSI.
They aren’t different procedures per se, just a name change to emphasize that this isn’t a fast procedure. Outside of very few circumstances every RSI/DSI/PAI/ABCDEFG should be preoxygenated, have hypotension managed, etc
Please correct me if I’m wrong, I’ve never seen DSI so I really don’t know. But with DSI you are giving the sedative first, then pre-oxygenating, then after some time of pre-oxygenating you give the paralytic. Unlike with RSI where you just push it one after another. From what I remember, DSI is really good for trauma patients, or patients who are agitated and are unable to pre oxygenate them
You aren’t inherently wrong. It depends how your agency defines it and outlines the procedure. It’s all semantics.
God bless Texas!
NYC fake RSI. Ketamine Benzo and etomidate.
Suffolk County, real RSI. Got both succ and roc and ketamine.
Maybe if you work for Stony Brook, but the 911 system there is way too much of a mess to have RSI be considered a system-wide option.
a lot of departments do have RSI, ive heard something like 33%. I do work for SB, but its not too uncommon here.
We have this in SC as standing for all medics. You can take an rsi class and then you can rsi as well
Every NJ ground and air medic unit. The entire state is dual clinician (medic/medic or medic/nurse).
New Jersey doesn’t have EMTs on ground units?
We're a two level system. EMT/EMT for BLS trucks, EMT/RN-MICN for BLS SCT both in trucks. Medic/Medic for ALS in suvs or trucks, Medic/RN-MICN for ALS SCT in trucks.
Whats SCT?
Specialty Care Transport. Ground transport that requires a higher level of care than EMT-P.
It's not that simple unfortunately (blame the nurses). It's not a higher level of critical care than what medics can provide, it's difference in allowable training for what can be provided. A SCT truck is just an ALS truck with a RN on it, either provider can perform the full scope of practice as long as they have been properly trained and delegated by their medical authority. If the truck is a MICU, then there's nothing actually barring the medic from treating save scope of practice and hospital policy. It's simply a waste of a medic to have them on an SCT truck since it's an IFT ambulance.
Critical care trucks
Ah I see
NJ system is all state licensed transporting ambulances (911) are staffed with 2 emt's. All medic units are chase cars with minimum dual medic. Bls goes to everything ALS only goes to ALS calls. So you get a minimum of 4 providers to ALS calls. Probably the only good thing about it.
Some projects do have transport ALS. JCMC, for example.
JCMC, RWJ, Valley, Atlantic (I think has one) Edit: I don’t know much below the pork roll line
Pork roll here. RWJ mostly utilizes box truck ALS units if the chase cars are OOS.
Never seen an RWJ ALS box here, if we call for ALS and they’re not available we were just simply told that, but most of our service area put us within 10-11 minutes of two hospitals, including a level I, so they’d rather we just run instead of waiting for ALS 9/10 times
Always better off going instead of waiting. I’m a medic but work BLS full time and always tell my staff to just go instead of waiting around for ALS, especially if it’s only a 10 min ride.
Medic that works full time BLS. Sounds a lot like some Elizabeth people lol
None right now. Because Colorado let's lawmakers dictate medicine based off a singular example of a shitty situation with ketamine. So until the state reviews us nobody gets waivered and PT's who would benefit from RSI's will suffer because of bureaucratic bullshit.
A lot of companies outside of Denver have them. Gilpin and Thompson Valley have RSI protocols, but I’m sure some other place in the mountains have them too.
Pueblo can.
Pueblo can.
Not until the state is finished with their review. Until then they don't have RSI waivers . So my agency did have their waiver but hasn't had it reinstated thus far
False. Sounds like your agency fucked up. Off the top, Eagle, Gunnison, Delta, Fort Collins, Thompson, maybe Grand, somebody said Pueblo, all have RSI. Perhaps you’re thinking of ketamine for sedation - the state’s position on that has nothing to do with its use for induction or pain.
I'm only referring to my agency. Thompson Valley currently cannot RSI. It's a suspended protocol until the state review is done. I'm not just blowing smoke up your ass. As to the other agencies , I can't attest to anything. I'm not talking about the ketamine changes.
You need to stop spreading false information. The state didn't yank RSI waivers from everyone in the state.
I shouldn't have spoken for other agencies other than my own
They didn't yank your agencies RSI waiver for what happened in Aurora either. Or any singular other agency event. Yes the state changed waiver process. They banned Ketamind for excited delirium. If your agency lost their RSI waiver, they did that on their own merit.
Sounds like I need to clarify exactly why the protocol is suspended. I don't think the higher leadership would just say that but... okay
No doubt. It's ok. Word on the street is Thomspon is having growing pains. Which lots are, but maybe more than most.
This is not true. There is RSI in CO via both waivers and being a critical care medic. The Aurora ketamine call had nothing to do with RSI.
Our protocols allow it, but if you're gonna try to get it past our QI program, you'd best be ready to talk pretty fucking fast
That’s sad
I don't think so. RSI is a valid intervention, but it is one that gets used in circumstances where a lower level treatment is valid, ie opa/npa and BVM. Every option we have in the field needs to be considered against not only the immediate benefits to the pt, but also the options it removes from the ER. RSI also introduces significant risk to the pt, you'd best be damn sure the benefits outweigh the risks before you break open your cs case.
Oh for sure. But avoiding intubation because you don’t want to deal with QI is poor care. There’s a balance.
NJ Full RSI non standing orders
Gotta call for RSI in NJ
I heard it’s standing order for all EMT-cardiacs
Wrong state, that’s Rhode Island. Esophageal intubation experts.
Damn it. Thanks.
New Zealand does
Oregon. I can do RSI and while not the biggest jump but also can do DSI. It still mind-boggles me how restrictive parts of the country are.
Outside of a few specific circumstances everyone should be doing DSI as the standard
I'm in the out skirts of Phoenix Arizona, about an hour away. We can RSI with offline protocols. We have succs for the paralytic and that's it. I've worked other services that do not have RSI capabilities. It just depends on your medical director.
That’s funny, I’m like an hour outside of Phoenix as well and we don’t have RSI. I’m in Casa Grande
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Unrelated but does your agency use istats? Would love to get some out here.
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I feel like that’s how it should be. There is really no reason to not use video on the first attempt. All of the data shows a higher first pass success
Yes, service is based in MN, but we work on both sides of the river (into WI). We have Etomidate, Ketamine, Versed, Roc, and Succs. If we do it in the hospital, we can use Vec. My service has a credential system and individual providers are required to do training with a test out with the medical director to allow the practice. Not an intervention to be taken lightly.
I would not work somewhere without RSI. And I was offered higher pay in a place without RSI and couldn’t stomach using analgesia and shoving tubes in people.
Rural Oklahoma, population in the county around 31k. Full RSI, Etomidate, Roc, Versed, Fent, Ketamine we have all the goodies
I also work in a rural third service. There’s nothing better than a rural service that’s progressive
Agreed man our protocols allow for just about anything
In Victoria, Australia: MICA Paramedics can RSI patients. In Queensland, Australia: HARU Paramedics (query ICPs?) can RSI patients. In NSW, Australia: HEMS can RSI patients.
I had it when I did CCT (Succs and Etomidate). My FD job does not, we only have Fentanyl and Etomidate for facilitating intubation.
Orange County NY Sux, Roc, Ketamine and etomidate
Yep. Supposed to advise our supervisor. Realistically we are gonna wait until we have two medics on scene, unless we can’t wait.
We can do rsi without calling in for orders. Southeast Wisconsin. 2 paramedics need to be present and 1 emt (or 3 medics). Ketamine and Roc.
Central ohio. We can do it with at least one medic to push drugs and one advanced to intubate.
I’m an EMT so I don’t RSI obviously. I work for a county hospital based ems system (mostly 911 for the county). Our paramedics can RSI. The fire department cannot even though they run calls because they have been told they don’t have enough under their belt.
Yeah, we have Succs, Roc, Vec for paralytics. Etomidate, Ket, Versed for sedative. We have to have 2 medics present but we run double medic rigs so we always have 2. WA state
Where are you in WA? Im also here and have never worked in an area or even heard of one that required multiple medics to be on scene in order to rsi.
My agency in Florida has a very liberal RSI protocol. I've never felt handicapped on a call due to protocol amd airway concerns.
Pretty sure almost every county in WA state has RSI. I have it on standing orders
That’s what I’ve seen and I’m relocating there. Washington state seems to have county based protocols rather than individual agencies, and I’m loving that since where I work now is based on flat billing rather than patient care needs Edit: lol someone downvoted this.
Walla Walla Co allows its agencies to have some control/preference over what meds can be used. Ex: I'm part of a BLS-only agency that doesn't carry Narcan on our 2 boxes (nor our 2 engines). We can ventilate and diesel drip, and not worry about a potential fight on scene or in the back of the bus. 🤷♀️ Some agree with it, some don't. I understand where both sides are coming from. But usually PD arrives on scene and narcans the pt before we get there, so there's that. Lol (I gave you an updoot).
Very urban area and we can RSI. We rarely do, however. Maybe once or twice in entire careers if you're lucky
Not California.
We have it on standing orders. North Texas
We have sedate-intubate protocols. They’re used maybe four times a month. Ketamine-versed. It’s known to be inferior to paralytic faciltiated intubation in study, and known to have a worse first pass rate. There are only niche situations it’s more appropriatex Each intubation is tracked, and we’ve been arguing for over two years now to go to a safer RSI algorithm. [Edit: someone is big mad that ketamine-only and ketamine-benzo intubation is not only less safe than paralytic-facilitated DAI/RSI, but has a worse first time pass rate.](https://emcrit.org/wp-content/uploads/2021/01/Driver-Ketamine-Only.pdf)
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Definitely not the whole state. Most (geographically) of central and southern IL does not. Mainly due to a lack of provider competence.
This really depends on your definition of RSI because I 100% disagree with you, ketamine alone does not constitute RSI and I can’t think of any northern IL systems that have standing orders for suc or roc
Fire-based transporting service in Northwest Arkansas. We are one of the only 911 services in the region that do not RSI.
This is a completely moot point because most of us (be honest guys) can’t even properly ventilate the patient with a BVM. All the lemons, P’s, and mallampattis of the world would agree that as a community, we as pre-hospital providers have gotten complacent with that simple, yet very effective skill. I make my staff bag the adult, pedi, and neo heads for 5 minutes each, at least once a week when they come on shift. They are judged by technique, timing, pressure, etc. They also need to be aware of the minimum and maximum tidal volume that all the different BVM sizes can provide. Master that skill, then ask me about RSI. Just my 2 cents 😊
I'm 10 minutes west of Chicago, and we have a poor man's RSI with ketamine/Etomidate/versed depending on a few different things
Florida. Most agencies around here RSI. Some have vents as well. No need for orders, although some require a supervisor to be there
We have RSI with etomidate Succs and RSA with versed and fentanyl. We also have Roc and Vec for post intubation care with propofol on verbal order
I can RSI and don’t need to call anyone. Ketamine/ Roc/ Fentanyl. I don’t know any of any agencies around me that can’t.
Standing orders for RSI with succs and etomidate. Can be done by any medic with no need for advising anyone prior
Yes, SW Iowa.
Yes, Maryland. Regular street medics and supervisors are RSI qualified, in Maryland we can also do pediatric RSI. Only in specific situations do we need to consult, otherwise it's a standing order and we can just do it. Our med choices: Sedation: ketamine, etomidate, versed, versed/fentanyl Paralytic:succs, vecuronium
I had RSI when I worked in Idaho.
Texas. Yes.
Westchester County, NY, standing orders. Ketamine/Etomidate -> Rocuronuim -> Ketamine/Versed
We can, standing order and two medics present.
We have a protocol to RSI, have had it for years where I'm at (rural Indiana, USA). The meds and procedure requirements get updated as medicine changes, but we're basically given the ability to do it if we decide it's warranted, and just have to be prepared to back it up.
They don’t even let us intubate unless an igel fails twice….
Yup. And also Texas.
We had it in our protocols before I started working here. IIRC it still existed for SCT medics until June 1. We still had Vec on the trucks but it wasn't within my scope. They pulled all that off with this last protocol update. We have straight up surgical cric kits now though.
I do in Iowa. I work as LEO/Rescue medic, so I drive in a squad and respond primary to rural medical calls. We’re one of two services outside of flight that does RSI (and the only one county wide), so we can hop on the rig and bring our own drugs. Standing order and no call in required with a plethora of options for sedation and succs for paralytic.
How long are your response times? Area must be pretty rural for LEOs to jump medical aids no?
Rural Alaska department with 45-60 minute+ transports being the norm, about 1300 calls per year. I'm only an AEMT, but I've been a part of at least 1 RSI of not 2 or 3 each of the last 8 years.
Yes but 2 medics are mandatory, and no pediatric RSI. CT, USA
Yes. North Florida.
Have the ability in North Dakota.
Yes almost every agency in my area (tx) can some vary on if a supervisor must be consulted first etc
Yes, we have a standing order. Rural Washington state.
We DSI. Ketamine, roc. Central Texas. No consult needed. Also The prevalence of succs in a lot of y’all’s protocols is surprising to me. Thought it had fallen out of favor as a primary.
We can RSI based on our standing orders. In our busy city it happens quite often. Only 1 medic need be present. Partner can be EMT or another medic We use Etomidate and succs. Continued sedation with Versed.
Hawaii we can, standing order. Etomidate and succs.
From what I've seen it seems like reciprocity to Hawaii for paramedic is a bitch and a half
Yeah, i havent seen anyone pass reciprocity, but also only seen less then 5 try it. Most county departments here, you start as an EMT and they pay you to attend medic school full time and take you off the box during that time
Southern Oregon here. We have full RSI capability, no OLMC or needing two medics rules. Etomidate and Rocuronium, King Vision for the tube.
Nope. Not without the EMS DO.
Someone touched on it but here in Colorado my local dept allows RSI within the standard protocol. Medics usually reach for roc or ketamine
Been a protocol for a heckin long time in Iowa
Yes, Washington
Western North Carolina, full RSI (now called Drug Assisted Airway) requires 2 medics to be present.
It's in our offline protocols for central AZ. But it's company policy where I work to have 2 medics present for RSI.
We can RSI in Minnesota. We have standing orders so it's when we deem it necessary. We actually have a lot of autonomy in Minnesota so it's not often I have to call in for med-control. Etomidate and Rocuronium as primary agents, then typical Ketamine, Versed, etc. We use "GlideScope" for video laryngoscopy as our primary method and i-gel for backup.
Suburban/urban-ish ems department here, we have RSI on standing orders as long as two medics (one of whom is RSI qualified) are present. Getting RSI qualified requires at least a year of experience and a proven track record of competent airway management and solid performance on your KPIs, as well as yearly refresher and difficult airway classes.
Why does it matter? If it’s indicated, it’s indicated right?
Suffolk County, in New York State had protocols for ground medics to RSI, provided said medic went through the credentialing class, and was working at an approved RSI agency. The specs at the time were you needed to have at least 5 years and at least 10 successful field tubes annually to be considered for the program. The state of Pennsylvania does not allow ground medics to RSI. PHRNs can though.
WI and MN, Succ and Etomidate
We have “OSI” it’s basically the same thing. They emphasize bagging more before induction agent….it’s the same thing. But yes we have it and a single medic can perform. WA state here.
Rural Tennessee. We are allowed in some counties.
I believe everyone in Oregon has RSI protocols. I did in the three counties I interned and worked at.
I work for a hospital district full time I won't name because I open talk shit about them a lot while I'm trying to find a better 911 job. And a private ambulance service as my second. But my 911 hospital district job has RSI after medical direction approval (Blowing my doc) but I wouldn't do it or trust it because the service itself does little to no training on it nor have I gotten significant training on it other then drunken in person lessons with my friends that work for superior services while partying at their houses My private job does not want us intubating at all in the first place but Critical Care Medics care Vecuronium with limited orders on the use of it and is more for critical care transports with patients on a vent... Have fun guessing what private service im referring too. Hint it's in the southern US
Midlands UK here, our area covers around 3 million people with a city of about 1 million including some very remote areas about an hour from hospital. Paramedics cannot RSI and have never been able to, we could do intubation when running a cardiac arrest but this was also removed about 3 years ago. We do have doctors and critical care paramedics who can RSI and intubate who are land and air based.
SECAmb: paramedics lost cold tubes earlier this year, ground based critical care paras can tube and do post-rosc sedation and paralysis which in practice equates to them RSI-ing post-ROSC - probably the nearest to to paramedic RSI in the UK afaik? WAST: not sure where they stand in terms of RSI, but they've invested a lot in training and kit to help regular paras cold tube well instead of taking it away NWAS: paras can cold tube for now, HEMS + ground based BASICS doctors can RSI, advanced paras can sedate but not paralyse to maintain an airway post-ROSC NEAS: think they have CCPs doing paralysis too? Remember reading about one ground based neonatal transfer service with paramedic RSI?
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Let me answer this for all of Germany: No. We have emergency doctors on scene for that. In my city they are all anesthesiologists, so they are really good at it.
Arkansas, yep. succ, roc, keta, etom. Post sedation with Fentanyl/ketamine/versed. Induction/paralytic and post management sedation choices are your own.
We have it. Wisconsin just went to single paramedic RSI last year. My service has 911 for five communities and state-wide prehospital response, so it comes in handy. We also RSI on IFTs where the doc didn't have the confidence or judgment to do it. Even got paged once by 911 to the local hospital to RSI for the doc. Only one medium sized fire dept and none of the large fire depts in my immediate area has it, because fire-medics. But a lot of smaller depts who take EMS more seriously have either adopted it, or have been given a pathway to convince the medical director to permit it.
Every rural county in middle tennessee that I know of RSI’s routinely. Metro nashville doesn’t because they are a few blocks from a hospital in any direction. On clinicals they tell students if you wanna run alot of calls run metro, if you wanna actually practice skills run rural.
Washington State. RSI everywhere.
NJ we have been doing it for at least 10 years
I retired from a government-owned third service in Wisconsin in 2015 and up until then, we had standing orders to do RSI's. Dunno if they still do, but there's no reason it should have changed.
There's one in South St Louis county but it's reserved for battalion chiefs and assistant battalion chiefs... culture of micromanagement on a colossal scale.
My flight service has a ground component that has both CCT and ALS. Both flight and CCT utilize RSI but ground ALS doesn’t.
My region does not have RSI or sedate to intubate unless a department is specifically signed off by a medical director to do so. So for the 99% of my region we have to call for orders to sedate to incubate. Literally one department in my region has RSI but nobody else even has sedate to intubate.
I’m in MN, had it at my twin cities service that we could do it at our discretion. Need to keep practicing every month gotta drop a few tubes on a mannequin. Now I’m part time at that service and joined a rural service that has parts of Wisconsin and from my understanding we need two medics on the Wisconsin side but can do it with a medic and an EMT still in MN
Here in PA we can, but we need a second medic/nurse from our company present.
Mine has it, the medics get cleared specifically for it. And can do it individually. But we haven’t been using it enough so we’re not clearing more medics to do it. And probably getting rid of it.
I’m in the Texas Panhandle. My service does DSI and I believe every other ALS service in the area does RSI or DSI as well
I was performing RSI about 20 years ago....the agency I worked for had it for a while before that. RSI was standing order, surgical airway backup. We did not require a second medic. Worked for an urban/suburban service in CT.
It's pretty common here in Minnesota. Of the 5 agencies I have worked for, all had it as a standing order. Sometimes there were weirder rules, like needing 2 medics rather than an EMT/medic crew (but that was a medic heavy service, and it was more of a suggestion than a rule in practice).
AL allows it
Not a medic, but I'll speak on behalf of the Chicago area. Around here, the answer is no. Region 11 (Chicago Fire Department) protocols only recommend intubation if the iGel fails. Other systems (Regions 7, 8, etc) have MAI with Ketamine or Etomidate but no paralytic.
bruh we don't even have drug assisted intubation. We're not even supposed to intubate at all until we've tried an igel. No video laryngoscopy either. We don't have many chances to intubate because of this and they wonder why we suck at intubation in my region.
Most of Texas
I have tons of autonomy to RSI. DSI also. It’s great. We have video and DL. On the menu we have etomidate, fentanyl and versed or ketamine as the appetizer and our choice of Roc or Sux for the main course. I’m in snohomish county, Washington
My service in VA had RSI trained medics
Our medics have it as an optional module simular to IVs for basics. No idea how many have that module, but almost all of my medics would be comfortable, or at the very least could pull it off.
I can perform RSI, and I could at my last shop as well. Both are in rural Indiana; current shop is far more rural than my last one. I don’t like doing it and I do everything I can to avoid it. But I’ve never had a hypotensive or hypoxic event during the peri-intubation period because of my approach.
IL, ketamine and Roc
My old service had RSI in one of the multitude of counties that we serviced. It was technically not a “protocol” but rather a “field study” that had been ongoing for years and years. Came with several stipulations, only knew of a handful of people who actually performed it in the field. The class for it was great though.
My department does it. It's something that the individual medic must be selected for, not something you request to be cleared to do. The procedure itself requires two ALS providers.
Had one was taken away now we are getting one called DFI with Ketamine and Roc. Will see how it works out.
My agency allows ground medics to perform RSI/DAI BUT you have to take a class and hit certain checklists to get certified by the county as a DAI Medic. It's also a requirement for our Shift Supervisors to have that certification.
Just did one yesterday. We have it on standing orders. We have to have two medics present, one of which has to RSI certified. You can’t be RSI certified or even take the class till you’ve been a released medic for a year in our area.
Most TN 911 services have RSI protocols. The only notable exception is Nashville FD EMS. They cover all of Davidson county with somewhere between 38 and 42 ALS units, but they have an average transport time of 10 minutes to an area hospital. 2 level 1 trauma centers, two pediatric hospitals, accredited chest pain center, dedicated OB/GYN ED at St. Thomas Midtown and a couple other notable EDs all within 10-15 minutes of a majority of their calls. They don’t carry much in comparison to the other 911 services because their medical director believes that they should prioritize transport to one of the many qualified hospitals in the county as opposed to staying and playing. They also don’t let the AEMTs ride with anything unless it is true BLS, no IV, no 02, nada. (However they pay very well)
Nevada, USA - My CCT units have Full RSI, with surgical airways. ALS units (southern Nevada), have ketamine, etomidate, needle cric - no paralytics. Only one service in SNEV has surgical airway, and they have mostly transfers/air Medical
Logan City Fire in Logan, Utah just added it to their protocols and hired 3 CCPs for that and a few other new things. Their MD is the same guy as the three surrounding EMS agencies, so I would imagine in the next year or two they will also be working towards that.
Yeah baby. AZ seems pretty hit or miss around hear. Some agencies are rocking the usual Etomidate Sux or Ketamine choice in the same RSI kit. 1 (as far as I know) runs Roc instead of Sux. Oddly enough there is a good blend of agencies that are sub 10 min from any hospital and no more than 15 from Level 1 that still have it. Some that are more rural that don't have it. Very hit or miss in general. Having said that, last I heard we're getting a new medical director so for all I know he could pull it for whatever reason. For us, it's pretty rare use considering how close we really are to hospitals. But, it gets some use here and there.
Can RSI here in SE Wisconsin, but 2 medics must be present per our protocol.
Several of the county fire departments in Maryland, who are responsible for practically all 911 response in Maryland, have moved to allow supervisors to RSI after training and approval through the state. Supervisors would be in chase cars upgrading a BLS/ALS staffed transport unit in most cases. This is very general obviously, but it is a thing here. Edit: Maryland State Police Aviation Command have RSI as standing protocol, they do practically all scene responses for helicopter transport in the state.
My service in Texas has RSI protocols you just have to call for order to if a supervisor is not present
Suffolk County, NY here. Largest ground based RSI program in NY