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Vec is a reasonable RSI option in specific circumstances of which you will likely never encounter prehospital. SUX has been the standard for decades now but you will likely see it fall to the side over the next three to five years. ROC is simply a 'purified' or improved version of VEC. ROC in dosing of 1-1.2mg/kg will give you similar onset of intubating conditions as SUX. Unfortunately at this dosage it's duration will exceed 40 minutes and likely approach 90 minutes in some patients. VEC at 0.1mg/kg will give you intubation conditions in approximately 2-3 minutes in most patients. Keeping in mind that our job is to obtain a secure/patent airway without/prior to the patient vomiting (THE ONLY REASON WE DO RSI), we need to select a medication that gives us rapid onset while only compromising their muscular tone for a minimal period of time. To date, that drug has never existed. Now I said you'll see SUX go away over the next few years. Here's why..... SUX has some pretty significant side effects, a couple of which would likely prove fatal if encountered in the prehospital setting. These are few and far between, but serious none the less. ROC can give us the rapid onset we need at high doses, it's only limitation is the duration. In the next 60 days you'll see the FDA release a new drug called Suggamadex for sale from Merck Pharmaceuticals. Suggamadex was initially being designed as a 'packaging technology' for ROC. It's a cyclodextrin molecule, imagine a styrofoam cup with no bottom. It's molecular shape is such that it binds around a ROC molecule quite nicely. It's bonding is ionic but it's such a great fit the bond acts covalent (doesn't want to break... ever). When a drug of any kind is 'bound' like this, be it to another chemical you injected, or simply a protein in the blood, the drug is rendered unusable at it's target sites. It's bioavailability is reduced or eliminated. The idea was that by placing the ROC in this cyclodextrin molecule, they could shelf it without refrigeration for longer periods of time. One problem. It wouldn't release the ROC once injected. So, they decided to try injecting just the cyclodextrin into a patient that already had ROC on board. Result.... it grabbed all the ROC causing a reversal of effects. This reversal agent has demonstrated that regardless of the 'depth of muscular relaxation' induced by the ROC, they can be reversed almost immediately with minimal side effects using Suggamadex. Long story short (too late I know), Suggamadex should allow us to use ROC for RSI and then safely reverse the paralytic should we fail the airway and need to get them breathing again. If this all plays out without any new surprises after release (remember Rapacuronium?), we will see SUX fade off into the sunset over the next few years. Interesting note, Suggamadex will reverse VEC almost as well as it does ROC. In my practice I find VEC is actually more forgiving than ROC. If I need a drug to wear off or be reversible quickly, VEC is actually a little more reliable than ROC for that. Best of luck with your protocol. Be sure to ask lots of questions, ask them to bring in someone that actually does this often to do your training (anesthesia). Thanks Will Wingfield