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Ok, as luck would have it, in my many years as a Medic I have never had to sedate someone to intubate them. THEN twice in 2 weeks I have had to attempt it. Hears the thing, we don't RSI here. We have Versed, Valium, Ativan and Morphine. NOW during our MedCon conferences/refreshers/conEDs the MedCon Dr's routinely say in these situations to call but generally you can go with 4 of Versed and 8-10 of Valium, BUT when you do call (yes the SAME EXACT Doc's) and suggest that, they tell you to just go with 2-4 of versed. Latest call was for a 100kg + pt unresponsive but clenched, MedCon only approved 2 of Versed...guess what...didn't do squat. Other pt was the same 2 doses of 2mg each....nada.

So I open the doors to you...What would you do?

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Unfortunately, your medical control probably knows how inadequately trained paramedics are. This makes them understandably quite nervous about delegating medical practice, with potentially deadly consequences, to those medics. You're going to have to earn their trust a little at a time. That means a period of cooking by the book and getting poor results before the numbers finally speak for themselves. Your rate of failure is going to have to be statistically significant, and the rate of patients dying as a result of that failure will have to match it. But if either number is off, meaning either 2 mg gets the job done, or patients don't die even when you fail, then they will go with the evidence that you don't need more.

Of course, this is all reinventing the wheel, as there are plenty of statistics and studies already out there that have researched this. You might spend a considerable amount of time finding those studies and statistics and putting them together to present along with the statistics from your practice as reinforcement.

That's really about the only way to go about it. Emotional "what ifs" and anecdotal hearsay isn't going to get the job done. Physicians want to see the evidence. Good luck!

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That means a period of cooking by the book and getting poor results before the numbers finally speak for themselves. Your rate of failure is going to have to be statistically significant, and the rate of patients dying as a result of that failure will have to match it.

Doesn't this run the risk though of perpetuating poor success rates and outcomes in prehospital intubation and putting another nail in the coffin for this procedure?

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LOL! Sure. But the results should speak for themselves. If the evidence says your theory doesn't hold up, then that's where the chips fall. The stats should make it possible to determine if what you are having is an overall failure of intubation, or if it is simply a failure of the inadequate muscular relaxation. But again, there's not much chance that this hasn't all been studied and published multiple times before, so if you're getting different results from everyone else, then it shouldn't be hard to narrow down why.

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Ok, as luck would have it, in my many years as a Medic I have never had to sedate someone to intubate them. THEN twice in 2 weeks I have had to attempt it. Hears the thing, we don't RSI here. We have Versed, Valium, Ativan and Morphine. NOW during our MedCon conferences/refreshers/conEDs the MedCon Dr's routinely say in these situations to call but generally you can go with 4 of Versed and 8-10 of Valium, BUT when you do call (yes the SAME EXACT Doc's) and suggest that, they tell you to just go with 2-4 of versed. Latest call was for a 100kg + pt unresponsive but clenched, MedCon only approved 2 of Versed...guess what...didn't do squat. Other pt was the same 2 doses of 2mg each....nada.

So I open the doors to you...What would you do?

Silly questions ...

Have you tried calling back after the original orders given were unsuccessful ?

What was the result of being unable to intubate these lightly sedated patients?

Have you tried speaking to one of those Doctors as a Qa/QI process or Call review? Can you sit down with the doctor to discuss it?

While on the phone/radio try a line such as "repeat orders back to doctor thank you but just in case that doesn't work as planned I'd like to have XYZ ready/on stand by"

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LOL! Sure. But the results should speak for themselves. If the evidence says your theory doesn't hold up, then that's where the chips fall. The stats should make it possible to determine if what you are having is an overall failure of intubation, or if it is simply a failure of the inadequate muscular relaxation. But again, there's not much chance that this hasn't all been studied and published multiple times before, so if you're getting different results from everyone else, then it shouldn't be hard to narrow down why.

Agreed. My issue isn't with research by any means, it's with practicing cookbook medicine and not acting as an advocate for your patient. In terms of disagreeing with your online direction, I'm with TK in taking the proactive approach and working to build a better relationship with medical direction. See if you can learn why it is you have this disjoint between your CME and your OLMC. Perhaps you're missing something in the big picture or perhaps the Doc is just reluctant to go full dose right off that bat.

Dust, I gave your original post another read and I think I read too much into your "cooking the book comment." Even surrounded in context, I managed to take it out of it. My bad.

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In Medic class I was surprised the first time we had to pick up a walkie talkie and radio a fake medical control in another room, its proved a very useful skill.

I never got any orders in class, always jacked it up lol

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I'm still reeling from the fact your Medcom thinks that 4mg of Versed will knock them out enough to facilitate endotracheal intubation!

It's very much a question of experience combined with science but I will not even attempt such an intervention until I've given a minimum of 10 mg combined with either fentanyl or alfentanyl.

I agree, however, with Dust. Such potentially dangerous procedures shoudn't be attempted by cook-book practitioners. You need years of practice before giving these drugs safely. Intubating a pt with 2mg of Versed on board will generally lead to all sorts of problems, starting with an enormous ICP rise.

WM

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