When I think of baseball, I tend to think of my hero growing up, Cal Ripken Jr. The baseball legend practiced for, and played in 2,632 consecutive games, which is known as “The Streak.” Ripken, who was inducted into the National Baseball Hall of Fame, was a model of consistency in his major league career. He had more than 3,000 hits, with a 0.276 average, and powered in 1,078 extra base hits — including 431 home runs.
Contributing to his reliable stats was his consistent routine. In a nearly identical fashion every day, he prepared to play ball by going through many of the same drills learned in recreation league baseball years earlier. Like many successful individuals — including our colleagues in EMS — Ripken established a positive reputation through diligence. There’s a notable difference, however, between professional baseball players and EMS providers: when was the last time you had batting practice, particularly when it comes to airway management?
Our system of initial EMS education often seems to be focused on preparing us for the test. Finite hours are available in the classroom, lab and clinical settings to transfer a great deal of information into the student’s mind. Instructors must first teach the basics of being an EMT or a paramedic and then cover a little bit of everything, ranging from the ordinary to the exceptional. In addition, state and national organizations often set minimum-hour requirements, which are considered bare minimums as various agencies compete to recruit quality graduates from certificate and degree programs.
Continuing education (CE) should expand our knowledge base and is essential in our continued development as prehospital providers. However, it’s equally important for providers to maintain the basic skills we learned in our initial training. From as early as the 1980s, studies have suggested that our skills rapidly deteriorate over time. One early study of first responders, EMTs and paramedics showed that although didactic — or classroom — knowledge was retained by providers, basic skill proficiency declined by more than 50 percent within two years.[i] Further, it has been shown that highly technical skills decline the fastest.[ii]
Another problem instructors regularly face is that students complain that they’re required to participate in CE classes that cover material they think they already know. Frontline providers consider CE sessions to be “sleep sessions,” or blocks of downtime when job tasks don’t have to be performed. They frequently state, “I learned this material in class. Why do I need to hear it again?”
Although the resistance may be because providers feel they truly know the material, it may also stem from a fear of being corrected in front of their peers. But this thought process goes against all the other reevaluations and reassurances we make every day. How many crews would start a shift with a portable radio that wasn’t fully charged, a used oxygen tank that wasn’t checked or a nearly empty fuel tank in the ambulance? Along with our tools that must be recharged, our skills, too, must be refreshed. In this case, it means continual practice and assessment of the skills we need the most. Marilyn Grey, school psychologist and author says, “Having it all together is like eating once and for all.” Unfortunately, many of us seem to think we have it all together, when in reality, taking a refresher course is like daily practice for baseball players.
I also like to remind providers there is no truth to the statement we do this every day. However, we may be responsible for it on the next call. The fact is we may do certain things over and over, but we do not execute every task we are responsible for every shift so we need to constantly prepare for the time when those skills will be needed.
Spring Training — Basic Airway Skills
When discussing the practice of basic skills, the obvious issue of opportunity arises. As many studies on prehospital skills have pointed out, the decreased opportunity to practice skills in the field may correlate with overall skill decline [iii] [iv] [v], particularly in the areas of advanced airway management.
Adding to the difficulty of practicing skills is the diminishing number of hospitals that allow EMS providers access to operating rooms. This means some paramedic students may graduate without having experienced any “live” intubations, and seasoned providers might have limited circumstances for skill practice and assessment during their careers.
The assertion reaches beyond initial education students learning a skill set and applies to active providers. I have served in two systems where we practiced the order for rapid sequence induction (RSI) five times at the start of every shift. This helped maintain RSI knowledge base and increase psychomotor skills for introducing an endotracheal tube into a patient’s airway. The agencies I worked for found it to be a useful exercise as paramedics would move from the simple to the complex — competing against one another in speed and difficulty.
The manikin may start on a table in a normal classroom configuration but quickly becomes suspended upside-down to simulate vehicle collisions or is placed in other difficult configurations.
Ray Fowler, MD, FACEP, another EMS medical director, agrees with Yamada’s approach. Fowler, deputy medical director for the Dallas Biotel System notes, “if a paramedic is not intubating once per month or once per quarter, they need to be doing regular manikin practice to maintain that very critical hand-eye coordination.”
Individual Coaching — Airway Judgments
Family members find an 82-year-old male relative with significant difficulty breathing and call 9-1-1. Medic one arrives on scene at 1:30 a.m. The patient is breathing 28 times per minute, his oxygen saturation is less than 50 percent on room air, and he has absent lower lung sounds with only wheezing in the upper lobes. His GCS is 10 (spontaneous eye opening, incomprehensible verbal response and pain withdrawal). His HR is 130 and BP is 120/95. The patient has a history of asthma and previous myocardial infarction (MI). He denies allergies, but currently takes Klor-Con, furosemide, Prednisone, metoprolol, Levothyroid, Isosorbide and spironolactone.
The crew quickly places the patient on supplemental oxygen and prepares an albuterol updraft. An IV line is placed and electrodes are attached to the patient to monitor his cardiac rhythm.
Both a three-lead and 12-lead ECG is performed, yielding sinus tachycardia at 130 without ST changes. During transport, the patient’s oxygen saturation increases to more than 80 percent and wheezing is noted throughout the lungs. An updraft of albuterol and Atrovent is administered, and the patient is transported to the local emergency department (ED).
But here’s where the story really begins. Because of the patient’s continued respiratory distress and the likelihood for respiratory arrest, he’s of concern to the ED physician, who decides the patient should be pharmacologically paralyzed for intubation. Using the rapid sequence induction (RSI) method, the physician, with only a cursory review of the patient’s history, medications and vital signs, orders his nursing staff to administer etomidate and Versed to sedate the patient and succinylcholine to induce paralysis. Shortly thereafter, the patient suffers cardiac arrest and succumbs to undiagnosed hyperkalemia.
Although this was an in-hospital situation, it could have easily happened to the EMS providers with whom the patient’s care originated or any of us who utilize succinylcholine-based RSI methods.
Furosemide tends to cause hypokalemia, but the patient was taking potassium chloride (Klor-Con) to counteract this tendency and normalize potassium levels. Further clues to the patient’s hyperkalemic history included the spironolactone, which is a weak diuretic, sometimes used in combination with other diuretics. Unlike Lasix, spironolactone doesn’t cause hypokalemia, but rather limits the excretion of potassium, potentially causing a relative hyperkalemia or at least a higher-than-normal potassium level.
There’s a common misconception that peaked T-waves will occur with hyperkalemia. In reality, they occur less than half the time. The lack of peaked, or tall, T-waves shouldn’t lead us to believe that hyperkalemia does or doesn’t exist. Hyperkalemia shouldn’t be assumed without either lab or field chemistry performed to confirm or rule out the condition using a lead II dynamic ECG tracing. There’s some evidence that peaked T-waves in the precordial leads are more accurate, but we are still making an unforced error.
In this case study, it was a physician who made the error in judgment on the patient’s airway, but EMS crews are often in the same situation, with too many decisions to make and too little time to manage a patient’s airway while preparing for transport to definitive care.
Across the U.S., EMS organizations are using RSI to facilitate intubation in a host of patients, from trauma victims to those with congestive heart failure, and some field providers have called for using the procedure more frequently in the field. Consistently, systems use short-acting succinylcholine (Anectine) to induce paralysis in patients, despite inherent dangers of the medication.
And RSI use has increased dramatically in the past 10 to 15 years as more ground units attempt to use the same skill set as their flight colleagues, often without similar training requirements, such as mandatory operating room rotations or minimum successful intubations per month or quarter. These services have met with considerable criticism as repeated studies indicate that patients don’t fare better when intubated in the field, much less when paralyzed using RSI.
Multiple problems exist with RSI, including appropriate dosing of both sedatives and paralytics, patient selection into the RSI group and oversight of the procedure. Hyperkalemia, secondary to succinylcholine, is just one of many negative interactions that this drug has with other medications. Given the difficulties of this specific drug, it may make sense to eliminate this issue in the equation?
Many organizations that utilize succinylcholine do so because of its short-acting nature. Whereas other paralytics can last for 45 minutes or longer, the depolarizing neuromuscular blocker succinylcholine lasts only five to 15 minutes. Most paralytics are non-depolarizing; succinylcholine is the only polarizing one.
It binds to muscarinic and nicotinic receptors and remains bound to the receptor site, causing muscle depolarization. Succinylcholine takes effect more quickly than non-depolarizing agents because pseudocholinesterase, an enzyme in the drug, causes natural degradation, but unlike acetylcholine (ACh), succinylcholine binds longer than acetylcholine.
Succinylcholine’s side effects include elevations in intracranial, intraocular and intragastric pressures; muscular fasciculation; rhabdomyolysis; and myoglobinuria. Additionally, negative inotropic and chronotropic effects may occur, and the drug has been associated with malignant hyperthermia, hyperkalemia, hypertension and dysrhythmias. Succinylcholine is also contraindicated in patients with crush injuries, glaucoma, penetrating eye injuries, neuromuscular disease, spinal trauma and patients who have experienced burns more than 24 hours earlier. Given all these contraindications are you sure the patient you are giving it to can receive it?
Hyperkalemia, which often causes cardiac dysrhythmias, can occur when the patient treated with succinylcholine has an undiagnosed elevated potassium level. It can also cause certain hyperkalemia-related cardiac disturbances, even when initial serum potassium levels are normal. Moreover, repeated dosages of succinylcholine, required because of its short-acting nature, may precipitate ECG changes at the nodal level, causing bradycardias and periods of asystole. This is especially dangerous in pediatric patients, but given the fact that any patient who would require the RSI procedure is already seriously ill or injured, depressing cardiac output may not be appropriate either.
Beyond the pharmacologic issues specific to the drug, there’s a “blame-and-excuse” factor involved with RSI and succinylcholine.
The American Heart Association (AHA) continues to refer to intubation as definitive airway management, and it remains so in paramedic practice and training. RSI has created an opportunity for paramedics to place endotracheal (ET) tubes in patients who will require an airway prior to reaching a state of apnea, with the resulting acidosis and bradycardias likely to co-exist.
However, many EMS systems choose to do RSI because they think they lower their risk having their providers use a shorter acting drug. They don’t. The argument for using succinylcholine because if you miss the tube — “it isn’t a big deal” — because anyone can bag for ten to 15 minutes, misses the entire point of RSI.
RSI intubation involves giving drugs that paralyze and then successfully placing the tube. It’s an issue of airway education and training, not which drugs are in the toolbox. RSI simply facilitates paralysis, pharmacologically. Any paramedic can push drugs and create paralysis. Short-acting paralysis via succinylcholine is no better than rocuronium or any other non-depolarizing paralytic if the crew doesn’t successfully intubate the trachea. The difference is the patient regains muscle tone more quickly, but is still without a definitive airway and still severely ill or injured.
The follow-up argument in favor of short-acting paralysis is that the intubation itself doesn’t matter because of the availability of rescue airways (Combitube, LMA and King Airway). If the intubation doesn’t matter, the period of paralysis should be secondary. If an EMS crew decides to induce paralysis in a patient to facilitate intubation, they should be well practiced in ET intubation with a strong understanding of the difficulty in the airway they’re planning to manage.
Studies have shown that airway management should be focused on advanced training, regular experience and close monitoring of a limited group of providers to be successful — maximizing opportunities to perform the skill set. Difficult airways don’t always have to be managed with ET intubation, and perhaps it’s better to plan to use another airway effort at some level.
A final issue is the lack of understanding that RSI doesn’t involve just succinylcholine, but also powerful sedatives, which will add to the bradycardic nature of succinylcholine. Versed and Valium both have significant bradycardic and hypotensive effects in varying degrees and should also be an area of concern for providers.
One responder from a major metropolitan city told me, “I think RSI has its place, but there’s a complacency factor [on the part of my department regarding training]. We don’t have CE on the procedure; just a protocol: We don’t get the training we need.”
His department recently had a case where a patient had fallen approximately 30 feet from an extension ladder and was intubated using short-acting etomidate and succinylcholine. The patient didn’t receive Versed, as required by protocol, and was awake as a flight crew placed his ET tube. Throughout the flight and transfer to the hospital, the patient was aware of his surroundings, but not sedated. Although this patient had an accelerated heart rate, RSI is a procedure that requires multiple medical calculations almost simultaneously to ensure safe, effective and sufficient paralysis.
Although RSI has its place in EMS, we must recognize the inherent dangers of the procedure and move toward a standard requiring organizations that perform RSI to have rigorous training programs associated with their protocols and pharmacologic agents.
EMS is similar to baseball in terms of the need to constantly practice the basics. When reduced to its main elements, baseball is a set of motor skills — batting, catching, throwing and running. Likewise, our core skill set in EMS doesn’t need to be overcomplicated.
Although practicing airway management skills every shift or once a month may seem like overkill, regular “batting practice” is important for long-term success. Whether our role is student, provider or educator, we should remember that many of the skills necessary to deliver prehospital care involve both motor skills and mental activity. Skill retention requires discipline and effort. With this mindset, your performance will be worthy of a hall of fame, just like that of baseball’s Iron Man, Cal Ripken.
Christopher Suprun, NRP, FP-C, is a flight paramedic/firefighter and Director of Education for Never Forget Foundation, a 9/11 based 501(c)(3) charity.References[i] Latman NS, Wooley K: “Knowledge and skill retention of emergency care attendants, EMT-As, and EMT-Ps.” Annals of Emergency Medicine. 9(4):183–189, 1980.[ii] Skelton MB, McSwain NE: “A study of cognitive and technical skill deterioration among trained paramedics.” Journal of the American College of Emergency Physicians. 6(10):436–438, 1977.[iii] Zautcke JL, Lee RW, Ethington NA: “Paramedic skill decay.” Journal of Emergency Medicine. 5(6):505–512, 1987.[iv] Bishop MJ, Michalowski P, Hussey JD, et al: “Recertification of respiratory therapists’ intubation skills one year after initial training: An analysis of skill retention and retraining.” Respiratory Care. 46(3):234–237, 2001.[v] Wayne MA, Slovis CM, Pirrallo RG: “Management of difficult airways in the field.” Prehospital Emergency Care. 3(4):290–296, 1999.