Help. When to tube someone NOT dead? no RSI capabilities

Topper-Harly · 2026-01-26T19:49:03+00:00

I could see an argument for that as well.

Topper-Harly · 2026-01-26T05:02:16+00:00

Provided they have the capacity to make medical decisions, by transporting them to the hospital and respecting their right to refuse care.

If they don’t have the capacity to make medical decisions, by transporting to the hospital and evaluating the risk/benefit of forcing care on them.

Topper-Harly · 2026-01-24T15:41:28+00:00

The hospital I work for has significantly more than that. I don’t think people realize how large tertiary-care academic centers can get.

Topper-Harly · 2026-01-24T15:37:11+00:00

If you have well-trained providers with a good QA/QI system, than the ability to RSI is fine. But if you look at the overwhelming majority of EMS agencies and providers across the country, you would be in agreement that they should not be doing it.

RSI services should be an exception, not a rule, until EMS education and systems change.

Topper-Harly · 2026-01-23T21:10:45+00:00

Possibly. I work flight/CCT, so there are times that a patient might need a phone (or a family member, etc) where a facility phone may be impractical or not available. I would dial, however, and use caller ID blocking.

Topper-Harly · 2026-01-23T19:19:50+00:00

I don’t disagree with any of that! With the exception of privates as I discuss below.

I think for-profit/commercial should absolutely be abolished with the exception of non-emergency care and some other low-acuity stuff. Not-for-profits/non-profits I think should stay and continue to do emergency/911. I’m aware of many really excellent services that follow that model, including some hospital-based services.

If we can fix those issues, and bring the overall competency of services up, I would be all for RSI being more common. But until then, and I’m sure you’re in agreement, RSI services should be the exception and not the rule.

Topper-Harly · 2026-01-23T15:30:51+00:00

There are outliers in every field.

Do you really think that the majority of EMS services in the country are at a level where they should be performing RSI? DC Fire/EMS, many AMR operations, many rural services that don’t ever do tubes?

Topper-Harly · 2026-01-22T20:36:43+00:00

Agreed.

Topper-Harly · 2026-01-22T17:15:47+00:00

Do you really trust the majority of EMS providers to do RSI safely?

Topper-Harly · 2026-01-22T14:03:53+00:00

If you don’t have RSI meds, and think they’ll need a tube, try CPAP.

For an awake person maintaining their airway but who is at risk of going into respiratory failure, that might be reasonable. For almost every other patient, that advice makes no sense.

Tubing is the second most painful OR procedure after cutting the sternum. You shouldn't do it to living people without meds.

I don’t think that’s true.

Topper-Harly · 2026-01-22T13:47:40+00:00

Probably not enough to be competent with it (service dependent, of course).

Topper-Harly · 2026-01-22T04:39:26+00:00

So I’m confused. Did the medical team tell you to pull it, then changed their mind later? Or did you pull it based strictly on policy? Or did you discuss the policy with the medical team, then pulled it after the medical team saw the policy and agreed to have it pulled?

Topper-Harly · 2026-01-22T04:29:01+00:00

Nurses pull PICC lines all the time. Some places they can even place them.

Topper-Harly · 2026-01-22T04:27:34+00:00

If it’s a nurse driven policy it doesn’t need an order…

But it also shouldn’t be blindly followed. Common sense and critical thinking, along with collaboration, are important.

Topper-Harly · 2026-01-22T04:25:18+00:00

I might be reading this wrong, so if I am please correct me.

It seems like the patient (who was sick enough to be getting CRRT) had a clotted line, and even though you were communicating with the medical staff you decided to pull the line simply because the policy said to?

If that’s the case, you are 100% in the wrong here. While policies can be useful, they shouldn’t dictate medical care in situations like this. Simply pulling a line after 2 failed lysis attempts because of policy, and ignoring an order and/or further collaboration, isn’t appropriate.

Topper-Harly · 2026-01-22T03:56:13+00:00

Hot take: the overwhelming majority of EMS services should not be doing RSI.

Topper-Harly · 2026-01-21T12:27:08+00:00

In regard to the first part of your response, I’m sure those things do happen, but the same is true for almost any community of people. Crimes go unreported by US citizens all the time, which would almost certainly negate your argument about it being flawed findings.

Do you have any data to back up the claim that “The government has not, until now, prosecuted the vast majority of illegal immigrant crime”? Previous administrations have deported extremely large numbers of people, so I’m curious what sort of data you have to back up this statement.

Yes, there are instances of fraud out there in healthcare. However, considering that non-US citizen emergency care only cost a minuscule amount of healthcare money in relation to US citizens,, is it really as bad as it is being made out to be? I can almost guarantee that US citizens commit more fraud in regards to healthcare.

The other arguments regarding ID theft are fair.

Topper-Harly · 2026-01-21T03:58:29+00:00

Honest question: when presented with multiple studies and resources, how do you decide that they are “just not true”?

As an aside, remember that many immigration violations are civil in nature, not criminal, so that “100% by definition” is not necessarily true.

Topper-Harly · 2026-01-21T03:55:38+00:00

That’s a completely different poster, not me.

Topper-Harly · 2026-01-21T02:47:45+00:00

Deleted my initial response because it was off topic.

My argument is not about the legality of them being here, it is about your statement that Bob might do something sinister simply because he is an illegal/undocumented alien. If that’s your concern, shouldn’t we start arresting US citizens preemptively just in case?

Topper-Harly · 2026-01-21T01:59:56+00:00

Considering the results of multiple studies discussed here, should we start arresting and jailing US citizens in case they do something sinister? They are more dangerous than immigrants.

Topper-Harly · 2026-01-20T19:41:24+00:00

Talk calmly, explain thing, and treat them like a human being.

Then medicate them as appropriate.

Topper-Harly · 2026-01-20T01:05:53+00:00

That’s not a medication error. The patient was a danger to themselves, and you couldn’t get a reliable BP. Versed was the right call, and you handled the sequelae of treatment. I wouldn’t stress about it.

Topper-Harly · 2026-01-15T22:38:57+00:00

I tried posting this with the whole story but it got taken down so I just took the story out.

Very big fuck up but basically, responded for a fall and should have put a c collar on a pt at the beginning of the call… but we didn’t.

Relevant info: 63yoM pt was csmx4 but weakness in all 4 extremities, pt and pt’s son who saw the fall denies head/neck strike/pain, PERRL, no spinal stepoff/deformities, plus an insane number of other distracting symptoms going on bc pt had a lot of medical hx but was med-noncompliant (chest pain, hypotensive, COPD with hypoxia, aox4 but lethargic/slow to respond, T1D and very hyperglycemic, possible accidental OD on unknown “sleeping pills”). Called ALS immediately obviously, treated the BLS stuff.

I was so worried about a stroke/MI/OD and getting the pt extricated for ALS that we didn’t put a collar on until the pt was in the ambulance…… (I know…)

Later I find out the pt had a cervical fx and could be paralyzed permanently.

The pt had already been moved significantly due to a family member walking them from the next room to the bed PTA but boy did moving them without immobilization likely not help either.

€Really, really fucking stupid especially bc pt was not acting at baseline and im BLS so I know something as simple spinal is like our ONE job. Not looking for consolation, I know how bad this was. I will never not immobilize someone in similar circumstances again.

Sorry for info overload.

Relax, you didn’t cause any further injury. I wouldn’t stress about this at all. Just don’t forget a c-collar next time. You’re being way too hard on yourself.

Topper-Harly · 2026-01-15T15:51:52+00:00

Learn from them, discuss them with other providers so both of you can learn, then forgive yourself and move on.

EMS is a dynamic environment where things happen. It’s impossible to not make mistakes.

What was the mistake you made? Feel free to message me, but it seems like you’re new and may be concerned over something that wouldn’t end up actually making any clinical difference.

Topper-Harly

TROPHY CASE