Colorado Medic Won`t Be Disciplined for Disputed RSI

Editor's Note: It has been brought to EMSResponder.com's attention that the following article requires an important correction. Randy Kuykendall, the state's chief of emergency medical and trauma services in the Colorado Department of Public Health and Environment, is misquoted in the second paragraph about the outcome of the state's investigation. The investigation found that the paramedic HAD NOT violated any state licensing guidelines.

The Colorado Springs Gazette has since published an updated and corrected article. For the most accurate and up-to-date information please visit Change in RSI Procedure Disputed in Colorado Springs.

Oct. 3--State medical officials won't take disciplinary action against an ambulance paramedic accused of misusing a controversial medical procedure.

D. Randy Kuykendall, the state's chief of emergency medical and trauma services in the Colorado Department of Public Health and Environment, said Tuesday that the investigation found the paramedic violated licensing guidelines, but state officials consider the matter closed.

Marilyn Gifford, an emergency physician who sits on a panel that oversees El Paso County ambulance contractor American Medical Response, called the July incident a "clear cut case of paramedics out of control."

Gifford made the statement in a July 25 letter to David Ross, AMR's physician adviser, in which she outlined a paramedic's use of rapid sequence intubation (RSI) after two doctors said the patient didn't require it.

RSI is an emergency procedure using drugs to temporarily paralyze a patient's jaw so a tube can be inserted to allow the patient to breathe.

Ross said Tuesday that the state's investigation corroborates his earlier conclusion that the paramedic's judgment was sound and warranted no discipline.

The paramedic's name has not been released.

The Emergency Services Agency, which includes Gifford and which oversees AMR's contract, asked AMR on Sept. 5 to use RSI only with physician oversight by phone or online for 120 days, or until a local assessment could be conducted. Before that, AMR used RSI under standing orders.

Gifford, Memorial Health System's head of emergency medicine, gave this account in her letter:

The patient was treated by two doctors and a nurse at the Surgery Center at Printers Park. The doctors told the AMR paramedics the patient "just needed transport" to Memorial's intensive care unit six blocks away after the patient showed signs of a stroke after a gastrointestinal procedure.

When the doctors left to allow the paramedic to load the patient, "apparently the paramedics decided to ignore the physicians and elected to attempt to intubate this patient," Gifford wrote.

Unsuccessful, the paramedic then used drugs to paralyze the patient and told a student paramedic with him to attempt again to intubate. That failed, so the paramedic tried to insert a tube.

Gifford said the paramedic tried to keep an anesthesiologist from entering the room, but she got in and used special equipment to insert the tube.

"This patient suffered significant damage from prolonged hypoxia" (lack of oxygen in the lungs), Gifford wrote. "I think this is the most clear cut case of paramedics out of control I have heard of."

She said it was "but one of many" cases where paramedics have injured patients performing RSI. "I can't blame the paramedic, but rather the system," she wrote. "I really don't see how you can continue to permit this misuse of a skill probably best reserved for the hospital."

When asked by Ross, Gifford cited one other case that concerned her, he said. Ross added that he disagrees with her position.

"I think with proper training and oversight, which we provide at AMR, it's a safe and beneficial procedure," Ross said.

"Can paramedics do this procedure safely and effectively? The answer is yes, they can. Does it make a difference in patient outcome? Even though literature is unclear, it is our belief anecdotally that we do help people, or we wouldn't be doing it."

Ross said the El Paso County Medical Society's Emergency Care Committee recently talked about RSI and will collect data on its use.

It's unclear what the committee expects to learn, as the state Health Department's Medical Services Division conducted a statewide study this year that was inconclusive, Kuykendall said.

"There is nothing, including in the literature searches, that RSI is an evil thing nor that it's the greatest thing in the world," he said. "In the right hands, in the right place, it's a very useful tool."

The state Board of Medical Examiners lifted a moratorium on RSI permits it imposed after the study was completed.

Gifford applied for an RSI permit last year on behalf of the Colorado Springs Fire Department and five small departments.

The permit was denied based on concerns over training, experience and skills maintenance, records show.

The state has no record of Gifford withdrawing her request, although she has said she did.

CONTACT THE WRITER: 636-0238 or pam.zubeck@gazette.com

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