Colorado Springs Debates Paramedic Use of RSI

Oct. 1--As the medical community debates how or whether a lifesaving medical procedure should be performed by paramedics, the Colorado Springs Fire Department's physician adviser has taken two stances on the issue.

Marilyn Gifford, head of Memorial Health System's emergency medicine and physician adviser to the Colorado Springs Fire Department, recently expressed concerns about the procedure even though a year ago she applied for permission for firefighters to use it.

At issue is rapid sequence intubation, an emergency procedure using drugs to temporarily paralyze a patient's jaw so a tube can be inserted to allow the patient to breathe.

Commonly called RSI, the procedure came into the spotlight when the state began investigating its use on a patient treated this summer by American Medical Response paramedics in El Paso County.

Because of medical confidentiality laws, little is publicly known about the case except that the patient survived the procedure. But Margaret Radford, vice chairwoman of the Emergency Services Agency, which oversees AMR's contract in El Paso County, described the case as serious.

On Sept. 5, the agency asked AMR to alter its use of the procedure. The ambulance company agreed to use RSI only with oversight by a physician online or by phone for 120 days while the ESA board considers whether to impose a permanent change.

AMR has used RSI for six years with permission from the State Board of Medical Examiners under a waiver that allows the procedure without direct oversight by a physician.

Emergency Services Agency Chairwoman Sallie Clark, an El Paso County commissioner, said the board wants the medical community to advise the ESA on RSI use before the board makes changes.

"That's the only procedure in pre-hospital care that can actually harm patients," Gifford said at a Sept. 5 ESA meeting about possibly changing the procedure. "The risk we take with paralyzing people is significant."

AMR's physician adviser, David Ross, responded that he disagreed with Gifford.

Radford, a Springs councilwoman, told Ross that Gifford wouldn't allow the Springs fire paramedics to use RSI due to her concerns.

Gifford said at the meeting she had withdrawn a waiver request. But a spokesperson for the Colorado Board of Medical Examiners told The Gazette, "I have no record of Dr. Gifford withdrawing her request."

In her 2006 application for an RSI waiver for 164 Springs firefighters and 26 others in five rural fire departments, Gifford wrote, "RSI has been subject to rigorous evaluation and peer review throughout the country, and I believe warrants implementation in our agencies."

She also wrote that RSI could provide a higher success rate with fewer complications.

The Colorado Board of Medical Examiners denied the application based on a recommendation from its Medical Advisory Group, which expressed "concerns" with training, experience and skills maintenance, Advisory Group and Board of Medical Examiners meeting minutes show.

The advisory panel also noted another EMS agency with 80 paramedics working under a waiver in El Paso County was asked and said 60 RSIs, less than one per medic, are performed annually.

"The addition of more waivered providers will further dilute the field experience, and it was felt impossible for reasonable skills maintenance to be possible with the numbers requested," the advisory group's minutes state.

In other words, it's hard to stay proficient when a paramedic rarely performs a procedure, the panel reasoned.

The El Paso County Medical Society's Emergency Care Committee will discuss RSI and may forward a recommendation to the ESA board, said Carol Walker, the society's executive vice president.

"This has become an appropriate time with the 120-day change to look into the entire process," she said. The committee is made up of doctors and medical personnel.

Clark said the ESA's Medical Control Committee will discuss RSI this week.

Clark said she couldn't explain why Gifford applied for an RSI waiver last year but now takes issue with the procedure.

Gifford declined to be interviewed for this article. Radford did not return calls seeking comment.

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

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