RSI, or Really Stupid Idea

R.S.I. stands for Rapid Sequence Intubation. Sometimes it stands for Rapid Sequence Induction. What is really being talked about here, is the administration of powerful paralytic drugs like succinylcholine. The benefit is that it is easier to perform endotracheal intubation on a paralyzed patient.

The problem is that once these drugs are administered, the patient is no longer able to breath on their own. You must breath for them. If after you paralyze them, you cannot secure their airway, they could die. If you fail to ventilate them properly, they will die. This is a pretty big risk to take if you ask me.

Is it is a good idea for Paramedics to make patients stop breathing? How did this technique first become popular? I think a real bad case of “rotor envy” brought this idea into widespread acceptance. Many Paramedics want more than anything to be Flight Medics. That is where this technique was first used. Just because it is “cool” and used on helicopters, does not automatically make it a good idea for ground transport units.

For Helicopter use, it does make some sense. Imagine you are at 1,000 feet with a Head Injury becoming combative and dangerously agitated. The patient may have a compromised airway, and hold the potential to bring the whole aircraft down. For this situation, I can appreciate the risk-benefit analysis of using paralytic drugs.

But for ground use I just do not see how the benefits outweigh the risks. The true goal of airway management is to Ventilate, not merely intubate. You can ventilate just fine without an ET Tube in place, if you are good at Basic Life Support. If you are not good at BLS, you should probably not become a Medic just yet. If you do not have good basic ventilation skills, you sure as heck better not make anybody stop breathing. Is it smart to increase patient risk to compensate for lousy BLS Skills? I sure don’t think so.

When I teach Nasal Intubation Techniques I always remind students that if it is very difficult to nasally intubate, you are probably doing the procedure on someone who does not need it. If the patient can protect their airway from you, they can protect their own airway, right? Patients that really need a nasal tube will practically help you put it in. Those unable to protect their airway can be intubated orally. Those that fall somewhere in the gray zone, can be properly ventilated until definitive care can be reached.

I cannot think of one single occasion in my almost 30 year EMS career, where so-called RSI would have made a difference. Those few patients I have been unable to intubate in the field (two), I was able to ventilate very well until ED arrival. Not one person has ever expired in my care for lack of this technique. So why do we need it?

I don’t think we do, and teaching Paramedics to make patients stop breathing is just a Really Stupid Idea.

UPDATE 2015 from Red Flags in Prehospital Airway Management by Henry E. Wang, MD – Controversies in Emergency Airway Management presented at NAEMSP Med Director Meeting Jan 5 2015

RSI for TBI Davis, J Trauma 2003 • Multicenter implementation of prehospital Rapid Sequence Intubation • 209 pts compared with 627 historical controls • RSI associated with increased death – OR: 1.6 [1.1-2.2] Conclusion: Prehospital RSI Does Not Save Lives (and May Harm)


About Dan White

I'm a retired Paramedic and EMS Instructor with 35 years EMS and emergency medical product experience. I love canoes, cars and EMS. I have written a lot about EMS Technology on the Paramedic Blog, the Insights on Innovation column for, on and I can be reached directly at 573-240-0002.
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17 Responses to RSI, or Really Stupid Idea

  1. Nae says:

    Dan ~
    I received the box yesteray.  What a wonderful surprise for my turn at duty; I was shocked and amazed at your generosity.  Moriah and I sat playing with the syphmomanometer (and I spent the rest of the day trying to say it properly).  That was fun!  The stethoscope works MUCH better than the Adscope product I was given, and I had fun comparing it to the other stethoscopes in the building.
    While I can\’t say that I\’m excited about the possibility of using the mask system – because that means someone is in BAD shape (and I prefer that people be healthy) – I will take some time to play with it and one of the resuscitation guys we have at the firehall.  I\’m looking forward to learning how to use it in a manner that will be efficient.
    Thank you so much for everything!  I am truly excited about becoming a better EMT, and these new tools will definitely get me on the road.
    God bless you and keep you,
    Nae  :o)

  2. Dan says:

    You are welcome Nae :>)

  3. paramedicmel says:

    Hey Dan,
    I am new to all of this and I wanted to email you but my computer is touchy and wouldn\’t let me. I wanted to ask you what part of Missouri do you live in? My husband and I are thinking about moving there, but we would have to look at jobs before we do. I am a Paramedic and he is an EMT. What do you suggest?

  4. Unknown says:

    Realy Stupid Idea you said it I\’m just not sure if by stupid you where refering to the practice or your thoughts on the procedure. For a salesman you talk a good game and no I dont have sales envy either. I think to be good medic you need to be somewhat arrogant but yiu have exceeded the limit. To think you have the skills to perform this in the air and I dont on the ground. Try to remember back to class brain death 4 – 6 minutes without oxygen if I RSI my patient and cant get the tube in I can manual bag my patient if I find it hard to bag by myself I have my driver stop and help thats 1 maybe 2 minutes how long does it take you to get help? I think it may take a little longer to land and get your pilot back there to help. Anectine lasts 4 – 6 minutes so my patient is breathing before you would even be on the ground. And I am realy immpressed with your 30 year career and only unable to intubate 2 patients theres that arrogant thing again. I think EMS is a calling and I am glad you answered it but you seem to be better at sales you might consider that it\’s time to pass the reigns to the next generation who are more adapt to new technoligies and dont fear change. 

  5. Dan says:

    Dear No Name,

    If you think I\’m arrogant now, you should have seen me when I was 24 and
    thought I knew everything:>) I’m sorry if you perceive I think I still do,
    which is far from the case. It sometimes seems I know fewer things are for sure
    with every passing year.

    I knew when I posted these thoughts they would be controversial. I might
    sometimes come off too strong when I\’m trying to make a point. The real
    underlying issue is not one of RSI; it is one of reliance on the BVM. The
    single reason we would ever need RSI is because without a tube, this marginally
    effective antique squeeze toy will barely keep anyone alive.

    But just to clear up one point. The reason I say it might make sense on a
    helicopter to use RSI is not because I think flight medics have skills ground
    medics don\’t. It\’s because the Risk vs. Reward calculation is different. They
    sometimes really need it more in the air. When you have a big guy with a head
    injury who is combative in a helicopter, this is no time to screw around. You
    have to take a risk to reduce a more pressing risk – crew safety. Snow them
    & put them on a good ventilator sure beats a wrestling match at 1,200 feet.
    It\’s about Behavior, not Ventilation. Please believe me when I say being under
    a rotor does nothing to inherently improve care. I think we use helicopters far
    too much, but that is a different rant.  

    I appreciate you sharing your thoughts,

  6. D says:

    I mostly agree with your rsi comments. I have rarely seen  the true need for it in the field. Even though I had one just the other day that I would have given my left eye tooth for some rsi.  A big head injured guy that had a steady flow of crapola in his airway ( even after I pulled out the crack) and after he seized and clamped down, it was all down hill airway wise. But thats why I am so close to the er, they tubed him and I boogied on down the road to the trauma center. Doing it myself would have saved me about 15 minutes and a trip across town.

  7. Unknown says:

    I completely disagree with you. I am a paramedic in alabama, and in the past three weeks, i have needed RSI both patients had a head injury. and were unresponsive. both needed to be flown by air transport to our trauma center in birmingham. on one i had a 45 minute ETAto the hospital, his teeth were clenched and was breathing 4 times a minute. the helicopter was unable to fly due to bad weather. luckily i had a paramedic student and was able to control the situation, we bagged him the entire way. on the other it was a single car mva with a head injury no other inuries. the patient was demonstrating beck\’s triad all the way he was responsinve on to pain with clenched teeth, he was combative, we restrained him and worked until the heliciopter arrived on htis call we had at least a one hour ETA to the trauma center.

  8. Dan says:

    Dear Alabama Medic,I appreciate the fact that you felt you needed
    something to help with these two patients. All I\’m concerned about is;
    Do you need to make them stop breathing, or do you really need some
    better ways to support respiration? If you had the patients that can
    breath on CPAP, you can keep them well ventilated
    without the need for ETT or BVM. If you had a time cycled
    volume-constant EMS ventilator, you could much more easily support
    those who can\’t move enough volume on their own. My point is
    that Yes, we do have unique challenges in pre-hospital airway
    management. But, are we asking for the right solution to the problem?

  9. yvette says:

    QUESTION (and thanks in advance):  If a patient is having episodes of emesis, and is unconcious, would a BVM be an effective airway?  What are the reasons for unsuccessful intubation?

  10. Dan says:

    Dear, Yvette,

    A BVM is a ventilatory adjunct – not an airway. It can be used with a variety of airways, from the most simple oral airway to the endotracheal tube airway. What the patient you described needs most, is rapid effective suctioning and proper positioning – so as to not compromise the airway.There are lot\’s of reasons for unsuccessful intubation, but in my opinion one of the least often appreciated is that I think EMS providers use blades that are too long.We are overkill junkies:>) We mostly use #3 Millers and #4 Macs, while more experienced and higher level clinicians like anesthesiologists more often use #2 Miller or #3 Mac. What happens (this is all my personal theory, and not substantiated in the medical literature) is that  Medics often put their blade down the esophagus, then slowly pull back until the glottis "pops" into view. This is bad technique (but I used to do it too), as we traumatize the airway rendering any subsequent attempt more difficult due to tissue swelling.Just my thoughts :>)

  11. yvette says:

    Thanks for taking the time to explain. I have a dilemma; so I\’ll just throw it out there.  My brother was in an MVA 2 months ago. The witness (game and fish warden) called 911 and requested air medics to land at the scene d/t the extent of injuries (multiple fractures on lower extremities). MVA happened approximately 25 minutes from nearest rural hospital. EMS responded first. Decided they would take him to the rural hospital via ground, and life flight could meet them there to get him to a higher level trauma center. EMS got into vehicle and did assessment. Brother alert, oriented, vitals stable, wheezing in lungs. Brother states he has asthma, no allergies, very talkative. Fire department arrives approx. 35 minutes after wreck occurred and begin extraction. No IV in place at this time. They do have him on oxygen and have placed a cardiac monitor. HR slightly elevated, 108 (he did state his pain level was a 10). After extraction, guess what…he begins going in and out of consciousness. No IV. They load him up. 15 minutes later he starts vomiting, having trouble breathing. The attempt ET tube. Fail.  Attempt Combitube. Fail. Bag him. IV attempted x 3 in ambulance. Failed. Stopped at three tries on upper extremities. No other site tried. He gets no fluids. Low and behold, shortly after respiratory arrest, he begins bradying down and goes into asystole (although when I look at the strips it looks more like vfib). No shock advised (apparently they use AED\’s on ambulance). They give CPR for the remainder of 6 minute ride until they reach destination. PA in ER easily intubates. ER doc (family physician) attempts to place subclavian line but can\’t because sternum has been broken (CPR or MVA). I wonder though, how could a subclavian line be placed when CPR is underway. Interesting. At any rate, 5 minutes later they pronounce him dead. He had no cardiac drugs, no fluids, no airway. I think he had no chance. QUESTION: Couldn\’t they have tried an LMA?  Couldn\’t they have obtained IO access to give fluids and drugs?  Please advise, and thank you in advance.

  12. Dan says:

    I have more questions for you than answers, but mostly I just want to scream.
    I am very sorry for your loss, and can appreciate the agony of your dilema. I lost my father in an MVA 3 years ago. In his case everything went right. The Medic was on scene before the cops, and got the nearly impossible nasal intubation (badley broken nose) on the first try. It did not matter in the end. Sometimes no matter how good or bad EMS does their job, fate has different plans.
    If I was in your situation looking at what happened I\’m pretty sure I would go crazy. No A, No B, No C. No Shit. 
    It sounds like you are in a fairly rural area, with maybe a not quite state of the art receiving ER and EMS System. So maybe even getting a tube & line in may not have mattered in the end. Sometimes, if you don\’t have a first rate Trauma Surgeon and a real Level 1 Trauma Center waiting for you at the end of the trip, nothing else you do right matters. You did not say what the final diagnosis or post showed as cause of death. It sounds like he had some real bad things going on.
    To respond to your specific questions; I am not a huge LMA fan. I like the Combitube better as a back up airway, and they had one. Yes, an IO route may have been of value but it is difficult to push a lot of fluid this way fast. Not every EMS system uses them, or can afford really good IO devices.
    What you do give me pause to reflect on; For many years I have protested the over use of helicopters, and rarely let them take my patients. I have ranted about using air transport based solely on mechanism of injury, or on anything that is not a true multi-systems trauma patient. But here is a situation where an over-cautious EMS System and a helicopter with a good flight Medic could have made all the difference in the world.
    I intended to give this a lot of thought.
    I\’m not very religous by nature, but I will be praying for you.

  13. Enrico says:

    Good day all,

    I’m a Paramedic in South-Africa and qualfied Emergency Care Practitioner (ECP), which here in SA is a rank above the usual ALS Paramedic. Receintly (2009) RSI was introduced to the ECP protocol after about 7 years of research.

    It is a 50/50 case for arguments fore and against RSI. As the Paramedic field is growing and its influence medically growing, the speciality of emergency medicine is what we do best. So my opinion is based on experience as a clinician, it is just as big a dicision to withold certian treatment that it is treating a certain way. This is what makes us clinicians, to have all the tools available and use them selectively and effectively to the benefit of our patients.

    On your initial message you said that in 30 years you never needed RSI, well congratulations to you, but I see the need every day. So it all depends on the setting you find yourself in. So to make generalizations will be detrimental.



    • phillydan says:

      Thanks for sharing Enrico,

      Everyone has different needs, for example; a flight medic in combat. They may need it more often. So may you. I just have not, and worry aloud why.

      I see a similar phenomenon with IO’s. A friends EMS Squad got the new bone drill and my friend “Peter” boasts he had 6 IO’s with it this year. I blurted out. “BUT Peter, I worked with you on and off 6 years and never saw you miss 3 IV’s”. He wry grinned “It is kinda cool”. At least he is being honest, which is the best you can ever expect from a really good friend.


  14. Rob Werner NREMT-P says:

    As a paramedic that hold multiple state licenses, and has been nationally registered for 25 years I find you and this article offensive.

  15. Morris says:

    I’ve read this post a few times and decided to comment.
    Your notion that ground medics want RSI because of “rotor envy,” is about as sound as the previous notion that women wanted independence due to “penis envy.” It’s ludicrous. It sounds to me (I am assuming you fly) that you really don’t like the idea of lowly ground paramedics performing your not-so-unique skill; you are aware multiple ground agencies perform RSI frequently and with great success right?
    Paramedics are extensions of the EM physician and should whenever possible treat patients exactly as the physician would. Geography should not dictate care.
    I freely admit that paramedic education is lacking in some areas and correspondingly that those personnel would not be good candidates to have this tool in the box. However, many of us are soundly and comfortably aware of the academic and practical pros/cons of this tool. I’ve seen more than a handful of cases that any ED physician would RSI upon showing at the doors (and they did).
    I’ll leave this as well, prehospital RSI is JUST AS SAFE as in hospital RSI when quality QA/QI is performed. A physician was present but the paramedic made first attempt on patients that wouldn’t otherwise be classically contraindicated to us (Obese, neck trauma, deformity, etc.) Note the extremely similar success rate.

    To wrap up, the key is good education, quality QA, and a medical director willing to be hands on. Not the blessed ones in a helicopter or in the ED.

  16. Lonman says:

    Being in the field for almost 30 years, I’ve seen this from alot of the older medics. “We didn’t need this in the past and we did just fine”. Really?? We delivered a lot of patients who didn’t stand a chance to the ED. RSI isn’t just about putting the patient down for the sake of putting them down. Mostly it is about taking control of the patient and their breathing. Making it a more controlled environment. Taking away the bodies “work of breathing” in a trauma situation (when needed), is a prudent thing to do. As far as IO, IV is the chosen method for access. As far as I can see it always will be. That being said, I don’t believe in screwing around, digging and trying several times for an IV when you have IO. And you CAN push the adequate amount of fluid. Use a pressure bag. The paramedic field is a dynamic field and always will be changing. Just because we get comfortable with a technique, doesn’t mean that there isn’t something better. I am a paramedic instructor and have been for a quite some time. One of the most important things I teach my students is not to become complacent. Always move forward with learning. I have seen lots of sages in this field with the “you don’t need all that fancy crap to save a patient”. And that really pisses me off to think that my family may be at the mercy of a hack like that.

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