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Survey of the use of rapid sequence induction in the accident and emergency department
  1. Kelvin D Wright
  1. Accident and Emergency Medicine, Wycombe General Hospital, Queen Alexandra Road, High Wycombe HP11 2TT, UK (Kwright{at}doctors.org.uk)
    1. Andrew J Cadamy
    1. C/o P&O Cruises (UK) Medical Department, Richmond House, Terminus Terrace,Southampton PO14 3 PN, UK (ajcadamy{at}compuserve.com)
      1. Michelle White
      1. Paediatric Intensive Care, Bristol Children's Hospital
        1. A Walker,
        2. J Brenchley
        1. Accident and Emergency Department, Leeds General Infirmary, Great George Street,Leeds LS1 3EX, UK

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          Editor,—The paper by Walker and Brenchley1 highlights a crucial area of emergency medicine practice. The key issues are “How are skills maintained” and “What is an acceptable period of training”.

          The authors state in their conclusions that the majority of accident and emergency (A&E) consultants thought that rapid sequence induction (RSI) would be undertaken by A&E staff if an anaesthetist were unavailable. If the A&E staff are only performing this procedure rarely then they will become de-skilled and will have a higher complication rate than a colleague performing the procedure on a regular basis. Anaesthesia is defined as an essential secondment for training, why have this secondment if the skills are not going to be actively used.

          In order to be given the responsibility of “on call” the anaesthesia minimum requirement is three months of supervised training. I feel that it is no coincidence that this also is the length of our secondment.

          References

          Editor,— As a doctor with a background in both anaesthesia and accident and emergency (A&E) medicine, and currently working in an emergency medicine environment, I read the paper by Walker and Brenchley with interest.1 I have been aware for some time now of the debate among emergency physicians, and anaesthetists, over their respective roles in emergency airway management. I suspect that anaesthetists are probably guilty of being of blindly territorial, and somewhat condescending, over the issue. However, I am also aware that among emergency physicians there is a slightly concerning “gung-ho” element to their approach to this procedure, which I believe betrays a lack of understanding of the technique, and of the risks involved. In illustration of this, I remember seeing in an A&E department of a hospital I have worked in, the abbreviation RSI expanded to “rapid sequence intubation”.

          The use of RSI of anaesthesia to facilitate intubation of the trachea is an inherently risky technique. So that the risk of regurgitation and aspiration is minimised, the patient is paralysed before control of the airway is assured. Furthermore, unlike in any other anaesthetic technique, the drugs used are given as a rapid bolus of a predetermined dose. These agents have real potential for causing harm and a thorough understanding of their actions is necessary to appropriately tailor the choice, and dose, of drugs used. While I accept that in most cases the technique is safe and effective, and that the complication rate is low, I would suggest that the risk of problems, serious problems, remains real. It requires not only training (such as the Advance Airway Course), but also experience (such as an anaesthetic attachment and supervised emergency intubations) in order to anticipate, and avoid, these problems, and to be able to safely retrieve any difficult situations that can be encountered despite this.

          It is this need for experience gained in practice that would seem to pose the major problem in UK emergency departments. The number of cases in the UK where drugs are required to facilitate “immediate airway protection” must be comparatively low and these cases are conceded to be the most testing, even for experienced anaesthetists.1 Additionally in the more common cases where airway protection is less urgent, and where subsequent management is likely to be the responsibility of the anaesthetists or ITU staff, it would seem appropriate that the team delivering definitive care is involved from the outset. Opportunity, therefore, for any one individual A&E physician to practise and maintain the skills they have been trained in would inevitably be infrequent. When faced with a case requiring RSI, even the most junior of on call anaesthetists is likely to have practised the technique more recently.

          With all of this in mind I would still maintain that there probably is a place for A&E physicians taking on advanced airway management in the UK. However, I feel this process must be approached with respect for the technique and a grasp of the need for practice and experience. Similarly anaesthetists should welcome this desire to share the responsibility for the “head end”, should not seek to unnecessarily shroud their art in mystery, and rather offer to facilitate the acquisition and maintenance of these skills.

          References

          Editor,— I read with interest the article by Walker and Brenchley regarding the use of RSI by accident and emergency (A&E) medical staff.1 Emergency medicine is characterised by the ABC approach with airway management as the first priority, which by definition includes performing RSI where necessary. Thus it is essential that A&E staff can do this competently and completely. Regular and routine practice of RSI will help prevent skill deterioration as will the use of patient simulators for airway training as described by Ellis and Hughes.2 Hence, A&E should manage all RSIs and not just occasional attempts in acute situations.

          Walker and Brenchley rightly point out that A&E patients “represent a distinct high risk subgroup” and that anaesthetists are concerned that “critically ill patients requiring immediate airway protection are the most difficult to manage”. Why then are operating department assistants (ODA) present at less than 50% of RSIs performed by A&E staff? The help of an ODA is of immense value to new anaesthesia SHOs as well as experienced consultants. Neither would presume to undertake an anaesthetic in a controlled theatre environment without an ODA present so why do A&E staff presume they can? Most emergencies arrive by ambulance and a radio warning of an impending arrival is received. At this point an ODA should be requested and anaesthesia and A&E departments should have clear policies to facilitate this. In all but the most unexpected and direst of airway emergencies an ODA should be present for a RSI.

          A&E medicine overlaps with many specialties and as anaesthetists we should stop being protective over RSIs and instead strive to share our airway expertise and our experience in using patient simulators for training.

          References

          Authors' reply

          We agree with the comments made by Wright and White.

          Cadamy notes that training and experience are essential. Part of the programme to introduce these skills in A&E would obviously include both inhouse training and courses such as the Advanced Airway Course, which is being introduced into the UK. We would suggest that emergency physicians should routinely undertake RSI in the department to maintain skills. Only attempting RSI of patients “in extremis” is clearly a recipe for disaster.

          Trained assistance is obviously the ideal, but may not always be available for the same reasons as anaesthetic help is not immediately accessible in all circumstances. There may be scope to train A&E nurses in these basic skills.

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