We should strive for a doctor to be present to receive all blue calls. It is important to acknowledge that our current working conditions (i.e. crowding) can make this challenging to achieve, but it remains the standard of care we should be aiming for.
ANYONE can initiate a MET call. This is NOT restricted to doctors. Resus nurses in particular should feel empowered to do so. There is no need to “run it by” a doctor. If in doubt pull the buzzer.
In frail, multi-morbid patients there is always a strong argument that RSI is not the appropriate course of action (risk of arresting on induction, risk of prolonged suffering in ICU without meaningful chance of successful extubation/recovery). However, every case is different and the decision is often not straightforward, especially with limited immediately available information (and no documented treatment escalation plan), which is often the case in the ED. Inevitably, we will all be involved in intubations which should never have happened.
Therefore, it is good practice to take every opportunity to discuss TEP/patient wishes with frail patients when they are NOT acutely unwell, and then ensuring the discussion is clearly documented, and appropriate electronic forms completed.
An ED RSI is a different ballgame to an elective intubation in theatres. Our patients are high risk for “RSI then they die” (because they are usually really sick!). Although it’s usually an anaesthetist or intensivist performing the laryngoscopy (**however see below**), RSI is very much a team game, and it is our responsibility to ensure that the procedure is done as safely as possible. The tube is the easy bit… It’s everything else (adequate preoxygenation, choice of induction drugs, management of haemodyamics etc) that is more nuanced.
**Laryngoscopy in resus can be performed by ANY airway trained practitioner. Advanced airway management is NOT solely the domain of our anaesthetic/ICU colleagues – that’s why there is 6 months of anaesthesia in UK EM training! As long as there is an anaesthetist in the room, EM trainees should always consider asking to perform supervised laryngoscopy… as long as it is clinically appropriate and doesn’t compromise the rest of the department. A career mission of mine is to change the culture around airway management in UK EDs - work is already underway which I’ll share on Substack soon. Watch this space!
Recommended Youtube lecture: “RSI then they die (How to intubate sick patients safely)” by First10EM. A brilliant talk.
Cheers for reading!
Robbie
