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Emerg Med J. 2007 July; 24(7): 480–481.
PMCID: PMC2658394

Rapid sequence intubations by emergency doctors: we can but are we?

Abstract

Background

Rapid sequence intubation (RSI) is used by emergency doctors routinely in many parts of the world, but it is unclear how many are using this technique in England and Wales.

Aim

To determine, through a telephonic survey, which specialty was performing RSIs.

Methods

All emergency departments were telephoned, and senior emergency doctors were asked which specialty provided this service, and whether this was done routinely, often, or could be either specialty.

Results

All 207 departments responded. 3 (1%) departments routinely had emergency doctors perform RSIs, and a further 3 (1%) had anaesthetists performing these routinely. In 33 (15.9%) departments, there were equal chances that it could either specialty. Anaesthetists provided the service routinely in 130 (62.8%) and often in 38 (18.4%) departments.

Conclusion

Although there are emergency doctors performing RSIs, the majority of RSIs are still being performed by anaesthetists. When this is added to the curriculum for the Fellowship of the College of Emergency Medicine from 2008, many departments, seemingly, will not be in a position to provide experience in this area.

Rapid sequence induction of anaesthesia is a specific technique originally used by anaesthetists, described formally in 1970 by Stept and Safar,1 who showed it to reduce the risk of aspiration of gastric contents. With the advent of critical care, this procedure was increasingly used for the rapid control and protection of the airway, and for ventilation. This technique is often referred to as rapid sequence intubation, particularly in the US (hereafter referred to as RSI).

There has been a move over the last 30 years for RSI to be performed by emergency doctors. According to the National Emergency Airway Registry, Boston, Massachusetts, USA, anaesthetists are reported to perform only 3% of all RSIs2 and 5.5% of RSIs in patients with trauma.3

The purpose of this survey was to find out which specialty is performing RSIs in emergency departments in England & Wales.

Methods

All 207 National Health Service emergency departments in England and Wales were telephoned by the investigators, and a middle grade or higher grade doctor was spoken to. It was felt that a more senior emergency doctor would be able to provide a more reliable answer to the questions posed. After a short description of the study, the question was posed and the answer given immediately entered into a database. Department telephone numbers were obtained using The Directory of Emergency and Special Care Units,4 with any changed telephone numbers updated from the official National Health Service website for that hospital. Departments that had closed or that had become minor injury units (defined as coverage of office hours by a single consultant, with no junior staff, no direct coverage by any doctor or admitted to being a minor injuries unit) were deleted from the telephone database and no data were obtained for these.

The middle grade, specialist registrar, or consultant was asked who performs the RSIs, choosing from one of five options; routinely an anaesthetist, often an anaesthetist, either, often an emergency doctor and routinely an emergency doctor. “Routinely” was used instead of “always”, so as to include exceptional circumstances whereby the expected specialty who would perform the RSI did not do so— for example, an emergency doctor performing the RSI because there was no anaesthetist available. “Often” was included to try and include departments where, although there was a predominance of one specialty, the other specialty performed RSIs sufficiently often to not make it exceptional. Seniority of the respondent and response were entered into an Excel spreadsheet.

Ethical approval was not obtained, as neither patients nor their records were involved in this survey, which was designed to describe current practice.

Results

All 207 emergency departments were successfully contacted during the period October–December 2006. Table 11 shows the respondents by grade.

Table thumbnail
Table 1 Respondents by grade

Table 22 and figure 11 show the answers to the questions.

figure em48082.f1
Figure 1 Responses to the questions.
Table thumbnail
Table 2 Responses to the questions

All hospitals in which RSIs were performed routinely by emergency doctors were teaching hospitals with consultant staffing levels of between 6 and 8.

Discussion

We provide baseline data on current practice with regard to RSI by specialty. This is the first such survey done in England and Wales, although Butler et al5 in 2001, as part of a wider study of specific differences between anaesthetists and emergency doctors' RSI performance, found that the RSI practitioner was an anaesthetist in 58% and an emergency doctor in 26% of the 60 RSIs.

A limitation of our method was the reliance on the overall impression of the respondent. However, this was felt necessary as most departments do not keep data on which specialty is doing RSIs.

The revised Fellowship of the College of Emergency Medicine curriculum, to be implemented in August 2007, incorporates RSIs into its core skills requirement.6 Hence, departments with emergency doctors with the skills to safely perform RSIs should become more commonplace, although it does appear that the ability of emergency departments to allow their emergency doctor trainees to perform RSIs is still less than ideal for the curriculum to be implemented effectively.

Conclusion

It appears that the majority of emergency departments in England and Wales continue to rely on anaesthetists to perform RSIs, with only a few departments doing emergency RSIs.

Abbreviations

RSI - rapid sequence intubation

Footnotes

Funding: None.

Competing interests: None.

References

1. Stept W J, Safar P. Rapid induction‐intubation for prevention of gastric content aspiration. Anesth Analg 1970. 49633–636.636 [PubMed]
2. Lockey D J, Black J J M. Editorial: emergency physicians: additional providers of emergency anaesthesia? Anaesthesia 2002. 57629–631.631 [PubMed]
3. Gun D E, Kulkarni R G, Walls R M. NEAR investigators. Trauma airway management in the emergency department—indications, methods, and success rates. American College of Emergency Physicians 1999 Research Forum. 1999;11–12 Oct.
4. CMA Medical Data The directory of emergency and special care units. Cambridge: CMA Medical Data, 1999
5. Butler J M, Clancy M, Robinson N. et al An observational survey of emergency department rapid sequence intubation. Emerg Med J 2001. 18343–348.348 [PMC free article] [PubMed]
6. College of Emergency Medicine FCEM curriculum version 3 – April 2006. http://www.emergencymed.org.uk/CEM/Curriculum/ (accessed 19 Apr 2007)

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