So I had my first RSI a couple of shifts ago.. I've had a few patients before who could have been RSI'd but being as close as we were to the hospital, hauling butt made more sense. Not so much for this one.
Called early in the morning for an elderly male having difficulty breathing. On arrival, found patient sitting in room on bed in tripod position on a nasal cannula. Pt states, in short word dyspnea, "This is it, this is the big one, I'm going to die". Pt has history of COPD and (possible) CHF, took his own albuterol before our arrival with no relief. Initial sat of 89%, etco2 of 29. Pt grey in color, accessory muscle usage, and pursed lips. BP decent, HR in the 130s.
I had a first responder put on an NRB, and had my partner call for a second truck for backup (We have a 30 minute transport MINIMUM to closest hospital). We get the patient on the cot and out to the rig, start him on a Duo-neb treatment, and while going to meet the other unit I started an IV.
As we pull up, the medic from the other truck jumped in and I told him what was going on (Said medic has been a medic longer than I've been alive). Patient was now satting 94%ish, etco2 dropped to 11, still breathing over 45 times a minute. He concurred with my plan to RSI, though suggested we probably could get away with just etomidate and skip the roc.
I give 200mcg of Fentanyl as the other medic pre-oxygenates and the 2 EMTs get some stuff set up. I proceed to give 20mg of Etomidate which promptly zonks out the patient (Zonks.. a medical word, look it up :P ) We lay the head down and discover that the patient now has trismus (lock jaw) from the Etomidate. Great. Pushed 70mg of Roc, which caused full paralysis and loosened the trismus.
Open the mouth and introduce the blade finding a very anterior glottic opening (Malampati 3). Introduce the bougie pass the glottic opening, feel the click, get tracheal lock, and slide the tube down the bougie. Tube confirmed with etco2, misting, visual, and lung sounds.
Within a few minutes of bagging, patient was 100%, etco2 kept at around 35-40, and had pink skin.
Took the patient to the hospital, and last I heard they were still in the ICU (Many days later)