It is 17:30 on a sunny fall day when a BLS engine from the Wilmington (DE) Fire Department, a BLS ambulance from Wilmington EMS, and a paramedic response unit from New Castle County EMS are dispatched to a "pedestrian struck." All three units arrive at about the same time to find a 15-year-old male face down in the roadway, not moving. The patient responds only to pain, is breathing irregularly and has contusions on his head. The crew immediately takes C-spine precautions and rolls him onto his back. One paramedic easily manipulates his jaw forward while an EMT applies oxygen via non-rebreather mask.

   After he is moved onto the backboard, the patient becomes combative. Several providers attempt to restrain him, but he continues to move his head and strike it against the backboard. His teeth are now clenched and the oxygen mask will not stay on his face.

   The region's level 1 trauma center is Christiana Hospital in Newark, DE. Ground transport in normal traffic conditions is about 15 minutes, but it is now rush hour and could take up to 30 minutes. The paramedics are concerned that the patient does not have a patent airway and his combativeness could worsen a head or neck injury. For these reasons they decide that this patient is a candidate for rapid sequence intubation (RSI), which was implemented three weeks earlier for New Castle County EMS.

   The patient continues to be combative after he is moved to the back of the ambulance. His pulse is 150 and the monitor shows sinus tachycardia, RR 36 and irregular, BP 160 systolic, and a pulse ox reading of 100% with the non-rebreather mask as close as he will allow it to be from his face. One of the paramedics calls Christiana to request orders for RSI while the other starts an IV in the patient's left arm.

   The paramedic requests permission to administer lidocaine, etomidate and succinylcholine to intubate the patient. He also requests orders to administer midazolam and vecuronium after intubation for longer-lasting sedation and paralysis. The base physician agrees and confirms doses for the medications.

   One paramedic draws up the medications and applies labels to the syringes while the other paramedic prepares an 8.0 ET tube with a stylette and syringe, turns on the suction unit, and places an open Thomas Tube Holder and end-tidal CO₂ circuit next to the patient's head.