Interventional Pulmonologist

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I can't put a number range on it since I frankly don't know. And yes many place has gas place the tube.

Sorry for hijacking, but why would places have anesthesia come place the tube? I mean, I know supposedly they are the airway experts and all, but I would assume that IM trained intensivists are perfectly capable of airway management, even for more difficult cases. Just seems like it would be easier to not bother with anesthesia, who I imagine is running the OR/managing the SICU anyway.

Originally Posted by AquaFortis

Sorry for hijacking, but why would places have anesthesia come place the tube? I mean, I know supposedly they are the airway experts and all, but I would assume that IM trained intensivists are perfectly capable of airway management, even for more difficult cases. Just seems like it would be easier to not bother with anesthesia, who I imagine is running the OR/managing the SICU anyway.

Your only mistake was trying to make sense of medical politics. Don't do that. It will eat you alive.

Originally Posted by AquaFortis

Sorry for hijacking, but why would places have anesthesia come place the tube? I mean, I know supposedly they are the airway experts and all, but I would assume that IM trained intensivists are perfectly capable of airway management, even for more difficult cases. Just seems like it would be easier to not bother with anesthesia, who I imagine is running the OR/managing the SICU anyway.

Good questions.

Originally Posted by AquaFortis

but I would assume that IM trained intensivists are perfectly capable of airway management,

mistake one was to think hospital politics make sense, mistake two is to assume all IM trained intensivists are trained adequately in airway management. There is placing a tube, and then there's placing a tube. I'd argue my program is horribly inadequate in airway management education, and if it weren't for comfort level from my IM program, I'd be a pansy as an attending. That being said, I also don't have much respect for the gas-passers' at my hospitals management of ICU airways. There are only 2 attendings who approach it in a manner that I think is appropriate. Most walk in and act like its no big deal, they have next to no difficult airway equipment with them, but it's actually the CRNAs who do most of the airways (I do my own when I can, which means only when I have an attending in house). But I've even had a gas attending admit on one of the bloodiest cases that we were better off letting the nurse try since he does more tubes than the attending yeah, that's a real captain of the airway ship. I'm waiting for the day when in the middle of the night they get in over their heads and loose an airway and trauma doesn't get there soon enough to cric since yet again, I'm not allowed to do that without my attendings present.

I'm usually pretty damn cocky when it comes to procedures, but in my mind the airway is different. If you don't have a healthy level of respect, it can and will bite you in the ass and someone will get hurt.

Thanks for the reply. So, it sounds like those of us interested in/considering IM/CCM in the future would be well-served in being aggressive about getting procedures in residency, correct? Did you all ask the programs you went to about procedures for residents (those relevant to hospitalist/CC medicine anyway)?

Yes, yes and yes

Originally Posted by Hernandez

mistake one was to think hospital politics make sense, mistake two is to assume all IM trained intensivists are trained adequately in airway management. There is placing a tube, and then there's placing a tube. I'd argue my program is horribly inadequate in airway management education, and if it weren't for comfort level from my IM program, I'd be a pansy as an attending. That being said, I also don't have much respect for the gas-passers' at my hospitals management of ICU airways. There are only 2 attendings who approach it in a manner that I think is appropriate. Most walk in and act like its no big deal, they have next to no difficult airway equipment with them, but it's actually the CRNAs who do most of the airways (I do my own when I can, which means only when I have an attending in house). But I've even had a gas attending admit on one of the bloodiest cases that we were better off letting the nurse try since he does more tubes than the attending yeah, that's a real captain of the airway ship. I'm waiting for the day when in the middle of the night they get in over their heads and loose an airway and trauma doesn't get there soon enough to cric since yet again, I'm not allowed to do that without my attendings present.

I'm usually pretty damn cocky when it comes to procedures, but in my mind the airway is different. If you don't have a healthy level of respect, it can and will bite you in the ass and someone will get hurt.

I would be interested to hear what things are being done (or not done) that makes you feel the anesthesiologists are mismanaging the airway.

Originally Posted by DrRobert

I would be interested to hear what things are being done (or not done) that makes you feel the anesthesiologists are mismanaging the airway.

1) It's next to never the anesthiologist, or the resident, it's almost always the crna. I do hate to watch a nurse do my procedures.
2) theyre never prepared, don't have suction, don't check the tube, rarey ask about labs, don't pre-oxygenate have no difficult airway equipment ready, when they get in over thier heads, it takes many minutes for them to run to OR to get their glidescope (yes, I've complained that we don't have our own)
3) as above, I had a pt in DIC need a tube, it was a bloody ****ing mess, and the attending looked scared and admitted that we'd be better off letting the crna keep trying since he did more intubations than him
4) I once had a anesthiologist leave the unit and left me without an airway before trauma shows up for a cric, without trying.....after he proceeded to lecture me that PCV pts must be paralyzed and berating me as to why this pt wasn't on APRV (hint, he was hypercapnic as ****)
5) that being said, they also have 2 of the better attendings I've seen with airways, But it isn't them on too often.

Originally Posted by Hernandez

1) It's next to never the anesthiologist, or the resident, it's almost always the crna. I do hate to watch a nurse do my procedures.
2) theyre never prepared, don't have suction, don't check the tube, rarey ask about labs, don't pre-oxygenate have no difficult airway equipment ready, when they get in over thier heads, it takes many minutes for them to run to OR to get their glidescope (yes, I've complained that we don't have our own)
3) as above, I had a pt in DIC need a tube, it was a bloody ****ing mess, and the attending looked scared and admitted that we'd be better off letting the crna keep trying since he did more intubations than him
4) I once had a anesthiologist leave the unit and left me without an airway before trauma shows up for a cric, without trying.....after he proceeded to lecture me that PCV pts must be paralyzed and berating me as to why this pt wasn't on APRV (hint, he was hypercapnic as ****)
5) that being said, they also have 2 of the better attendings I've seen with airways, But it isn't them on too often.

Your concerns about inadequate preparation are valid. Preparation is everything when it comes to airway. Granted in an emergency situation there isn't a lot of time for preparation.

As to your concern about the CRNA doing most of the non-OR emergency intubations... you should consider yourself lucky that you have a CRNA. In my private practice group, the physicians are too busy in the ORs managing patients. Our primary responsibility is with our patients in the OR. We do floor/ICU intubations as a courtesy to the hospital. We almost never have a doc available to intubate someone outside the OR... we send our CRNAs. And let's face it... they are the second most experienced people in the hospital with airway management. You should consider yourself lucky... a lot of hospitals will have RTs, EM docs, Hospitalists, etc. that are responsible for emergency airways. Obviously having an anesthesiologist would be the best option, but it's just not realistic.

I've always wondered why the Pulm/CC guys are never around to intubate their patients ... our department (anesthesia) does about 98% of non-OR intubations in the hospital. Not to mention most of the A-lines and Central lines.

I did an internal medicine internship and put in over 50 central lines. Every hospitalist should be able to put in their own lines... but they say it's not in their scope of practice. wtf?

I don't consider myself lucky to have a nurse do my job. I'm irritated that as a critical care fellow I should be doing all my airways.

Politics aside, let's face it, even emergent intubations rarely fall into the nearly dead/ newly dead type of airway that demands action without preparation

Originally Posted by Hernandez

I don't consider myself lucky to have a nurse do my job. I'm irritated that as a critical care fellow I should be doing all my airways.

Politics aside, let's face it, even emergent intubations rarely fall into the nearly dead/ newly dead type of airway that demands action without preparation

I commend your sense of responsibility. I wish all critical care physicians would do their own airways. But in every hospital I've been at, they almost never do.

You can do everyone a favor by doing your own airways when you go into practice. But based on my experience, a nurse will be doing your airways (or maybe even a RT).

Originally Posted by DrRobert

I commend your sense of responsibility.

Anesthesia at the hospital I did IM taught me a healthy dose of respect for the airway. So please don't think this was a rant against all anesthesia. I plan on taking responsibility for my PTs, including most airways.

Originally Posted by DrRobert

I commend your sense of responsibility. I wish all critical care physicians would do their own airways. But in every hospital I've been at, they almost never do.

You can do everyone a favor by doing your own airways when you go into practice. But based on my experience, a nurse will be doing your airways (or maybe even a RT).

Why is this? Do you think they don't feel confident in their airway skills or do they just not want to intubate? I'm just a lowly med student but I imagine that if I was a physician I would enjoy intubating my own patients.

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