Sharing the airway

[VisionaryTics]

Quick question. I'm an ENT intern, and there's been a few cases where my seniors/attendings leave the room so I can close/finish the case and I'm alone with the anesthesiologist/CRNA while the patient is waking up.

Sometimes, I'm kind of nervous about the airway (extensive instrumentation and manipulation of the larynx, bleeding in the mouth/oropharynx, etc). Occasionally, I have been standing next to the head of the bed (with the anesthesiologist in pole position) with my headlight on just to make sure that the coughing, bucking patient who just had the tube pulled didn't cough out the finger-of-eight suture tamponading off an oropharyngeal bleed.

I'm not at the point in my training where routinely my cases have the airway algorithm of "awake FOI" -> "awake trach", but there's been a few times where I wanted to be present and vigilant in management of the airway peri-operatively. I had an anesthesia attending in med school who told me he thought that surgeons and especially otolaryngologists had an inflated opinion of their airway skills and that they should get out of the way unless a surgical airway is necessary.

What do you guys prefer in situations like the above (some sheninigans going on in airway, but probably not about to cric the patient)? Get the hell out of the way, let the anesthesiologist manage the airway? Come on over, have a look, an extra pair of hands suctioning and assessing things is useful? I don't want to step on toes and I haven't really been able to figure out the anesthesia-otolaryngology dynamic.

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[Mman]

Quick question. I'm an ENT intern, and there's been a few cases where my seniors/attendings leave the room so I can close/finish the case and I'm alone with the anesthesiologist/CRNA while the patient is waking up.

Sometimes, I'm kind of nervous about the airway (extensive instrumentation and manipulation of the larynx, bleeding in the mouth/oropharynx, etc). Occasionally, I have been standing next to the head of the bed (with the anesthesiologist in pole position) with my headlight on just to make sure that the coughing, bucking patient who just had the tube pulled didn't cough out the finger-of-eight suture tamponading off an oropharyngeal bleed.

I'm not at the point in my training where routinely my cases have the airway algorithm of "awake FOI" -> "awake trach", but there's been a few times where I wanted to be present and vigilant in management of the airway peri-operatively. I had an anesthesia attending in med school who told me he thought that surgeons and especially otolaryngologists had an inflated opinion of their airway skills and that they should get out of the way unless a surgical airway is necessary.

What do you guys prefer in situations like the above (some sheninigans going on in airway, but probably not about to cric the patient)? Get the hell out of the way, let the anesthesiologist manage the airway? Come on over, have a look, an extra pair of hands suctioning and assessing things is useful? I don't want to step on toes and I haven't really been able to figure out the anesthesia-otolaryngology dynamic.

that's attending to attending level discussion and on a case by case basis. If your attending surgeon isn't around for the wake up, I'd essentially stay out of the way unless asked for assistance.

 

[Noyac]

Agreed, get out of the way BUT be present if needed. I have done many many intense airway cases with ENT present. I will say that having someone standing there with presumed emergent cric skills is somewhat comforting. However, I have not found an ENT to my knowledge that had better airway management skills. But this isn't a pissing contest either. If the anesthesiologist has the airway under control but can't intubate then "taking a look" is feasible. If not, then don't waste time and move to cric, that's your expertise. Pts with a scar on their neck sue for less than families who just lost their mom,father,whatever

 

[urge]

You are an intern. Stay away. Far away.

 

[deleted59964]

You are an intern. Stay away. Far away.

way to welcome a visitor

visionary - it's a fair bet though that at present that your non surgical airway skills << the anaesthetist.
when you're a crusty old surgeon who's been looking down airways for decades - that may be different - especially if your anaesthetist is junior in their training.

I appreciate the ENT surgeon staying in the room if I'm (or if they're) concerned -- but I'll ask for help if I need it... Even if at present you help by calling your boss!

 

[ZzzPlz]

I thought this was going to be a thread about ICU resident and fellows always trying to steal our stat intubations

 

[RxBoy]

About a couple months ago I responded to a stat page for a patient on the floor. I arrive and all I see is a patient in severe angioedema. Im talking about a tongue the size of a baseball. First thing I ask for is ENT at bedside stat. The crna brings me the difficult airway cart. ENT surgeon that I know very well shows up. I ask him to get ready for an invasive airway. This pt might i add was probably 300 lb. He also bit his tongue and there was nothing but blood in his throat.

I take the FOB, take a look down through the nasal passage and see nothing but blood and secretions. Suction, take a look again and see nothing but blood and secretions. His airway was so swollen I had a difficult time even passing the scope past his nasal passages. ENT keeps his distance but asks if he can do anything to help. I told him get the scalpel ready. Pt who was previously agitated and fighting suddenly stops moving. Pulse ox drops to 60's. I tell ENT to cut. Does a cricothyrotomy in 30 sec flat. We get tube in and start bagging. Pulse px returns to 90's. Next day pt gets a trach and 2 day later walks out of the hospital.

Never once did he interfere with my management. And Im talking about an ENT that has 20 years experience on me. He trusted my judgement. If he was trying to be pushy and take a look with the fiberoptic scope, that pt probably would died. He would of been more focused on fiddling with the scope than trying to secure the airway any means necessary. I grew an immense respect for ENT that day.

Respect us and we'll respect you.

 

[deleted547339]

I thought this was going to be a thread about ICU resident and fellows always trying to steal our stat intubations

The ICU intubations are anesthesia's where you're at? I'm an EM resident and the only time anesthesia gets called for an airway in our MICU is if it's expected to get really, really messy....even then, it just doesn't happen ever.

 

[jwk]

The ICU intubations are anesthesia's where you're at? I'm an EM resident and the only time anesthesia gets called for an airway in our MICU is if it's expected to get really, really messy....even then, it just doesn't happen ever.

Maybe it should.

 

[Mad Jack]

The ICU intubations are anesthesia's where you're at? I'm an EM resident and the only time anesthesia gets called for an airway in our MICU is if it's expected to get really, really messy....even then, it just doesn't happen ever.

My old hospital (a very large teaching hospital) had anesthesia do intubations anywhere outside of the ED. Kept the rate of errors/complications down to pretty much zero during intubation.

 

[Vaporized]

The ICU intubations are anesthesia's where you're at? I'm an EM resident and the only time anesthesia gets called for an airway in our MICU is if it's expected to get really, really messy....even then, it just doesn't happen ever.

So who does them, ICU attending, respiratory therapy? I'm currently at the VA doing hearts and have only gone to floor intubations when RT has difficulty.

 

[ZzzPlz]

The ICU intubations are anesthesia's where you're at? I'm an EM resident and the only time anesthesia gets called for an airway in our MICU is if it's expected to get really, really messy....even then, it just doesn't happen ever.

We do all intubations outside the ER. When someone needs a tube, they activate the "stat intubation" pager. Two anesthesia residents carry the pagers 24/7 along with the ICU pharmacist who shows up with drugs and an RT who gets the vent set up.

Even when a seasoned anesthesia resident is rotating in the ICU they still call the pagers so the rest of the team shows up.

It's annoying to show up to an intubation in the middle of the night and see your fellow anesthesia resident (rotating in ICU) securing the tube already. I've dabbled with the idea of just tubing the patient without calling for a stat intubation while I'm rotating on ICU so my colleagues don't have to come but if there was ever an issue and I told the nurses not to call.... That wouldn't look very good.

 

[ZzzPlz]

Lately it seems like about half the time there is another resident waiting in the patient's room requesting we let them intubate.

Puts us in an awkward situation--I like letting others get the experience but I have no idea what kind of airway experience the resident has and the situation is never optimal for learning.

When staff is with me I let them decide if they will let the resident intubate--it's their license on the line

If I'm alone I ask if the ICU staff is around and willing to take responsibility, which is almost never. If ICU staff isn't there, I tube the patient.

 

[deleted162650]

In residency we responded to all non ED intubations (and occasionally some in the ED). Senior residents would typically go alone or with a junior while our staff was "available" if necessary. A couple of times the ICU staff asked if we (the anesthesia team) would be willing to supervise their resident secure the airway. My response to them was always "No, either you can supervise your resident or I'm gonna do it." They always let me do it.

 

[Noyac]

I always let them do it and didn't have an issue supervising. That's just me. I guess I always felt like I could remedy any situation ( almost to a fault) and I wanted others to be as proficient as possible. Plus, it never hurts to be seen as the expert which will quickly occur once you bail someone out.

 

[deleted547339]

Wow. That's kind of surprising. The MICU fellow handles all tubes in the MICU +/- the resident rotating in the MICU. If it's an IM resident, they usually are afraid of it. EM residents will tube with the fellow around.

There's also a code/rapid response/floor nurse freaked because the patient looked at her funny team that responds to other issues. That team is staffed by moonlighters. Split between PCC, anesthesia and EM. In the SICU, they'll call this team to intubate because it brings the pharmacist and RT, etc.

I'm planning on doing a critical care fellowship and can't imagine going to a program where I was calling anesthesia every time I wanted to intubate a patient. I have tremendous respect for anesthesia's mastery of the airway, but I feel like the training would be suspect if I wasn't the one managing it.

 

[Noyac]

Many of you are in big academic centers with unlimited resources. But that's not how most practices are. Most are running a significantly different plan with limited resources after hours. I just supervised a flight nurse while she intubated my first case today. We do this a few times a month. We go home when the work is done and call is from home. Same with ICU attendings. The only people with any airway skills at off hours is usually the ER doc ( not very good skills there but they get the job done usually) and flight team or RT. RT's don't intubate in my facility but they can help with the airway fine. So it is nice to assist these folks with some training from time to time. We have tried to get the ER docs to come to the OR for some intubations but they all seem to think they are above this. Their loss and their pts as well.
So what I am getting at is that "we" are the most experienced airway managers in any setting without a doubt. So no need to gobble up all the intubations. Assist others and be ready to intervene when you see trouble coming. But train others so that you won't be handed a **** show when they get in over their heads.

 

[deleted171991]

I'm planning on doing a critical care fellowship and can't imagine going to a program where I was calling anesthesia every time I wanted to intubate a patient. I have tremendous respect for anesthesia's mastery of the airway, but I feel like the training would be suspect if I wasn't the one managing it.

I don't feel like that at all. I am not interested in intubating many more patients, or putting in more A-lines or central lines (beyond removing the rust that has set in), I am interested in learning critical care thinking. (I actually refused to sign with a CCM program where the on-call ICU team runs every code in the hospital, and intubates every single patient needing it in the ICU.) I think it makes for both a bad residency (numerous off-floor intubations are a must for anesthesia residents) and possibly fellowship experience (why waste my time doing stuff that I have already mastered?).

 

[deleted547339]

Many of you are in big academic centers with unlimited resources. But that's not how most practices are. Most are running a significantly different plan with limited resources after hours. I just supervised a flight nurse while she intubated my first case today. We do this a few times a month. We go home when the work is done and call is from home. Same with ICU attendings. The only people with any airway skills at off hours is usually the ER doc ( not very good skills there but they get the job done usually) and flight team or RT. RT's don't intubate in my facility but they can help with the airway fine. So it is nice to assist these folks with some training from time to time. We have tried to get the ER docs to come to the OR for some intubations but they all seem to think they are above this. Their loss and their pts as well.
So what I am getting at is that "we" are the most experienced airway managers in any setting without a doubt. So no need to gobble up all the intubations. Assist others and be ready to intervene when you see trouble coming. But train others so that you won't be handed a **** show when they get in over their heads.

Hey now. We many not perform as many intubations as y'all, but that doesn't mean we're not competent. At some point, there is certainly a diminishing return (assuming you keep up your proficiency). I think anesthesia has been asked to tube 1-2 patients in the department where I'm training in the past year. Just because y'all do more doesn't mean we're not good (assuming your ED doesn't suck, which obviously some do).

 

[deleted547339]

I don't feel like that at all. I am not interested in intubating many more patients, or putting in more A-lines or central lines (beyond removing the rust that has set in), I am interested in learning critical care thinking. (I actually refused to sign with a CCM program where the on-call ICU team runs every code in the hospital, and intubates every single patient needing it in the ICU.) I think it makes for both a bad residency (numerous off-floor intubations are a must for anesthesia residents) and possibly fellowship experience (why waste my time doing stuff that I have already mastered?).

I'm not worried about the CVLs, A-lines or tubes. I think, like you said, once you're proficient, you need to maintain. What I do think is that it speaks to the quality and attitude of the department.

But I think I also have a different perspective as I'm not exclusively looking at anesthesia CC fellowships. I'm hopefully going to find a good multidisciplinary program.

 

[Noyac]

Hey now. We many not perform as many intubations as y'all, but that doesn't mean we're not competent. At some point, there is certainly a diminishing return (assuming you keep up your proficiency). I think anesthesia has been asked to tube 1-2 patients in the department where I'm training in the past year. Just because y'all do more doesn't mean we're not good (assuming your ED doesn't suck, which obviously some do).

I didn't say ER folks aren't competent. I just said they weren't particularly skilled.
So let me clarify some. ER people can intubate well enough but their preparation is poor and if they run into trouble they are screwed. They don't seem to plan well for the failed attempt. They also don't seem to know how to do awake intubations when things don't look favorable. I understand that the opportunity to perform awake intubations is limited in the ER but it does exist, I just did one. Pt with a pharyngeal abscess and drooling.
So TNR, I'm not trying to start some sort of pissing match. I'm just making some observations. If your experience and training is different then I welcome your employment at my facility. My ER docs can intubate fine and the Glidescope has helped tremendously with the more difficult airways but my previous comments still stand.

 

[deleted547339]

I didn't say ER folks aren't competent. I just said they weren't particularly skilled.
So let me clarify some. ER people can intubate well enough but their preparation is poor and if they run into trouble they are screwed. They don't seem to plan well for the failed attempt. They also don't seem to know how to do awake intubations when things don't look favorable. I understand that the opportunity to perform awake intubations is limited in the ER but it does exist, I just did one. Pt with a pharyngeal abscess and drooling.
So TNR, I'm not trying to start some sort of pissing match. I'm just making some observations. If your experience and training is different then I welcome your employment at my facility. My ER docs can intubate fine and the Glidescope has helped tremendously with the more difficult airways but my previous comments still stand.

Fair enough. I misunderstood your original statement.

The few times anesthesia has been called for an airway, it has been like you described. Head and neck cancer with impending disaster, abscess with trismus, etc

Awake intubation is really just starting to break into main stream of EM education. A lot of the EM and CC podcasts lecture on it. Someone in my department actually did an awake nasal intubation on a guy with trismus this week. That is something I would love to go to the OR to get some experience with.

We get a lot of experience in the OR and the ER. Every time we tube, we have the airway cart (bougie, LMAs of all sizes, oral/nasal airways, cric kit, etc), suction, capnography, the VL at bedside, etc.

I have heard of some residents moonlighting only to find out the ED didn't even stock boogies.....

 

[OB1🤙]

My tangential take: the actual plastic through cords part of intubating is a monkey skill. Anyone can do it after enough practice.

It's the medical management of the intubation that makes us better at it than anyone else IMO.

We can choose the most appropriate meds in the most appropriate doses. We can chase those meds with bumps of pressors/inotropes PROACTIVELY rather than reactively.

Many other services have a one-size-fits-all approach to meds, and it doesn't always serve the patient well.

Being able to give a dash of this, a pinch of that- keeps the patients more stable and prevents the dreaded post-intubation hemodynamic crumps.

I think this stuff matters way more than the actual procedure. That isht is easy.

 

[Noyac]

Fair enough. I misunderstood your original statement.

The few times anesthesia has been called for an airway, it has been like you described. Head and neck cancer with impending disaster, abscess with trismus, etc

Awake intubation is really just starting to break into main stream of EM education. A lot of the EM and CC podcasts lecture on it. Someone in my department actually did an awake nasal intubation on a guy with trismus this week. That is something I would love to go to the OR to get some experience with.

We get a lot of experience in the OR and the ER. Every time we tube, we have the airway cart (bougie, LMAs of all sizes, oral/nasal airways, cric kit, etc), suction, capnography, the VL at bedside, etc.

I have heard of some residents moonlighting only to find out the ED didn't even stock boogies.....

It would be very difficult to "go to the OR" to get the experience you want if you are talking about the occasion visit. The problem is that we do "awake" intubations rarely as well, when you compare to how many intubations we do. But I'm glad to here that it is entering into the training of ER and possibly CC residents. My suggestion would be that every ER resident were required to do an extended stint in the OR, let's say 3 months at least, during their training. This would give them an idea of how to do the things Hawaiian Bruin described and the occasional awake intubation. Other than that I don't know how you get the experience. Personally, I don't see a better solution to awake intubations other than to call an anesthesiologist. In other words, if you are that concerned about the airway then just call. Pride should take a back seat. And if this sounds like I'm tooting my horn, im not. There are many things an ER doc can do that I'm not trained for.

The reason these ER's don't stock boogies or any other advanced airway device is because they don't know how to use them. If they had experience with these devices they would stock them.