Asking anesthesia to let you intubate during codes/emergent airways

[tiedyeddog]

My surgical subspeciality requires a ton of ICU months as an intern. I have already completed 3 months of ICU and have another 3 to do. I probably see 1-2 emergent airways requiring reintubation a week while in the ICU. For whatever reason my attendings hardly ever do the intubations themselves and call anesthesia to do it.

My question is it reasonable to ask anesthesia attendings and residents I don't know if they will give me a try or two before they take over during emergent airways? I am required to get 10 "airways" by my speciality and so far have only gotten percutaneous trach's so I have limited experience actually trying intubations myself. I do an anesthesia rotation but I am guessing there is a big difference between intubated in the controlled OR compared to in the ICU when all hell is breaking loose. Any thoughts?

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[Raryn]

My surgical subspeciality requires a ton of ICU months as an intern. I have already completed 3 months of ICU and have another 3 to do. I probably see 1-2 emergent airways requiring reintubation a week while in the ICU. For whatever reason my attendings hardly ever do the intubations themselves and call anesthesia to do it.

My question is it reasonable to ask anesthesia attendings and residents I don't know if they will give me a try or two before they take over during emergent airways? I am required to get 10 "airways" by my speciality and so far have only gotten percutaneous trach's so I have limited experience actually trying intubations myself. I do an anesthesia rotation but I am guessing there is a big difference between intubated in the controlled OR compared to in the ICU when all hell is breaking loose. Any thoughts?

Completely institution dependent. At the main hospital I work at, the MICU service responds to all codes that aren't on a primary general surgery service and is responsible for all intubations that result from those codes. We only call anesthesia if we feel the airway will be particularly difficult. Seniormost member of the team gets right of first refusal, which is usually either the fellow (during the daytime) or the PGY2-3. If it's a thin person that doesn't seem to have a particularly difficult airway, we'll frequently let our interns try.

Other hospitals I'm familiar with, anesthesia responds to all codes and gets priority for all airways. The CA1 anesthesia resident can hip check the PGY6 pulmonary fellow and do the airway. It's probably better for patient care most of the time, but worse for training. If you're at one of those institutions, you can try asking nicely, just don't be surprised if they say no.

 

[Druggernaut]

I think it depends on your definition of "emergent." The little old lady with no teeth who is failing extubation, is NPO, and who you can easily ventilate? Sure, I'd ask, the worst they could do is say "no." Morbidly obese bearded man who has been vomiting, aspirated, and is now desaturating and peri-arrest? I'd stay out of the way unless you're confident in your skills and have done way more than your required 10.

There is a difference between intubating in the perfect OR environment and the floor, ICU, or ED, but that's fine. If you're only required to get 10 intubations and will have to work to get them, it doesn't sound like a critically important skill for your specialty and not something you have to worry about being an expert in.

 

[typhoonegator]

Intubating in the OR with soft music in the background is very different from the ICU, but within the ICU there is a vast spectrum of intubation climates. Many are very routine, and in those cases as an ICU attending I strongly endorse having my fellows get a crack, and residents later in the year. But we have an airway service staffed by the SICU and anesthesia who handle most unplanned airway issues in the hospital, such as codes, emergent airways, etc. Because I work in a teaching hospital, I rarely intubate myself anymore, because there are always people around who (a) need to get trained to do it well, and (b) can do it better than I can, particularly when things get hairy (and you can't always predict when that is going to happen). But if anesthesia/airway is there, and it's far enough into the year that the anesthesia residents have gotten a look at a lot of airways, then I strongly endorse having the ICU housestaff get a try -- as long as the anesthesia/airway attending has looked at the patient and feels it is appropriate. I would never override them, however, even though it is technically "my" patient.

I always think these airway quotas for rotations are pretty useless. I guess they motivate people to get their hands dirty, but it sometimes sends the message that you are somehow competent to perform the procedure after the quota is met. Even with supervision, 10 carefully selected intubations in no way qualifies anyone I've ever trained to perform the procedure without immediate bedside attending support. Those anesthesia folks do hundreds and hundreds of intubations under duress, and there are still situations that get nasty. It's a tough gig.

 

[235009]

I think you might be misunderstanding your program's requirements. They're probably asking that you get 10 surgical airways not intubations.

 

[tiedyeddog]

I think you might be misunderstanding your program's requirements. They're probably asking that you get 10 surgical airways not intubations.

In the required case numbers for my specialty a variety of things count as airways; perc trachs, crics, intubations, hell even bronching a patient can be logged as an airway. My program director told me specifically why we do anesthesia is for the intubations because he wants us to be able to feel somewhat comfortable with them.

 

[235009]

In the required case numbers for my specialty a variety of things count as airways; perc trachs, crics, intubations, hell even bronching a patient can be logged as an airway. My program director told me specifically why we do anesthesia is for the intubations because he wants us to be able to feel somewhat comfortable with them.

You should probably focus on perc trach and cric. Get the intubation experience in the OR as expected. Gotta learn to walk before you run.

 

[chocomorsel]

In my residency the surgical residents who spent the most time in the ICU where general surgeons. But I didn't think it was more than two months a year. What field area are you in? Great experience anyway.

 

[tiedyeddog]

In my residency the surgical residents who spent the most time in the ICU where general surgeons. But I didn't think it was more than two months a year. What field area are you in? Great experience anyway.

Neurosurgery

 

[chocomorsel]

Neurosurgery

Absolutely. Totally forgot about you guys. Yes, you do spend a lot of time in the ICU.

 

[tiedyeddog]

Absolutely. Totally forgot about you guys. Yes, you do spend a lot of time in the ICU.

We do more than every other field I can think of besides those doing critical care fellowships, it has been a painful but tremendous learning experience.

 

[chocomorsel]

We do more than every other field I can think of besides those doing critical care fellowships, it has been a painful but tremendous learning experience.

You guys absolutely need it though. In residency the neurosurgeons ran their ICUs with a little help front the neurologists. Mostly by themselves. Which I felt was great.

 

[evilbooyaa]

I don't think Neurosurgery is supposed to be good at emergent intubations... if they're calling you, they probably need a surgical airway. I'd focus on crics outside of the OR.

 

[Impromptu]

Where should you learn how to intubate? In a chaotic situation where one false move can result in the death of the patient, or in the operating room where everything is calm and serene, the patient is preoxygenated nicely, and you have an anesthesiology resident and attending right beside you to guide you. Newbies are prone to missing intubations in the calm operating room, so why try and learn in a difficult situation.

The obvious answer is to learn how to intubate in the operating room on your anesthesiology rotation. Get the basic skill set down and you will be 100X better in an emergency.

 

[chocomorsel]

I don't think Neurosurgery is supposed to be good at emergent intubations... if they're calling you, they probably need a surgical airway. I'd focus on crics outside of the OR.

If he/she is running an ICU by himself or herself and a patient is crumping and anesthesia is immediately unavailable, then intubation is a good skill to have. Like I said, the neurosurgeons ran their own ICU in my residency. Back in the day, surgeons knew how to intubate.

 

[tiedyeddog]

If he/she is running an ICU by himself or herself and a patient is crumping and anesthesia is immediately unavailable, then intubation is a good skill to have. Like I said, the neurosurgeons ran their own ICU in my residency. Back in the day, surgeons knew how to intubate.

Unfortunately at my institution the ICU is run by neuro intensivists but at plenty of places the neuro ICU us staffed totally by neurosurgery and all intubations are done by neurosurgery in the unit. One of the places I did a sub internship at didn't allow any neurologists in the unit.

 

[typhoonegator]

You say that like not allowing specialists into the neurosurgical unit is somehow a badge of honor. This is hubris. Many specialists train a long time to be good at what they do, and going through a neurosurgery residency does not simultaneously make you an expert neurologist, critical care physician, and surgeon. I did more years of training than any neurosurgery resident, and I consider myself halfway good at only 2 of those. I work with neurosurgeons and their residents literally every day. That's my job. There is absolutely no way they could manage a 20+ bed neuroICU at a quaternary care medical center employing evidence-based practice without a critical care team. And why should they? They have strong opinions on the critical care aspects of the neurosurgical issues for each patient, as they should, but they don't know jack about the relative benefits of volume-targeted pressure control ventilation. Are you going to consult pulmonary to take care of the vent, but take pride in not having a neurocritical care team? Because that's just silly. When was the last case of limbic NMDA receptor encephalitis you treated?

There are very few patients that you can't bag until help arrives, or at least jam an LMA into. In a perfect world you'd always feel ready for every emergency, but most places that have a neurosurgeon hanging around in the ICU have someone who is way better than them at intubating readily available.

Sorry for the rant. TL;DR intensivists do more in a real neuroICU than just get in the way of the healing hands of an "expert" neurosurgeon.

 

[tiedyeddog]

You say that like not allowing specialists into the neurosurgical unit is somehow a badge of honor. This is hubris. Many specialists train a long time to be good at what they do, and going through a neurosurgery residency does not simultaneously make you an expert neurologist, critical care physician, and surgeon. I did more years of training than any neurosurgery resident, and I consider myself halfway good at only 2 of those. I work with neurosurgeons and their residents literally every day. That's my job. There is absolutely no way they could manage a 20+ bed neuroICU at a quaternary care medical center employing evidence-based practice without a critical care team. And why should they? They have strong opinions on the critical care aspects of the neurosurgical issues for each patient, as they should, but they don't know jack about the relative benefits of volume-targeted pressure control ventilation. Are you going to consult pulmonary to take care of the vent, but take pride in not having a neurocritical care team? Because that's just silly. When was the last case of limbic NMDA receptor encephalitis you treated?

There are very few patients that you can't bag until help arrives, or at least jam an LMA into. In a perfect world you'd always feel ready for every emergency, but most places that have a neurosurgeon hanging around in the ICU

Sorry for the rant. TL;DR intensivists do more in a real neuroICU than just get in the way of the healing hands of an "expert" neurosurgeon.

Whoa, hit a nerve here...

The specific place I mentioned in my prior comment did not admit nonsurgical patients to their ICU so they never treated NMDA encephalitis, instead those patients were admitted to the micu and neurology was consulted. I personally have taken care of patients with NMDA encephalitis recently but have absolutely no desire to make a career out of doing so as there is no surgical management of these patients. Lump in CIDP exacerbations, MS flares, patients in status as their primary issue as well.

 

[BigRedBeta]

Yes, the OR is not real life. Don't tell the anesthesiologists that.

However, crawl before you walk. That anesthesia rotation will get you the numbers you need and provide a better fund of knowledge to get to the emergent cases. Maybe it's because I work with in the Pediatric ICU, but I can't imagine that the culture of a place where anesthesia intubates even in the ICU is going to let the off service intern take first shot. That's about the last scenario I'd want an inexperienced person learning. But...I often find that lots of things are "normal resident experiences" in the adult world which would never happen in pediatrics.

 

[link2swim06]

Yes, the OR is not real life. Don't tell the anesthesiologists that.

However, crawl before you walk. That anesthesia rotation will get you the numbers you need and provide a better fund of knowledge to get to the emergent cases. Maybe it's because I work with in the Pediatric ICU, but I can't imagine that the culture of a place where anesthesia intubates even in the ICU is going to let the off service intern take first shot. That's about the last scenario I'd want an inexperienced person learning. But...I often find that lots of things are "normal resident experiences" in the adult world which would never happen in pediatrics.

I have had strange experiences with procedures in general in the pediatric world (coming primarily from the adult world, emergency medicine). Much less autonomy is given at equal levels of training.

I found it kinda bizarre and comical that during my PICU rotation the first-year fellow was 'teaching me' to put in a CVC when I had probably done >20 more than he had done.

 

[BigRedBeta]

I have had strange experiences with procedures in general in the pediatric world (coming primarily from the adult world, emergency medicine). Much less autonomy is given at equal levels of training.

I found it kinda bizarre and comical that during my PICU rotation the first-year fellow was 'teaching me' to put in a CVC when I had probably done >20 more than he had done.

That's an extraordinarily common experience. However, that supervision is something your predecessors have earned for you whether through asking for it, ignorance of pediatric issues, general discomfort with sick kids, or through missteps that have lead to bad outcomes.

As for the PICU fellows...not everyone realizes just how independent residents are in the adult world. If they were residents somewhere without much interaction with the ER residents, they may be completely clueless. There are ways to be gentle but make your point that you do have experience in the process, just not the patient population.