Bacchus

Staff member
Administrator
10+ Year Member
Apr 28, 2007
20,979
2,283
Status
Attending Physician
I had an OB resident nearly make me cry :'(. Whatevs.
 

Kaustikos

Archerize It
10+ Year Member
Jan 18, 2008
12,205
4,164
Always Bespin
Ugh... I've had a couple.

The recent one, though, are anesthesia attendings that are so... anti-letting med students do intubations.
First attending didn't even think to let me when the CRNA handed me the Mac. He took it from my hand and gave it back to her...
Today, tho, I was kinda annoyed because a different attending let me do it on one patient and I nailed it. Second patient - I get the blade in and see the epiglottis/cords. I insert the tube and KNOW I'm in. Unfortunately, when they pulled the guide wire, the tube came up a bit and the bag wouldn't inflate. I wanted to try again but he went ahead and did it. Sure enough - the nurse had forgot to inflate the cuff when I had the tube in...

But forreal - If I say I know/can do one, I'm not lying. And if my attempt isn't 100% perfect it's because you guys don't let us really try. Practice dummy's don't help...
 

neutropeniaboy

Blasted ENT Attending
15+ Year Member
Feb 10, 2002
948
198
USA
Status
Attending Physician
But forreal - If I say I know/can do one, I'm not lying. And if my attempt isn't 100% perfect it's because you guys don't let us really try. Practice dummy's don't help...

Classic Millennial!

You have no idea what problems you can encounter when dealing with an airway, even in controlled circumstances.

I suggest you take opportunities that are granted to you because you've earned them rather than to expect them because you feel entitled to them.
 

Top Gun

10+ Year Member
Feb 13, 2007
1,442
211
42
Status
Attending Physician
Ugh... I've had a couple.

The recent one, though, are anesthesia attendings that are so... anti-letting med students do intubations.
First attending didn't even think to let me when the CRNA handed me the Mac. He took it from my hand and gave it back to her...
Today, tho, I was kinda annoyed because a different attending let me do it on one patient and I nailed it. Second patient - I get the blade in and see the epiglottis/cords. I insert the tube and KNOW I'm in. Unfortunately, when they pulled the guide wire, the tube came up a bit and the bag wouldn't inflate. I wanted to try again but he went ahead and did it. Sure enough - the nurse had forgot to inflate the cuff when I had the tube in...

But forreal - If I say I know/can do one, I'm not lying. And if my attempt isn't 100% perfect it's because you guys don't let us really try. Practice dummy's don't help...
You were allowed to attempt. And on your second attempt, the attending did it when your tube came out because he didn't want to waste time. When a patient is being induced, it is critical to get the intubation right away because the patient has already received muscle relaxants and cannot breathe on his/her own without a ventilator. There is no time to screw around getting the tube in. And for that matter, how can you say you KNEW you were in? Did you auscultate the lungs and the trachea to make sure you were in? Did you check the end-tidal CO2 detector? This doesn't even come close to qualifying as a horrible attending/resident story.
 

SouthernSurgeon

Lifetime Donor
10+ Year Member
Dec 17, 2008
4,363
8,300
Status
Resident [Any Field]
Ugh... I've had a couple.

The recent one, though, are anesthesia attendings that are so... anti-letting med students do intubations.
First attending didn't even think to let me when the CRNA handed me the Mac. He took it from my hand and gave it back to her...
Today, tho, I was kinda annoyed because a different attending let me do it on one patient and I nailed it. Second patient - I get the blade in and see the epiglottis/cords. I insert the tube and KNOW I'm in. Unfortunately, when they pulled the guide wire, the tube came up a bit and the bag wouldn't inflate. I wanted to try again but he went ahead and did it. Sure enough - the nurse had forgot to inflate the cuff when I had the tube in...

But forreal - If I say I know/can do one, I'm not lying. And if my attempt isn't 100% perfect it's because you guys don't let us really try. Practice dummy's don't help...
Don't f**k with the airway.

As a surgery resident, I've done just enough intubations to be truly humbled/terrified by them. If I'm in the OR, and there is any difficulty with the intubation, they get my 100% undivided attention, and one of the first things I do is look over to the Mayo to make sure the scrub nurse has a scalpel up already.

I think it's completely appropriate for an attending to give med students one pass at the airway. After that it's not fair to the patient.
 

Kaustikos

Archerize It
10+ Year Member
Jan 18, 2008
12,205
4,164
Always Bespin
BUT MOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOM


Or - I know I know. I'm being overzealous. And it's not about entitlement, it's about wanting to practice/perfect it. But like he said - you don't get good doing this stuff in med school. You get good after doing it 100x's.
 

inmyslumber

ASA Member
10+ Year Member
Jan 8, 2007
173
46
Status
Attending Physician
Ugh... I've had a couple.

Sure enough - the nurse had forgot to inflate the cuff when I had the tube in...

...
Way to blame someone else, i.e. "the nurse." If it is your airway, you need to take responsibility for the complete intubation procedure including being sure the cuff is inflated, ETCO2 is present, and the lungs auscultated.

In the end, the Attending Anesthesiologist should do what he/she feels is best for the patient.
 
  • Like
Reactions: MerickManual

neutropeniaboy

Blasted ENT Attending
15+ Year Member
Feb 10, 2002
948
198
USA
Status
Attending Physician
Don't f**k with the airway.

As a surgery resident, I've done just enough intubations to be truly humbled/terrified by them.
And I've taken over for anesthesiologists in order to intubate or provide a surgical airway enough to raise the hairs on my neck every time an intubation takes more than a few seconds.

In my room, everyone but the anesthesiologist shuts up during intubation and both my resident and I have gloves on ready to go.

Yes, don't f--- with the airway.
 

gators21

5+ Year Member
Mar 16, 2011
224
123
Status
Resident [Any Field]
Ugh... I've had a couple.

The recent one, though, are anesthesia attendings that are so... anti-letting med students do intubations.
First attending didn't even think to let me when the CRNA handed me the Mac. He took it from my hand and gave it back to her...
Today, tho, I was kinda annoyed because a different attending let me do it on one patient and I nailed it. Second patient - I get the blade in and see the epiglottis/cords. I insert the tube and KNOW I'm in. Unfortunately, when they pulled the guide wire, the tube came up a bit and the bag wouldn't inflate. I wanted to try again but he went ahead and did it. Sure enough - the nurse had forgot to inflate the cuff when I had the tube in...

But forreal - If I say I know/can do one, I'm not lying. And if my attempt isn't 100% perfect it's because you guys don't let us really try. Practice dummy's don't help...
Yea.... that is your responsibility to inflate the cuff. Intubations aren't just putting the ET tube passed the cords and then being all "Im done. If I say I did it then I did it, gosh". If you are at the head of the table, then you are the one in control.
Sounds to me like a story of terrible med student
 
  • Like
Reactions: ommnomm

Perrotfish

Has an MD in Horribleness
10+ Year Member
May 26, 2007
8,062
3,975
Status
Attending Physician
You were allowed to attempt. And on your second attempt, the attending did it when your tube came out because he didn't want to waste time. When a patient is being induced, it is critical to get the intubation right away because the patient has already received muscle relaxants and cannot breathe on his/her own without a ventilator. There is no time to screw around getting the tube in. And for that matter, how can you say you KNEW you were in? Did you auscultate the lungs and the trachea to make sure you were in? Did you check the end-tidal CO2 detector? This doesn't even come close to qualifying as a horrible attending/resident story.

Neutropeniaboy said:
Classic Millennial!

You have no idea what problems you can encounter when dealing with an airway, even in controlled circumstances.

I suggest you take opportunities that are granted to you because you've earned them rather than to expect them because you feel entitled to them.
gators21 said:
Yea.... that is your responsibility to inflate the cuff. Intubations aren't just putting the ET tube passed the cords and then being all "Im done. If I say I did it then I did it, gosh". If you are at the head of the table, then you are the one in control.
Sounds to me like a story of terrible med student
I don't think I'm unique in seeing the dichotomy between how medical students and residents are taught airways. As a medical student my experience was similar to the OP: one shot, lots of pressure, very little instruction, often going months in between attempts. When I got my first (presurgical, not RSI) airway as a resident I was expecting a similar experience. One minute in I said "I'm sorry I can't visualize the cords" and mournfully expected the attending to swoop in and grab the mac. Then the attending helped correct my technique. Then he helped me reposition. Then I STILL missed, we took the blade out, bagged the patient back up, and tried again and I got it. Rinse and repeat with several different attendings and I started to get a little more comfortable (and need less correction/many fewer attempts). Its a skill. It takes time, instruction, and lots of reps.

Tubing a sedated patient with health lungs is not an emergency and should not be treated like one. There is no indication whatsoever for the anesthesiologist to snatch the mac from your hands after one attempt. It takes healthy adults a long time to desat, they're hooked up to monitors so you should know exactly when it happens, and even if they do start to desat you should be able to bag mask the patient indefinitely if you needed to. Also the attitude that medical student intubations is a privilege is a disservice not just to our students but to our patients. This isn't a procedure like a lap chole or a delivery, which only a minority of physicians will need to ever do, this is part of ACLS. And right now, by making medical student airways a last priority, we produce interns who might be responsible for doing their first successful intubation during an RSI on a crashing asthmatic. That IS an emergency, and if you miss you might spend 20 minutes bagging the patient back up if you get them back at all.
 

neutropeniaboy

Blasted ENT Attending
15+ Year Member
Feb 10, 2002
948
198
USA
Status
Attending Physician
Tubing a sedated patient with health lungs is not an emergency and should not be treated like one.
During my third year out of residency I was about to do a tympanomastoidectomy on a healthy 38 year old woman. A second year anesthesiology resident dislocated one of the arytenoids, lacerated the posterior commissure and caused an obstruction with a lot of bleeding. Neither the attending nor I could intubate the patient after that and I performed a cric on the patient.

That's extreme.

I've seen plenty of blood tinged sputum in the ET tubes of healthy adults put through the ringer. I've seen chipped teeth. I've seen lip lacerations. I saw an attending put an ET tube through the soft palate. I've seen people develop asystole.

I've seen enough to make me believe that every airway procedure is one waiting to be a disaster and that while I am amenable to having students and residents learn, I have very little tolerance for mistakes in this area.

And while, yes, medical students need to learn, they have a lot of years to do so. As long as my name is listed as the attending surgeon, I'll make sure my patients are manipulated as little as possible and by as few as possible.

This is more of an issue of dealing with students like the OP who feel like they actually know what they are doing and feel this unearned sense of entitlement.
 
Last edited:
  • Like
Reactions: Carl Seitan

KnuxNole

Sweets Addict
10+ Year Member
May 3, 2006
4,623
1,456
Status
Attending Physician
BUT MOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOM


Or - I know I know. I'm being overzealous. And it's not about entitlement, it's about wanting to practice/perfect it. But like he said - you don't get good doing this stuff in med school. You get good after doing it 100x's.
Be thankful for the opportunity, after all, the attendings easily could have never let you near intubating patients! Getting a chance to do a few as a med student is awesome in general! After all you are the guest, as a young buck.
 
  • Like
Reactions: Kaustikos

Kaustikos

Archerize It
10+ Year Member
Jan 18, 2008
12,205
4,164
Always Bespin
I guess I should clarify - I wasn't holding the syringe in my hand, the nurse was. This wasn't a "Yeah, I got it in that's it". They were guiding/assisting me, like they should have and I'm thankful for. I wasn't mad at the nurse either. You guys are misinterpreting what I said as "OMG THIS GUY IS HORRIBLE" when it's more like "Meh, I don't really have much to share so I'll just say this is what I have". If that's the worst story I have, then that's a good thing. And since no one else is sharing... I had to say something.

Again - It wasn't me placing blame on the nurse. It was just what happened. I was just eager to do it and disappointed that it didn't work and I wasn't allowed to try again. Not because I feel entitled, but because if I fail - I at least like to rectify my mistake if I can. Yeah, I know med students don't get that opportunity, which I understand. But it doesn't mean I shouldn't want to try again/feel disappointed I wasn't allowed to try again. Some people fail and give up without trying again. I'm not like that.
 

SouthernSurgeon

Lifetime Donor
10+ Year Member
Dec 17, 2008
4,363
8,300
Status
Resident [Any Field]
Tubing a sedated patient with health lungs is not an emergency and should not be treated like one.
You're right. It's not an emergency.

Neither is an elective central line placement. Neither is inserting a Veress needle for a laparoscopic case. Neither is a paracentesis on the floor.

And yet, I've seen each of the above (intubation attempt included) kill or seriously maim a patient.

"Nonemergent" isn't an excuse to let your vigilism down and take an invasive procedure for granted. Neutropeniaboy has some very sobering examples of routine intubation attempts gone wrong. So does every anesthesiologist, and a lot of surgeons.

The training of a resident who intubates patients routinely (ED, anesthesia, surgery) is, appropriately, a very different endeavor than the training of a med student.
 

Kaustikos

Archerize It
10+ Year Member
Jan 18, 2008
12,205
4,164
Always Bespin
Be thankful for the opportunity, after all, the attendings easily could have never let you near intubating patients! Getting a chance to do a few as a med student is awesome in general! After all you are the guest, as a young buck.
Yup, exactly. I never forget that. I don't feel entitled to this ****, I just want to do it.
 

SouthernSurgeon

Lifetime Donor
10+ Year Member
Dec 17, 2008
4,363
8,300
Status
Resident [Any Field]
I guess I should clarify - I wasn't holding the syringe in my hand, the nurse was. This wasn't a "Yeah, I got it in that's it". They were guiding/assisting me, like they should have and I'm thankful for. I wasn't mad at the nurse either. You guys are misinterpreting what I said as "OMG THIS GUY IS HORRIBLE" when it's more like "Meh, I don't really have much to share so I'll just say this is what I have". If that's the worst story I have, then that's a good thing. And since no one else is sharing... I had to say something.

Again - It wasn't me placing blame on the nurse. It was just what happened. I was just eager to do it and disappointed that it didn't work and I wasn't allowed to try again. Not because I feel entitled, but because if I fail - I at least like to rectify my mistake if I can. Yeah, I know med students don't get that opportunity, which I understand. But it doesn't mean I shouldn't want to try again/feel disappointed I wasn't allowed to try again. Some people fail and give up without trying again. I'm not like that.
I don't think people are trying to be too harsh on you. The nursing thing is an important point - as inmyslumber pointed out, when you are performing a procedure, you need to take control and responsibility over every aspect of it. You should build into your routine for the procedure both to (a) specifically ask someone to inflate the cuff for you or do it your self and (b) verify manually that the cuff is inflated
 

neutropeniaboy

Blasted ENT Attending
15+ Year Member
Feb 10, 2002
948
198
USA
Status
Attending Physician
The training of a resident who intubates patients routinely (ED, anesthesia, surgery) is, appropriately, a very different endeavor than the training of a med student.
This is exactly my sentiment as well.
 

Kaustikos

Archerize It
10+ Year Member
Jan 18, 2008
12,205
4,164
Always Bespin
During my third year out of residency I was about to do a tympanomastoidectomy on a healthy 38 year old woman. A second year anesthesiology resident dislocated one of the arytenoids, lacerated the posterior commissure and caused an obstruction with a lot of bleeding. Neither the attending nor I could incubate the patient after that and I performed a cric on the patient.

That's extreme.

I've seen plenty of blood tinged sputum in the ET tubes of healthy adults put through the ringer. I've seen chipped teeth. I've seen lip lacerations. I saw an attending put an ET tube through the soft palate. I've seen people develop asystole.

I've seen enough to make me believe that every airway procedure is one waiting to be a disaster and that while I am amenable to having students and residents learn, I have very little tolerance for mistakes in this area.

And while, yes, medical students need to learn, they have a lot of years to do so. As long as my name is listed as the attending surgeon, I'll make sure my patients are manipulated as little as possible and by as few as possible.

This is more of an issue of dealing with students like the OP who feel like they actually know what they are doing and feel this unearned sense of entitlement.
Okay, no it's not a sense of entitlement. Read what I said above - I wanted to rectify my mistake. This has nothing to do with entitlement and everything to do with just learning to do something right. If I had tried again and failed - I would've gladly let them take over. I've failed putting an IV line and I stop at 2 tries. I never try more than that. I know when I should stop and let someone experienced try.

But honestly - your attitude about these situations isn't even remotely warranted. Don't work at a teaching hospital if you somehow have this idea about students feeling entitled because they want to try again. Or if they want to try/ask you to try. In the end - I felt confident that my skills prior to this rotation were sufficient that I could do this. And guess what? I've done it multiple times now and succeeded. Was it A+ placement/technique? **** no.
The one thing I've learned is that if someone asks you if you can do something in the OR, you don't answer no. You answer either "yes you can" or "I really want to try/like the opportunity". I know my limits but I'll be damned if I sit back and watch when I have the opportunity to do these things. The one thing I don't like is failure and that gets me flustered. I want to succeed because I want to be good at this when I'm taking care of patients. I got upset with that scenario because I didn't get it right and I found out I could've rectified/fixed it. But everyone is right and I agree 100% - I was given the opportunity which I'm glad I was. But just stop with the condescending remarks and assumptions. Because you're not even remotely right.


And also - way to blow this out of proportion. OMG YOU CAN PLACE AN ET TUBE AND HIS HEAD WILL EXPLODE! Right, so you're telling me you'd kill a student if he had the opportunity to place an ET on that situation and succeeded with all the issues you talked about? Because truth be told - if I was in that scenario and someone asked me to - I would try. This isn't entitlement. It's confidence and courage. I'm just a medical student, but I'll be damned if I bow down/step out from an opportunity. You hand me that tube/needle driver/camera/garbage bag - I won't be the person cowering in fear from it. If I screw up - I want the chance to fix it, that's all. Will I always - **** no. But I'll take that chance.
 

Mad Jack

Critically Caring
5+ Year Member
Jul 27, 2013
35,437
64,824
4th Dimension
Ugh... I've had a couple.

The recent one, though, are anesthesia attendings that are so... anti-letting med students do intubations.
First attending didn't even think to let me when the CRNA handed me the Mac. He took it from my hand and gave it back to her...
Today, tho, I was kinda annoyed because a different attending let me do it on one patient and I nailed it. Second patient - I get the blade in and see the epiglottis/cords. I insert the tube and KNOW I'm in. Unfortunately, when they pulled the guide wire, the tube came up a bit and the bag wouldn't inflate. I wanted to try again but he went ahead and did it. Sure enough - the nurse had forgot to inflate the cuff when I had the tube in...

But forreal - If I say I know/can do one, I'm not lying. And if my attempt isn't 100% perfect it's because you guys don't let us really try. Practice dummy's don't help...
Only giving noobs 1 shot is SOP. Experienced residents that generally don't mess up but aren't the sharpest get two shots.

Just some tips for practicing so if you get another shot it goes really well. You should always be aware of where everything is when intubating. Have a system and a routine, make sure everything is laid out to your liking before you start (piss poor preparation leads to piss poor performance)- suction on one side, bag on the other, 10cc syringe attached to your ETT, capnometer on one side or the other where you can reach it, and tape or an ETT holder at the ready. Lay it out the same every time. After the intubation, you should have a set routine- have someone pull out your stylet while you hold the ETT in two fingers with the rest of your hand locked onto their face similar to how you hold when you bag, and use the other hand to bag while someone listens for breath sounds. While you're doing this, you WATCH them inflate the cuff, and you better look at that cuff and make SURE it's inflated. Give it a squeeze if you aren't certain.

Getting the tube in is only half the process. If you don't properly confirm placement, keep it in place, and secure it, you ****ed the whole thing up. Half an intubation is just as bad or worse than no intubation at all. Most people practice getting the tube in 100 times more than what comes after they get it in, when both parts of the process are equally important.
 

Kaustikos

Archerize It
10+ Year Member
Jan 18, 2008
12,205
4,164
Always Bespin
I don't think people are trying to be too harsh on you. The nursing thing is an important point - as inmyslumber pointed out, when you are performing a procedure, you need to take control and responsibility over every aspect of it. You should build into your routine for the procedure both to (a) specifically ask someone to inflate the cuff for you or do it your self and (b) verify manually that the cuff is inflated
I agree. I just want people to understand I'm not someone feeling entitled. Nor do I place blame on others for my mistakes. The point is just how I need to learn to be okay with making mistakes :lol:
 

Kaustikos

Archerize It
10+ Year Member
Jan 18, 2008
12,205
4,164
Always Bespin
Only giving noobs 1 shot is SOP. Experienced residents that generally don't mess up but aren't the sharpest get two shots.

Just some tips for practicing so if you get another shot it goes really well. You should always be aware of where everything is when intubating. Have a system and a routine, make sure everything is laid out to your liking before you start (piss poor preparation leads to piss poor performance)- suction on one side, bag on the other, 10cc syringe attached to your ETT, capnometer on one side or the other where you can reach it, and tape or an ETT holder at the ready. Lay it out the same every time. After the intubation, you should have a set routine- have someone pull out your stylet while you hold the ETT in two fingers with the rest of your hand locked onto their face similar to how you hold when you bag, and use the other hand to bag while someone listens for breath sounds. While you're doing this, you WATCH them inflate the cuff, and you better look at that cuff and make SURE it's inflated. Give it a squeeze if you aren't certain.

Getting the tube in is only half the process. If you don't properly confirm placement, keep it in place, and secure it, you ****ed the whole thing up. Half an intubation is just as bad or worse than no intubation at all. Most people practice getting the tube in 100 times more than what comes after they get it in, when both parts of the process are equally important.
oh I know. Believe me - they asked me to do it and I got tunnel vision. Which is why the anesthesiologists said "I couldn't tell if you were placing an ETT or trying to make out with the guy at first" :lol:
 

Perrotfish

Has an MD in Horribleness
10+ Year Member
May 26, 2007
8,062
3,975
Status
Attending Physician
And while, yes, medical students need to learn, they have a lot of years to do so. .
I don't disagree with most of what you wrote, but I disagree with this strongly. In my opinion medical student don't have a lot of years to learn intubations, they have just the short span of time before they start residency. Intubation is a skill that residents need to come in competent and comfortable with., and the fact that basically none of them do is a major failure on the part of our medical education system. Even the most junior resident is responsible for resuscitations, and resuscitations mean being prepared to manage your patient's airway. Like most non-anesthesia residents I have never done a cric, and I came into residency with three attempt intubations (one successful), and I had precious little experience even bag-vale masking. Do you think that's enough to manage an airway in an emergency? To match your horror story (which ended with nothing worse then a cric and a stable, protected airway) I have stories of patients in respiratory failure who were hypoxic for minutes while awaiting definitive airway management from a night time code/rrt team that needs to sprint across a hospital because the resident couldn't intubate or even effectively bag mask.

Its easy to be protective of the patient in front of you, but like everything else in our medical training the minimal risk of harm in that patient can be outweighed by the much more real risk of producing a resident/attending who doesn't know what to do when he's on his own. Medical students need to learn airway management in the OR so that they can manage airways correctly outside of the OR when they are alone during Intern year, on night float, with a sleeping senior on the other side of the hospital and a home call attending on the other side of the city.

while I am amenable to having students and residents learn, I have very little tolerance for mistakes in this area.
Also, you can't be amenable to learning and not be tolerant of mistakes. If you're not making mistakes you're done learning. You can be intolerant of inadequate preparation or inattentiveness, but mistakes are a non-negotiable part of education. If you're intolerant of them all you're doing is kicking the can down the road and letting the student/resident make his mistakes when there is no one around to correct him.
 

KnuxNole

Sweets Addict
10+ Year Member
May 3, 2006
4,623
1,456
Status
Attending Physician
If I was responsible for intubating in the first month of residency, I'd wet my pants D:
 

Siggy

10+ Year Member
Oct 27, 2004
3,590
1,452
34
Status
Fellow [Any Field]
[snip Airway is important, but we don't teach medical students how to manage the airway]
The problem, however, is how to we rectify the situation. I was luck enough to snag an anesthesiology rotation at the end of 3rd year and got a couple successful intubations, a lot of attempts (enough that the entire process seemed to slow down... for example, my first RSI felt like it immediately desated), and a lot of practice with the BVM and placing LMAs.

However, there were a lot of days where I didn't get a single shot at intubating either because they were all LMAs or we had paramedic students rotating from room to room getting their tubes (and I'd argue that a paramedic student takes priority over the medical student). Short of requiring every 3rd or 4th year to do an anesthesiology rotation, how do we rectify the situation?
 

Perrotfish

Has an MD in Horribleness
10+ Year Member
May 26, 2007
8,062
3,975
Status
Attending Physician
Short of requiring every 3rd or 4th year to do an anesthesiology rotation, how do we rectify the situation?
I wouldn't do anything short of that. If I was designing a curriculum I would have a mandatory minimum number of intubations for medical students, either incorporated into the surgery month or in a separate anesthesiology rotation (2 weeks would probably be enough to at least attempt a couple of dozen).
 
  • Like
Reactions: Lev0phed
Jan 12, 2014
6
1
Status
Resident [Any Field]
the worst are the attnedings who are super friendly with you and then rip you a knew one on evaluations...ughhh snakes
YES! I had one of those in medical school. Even told me she would write me a letter of recommendation for residency, then told me she couldn't. All this because a resident (who I didn't even work with) told her I was a slacker. I ASSURE you, I was there doing notes before everyone else, and never went home early. Anyway, nothing I could do about it. She said, if you will prove yourself in another month of rotation, I would consider it. Nevermind.
 

neutropeniaboy

Blasted ENT Attending
15+ Year Member
Feb 10, 2002
948
198
USA
Status
Attending Physician
Also, you can't be amenable to learning and not be tolerant of mistakes. If you're not making mistakes you're done learning.
I disagree.

How many mistakes is a tolerable number of mistakes, and at what level of error is it considered tolerable?

If I let the resident drill a mastoid and he drills into the ear canal, is that tolerable? Probably. If I let him drill and he drills into the sigmoid sinus resulting in 500cc of blood loss? Perhaps. If I let him drill the mastoid and he drills through the lateral semicircular canal, which results in permanent disability, is that tolerable? If I let him drill the mastoid and he drills through the facial nerve causing permanent paralysis of the face, is that tolerable?

Hey, one needs to make mistakes in order to learn.

That's why physicians don't get sued - patients will understand it's all for the sake of learning and passing off knowledge to the next generation of physicians.

Some mistakes are fine - I agree - since they don't harm the patient in the end and they do result in learning. Other mistakes result in learning and permanent disability. Other mistakes occur despite exercising best practices and the standard of care.

Learning is good, and mistakes are expected. Expecting something is different from tolerating something. Some mistakes are devastating. The privilege to be put in a position where one could possibly cause a devastating injury or death is earned based on demonstrated skill - not simply because one is paying $50,000/year for the education or on a rotation.
 

mercaptovizadeh

ἀλώπηξ
10+ Year Member
Oct 16, 2004
6,888
992
Status
I did my 2-week anesthesia rotation in pediatric anesthesia. Their tolerance for futzing was VERY low. I did lots of BMV, lots of LMAs, and got maybe 7 or 8 chances to intubate, of which I'd say 4 were successful. At the slightest sign of distress on my part (that was about 15-20 seconds into the intubation when I had failed to visualize the cords), the attending swooped in and took over. As well he or she should!

I am no surgeon (I loved my surgery rotation), but managing the airway is frankly way more terrifying to me than anything I saw in surgery, and I could never do anesthesia. Maybe it's also why I would find gravid intrauterine manipulations of the fetus without ultrasound to be terrifying. Without visualization there is such a lack of control.

In surgery (apart from trauma, I would think), you can have a lot more anticipation, a lot more visualization and control. In anesthesia, I had no idea when or how I would see those cords and visualizing them was way harder than it would seem from watching the anesthesiologist or from practicing on dummies.
 

HooliganSnail

5+ Year Member
Mar 13, 2012
640
642
Status
Resident [Any Field]
I have to disagree with a lot of the attendings commenting on this medical student thread.

I have never had the opportunity to intubate. Not once. I have three months of medical school left. Next year I will be an ER intern ( you know, one of those specialties that deals with airways a lot). O well, I guess I'll learn how to do it then on the fly.

Hopefully, it won't be a disaster with a crashing patient at 2am. The scary part is that is a very possible reality. It could actually occur

Everyone has do something for the first time. You have to let us try.

Yes, lots of bad things can happen with airways, but if the attending is standing right next to you showing you how to do it, then patient safety is being respected.

If you are one of these attendings who doesn't teach their medical students, then you are wrong. You are not doing your job.
 

Wordead

10+ Year Member
Dec 21, 2007
1,851
2,025
Status
Resident [Any Field]
Odd series of stories from attendings here - I was allowed multiple tries to intubate. God knows I needed them early on. I tried maybe 5 times on one of my earlier attempts. Doesn't a patient not even come into danger of desaturating for 3+ minutes? I'm wondering why my attendings are so different.

And never being allowed to intubate is crazy, especially if you're going into ER....that almost borders on dangerous in my mind.
 

Bacchus

Staff member
Administrator
10+ Year Member
Apr 28, 2007
20,979
2,283
Status
Attending Physician
Odd series of stories from attendings here - I was allowed multiple tries to intubate. God knows I needed them early on. I tried maybe 5 times on one of my earlier attempts. Doesn't a patient not even come into danger of desaturating for 3+ minutes? I'm wondering why my attendings are so different.

And never being allowed to intubate is crazy, especially if you're going into ER....that almost borders on dangerous in my mind.
It concerns me a bit. I did anesthesia at a very, very small hospital where I thought I had one of the best experiences of my rotation years. But now, I wonder if my attending was being too generous. I took as long as needed usually with intubations. If the patient dropped to the low 90s, we would bag them and I'd reattempt. The attending never seemed outwardly concerned. Hmm.
 

KnuxNole

Sweets Addict
10+ Year Member
May 3, 2006
4,623
1,456
Status
Attending Physician
Odd series of stories from attendings here - I was allowed multiple tries to intubate. God knows I needed them early on. I tried maybe 5 times on one of my earlier attempts. Doesn't a patient not even come into danger of desaturating for 3+ minutes? I'm wondering why my attendings are so different.

And never being allowed to intubate is crazy, especially if you're going into ER....that almost borders on dangerous in my mind.
I never did a gas rotation, thus I never learned how to intubate before residency. I have had amazing ED attendings during my ED month, and feel slightly more comfortable intubating. Which is kinda cool...increasing your skillset is always a nice feeling :)
 

VisionaryTics

Señor Member
10+ Year Member
Jan 14, 2009
1,925
2,315
Status
Fellow [Any Field]
I have never had the opportunity to intubate. Not once. I have three months of medical school left. Next year I will be an ER intern ( you know, one of those specialties that deals with airways a lot). O well, I guess I'll learn how to do it then on the fly.
This is precisely my thoughts on why noobs should get a shot to intubate stable patients during an anesthesia rotation.

I got about 10-15 intubations during my anesthesia rotation, including a couple where I didn't get it initially and I was allowed to try again with a straight blade. I thought it was a tremendous learning experience, and incredibly helpful and important to me. I'm going into otolaryngology, and as a 2nd year resident (not too far away now), I will be called to intervene on $hitshow deteriorating airways. I'm glad the first few times I intubated somebody (or troubleshoot an intubation) didn't happen when the patient was crumping in front of me.
 

Jorts

7+ Year Member
Jul 10, 2012
27
15
Status
Medical Student


I don't disagree with most of what you wrote, but I disagree with this strongly. In my opinion medical student don't have a lot of years to learn intubations, they have just the short span of time before they start residency. Intubation is a skill that residents need to come in competent and comfortable with., and the fact that basically none of them do is a major failure on the part of our medical education system. Even the most junior resident is responsible for resuscitations, and resuscitations mean being prepared to manage your patient's airway. Like most non-anesthesia residents I have never done a cric, and I came into residency with three attempt intubations (one successful), and I had precious little experience even bag-vale masking. Do you think that's enough to manage an airway in an emergency? To match your horror story (which ended with nothing worse then a cric and a stable, protected airway) I have stories of patients in respiratory failure who were hypoxic for minutes while awaiting definitive airway management from a night time code/rrt team that needs to sprint across a hospital because the resident couldn't intubate or even effectively bag mask.

Its easy to be protective of the patient in front of you, but like everything else in our medical training the minimal risk of harm in that patient can be outweighed by the much more real risk of producing a resident/attending who doesn't know what to do when he's on his own. Medical students need to learn airway management in the OR so that they can manage airways correctly outside of the OR when they are alone during Intern year, on night float, with a sleeping senior on the other side of the hospital and a home call attending on the other side of the city.



Also, you can't be amenable to learning and not be tolerant of mistakes. If you're not making mistakes you're done learning. You can be intolerant of inadequate preparation or inattentiveness, but mistakes are a non-negotiable part of education. If you're intolerant of them all you're doing is kicking the can down the road and letting the student/resident make his mistakes when there is no one around to correct him.
Thank you for being the voice of reason on this thread. The attendings commenting are the exact attendings that should NOT be at a teaching hospital and drive me crazy. They are the type of people creating under prepared residents and bastardizing medical education.

Intubating is a skill set all medical students should know how to do and frankly we don't. I did a 2 week anesthesia rotation and the polarity among the attendings for what I was allowed to do/not allowed to do was comical. The great teachers were right by my side guiding me on how to intubate and if I made a mistake or couldn't visualized the cords (at which point I would start to freak out and try to have them take over) they would calm me down, and help me visualize the cords. If I still couldn't get it or felt too uncomfortable then they would take over. (my first intubation, I tubed the goose, the attending pulled the tube out and put it in in 5 seconds total. Was a great learning experience for me and never did it again and the patient was never in danger). I know you have horror stories as above, but like the 1/1,000,000 side effects of drugs they are very rare and intubating a stable patient is a very safe procedure, especially with an attending standing right there watching. I even asked this great teachers about this and they explained you can bag-valve the patient forever and the patient was satting great the whole time so there was no rush/nothing to worry about. It is far more dangerous for us not to learn how to intubate when we truly need to do it in an emergency.

Then I had other attendings who wouldn't let me intubate at all, or I would look for 10 seconds without seeing the cords and they would swoop in. Give me a break. These types of attendings (/residents) carry over to other aspects of medicine (such as internal/surgery (surgeons were the worst in my experience)) which for their own convenience turn the student role into one of shadowing, rather than letting the student take ownership of the patient. Hell, all of medical education is going this way b/c of liability issues. At my hospital, student notes dont count (aka residents cant copy/paste or sign/addend our notes) and have to do their notes themselves. We cant put in orders (even on our Sub-I). I will start residency without ever having put in 1 order. I have done 1 LP and no other procedures, even after a month long critical care "sub-I"
 

neutropeniaboy

Blasted ENT Attending
15+ Year Member
Feb 10, 2002
948
198
USA
Status
Attending Physician
Jorts, with your limited experience doing just about everything that has to do with medicine, I think I'll rely on my acquired knowledge and experience as a teaching physician - who above all else has the patient's best interest in mind - to judge who has the privilege to perform any procedure on my patients when in front of me.

It's funny: I know a lot of your professed great teaching physicians (i.e., not the "crazy" ones like me who shouldn't be in a teaching institution) who pull me aside when they are having surgery to request that no students or residents touch them.

Yes, medical students need to acquire skills, but not before I've judged my residents to be competent and never for the sake of "practice" or if I deem the situation unsuitable for a student.

Sent via Tapatalk
 
Last edited:
  • Like
Reactions: ommnomm and sb247

pianoman511

Member
10+ Year Member
Jun 8, 2005
515
7
Buffalo, NY
Status
Attending Physician
I agree with the above poster. In my program we have med students rotating often but the priority for intubations are the interns because they need to get credentialed. That being said if I have a med student I think can tube a patient and my attending is okay with it then I give them a shot while standing right next to them.

I think intubating is an important skill but realistically it is a skill you need to practice regularly to be proficient at. Not that IM or FP residents don't need to know the basics, but the priority goes to EM and anesthesiology.
 

evilbooyaa

Staff member
Moderator
7+ Year Member
Oct 10, 2011
5,331
4,076
Status
Resident [Any Field]
Jorts, with your limited experience doing just about everything that has to do with medicine, I think I'll rely on my acquired knowledge and experience as a teaching physician - who above all else has the patient's best interest in mind - to judge who has the privilege to perform any procedure on my patients when in front of me.

It's funny: I know a lot of your professed great teaching physicians (i.e., not the "crazy" ones like me who shouldn't be in a teaching institution) who pull me aside when they are having surgery to request that no students or residents touch them.

Yes, medical students need to acquire skills, but not before I've judged my residents to be competent and never for the sake of "practice" or if I deem the situation unsuitable for a student.

Sent via Tapatalk
I understand your reservations about patient safety and not letting med students touch your patients. Really, I do.

However, quick question - Do you think it is important for med students (especially future ER/Anesthesia/ENT residents but across all fields) to learn (and practice) how to intubate and/or bag-mask ventilate while they are in medical school?
 

SouthernSurgeon

Lifetime Donor
10+ Year Member
Dec 17, 2008
4,363
8,300
Status
Resident [Any Field]
I understand your reservations about patient safety and not letting med students touch your patients. Really, I do.

However, quick question - Do you think it is important for med students (especially future ER/Anesthesia/ENT residents but across all fields) to learn (and practice) how to intubate and/or bag-mask ventilate while they are in medical school?
It's a reflection on the state of medical education. I have zero expectation that our incoming interns can perform any procedure with competency.

I'm going to make up some statistics based on my anecdotal experience. I'd say currently less than 10% of interns that I've directly supervised can competently place a central line, arterial line, chest tube, or intubate. And that is among the interns that self-selected for a procedural specialty.

I think in theory in an ideal world medical schools would prepare students to do all of those things with competency. But I think at present, that is not the reality of medical school. Not saying I agree with that, but it is the present state of things.

Which is why the ACGME now explicitly requires direct supervision for interns to perform any of these tasks until they have demonstrated competency.

As to how to change it? That's a really difficult question. Now that we've allowed procedural training/competency to slide uphill it is unlikely to slide back down anytime soon. Individually, I have no problem teaching a medical student a procedural skill - I've supervised students doing all of the activities I listed above. I will let them struggle, but only to a point, and only at steps in the procedure that are unlikely to harml a patient. And, the real kicker is, they only get to do it once my interns have done enough to be competent (or the interns aren't around).
 

Perrotfish

Has an MD in Horribleness
10+ Year Member
May 26, 2007
8,062
3,975
Status
Attending Physician
As to how to change it? That's a really difficult question. Now that we've allowed procedural training/competency to slide uphill it is unlikely to slide back down anytime soon. Individually, I have no problem teaching a medical student a procedural skill - I've supervised students doing all of the activities I listed above. I will let them struggle, but only to a point, and only at steps in the procedure that are unlikely to harml a patient. And, the real kicker is, they only get to do it once my interns have done enough to be competent (or the interns aren't around).
I really don't think its that hard to change: just add mandatory minimum numbers of procedures to medical school like you have for Intern year.
 

evilbooyaa

Staff member
Moderator
7+ Year Member
Oct 10, 2011
5,331
4,076
Status
Resident [Any Field]
It's a reflection on the state of medical education. I have zero expectation that our incoming interns can perform any procedure with competency.

I'm going to make up some statistics based on my anecdotal experience. I'd say currently less than 10% of interns that I've directly supervised can competently place a central line, arterial line, chest tube, or intubate. And that is among the interns that self-selected for a procedural specialty.

I think in theory in an ideal world medical schools would prepare students to do all of those things with competency. But I think at present, that is not the reality of medical school. Not saying I agree with that, but it is the present state of things.

Which is why the ACGME now explicitly requires direct supervision for interns to perform any of these tasks until they have demonstrated competency.

As to how to change it? That's a really difficult question. Now that we've allowed procedural training/competency to slide uphill it is unlikely to slide back down anytime soon. Individually, I have no problem teaching a medical student a procedural skill - I've supervised students doing all of the activities I listed above. I will let them struggle, but only to a point, and only at steps in the procedure that are unlikely to harml a patient. And, the real kicker is, they only get to do it once my interns have done enough to be competent (or the interns aren't around).
This is a fair assessment. If the prevailing thought process is that incoming interns are not expected to know what they are doing whatsoever in terms of procedural abilities, then fine. However, it seems like some attendings who post on this forum want to have their cake and eat it too. They want interns to come in with experience with basic procedures but don't want to allow their medical students to actually learn (and practice) how to do those procedures.

Also, if there is a discrepancy in how many procedures medical students have done, then doesn't that give an incoming Anesthesia PGY-2 with lots of intubations as a M3/M4 (even 1 year removed from doing intubations) an advantage over another anesthesia PGY-2 who didn't get the same ability to intubate as a medical student?
 

SouthernSurgeon

Lifetime Donor
10+ Year Member
Dec 17, 2008
4,363
8,300
Status
Resident [Any Field]
This is a fair assessment. If the prevailing thought process is that incoming interns are not expected to know what they are doing whatsoever in terms of procedural abilities, then fine. However, it seems like some attendings who post on this forum want to have their cake and eat it too. They want interns to come in with experience with basic procedures but don't want to allow their medical students to actually learn (and practice) how to do those procedures.

Also, if there is a discrepancy in how many procedures medical students have done, then doesn't that give an incoming Anesthesia PGY-2 with lots of intubations as a M3/M4 (even 1 year removed from doing intubations) an advantage over another anesthesia PGY-2 who didn't get the same ability to intubate as a medical student?
A graduating anesthesia resident will have performed hundreds and hundreds (thousands even? I have no idea) of intubations...does it particularly matter for their training whether they start residency with 1 or 20? Might make the first few weeks more painful but after that I doubt it matters.
 

evilbooyaa

Staff member
Moderator
7+ Year Member
Oct 10, 2011
5,331
4,076
Status
Resident [Any Field]
A graduating anesthesia resident will have performed hundreds and hundreds (thousands even? I have no idea) of intubations...does it particularly matter for their training whether they start residency with 1 or 20? Might make the first few weeks more painful but after that I doubt it matters.
Fair point. I guess I am focused on the first few weeks as those are supposedly the hardest weeks of a new internship/residency/job/fellowship/etc.