Average Intubation # In Residency

[TheComebacKid]

I love how people get so territorial in the ivory towers. If I wanted to go down to the MICU and place all the central lines the intensivist would say "Thank you very much" and let me have them. Same with MICU intubations, emergent deliveries etc. This squabbling over procedures simply doesn't exist except for everyone trying to get out of them!

When you are a resident, procedural experience matters. Your training as an EM resident should be prioritized for patients who need procedures in the department. I know most of the community attendings look at procedures as being a huge time sink, something that kills your workflow and your RVUs. But as a resident, that stuff is not a priority for me right now, I'm focusing on learning the medicine and getting the experience.

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[The Physician Philosopher]

I don't get why people feel the need to be involved in the ED. I get it that ortho needs reductions for their training, and surgery needs some chest tubes, but there is virtually no need for anesthesia to ever come to a single airway unless they are asked to.

I could go into this in depth, but that would create a giant pissing match. Suffice it to say that at our medical center anesthesia comes to every single level 1 trauma and that the ED gets the first shot. This is the resident, supervised by their attending. We literally do not cross the red-line to come into the bay unless asked by the ED or the trauma team running the trauma. If the ED cannot get it and the patient is not doing well (not able to be bagged back up) or it is particularly difficult, then we take over. This accomplishes good education for the ED resident in terms of experience, and also allows for patient safety.

The point is that this is not all about education. Patient safety plays a factor, too. If your mother/daughter/father/brother/etc were in dire straits would you want the two providers to be having a competition over who is more qualified or would you want the most qualified person to put the tube in (if there were difficulties). With the simple mantra, "put the patient first" I don't even understand how this turns into a debate.

I think that you can maintain adequate education standards by always allowing the ED the first look (or two if able to be BVM back up), but if they are having trouble it makes no sense to me to keep shuffling around ED providers when there is someone else available with a different skill set and more airway experience.

This is not to diminish the skill-set of ED docs. I think you guys do a wonderful job handling extremely difficult situations (including difficult bloody airways). It just bothers me when people are more worried about getting their toes stepped on than doing the right thing for the patient.

 

[TheComebacKid]

I could go into this in depth, but that would create a giant pissing match. Suffice it to say that at our medical center anesthesia comes to every single level 1 trauma and that the ED gets the first shot. This is the resident, supervised by their attending. We literally do not cross the red-line to come into the bay unless asked by the ED or the trauma team running the trauma. If the ED cannot get it and the patient is not doing well (not able to be bagged back up) or it is particularly difficult, then we take over. This accomplishes good education for the ED resident in terms of experience, and also allows for patient safety.

The point is that this is not all about education. Patient safety plays a factor, too. If your mother/daughter/father/brother/etc were in dire straits would you want the two providers to be having a competition over who is more qualified or would you want the most qualified person to put the tube in (if there were difficulties). With the simple mantra, "put the patient first" I don't even understand how this turns into a debate.

I think that you can maintain adequate education standards by always allowing the ED the first look (or two if able to be BVM back up), but if they are having trouble it makes no sense to me to keep shuffling around ED providers when there is someone else available with a different skill set and more airway experience.

This is not to diminish the skill-set of ED docs. I think you guys do a wonderful job handling extremely difficult situations (including difficult bloody airways). It just bothers me when people are more worried about getting their toes stepped on than doing the right thing for the patient.

Your point regarding patient safety is of course, very valid. We should not allow interns to do lifesaving heroic procedures on patients who are 3 seconds away from losing a pulse. But as an ED resident, we are supervised by an ED attending 24/7. I have had several airways (more than I would like to admit) that I was not able to successfully intubate, and my attending had to take over (as they should have). But I have never had a case where my attending couldn't get the airway and then had to ask the CA-1/CA-2 anesthesia resident to come and take over. The truth of the matter is that the majority of the services at an academic level 1 trauma center have little understanding of how the majority of ED physicians will practice: in a community hospital without any anesthesia (or any other specialty service for that matter) back up. When I graduate in 2 years and go work in the community, you guys will be at home in the middle of the night and I will have to do an awake fiberoptic intubation on my own, or struggle with a difficult bloody airway on someone with radiation to the neck. I wish that our resident colleagues would understand this and help facilitate our training instead of pushing us aside and taking over, so we can continue to deliver high quality and safe patient care later in our careers. I fully concede that the anesthesia attending has more comprehensive airway experience than the EM attending. But precisely because the anesthesia attending is at home sleeping in the middle of the night, instead of saying "Those ED docs are so bad at intubating!" I would like them to say, "We need to make sure they get the best training possible so they are ready"

I cannot deny that some of this is ego driven. And some of this is partially my fault for choosing a specialty where we depend on our consultants for help. But I do get irked that as an emergency physician in training, I have virtually zero emergency expertise in the eyes of others and I have to be told by other services on how to handle an emergency. I wish that sometimes other services learned what it's like to be pushed aside. I brought up this example earlier. But lets say hypothetically as an EM physicians we are very good at ACLS. If you guys had a code in the OR on the table and we came upstairs and pushed you aside and said "we got it from here" I think it would be pretty blasphemous. Put yourself in those shoes. (P.S. I rotated on a medicine floor rotation. The codes on the floor were an absolute s***show. I let the medical residents get their training and learn how to run them instead of pushing them aside).

I recognize that we are not going to be the best at everything in the ED, and the nature of our specialty as generalists necessitates us asking for help. But I think the House of God would be a better place if other services facilitated the ED docs getting better at managing emergency care in the ED instead of trying to take over and micromanage everything we do.

 

[Vigileo]

Thanks all for the interesting responses. My original intention wasn't necessarily to generate a "discussion" (or pissing match, however you want to put it). As a medicine trained person who works in the MICU, our airway experience/training is more similar to the ED than the average OR anesthesia experience, though I would argue still slightly different than the ED. The vast majority of our intubations are for primary respiratory failure, making it an already risky manuever, or in the setting of hemodynamic collapse. As such, the vast majority of these intubations are "high-risk" or "difficult" to begin with. Not always from an anatomic perspective, though we do get the not infrequent GI bleed intubation and where I'm from, lots of morbidly obese intubations. I'm never going to have as many intubations as an anesthesiologist. As a fellow I've spent as much time as possible with the anesthesia to learn from them and get OR repetitions for muscle memory and technique. They've been quite open to teaching. We don't call them often in our MICU, but when we do, for the most part, they are happy to be there and assist, and I want to learn from them as well as our ED colleagues. I've also helped them out once or twice for the rare middle of the night bronchoscopies turned into bloody disasters. I think repetitions are important for us to help with muscle memory and proper technique, because for the most part, the rest of my intubations in the unit are rarely straight forward. Hence why I thought it would be helpful for me to gauge my airway experience thus far to the ED as the most similar physician and type of airway management training. Thanks all!

 

[alpinism]

Any resident claiming to have done a ton of crics is either absolutely horrible at intubating or straight up lying to your face.

That being said its not unreasonable and probably a good thing if they've done 1 or 2 during residency.

 

[Jlaw]

I'm halfway through a 3yr residency and have about 50 tubes...will likely end up with around 100. Would easily have 4x as many if it weren't for non invasive, I probably lose 1-2 tubes per shift because of it. Never seen or done a real cric but do 3 or 4 per year on cadavers and a few of my classmates have done 1 or 2 in the ED. IRL crics are rare with all the airway toys we have nowadays. My older attendings used to do ton of them when all they had was a laryngoscope and a scalpel.