CHOP intubations

[2008 EM Reviews]

I have a question for EM residents who work at CHOP. At my Penn interview I discovered something I had not realized during some other Philly interviews - several residents mentioned they don't intubate kids in the CHOP ED as people come from all over the world for airway training there and instead intubations are done by the Pedi EM fellow or they call upstairs for a team of people in the PICU. The PICU fellow is also the person who usually intubates in the CHOP PICU. This sounds terrible to me and I've not encountered this policy at any other program. One senior resident said he got 1 tube in the PICU and 1 said they got lucky and were allowed to intubate a non-trauma airway in the ED, but that these were exceptions. Penn has 1 wk of pedi anesthesia but it seems to me this is to compensate for the lack of actual airway experience, not for extra tubes. I also went to Jefferson where they do 1 month in the CHOP ED and Albert Einstein Medical Center where they do 1 month in the CHOP ED and CHOP PICU. These 2 programs, however, do go to other pedi EDs as well so CHOP is not their only chance to intubate kids. Jefferson does 2 wks of pedi anesthesia also. I am hoping someone who has worked at CHOP could comment on their experience. I am trying to figure out if this lack of non-controlled, peds airway experience is a "dealbreaker" for me and make me not rank these Philly programs highly. Thanks for your help and I hope no one minds too much I am posting anonymously under this name...

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[jazz]

i don't have firsthand knowledge about CHOP.
i trained in the philly area and i heard the above complaints a lot -- mainly that your experiences at CHOP are limited b/c they have so many specialized fellows that take all the procedures.

in general, it's hard to get a large number of peds intubation in residency for several reasons.

1. the actual number of airways are much fewer than adult airways/intubations
2. when a child/infant needs an airway, people panic. thus, anesthesiologist, PICU attendings, NICU attendings, etc get nervous giving up those intubations to EM residents for practice.

i think peds anesthesia rotations were created to address the above. it's a much more controlled environment (which obviously is not what occurs in the ER) but allows the people in control of airways (anesthesia) to be more comfortable in allowing EM residents attempt the airway

your actual intubations in pedi ER's are rare. it's not common for kids to come in and need intubations. so unfortunately most of your pedi airways are going to come in the NICU/PICU and OR vs. the ER.

i wouldn't change a rank list solely based on the issue of number of pediatric airways. i think you'll find across the country that the number is low...

 

[TylerDurden]

Having just visited a fair number of Peds EDs for my fellowship interviews, I can tell you this seems to me to be the norm. At almost all Peds EDs where fellows work, the fellows are given the first opportunity for all airway cases. Most of the m come from Peds residencies, and therefore have little to no airway experience. They need to learn how to intubate.

At my program in Boston, we rotate at Childrens for most of our Peds experience. Once in awhile, we will get an airway there, but more often they go to the fellows. We rotate in another PICU and Peds ED, where we get other childrens' airways.

 

[MedDeac]

I think it is an excellent idea that the first time you ever intubate a child is when you're are out in practice and have no backup to come in and save you . these anesthesia attendings, PICU attendings, etc. are doing a major diservice in teaching institutions by stepping in front of EM residents. the absolute best time to do these the first time is when there is an "expert" standing right beside you. At my instituition you can intubate in the peds OR during the anesthesia rotation and maybe get a few tubes in the PICU. other than that they are hard to come by for reasons listed above. however being "protected" from these intubations now is not going to make it less neccessary when out on your own.

 

[Hercules]

Agree with most of what's been said above. As a third year resident, the number of ED intubations I've done is relatively low but this is due to the rare nature of the procedure rather than having someone else step in. At my program, the peds EM fellow has first right on airways in the Children's ED, but I've never had them push me aside on an airway for my patient. We also don't have anyone come down from upstairs for the airway. I think both of those situations would be frustrating to me as an EM resident.