CRNA concerns

[akinetopsia]

I’m just an intern... in medicine no less. I don’t claim to be a master of the airway. I’ve done some 50 intubations in my short time.

But I’ve recently had some experience watching a particular CRNA intubate and I’ve had some concern that she may not exactly know what’s she’s doing. Both times I’ve seen her she has attempted 4 and then 5 times before successfully getting the airway. I always thought the recommended limit was 3? We have an Intensivist on-call that she could’ve called. One time the anesthesiologist actually told her to hand over the blade and she barked at him. And even just watching her maneuver the Mac and hyperangulated VL, I don’t think she knows what she’s doing. I’m just assuming the anesthesiologists that work over her would’ve noticed if that was true so maybe I just caught her a few bad days? Not really sure if I should just move about my day but I would really appreciate any input on the matter. Thank you in advance!

Hold up: as an IM intern, you've done 50 intubations? I'm an anesthesia intern and I haven't done 50 this year and I've actually rotated on an anesthesiology block.

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[nimbus]

Hold up: as an IM intern, you've done 50 intubations? I'm an anesthesia intern and I haven't done 50 this year and I've actually rotated on an anesthesiology block.

Maybe they gave all the COVID intubations to the intern???

 

[GassYous]

Maybe they gave all the COVID intubations to the intern???

I did a ton of intubations and lines in the covid icus. More than I wanted actually.

 

[Katheudontas parateroumen]

Graduating in a few months and have done well over 500 DL (with using all sorts of bougie, light wand, nasal, intubating LMAs) and a couple hundred VL (more so since COVID) but only about 50 FOB including 10 awake. And even more LMAs. So in total so far likely over 1000 sorts of airways. I still feel quite humbled with airways. So it just absolutely amazes me when people are like "Oh yeah i've done 50 intubations, feel pretty comfortable". Like seriously? Dang I definitely do not have that much confidence.

Caveat is- I would say I feel "comfortable" by mid CA2 year (>300 DLs by then). But still not as comfortable as some of these non-anesthesia people on here are saying. But absolutely never with 50 or even 100. That's seriously a first few months CA1 starter pack.

 

[Iso4ane]

I got called at 3 am to asses the beeping epidural pump and worsening pain. I checked my notes and wasn't aware of any epidural in that patient. I get there and the dude is chilling in the chair doing a crossword. His pain was fine. Also, he had no epidural, the beeping thing was an IV pump with an empty bag of saline.

Or when the nurse pages you (probably on surgeons request) to adjust the epidural because the patient is hypotensive. You mean on the patient we already removed the epidural last night for similar reason?

 

[Wolverines83]

I am probably a little over 100, finishing EM residency. I see your point. I guess I was just trying compare it to other activities we do. Take someone who skis. It takes a while to log 100 full runs down the mountain (real west coast skiing, not Vermont). By the time you get to ~80 or so it's not unreasonable that you are finessing single blacks. I would say that is very good. Not the expert that is a seasoned attending anesthesiologist (or double/triple black/heliskiing rider). But it seems that many of you think the number is higher than I would have thought and I don't really have a leg to stand on.

Hahah.

Given that west coast skiing is stupidly and boringly easy...you would probably need 100 runs out there. East coast? Takes a lifetime.

Ski good or eat wood!

Sorry, had to!

 

[nimbus]

Given that west coast skiing is stupidly and boringly easy...you would probably need 100 runs out there. East coast? Takes a lifetime.

Ski good or eat wood!

Sorry, had to!

Vermont ice and -30 temps make it a survival issue.

 

[D P356]

When on call and alone, I generally always bring a glidescope into every case. Most of my GETA are DLs.
If I need it urgently, the call crew may or may not know where to find it.

Something I’ve learned is to put the pt well-being above my pride

attitude, PREPARATION and effort are the things I can control.

Still waiting to try that 2 handed DL using my foot to hold cric pressure.
I’ve heard you can put the yankauer in your mouth and inhale to provide suction should you need it, especially if all your hands are busy DLing.
I think I learned that from @nimbus

shout out to @abolt18 who shared with me how to suction my farts.

 

[abolt18]

shout out to @abolt18 who shared with me how to suction my farts.

I did??? Dang I don't remember this. I also don't know that I have any technique in mind for doing this, but if I did, I'm glad I could share it with you.

 

[D P356]

I did??? Dang I don't remember this. I also don't know that I have any technique in mind for doing this, but if I did, I'm glad I could share it with you.

yeah, something about sitting on the suction tubing to create a wind tunnel with the suction maxed out. You don’t even have to drop trou.

I’m just kidding. It was a joke at my residency program.

 

[deleted162650]

I’ve heard you can put the yankauer in your mouth and inhale to provide suction should you need it

Just don’t forget then Lukens trap.

Can also go with a Yankauer in each nostril for those bloody trauma airways or tonsillar re-bleeds.

I’m very intrigued by the cricoid with your foot technique. Gonna try that on Monday.

 

[D P356]

Just don’t forget then Lukens trap.

Can also go with a Yankauer in each nostril for those bloody trauma airways or tonsillar re-bleeds.

I’m very intrigued by the cricoid with your foot technique. Gonna try that on Monday.

good call on the Lukens trap. For a hands free BAL/sputum culture I suppose you could have the yankauer/tracheal suction catheter in a nostril, and use your mouth as the lavage reservoir.

Best to gurgle listerine or some other antiseptic mouth wash to avoid specimen contamination

 

[nimbus]

When on call and alone, I generally always bring a glidescope into every case. Most of my GETA are DLs.
If I need it urgently, the call crew may or may not know where to find it.

Something I’ve learned is to put the pt well-being above my pride

attitude, PREPARATION and effort are the things I can control.

Still waiting to try that 2 handed DL using my foot to hold cric pressure.
I’ve heard you can put the yankauer in your mouth and inhale to provide suction should you need it, especially if all your hands are busy DLing.
I think I learned that from @nimbus

shout out to @abolt18 who shared with me how to suction my farts.

Just don’t forget then Lukens trap.

Can also go with a Yankauer in each nostril for those bloody trauma airways or tonsillar re-bleeds.

I’m very intrigued by the cricoid with your foot technique. Gonna try that on Monday.

good call on the Lukens trap. For a hands free BAL/sputum culture I suppose you could have the yankauer/tracheal suction catheter in a nostril, and use your mouth as the lavage reservoir.

Best to gurgle listerine or some other antiseptic mouth wash to avoid specimen contamination

True story. One of my former partners was on a plane and there was a couple with a baby next to him. Their baby was congested and wailing so the dad put his mouth over the baby’s mouth and nose and “decongested” him.

 

[GassYous]

True story. One of my former partners was on a plane and there was a couple with a baby next to him. Their baby was congested and wailing so the dad put his mouth over the baby’s mouth and nose and “decongested” him.

My mom used to do that. I told her last week that she needs to stop.

 

[deleted162650]

Their baby was congested and wailing so the dad put his mouth over the baby’s mouth and nose and “decongested” him.

At least use one of these and pretend to be a civilized human being:

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[deleted875186]

Graduating in a few months and have done well over 500 DL (with using all sorts of bougie, light wand, nasal, intubating LMAs) and a couple hundred VL (more so since COVID) but only about 50 FOB including 10 awake. And even more LMAs. So in total so far likely over 1000 sorts of airways. I still feel quite humbled with airways. So it just absolutely amazes me when people are like "Oh yeah i've done 50 intubations, feel pretty comfortable". Like seriously? Dang I definitely do not have that much confidence.

Caveat is- I would say I feel "comfortable" by mid CA2 year (>300 DLs by then). But still not as comfortable as some of these non-anesthesia people on here are saying. But absolutely never with 50 or even 100. That's seriously a first few months CA1 starter pack.

I would also say begining of CA2 year I was comfortable with DL, Having done probably about 200-300 DL intubations.

comfortable meaning I could recongnize immediately if someone was difficult with a DL blade, and able to pass a tube without a clear view in these cases.

With 100 intubations, I still felt like if I couldn’t see it on DL, someone else probably could, and I would keep trying or use more force to try and get a better view.