ED airways

[mick2003]

The ED physicians at one of the hospitals that I work at (teaching facility) consider themselves to be extremely skilled with the airway, yet page for "anesthesia back-up" for likely challenging/difficult airways.

At first, I thought it great that they limited my trips to the ER, but knew when they needed help. In fact, when responding to these pages, they demand that the anesthesia provider stand by while they manage/mismanage the airway and essentially ask for an emergency consult once their attempts have failed.

Personally, I have no interest in going to the ED and they can manage all of the airways they want to without me. I do have a problem when I am called to the bedside for a consult, but am restricted procedural access to the patient based upon current departmental policies (at this institution, the ED physician is the attending of record until admitted to the floor -- much to the chagrin of the surgeons/intensivists who will ultimately care for the patient).

I don't want to malign our ED collegues, but don't call me for help and then refuse to accept it until you are in dire straits. So far in these instances my only recourse has been to make a scene, state that they are doing the patient a misservice and let them know that part of my "anesthesia consultation" will be to document in the chart that I recommend the most senior anesthesia provider available manage the airway (ie: not the ED intern in the pt with a documented difficult airway).

Am I the only one to deal with this issue? If not, how do others handle it (in a professional fashion?)

Mick

---

Members don't see this ad.

 

[Planktonmd]

The ED physicians at one of the hospitals that I work at (teaching facility) consider themselves to be extremely skilled with the airway, yet page for "anesthesia back-up" for likely challenging/difficult airways.

At first, I thought it great that they limited my trips to the ER, but knew when they needed help. In fact, when responding to these pages, they demand that the anesthesia provider stand by while they manage/mismanage the airway and essentially ask for an emergency consult once their attempts have failed.

Personally, I have no interest in going to the ED and they can manage all of the airways they want to without me. I do have a problem when I am called to the bedside for a consult, but am restricted procedural access to the patient based upon current departmental policies (at this institution, the ED physician is the attending of record until admitted to the floor -- much to the chagrin of the surgeons/intensivists who will ultimately care for the patient).

I don't want to malign our ED collegues, but don't call me for help and then refuse to accept it until you are in dire straits. So far in these instances my only recourse has been to make a scene, state that they are doing the patient a misservice and let them know that part of my "anesthesia consultation" will be to document in the chart that I recommend the most senior anesthesia provider available manage the airway (ie: not the ED intern in the pt with a documented difficult airway).

Am I the only one to deal with this issue? If not, how do others handle it (in a professional fashion?)

Mick

If I get called to the ER I am going to manage the airway.
Although I don't work in a university hospital where they have interns that need to practice I don't think an anticipated difficult airway is a practice case for an intern.

 

[jwk]

The ED physicians at one of the hospitals that I work at (teaching facility) consider themselves to be extremely skilled with the airway, yet page for "anesthesia back-up" for likely challenging/difficult airways.

If we get called, we do it, no questions asked. If you don't want us to do it, then don't call.

Why are are more surgical airways done in the field and ER than they are anywhere else? Because they don't intubate and manage an airway near as well as anyone from anesthesia. They of course will deny that, but hey, the truth hurts sometimes.

 

[coprolalia]

We only get called when they can't get it in. And, if they can't get it in, I assume it's a pretty bad airway and bring "devices" with me that they don't keep in their department. And, if I'm called and show up, I put the tube in.

The system you have sounds like abuse.

-copro

 

[Coastie]

Hilarious thread. I've run into some pretty cocky ER people with regards to airways.

Unfortunately, so have my patients.

'Nuff said.

 

[coprolalia]

Hilarious thread. I've run into some pretty cocky ER people with regards to airways.

Recently had a sick elderly patient come in for a planned procedure (for AVR with prior history of ICMO and CHF requiring multiple prior hospitalizations, including MICU time, before getting relatively under control). In the course of our conversation, I described some of the risks, etc. of the anesthetic. We got to the part about chipping teeth. She informs me she had a chipped tooth from being intubated. Conversation midway through went like this...

"There are other minor risks such as lacerated lip and chipped teeth. If this happens, we can discuss afterwards."

"I had my tooth chipped."

"When you were intubated?"

"Yes."

"How'd that happen? Were you going to the operating room?"

"No. I was really sick and was intubated in the emergency department."

"Oh, we'll probably that happened because you were having an emergency and they needed to save your life. Sometimes, unfortunately, these things happen. But, today, we'll be in a much more controlled, less urgent situation. I've done hundreds of intubations and I've never chipped a tooth."

She smiled. Was mildly obese, but able to open wide. Mallampati I. And, needless to say, I didn't chip any of her teeth.

True story. Never diss your colleagues.

-copro

 

[VentdependenT]

The ED physicians at one of the hospitals that I work at (teaching facility) consider themselves to be extremely skilled with the airway, yet page for "anesthesia back-up" for likely challenging/difficult airways.

At first, I thought it great that they limited my trips to the ER, but knew when they needed help. In fact, when responding to these pages, they demand that the anesthesia provider stand by while they manage/mismanage the airway and essentially ask for an emergency consult once their attempts have failed.

Personally, I have no interest in going to the ED and they can manage all of the airways they want to without me. I do have a problem when I am called to the bedside for a consult, but am restricted procedural access to the patient based upon current departmental policies (at this institution, the ED physician is the attending of record until admitted to the floor -- much to the chagrin of the surgeons/intensivists who will ultimately care for the patient).

I don't want to malign our ED collegues, but don't call me for help and then refuse to accept it until you are in dire straits. So far in these instances my only recourse has been to make a scene, state that they are doing the patient a misservice and let them know that part of my "anesthesia consultation" will be to document in the chart that I recommend the most senior anesthesia provider available manage the airway (ie: not the ED intern in the pt with a documented difficult airway).

Am I the only one to deal with this issue? If not, how do others handle it (in a professional fashion?)

Mick

I personally have had to deal with this once. It pissed me off, badly. Here ya go:

300 lb 5'9'' 50 y/o AA male with ENORMOUS TIGHT BELLY. Like bounce a quarter off that thing tight. Sats in 80's. Breathing 40's and tiring out. Obtunded.

Now...I walk in, see this. Guy has a friggen FACE MASK ON! Nobody helping him breath. Not even a GD non-rebreather.

ER dude is standing at the head of the bed, scope open, just ready to cowboy this mess.

I say, "hey, anesthesia is here. Do you want us to take the airway?" Guy says, "naww, I just want you here for BACKUP." I say, "Ok man. So this is YOUR AIRWAY." I'm just going to watch. I'm NOT INVOLVED.

ER dude says, "OK LETS GO! NURSE Stick of ETOMIDATE (yipes!), 200 of SUX, NOW (double yipes)!

I say, "hey bud, you wanna take the guy OUT OF TRENDELENBERG FIRST? Or how about ASSIST BAGGING HIM FOR A BIT?"

ER dude, "OH yeah, sounds good."

Well, you know the rest of the story don't ya........ I think that will be the LAST TIME that guy does that when help is around.

I did save that guys life. At least for the night. I also saved him from being the guinea pig for the "never even been studied cook rapid cric kit" that the ER guy was screaming for before I SHOVED HIM OUT OF THE WAY.

 

[Coastie]

ER: Family practice with an ego?

I personally have had to deal with this once. It pissed me off, badly. Here ya go:

300 lb 5'9'' 50 y/o AA male with ENORMOUS TIGHT BELLY. Like bounce a quarter off that thing tight. Sats in 80's. Breathing 40's and tiring out. Obtunded.

Now...I walk in, see this. Guy has a friggen FACE MASK ON! Nobody helping him breath. Not even a GD non-rebreather.

ER dude is standing at the head of the bed, scope open, just ready to cowboy this mess.

I say, "hey, anesthesia is here. Do you want us to take the airway?" Guy says, "naww, I just want you here for BACKUP." I say, "Ok man. So this is YOUR AIRWAY." I'm just going to watch. I'm NOT INVOLVED.

ER dude says, "OK LETS GO! NURSE Stick of ETOMIDATE (yipes!), 200 of SUX, NOW (double yipes)!

I say, "hey bud, you wanna take the guy OUT OF TRENDELENBERG FIRST? Or how about ASSIST BAGGING HIM FOR A BIT?"

ER dude, "OH yeah, sounds good."

Well, you know the rest of the story don't ya........ I think that will be the LAST TIME that guy does that when help is around.

I did save that guys life. At least for the night. I also saved him from being the guinea pig for the "never even been studied cook rapid cric kit" that the ER guy was screaming for before I SHOVED HIM OUT OF THE WAY.

 

[Noyac]

I don't mind standing bye helping out if needed. Afterall, I may be in their ER someday, god forbid, and I would like them to have all the experience they can get b/4 I get there.

 

[jetproppilot]

VENTY: "UH, YA WANNA TAKE HIM OUTTA TRENDELENBERG FIRST??"


HAHAHAHAHAHAHAHA

Thats a classic one, Homes.

 

[swpm]

Oooh, an ER airway botching bashing thread.

As a CA-1 doing my month in the unit, I went down to the ER to admit a drug overdose. The patient was somnolent but easily arousable, but they decided to intubate her. Morbidly obese, small mouth with teeth that could eat an apple through a chain link fence, naturally a full stomach.

I said the airway looked hard and suggested they call for anesthesia, but they go ahead and induce her with some etomidate and succ (with the patient's husband sitting in the chair next to the gurney) and give the rotating MS3 a crack at her. He said "I don't see anything" and quickly stepped aside.

After 8-10 DLs by an ER resident and attending, one goosed tube, and a lot of struggling to BVM her, she starts waking up enough to resist their efforts. I suggested they pause and let her breathe on her own, and that anesthesia could secure her airway more safely. But they cowboy ahead with more etomidate and a second dose of succ. I paged the anesthesia call team at that point, then offered to try myself.

Attending tries again, she vomits. He suctioned her and handed me the laryngoscope, and I struggled with my CA-1 semicompetence but was able to get a grade III view and intubate her.

Meanwhile, hubby is sitting there with wide eyes and a slack jaw, white-knuckle clutching the ER-provided plastic bag full of his wife's clothes on his lap. The next day I got to explain to him what aspiration was all about and why his wife was still intubated.

The ER residents here rotate through anesthesia for a month for "airway experience" but I wonder if tubing a bunch of healthy young adults under optimal conditions just gives them a false sense of security and confidence.

 

[Planktonmd]

I am not trying to criticize ER docs in any way but I had the pleasure of sitting across the table of an ER physician during a deposition and listen to her say that she thinks that she is as competent as a board certified anesthesiologist in airway management, and that the only difference was that they have to manage airways in tougher less controlled situations.
The worst part of that story is that I never had the opportunity to respond.

 

[RxnMan]

...The ER residents here rotate through anesthesia for a month for "airway experience" but I wonder if tubing a bunch of healthy young adults under optimal conditions just gives them a false sense of security and confidence.

How would you change their curriculum?

 

[Coastie]

I am not trying to criticize ER docs in any way but I had the pleasure of sitting across the table of an ER physician during a deposition and listen to her say that she thinks that she is as competent as a board certified anesthesiologist in airway management, and that the only difference was that they have to manage airways in tougher less controlled situations.
The worst part of that story is that I never had the opportunity to respond.

I've heard the same thing from ER folks.

 

[Coastie]

How would you change their curriculum?

Curriculum is fine. Changing their expectations and helping them see reality....that's the key here.

 

[TheMightyAngus]

I am not trying to criticize ER docs in any way but I had the pleasure of sitting across the table of an ER physician during a deposition and listen to her say that she thinks that she is as competent as a board certified anesthesiologist in airway management, and that the only difference was that they have to manage airways in tougher less controlled situations.
The worst part of that story is that I never had the opportunity to respond.

Seems like the defense attorney would dispute that by pointing out the difference in the number of intubations a typical ER doc performs during residency vs. how many an anesthesiologist performs. No?

 

[Fastrach]

The ER residents here rotate through anesthesia for a month for "airway experience" but I wonder if tubing a bunch of healthy young adults under optimal conditions just gives them a false sense of security and confidence.

I think most of us go thru a similar point some time during CA-1 year, only to get knocked on our butts by a full-on difficult airway, at which point we learn the amount of respect these situations are due. It's just a matter of reaching the numbers, I guess, which the ED folks just don't get. That and having all the right tools at your disposal when the **** hits the fan. Whoever told the ED guys at my institution that the Glidescope was the be-all-end-all in airway management needs to be drug out and shot.

 

[jetproppilot]

How would you change their curriculum?

Know what gives us the ability to intubate a gravid fire ant, dude?

Repetition.

Like all of you out there, I'm pretty smart.

But I aint no rocket scientist.

The reason I'm so deft at intubation is because I do it every day I work...and I've learned tricks over the last eleven years....and over the years I've watched and learned from people better than me. This statement applies to all deft attendings out there.

Oh, I almost forgot.

I also yield THE FORCE.

I'll defer to Mil to explain to you what THE FORCE is....and why some clinicians have it and some don't.

Doing something over and over in all situations....easy, hard, catastrophic, etc...contributes greatly to an individual getting great at something.

Tiger Woods still hits hundreds of balls a day.

Warren Buffet is still in the game with the same work ethic he had forty years ago.

So even the greats in their individual "specialties" practice their trade every day.

So your question is a good one since an ER doc doesnt intubate every day...or every week....or maybe not every month....how do you become deft at something with that kinda frequency?

The answer is....you may not become deft at it.

The answer I guess is an ER doc will gain only a certain level of prowess at any procedure...including intubation....yes some will be better than others as in all things....but by definition an ER doc is supposed to be the jack of all trades. Thats a hefty pair of pants to fill. An individual can only fill them so much, when so much is expected.

...unless theres some continuing education rotation, they, or we, cant expect them to be able to tube everyone.

That being said, some ER docs are quite deft at intubation.

Which is probably a reflection of their practice, and how many people they have to intubate.

 

[mick2003]

I don't mind standing bye helping out if needed. Afterall, I may be in their ER someday, god forbid, and I would like them to have all the experience they can get b/4 I get there.

I agree and have no problem handing airways over in the appropriate circumstances. My concern is for the patient and my own liability when I am expected to stand by and watch the hypoxic post-pneumonectomy pt on coumadin being manhandled and then asked to step in to manage a bloody edematous mess (fortunately, most of the time my CA-2 easily passes the tube).

I'm not sure if this is an academic issue, but in my private practice job (no trainees in the hospital) things seem to go a bit smoother. Each subspecialist does their part, no one is trying to out match the other, and we all go home early.

Mick

 

[militarymd]

Don't forget....some ER MD's have the force on their side also...

 

[militarymd]

I agree and have no problem handing airways over in the appropriate circumstances. My concern is for the patient and my own liability when I am expected to stand by and watch the hypoxic post-pneumonectomy pt on coumadin being manhandled and then asked to step in to manage a bloody edematous mess (fortunately, most of the time my CA-2 easily passes the tube).

I'm not sure if this is an academic issue, but in my private practice job (no trainees in the hospital) things seem to go a bit smoother. Each subspecialist does their part, no one is trying to out match the other, and we all go home early.

Mick

probably an academic thing....my ER guys and I don't have problems.

 

[jetproppilot]

I am not trying to criticize ER docs in any way but I had the pleasure of sitting across the table of an ER physician during a deposition and listen to her say that she thinks that she is as competent as a board certified anesthesiologist in airway management, and that the only difference was that they have to manage airways in tougher less controlled situations.
The worst part of that story is that I never had the opportunity to respond.

Chick needs medication for delusional ideation.

 

[GasEmDee]

Wow...8 to 10 times.

I wonder what kind of airway management experience ER docs receive besides direct laryngoscopy, e.g., what other airway tools have they used and what backup plans do they have in their minds?


On a separate note, I knew a medicine-trained critical care fellow who had been known on multiple occasions to attempt intubation on his own, push muscle relaxants, fail the intubation, and then call for help.

Granted, if the situation were dire enough, the solo intubation might be acceptable, but then there would be no need for induction agents and muscle relaxants.

Oooh, an ER airway botching bashing thread.

As a CA-1 doing my month in the unit, I went down to the ER to admit a drug overdose. The patient was somnolent but easily arousable, but they decided to intubate her. Morbidly obese, small mouth with teeth that could eat an apple through a chain link fence, naturally a full stomach.

I said the airway looked hard and suggested they call for anesthesia, but they go ahead and induce her with some etomidate and succ (with the patient's husband sitting in the chair next to the gurney) and give the rotating MS3 a crack at her. He said "I don't see anything" and quickly stepped aside.

After 8-10 DLs by an ER resident and attending, one goosed tube, and a lot of struggling to BVM her, she starts waking up enough to resist their efforts. I suggested they pause and let her breathe on her own, and that anesthesia could secure her airway more safely. But they cowboy ahead with more etomidate and a second dose of succ. I paged the anesthesia call team at that point, then offered to try myself.

Attending tries again, she vomits. He suctioned her and handed me the laryngoscope, and I struggled with my CA-1 semicompetence but was able to get a grade III view and intubate her.

Meanwhile, hubby is sitting there with wide eyes and a slack jaw, white-knuckle clutching the ER-provided plastic bag full of his wife's clothes on his lap. The next day I got to explain to him what aspiration was all about and why his wife was still intubated.

The ER residents here rotate through anesthesia for a month for "airway experience" but I wonder if tubing a bunch of healthy young adults under optimal conditions just gives them a false sense of security and confidence.

 

[TysonCook]

Just from a PGY2 ED guy...

I agree with a lot of what you state above. For the record, I DO consider the anesthesiologist to be the expert, because in the end that is YOUR field of specialty. It all depends on situation, but there are several things to note that I have observed.

1) Some ED physicians don't get great training at airways secondary to CRNA training programs. Not to start a bashing thread, but at our institution (900 bed, level I trauma), I would go at 5:30am, talk with all the patients before their procedures, evaluate their airway, and then go to the "board". Of all 32 OR's, around 20 would have CRNA students intubating (so NO residents), the others where LMA's, locals, or CRNA/anesthesiologists that didn't let ANYONE touch the patients.

After a month of rotating, begging, a$$ kissing, and getting BUMPED (CRNA would prefer a CRNA student because "they need the training more"), I was able to DL only ~60 cases (ave 2-3 day). 95% of the cases and teaching was CRNA to student, or anesthesiologist to CRNA....oh and forget about peds cases. (this was same at my med school rotation as well)

I didn't expect to be an "expert" after 60 cases, but I know that if any one of the anesthesiologists had taken me aside, said this is what is wrong w/ED intubations, and lets work on this/that, and here is a trick or two that I've learned. I may not muck up the airway in the ED, or call much sooner than I might have otherwise.

2) On average, if I'm in our high acuity area, we'll intubate around 1-3 patients/shift. The most I've had is 6 in one shift. For my procedure log I'm about at ~250, only 60 of which are controlled OR cases, the rest are vomiting, copd'ers, s/p prior trach, w/RR of 60. The majority of my airways are what some would consider "difficult" conditions, so I generally feel comfortable...which unfortunately leads to a bloody edematous mess. You never know when this is going to happen, and maybe it's cowboy, but if you can honestly look at all your cases and can say 100% that you have NEVER had a problem, then I'm amazed (including during your training)

3) I just want to reiterate that I (and 99% of my colleagues) still consider the anesthesiologists to be the expert. I've seen some pretty amazing intubations in people that have blown their face off w/a shotgun, vomited, in c-spine precautions get intubated without problems in the ED.....I've also seen little grandma get MANHANDLED by the ED as well....all doctors have different levels of training, different skill sets, and different abilities (see #2).

3a) a corollary to 3 is that the bloody mess that you may be looking at may be because 3+ attempts were made in the field by medics, then the resident (who may be a rotator, which we do have a lot of, not a ED resident), then the attending). A "reasonable" look by the attending may be attempt #6, even though it is his/her first look. The whole medic intubating is a whole different story

4) If you are in the room, (doesn't matter if its in the MICU, SICU, TICU, or at a code), or if you are called, I WILL defer to YOU, but I introduce myself, and then ASK if I can intubate with your help. I'm still learning and I sincerely VALUE your opinion and help.

5) Nurses get freaked out on the floors, sometimes in the ED, and will page anesthesiology WITHOUT an order or us asking. This may be why you've been called and then asked to "stand by". I frankly find it offensive that a specialist would be called and then asked to stand by for "backup" and don't blame you for being offended. I 100% agree with you that if you are there, you get the airway (and teach me while you're at it, or afterwords). Also, you have some cool toys and techniques that we don't.

6) In the end, a lot of the ED physicians are going out to practice in hospitals that don't have anesthesiologists in house, it would BENEFIT us all to get the best training (AND TEACHING), while we can. I think that this is why the mantra of the ED is sometimes expert in airways, because in the end we really NEED to be. A lot of hospitals have ED as their only code team, and if you need a tube, the ED is who you call.

Sorry for the long post, but WE KNOW WE ARE NOT SPECIALISTS (we get this from pediatricians, orthos, gen surg, optho, ENT, IM, anesthesiology, cardiology....you get the point)...but a lot of times WE ARE ALL THAT THE PATIENTS GOT...it may not be the best, hopefully not the worst, but in the end hopefully a good second choice.

Teach me, show me, help me, because in the end it might be you (or me) getting a tube

 

[militarymd]

tyson is 100% correct.

ED guys get a bad rap from the 1 or 2 guys with too much ego that we've all interacted with at some time in our past.

Same applies to many anesthesiologists, CRNAs, or other such clinicians who GIVES each of their area of expertise a bad rap because of their attitude.

I've interacted with a couple of ED guys on their forum...giving suggestions on learning...and was rebuked because I offerred a different POV....same kind of treatment I get here....so I felt right at home in their forum.

 

[Gern Blansten]

Tyson,
You are very humble. I wish the ED residents(and staff) were as humble at our place. My guess is that you are a PGY-1 who has not yet been fully indoctrinated. It is my hope that you will retain some bit of your humility and respect for other specialties once you finish your training. Many in your specialty (and ours) do not.
Regards,
GB

 

[toughlife]

Just from a PGY2 ED guy...

I agree with a lot of what you state above. For the record, I DO consider the anesthesiologist to be the expert, because in the end that is YOUR field of specialty. It all depends on situation, but there are several things to note that I have observed.

1) Some ED physicians don't get great training at airways secondary to CRNA training programs. Not to start a bashing thread, but at our institution (900 bed, level I trauma), I would go at 5:30am, talk with all the patients before their procedures, evaluate their airway, and then go to the "board". Of all 32 OR's, around 20 would have CRNA students intubating (so NO residents), the others where LMA's, locals, or CRNA/anesthesiologists that didn't let ANYONE touch the patients.

After a month of rotating, begging, a$$ kissing, and getting BUMPED (CRNA would prefer a CRNA student because "they need the training more"), I was able to DL only ~60 cases (ave 2-3 day). 95% of the cases and teaching was CRNA to student, or anesthesiologist to CRNA....oh and forget about peds cases. (this was same at my med school rotation as well)

I didn't expect to be an "expert" after 60 cases, but I know that if any one of the anesthesiologists had taken me aside, said this is what is wrong w/ED intubations, and lets work on this/that, and here is a trick or two that I've learned. I may not muck up the airway in the ED, or call much sooner than I might have otherwise.

2) On average, if I'm in our high acuity area, we'll intubate around 1-3 patients/shift. The most I've had is 6 in one shift. For my procedure log I'm about at ~250, only 60 of which are controlled OR cases, the rest are vomiting, copd'ers, s/p prior trach, w/RR of 60. The majority of my airways are what some would consider "difficult" conditions, so I generally feel comfortable...which unfortunately leads to a bloody edematous mess. You never know when this is going to happen, and maybe it's cowboy, but if you can honestly look at all your cases and can say 100% that you have NEVER had a problem, then I'm amazed (including during your training)

3) I just want to reiterate that I (and 99% of my colleagues) still consider the anesthesiologists to be the expert. I've seen some pretty amazing intubations in people that have blown their face off w/a shotgun, vomited, in c-spine precautions get intubated without problems in the ED.....I've also seen little grandma get MANHANDLED by the ED as well....all doctors have different levels of training, different skill sets, and different abilities (see #2).

3a) a corollary to 3 is that the bloody mess that you may be looking at may be because 3+ attempts were made in the field by medics, then the resident (who may be a rotator, which we do have a lot of, not a ED resident), then the attending). A "reasonable" look by the attending may be attempt #6, even though it is his/her first look. The whole medic intubating is a whole different story

4) If you are in the room, (doesn't matter if its in the MICU, SICU, TICU, or at a code), or if you are called, I WILL defer to YOU, but I introduce myself, and then ASK if I can intubate with your help. I'm still learning and I sincerely VALUE your opinion and help.

5) Nurses get freaked out on the floors, sometimes in the ED, and will page anesthesiology WITHOUT an order or us asking. This may be why you've been called and then asked to "stand by". I frankly find it offensive that a specialist would be called and then asked to stand by for "backup" and don't blame you for being offended. I 100% agree with you that if you are there, you get the airway (and teach me while you're at it, or afterwords). Also, you have some cool toys and techniques that we don't.

6) In the end, a lot of the ED physicians are going out to practice in hospitals that don't have anesthesiologists in house, it would BENEFIT us all to get the best training (AND TEACHING), while we can. I think that this is why the mantra of the ED is sometimes expert in airways, because in the end we really NEED to be. A lot of hospitals have ED as their only code team, and if you need a tube, the ED is who you call.

Sorry for the long post, but WE KNOW WE ARE NOT SPECIALISTS (we get this from pediatricians, orthos, gen surg, optho, ENT, IM, anesthesiology, cardiology....you get the point)...but a lot of times WE ARE ALL THAT THE PATIENTS GOT...it may not be the best, hopefully not the worst, but in the end hopefully a good second choice.

Teach me, show me, help me, because in the end it might be you (or me) getting a tube

Great attitude. You'll go far in life.

 

[Bougie]

Good post Tyson. ER docs at my institution differ from anesthesiologists in that they often overlook the basic tenets of airway management (positioning, preoxygenation, suction equipment, backup plans, effective mask ventilation) and rush in Rambo style and then then find themselves up sh*ts creek. >95% of intubations allow for a at least a few seconds of planning before pushing drugs or pushing in a tube. Get the basics right.

 

[Noyac]

Just from a PGY2 ED guy...

I agree with a lot of what you state above. For the record, I DO consider the anesthesiologist to be the expert, because in the end that is YOUR field of specialty. It all depends on situation, but there are several things to note that I have observed.

1) Some ED physicians don't get great training at airways secondary to CRNA training programs. Not to start a bashing thread, but at our institution (900 bed, level I trauma), I would go at 5:30am, talk with all the patients before their procedures, evaluate their airway, and then go to the "board". Of all 32 OR's, around 20 would have CRNA students intubating (so NO residents), the others where LMA's, locals, or CRNA/anesthesiologists that didn't let ANYONE touch the patients.

After a month of rotating, begging, a$$ kissing, and getting BUMPED (CRNA would prefer a CRNA student because "they need the training more"), I was able to DL only ~60 cases (ave 2-3 day). 95% of the cases and teaching was CRNA to student, or anesthesiologist to CRNA....oh and forget about peds cases. (this was same at my med school rotation as well)

I didn't expect to be an "expert" after 60 cases, but I know that if any one of the anesthesiologists had taken me aside, said this is what is wrong w/ED intubations, and lets work on this/that, and here is a trick or two that I've learned. I may not muck up the airway in the ED, or call much sooner than I might have otherwise.

2) On average, if I'm in our high acuity area, we'll intubate around 1-3 patients/shift. The most I've had is 6 in one shift. For my procedure log I'm about at ~250, only 60 of which are controlled OR cases, the rest are vomiting, copd'ers, s/p prior trach, w/RR of 60. The majority of my airways are what some would consider "difficult" conditions, so I generally feel comfortable...which unfortunately leads to a bloody edematous mess. You never know when this is going to happen, and maybe it's cowboy, but if you can honestly look at all your cases and can say 100% that you have NEVER had a problem, then I'm amazed (including during your training)

3) I just want to reiterate that I (and 99% of my colleagues) still consider the anesthesiologists to be the expert. I've seen some pretty amazing intubations in people that have blown their face off w/a shotgun, vomited, in c-spine precautions get intubated without problems in the ED.....I've also seen little grandma get MANHANDLED by the ED as well....all doctors have different levels of training, different skill sets, and different abilities (see #2).

3a) a corollary to 3 is that the bloody mess that you may be looking at may be because 3+ attempts were made in the field by medics, then the resident (who may be a rotator, which we do have a lot of, not a ED resident), then the attending). A "reasonable" look by the attending may be attempt #6, even though it is his/her first look. The whole medic intubating is a whole different story

4) If you are in the room, (doesn't matter if its in the MICU, SICU, TICU, or at a code), or if you are called, I WILL defer to YOU, but I introduce myself, and then ASK if I can intubate with your help. I'm still learning and I sincerely VALUE your opinion and help.

5) Nurses get freaked out on the floors, sometimes in the ED, and will page anesthesiology WITHOUT an order or us asking. This may be why you've been called and then asked to "stand by". I frankly find it offensive that a specialist would be called and then asked to stand by for "backup" and don't blame you for being offended. I 100% agree with you that if you are there, you get the airway (and teach me while you're at it, or afterwords). Also, you have some cool toys and techniques that we don't.

6) In the end, a lot of the ED physicians are going out to practice in hospitals that don't have anesthesiologists in house, it would BENEFIT us all to get the best training (AND TEACHING), while we can. I think that this is why the mantra of the ED is sometimes expert in airways, because in the end we really NEED to be. A lot of hospitals have ED as their only code team, and if you need a tube, the ED is who you call.

Sorry for the long post, but WE KNOW WE ARE NOT SPECIALISTS (we get this from pediatricians, orthos, gen surg, optho, ENT, IM, anesthesiology, cardiology....you get the point)...but a lot of times WE ARE ALL THAT THE PATIENTS GOT...it may not be the best, hopefully not the worst, but in the end hopefully a good second choice.

Teach me, show me, help me, because in the end it might be you (or me) getting a tube

Tyson please refer to my post earlier #9. I have no problem standing by and by the way, the ER is your turf and I am a visitor. Tell me what you need from me and I will be happy to help. If I see a disaster in the making I will speak up, trust me.

As far as point #1 of yours. Many folks look at intubation being the end all be all of airway management. I remember the resident attitude when I was a resident. It was sort of like Hyenas at a dead carcase fighting for a piece. Everyone wanted the procedure. Now put a few nurses with a chip on their shoulder in the mix and the procedures become even harder to get. But I can offer one bit of advice in this situation. One of the most important airway management skills is "effective" mask ventilation. I know that in the ER, masking a pt is usually contraindicated but if you can't intubate then you need to mask them. You are not going to get a nurse to turn over a procedure (intubation) but you will most likely get them to let you mask the pt as they go to sleep. Just doing this over and over for a few minutes each time will teach you skills that will save your arse someday.

Another thing you can try is to grab an attending or senior resident and ask them for help while in the OR. Tell them that you aren't getting as comfortable with intubations as you would like (even if you are comfortable) and could they find some intubations for you and give you some experience with some of our toys.

Don't worry about relations when you get out in the private practice world. Everywhere I have been the ER physician/anesthesiologist relationship has been great.

 

[Arch Guillotti]

Somehow I have avoided ED airway didsasters and turf battles during residency. So I guess I would say that the guys in the ED handle their business, at leats on the shifts I have been on. I have heard tales from other residents though, ones who have been pulled into ED fiascos.

I have had my share of on the floor fiascos though (even I couple at my own hands that I managed to squeak out of somehow). Usually it involved a failed induction with multiple DL attempts - we all know the drill. The dumbest thing I ever saw was an IM resident trying to do a DL with the laryngoscope in the right hand and the tube in the left hand. Rarely is the pt. positioned properly and I doubt they are preoxygenated much. Masking is the worst of all, but usually that is due to the RT smushing the mask down on the face rather than giving jaw thrust. I have been on a number of full blown codes where I have had to go some great distance to get there (5 minutes or so) and CPR is in progress, somebody is having a go at the femoral central line, and of course poor masking with an airway FULL of CRAP. The suction is the first thing that I always holler for. Sometimes it is so bad that I don't even put in the yankaeur, I just suck the junk out through the hose. Good times.

 

[roja]

Noyac-

Great words. We have a residency here and thankfully, our relationships are all very good. The few airways I have called for back up have been unintubateable, ended up with surgical airways and did fine. Minus two that ended up in the OR, both did poorly (airway never touched in the ED) and that was because it was a cluster from the moment they walked in the door.

Good BVM is absolutely essential and we hammer positioning into our residents ad naseaum. Nothing ticks me off more than one of my residents trying to use a 'mac as a miller' (god help me I have beat that out of them) or not sweeping with the blade. Unfortunately we don't often have the time that is had in the OR, but as Tyson pointed out, good technique needs to be practiced over and over again. Thankfully our gas folks love to teach and do outstanding jobs teaching our residents in the OR so that when they get into the ED they have a strong foundation to build on.

Unfortunately, in every field there are jerks and arrogant bastards. And they spoil it for the rest- in all fields.

 

[Planktonmd]

Noyac-

Great words. We have a residency here and thankfully, our relationships are all very good. The few airways I have called for back up have been unintubateable, ended up with surgical airways and did fine. Minus two that ended up in the OR, both did poorly (airway never touched in the ED) and that was because it was a cluster from the moment they walked in the door.

Good BVM is absolutely essential and we hammer positioning into our residents ad naseaum. Nothing ticks me off more than one of my residents trying to use a 'mac as a miller' (god help me I have beat that out of them) or not sweeping with the blade. Unfortunately we don't often have the time that is had in the OR, but as Tyson pointed out, good technique needs to be practiced over and over again. Thankfully our gas folks love to teach and do outstanding jobs teaching our residents in the OR so that when they get into the ED they have a strong foundation to build on.

Unfortunately, in every field there are jerks and arrogant bastards. And they spoil it for the rest- in all fields.

Thank you for the nice post.
2 little details to add:
1- There is nothing wrong in "using a mac as a miller" it's actually a nice technique to learn that can help if you are using a mac and find a huge epiglottis.
2- No one is "unintubatable", every patient can be intubated but not every practitioner can intubate every patient.

 

[jbar]

I'm not sure I see what the problem is with paging anesthesia to stand by for an intubation that looks tough but that the ED wants to try. It beats them trying on their own and then only paging when things have gone down the tubes, so to speak.

 

[VentdependenT]

I'm not sure I see what the problem is with paging anesthesia to stand by for an intubation that looks tough but that the ED wants to try. It beats them trying on their own and then only paging when things have gone down the tubes, so to speak.

You have missed the point my friend.

You don't page a specialist stat to have them standby and watch you "try" to do the procedure for which they specialize in.

 

[jbar]

I can understand the frustration of being in that position, just not sure what the solution is. Should the ED not try tough tubes and have anesthesia do all of them? Or should they try tubes they are worried about and not page till it's too late? I know the perfect solution would be for there to be a lot most intubation training during EM residency, but assuming that isn't possible, what would you recommend for an EM doc who is worried about a particular tube?

 

[VentdependenT]

I can understand the frustration of being in that position, just not sure what the solution is. Should the ED not try tough tubes and have anesthesia do all of them? Or should they try tubes they are worried about and not page till it's too late? I know the perfect solution would be for there to be a lot most intubation training during EM residency, but assuming that isn't possible, what would you recommend for an EM doc who is worried about a particular tube?

Call anesthesia. Help em out when they get down there.

No bonus points for ego. Just get the job done safely.

If youre worried then give us a call. We don't mind responding and securing the airway. Hell, its our bread and butter. However we don't want to be given an emergency page to the ER to standby and bail someout out of an airway disaster that didn't need to happen in the first place.

 

[Hayduke]

Call anesthesia. Help em out when they get down there.

No bonus points for ego. Just get the job done safely.

If youre worried then give us a call. We don't mind responding and securing the airway. Hell, its our bread and butter. However we don't want to be given an emergency page to the ER to standby and bail someout out of an airway disaster that didn't need to happen in the first place.

Vent-
I dig you the most. I have followed your posts and looked to you for guidance since my MS2 year. But I disagree with your focus here.

Gas guys are the hands-down pros in airway land. As a future EP I look to y'all for instruction, support and possibly a bail out.

At my place when we anticipate a problem (very rare) we give a call and try to paint the picture as accurately as possible. If the situation calls for it, I am your assistant. Whatever I can do to make Anasthesia's job easier is what I can do for that patient. If it looks better than originally thought, I will ask if gas will let me give it a shot with their help. I have never been refused from a resident or attending. These have all been great learning cases. CRNAs are another matter.

Anasthesia is called for "stand-by" on all of our L1 and L2 traumas. Of course so is surgery. Both specialties show up immediately. The patient may need an airway guru and he may need somebody with a knife. In the meantime, it's our department, and our patient.

I hear you regarding stat specialty call then getting used as a stand by. In those traumas, the gas guy is the one I look for. He comes to the head of the bed with me. I actively engage that person so that when the badness comes we are not strangers/adversaries gunning for a procedure. Rather we are a team with me as pupil/assistant/hopeful procedurist looking to help out that person on the cot.

The question comes...why is the ED resident even there? I think you'll appreciate the answer as a future fellow then attending. When I leave this purgatory of academia and head out to my back-of-beyond community center I will be the one at the head of the bed securing that difficult airway. Meanwhile you dream away a night on your CT or (god forbid) OB floor. Tolerating and hopefully sharing your expertise with us now frees you from the pit later on. Thank you for the teaching.

That's an intern's .02.

 

[VentdependenT]

good post

 

[Tenesma]

there is an easy solution to this

if you show up per their request but they don't let you do anything as you watch them start to struggle - you can easily point out that

1) ATLS recommends that the most experienced laryngoscopist takes over the airway - then look around for dramatic effect, and then point at your self and say "that's me"

2) that you are a consultant not a baby-sitter - then tell them that you are leaving and they can re-consult you should the need arise

3) if they say that they need you as back-up to their botched efforts, then tell them that if they keep on making a mess they won't need anesthesia for expert airway management, they will need surgery for expert emergent cric...

 

[roja]

Thank you for the nice post.
2 little details to add:
1- There is nothing wrong in "using a mac as a miller" it's actually a nice technique to learn that can help if you are using a mac and find a huge epiglottis.
2- No one is "unintubatable", every patient can be intubated but not every practitioner can intubate every patient.

Thank you.

to address your points: for an anesthesiologist, I would say, there is nothing wrong with using a mac as a miller. You guys tube day in and day out and learn nice little finesse tricks. however, in the ED, I beat this practice out of my residents (because it is usually accompanied by putting a mac in the middle of the mouth and pushing the tongue back). A mistake borne of inexperience with a poor backup plan (they invariably would use a Mac 4 with the arguement that when they can't see they could lift up the epiglottis as opposed to using a mac 3 with good technique and THEN lifting the epiglottis if it is big and floppy.).

Some people are unintubatable. My first surgical airway had the anesthesia attending (who is also our SICU director and a serious bada**) try more than 10 times (pt was thankfully bagable). No tube was going through his chords. Second was an allergic reaction that was edematous the entire way down. Third was an angioedema that anesthesia couldn't even get a blade in the mouth. Close friend shows a lecture from his ICU days where a patient had extensive jaw surgery, clips, pins etc in and around the face.
Point being, they aren't, thankfully, common, but some patients are not intubatable.

 

[Planktonmd]

Some people are unintubatable. My first surgical airway had the anesthesia attending (who is also our SICU director and a serious bada**) try more than 10 times (pt was thankfully bagable). No tube was going through his chords. Second was an allergic reaction that was edematous the entire way down. Third was an angioedema that anesthesia couldn't even get a blade in the mouth. Close friend shows a lecture from his ICU days where a patient had extensive jaw surgery, clips, pins etc in and around the face.
Point being, they aren't, thankfully, common, but some patients are not intubatable.

I think you are saying that some people might be impossible to intubate with direct layngoscopy, which is true, and even if you are a "bad a** attending that runs the ICU" there might be situations where DL could be impossible regardless of how many times you try, this does not make the patient "unintubatable" it makes that specific technique in the hands of that specific practitioner under those specific circumstances unsuccessful.

 

[roja]

I think you are saying that some people might be impossible to intubate with direct layngoscopy, which is true, and even if you are a "bad a** attending that runs the ICU" there might be situations where DL could be impossible regardless of how many times you try, this does not make the patient "unintubatable" it makes that specific technique in the hands of that specific practitioner under those specific circumstances unsuccessful.

I'm curious what other technique would have worked? when chords are swollen to not allow passage of any ETT through them? Nasotracheal wouldn't work, and I can't think of any other technique. I personally would love to never have to do a surgical airway again. however, I imagine I will. (what do you do when a massive gi bleeder is outpacing your suction? ) These are rare rare cases, but they happen. I do think that 99% of pt's are intubatable. however, like all things in medicine, there are no absolutes, including 'intubatability'.

 

[Egon]

This is a real intersting thread and a lot of good points. I'm an ED attendning at an academic program and did residency at Mt Sinai where I did a lot of work with anesthesia/Adam Levine in advanced airway. We really stressed airway as part of our training, from basic techniques to advanced airway electives using fiberoptics, glidescopes, etc. Our PD also made us all go to an airway CME conference as residents. (I did anesthesia my second to last rotation in medical school, and if it was earlier would have had a really really hard time deciding between the two fields.)

What I found eye-opening was that at the CME conference they had EM attendings from all over the country, and it was a little scary even how some were holding the laryngoscope, (ie wrong hand), never used RSI (were giving inadequate doses of versed for intubations instead), etc, but I guess that's why they were at the course... Some of the attendings who grandfathered into the specialty had developed some pretty scary techniques over time and I found skills to be nonuniform across the specialty.

I think as time goes on the training of physicians working in the ED will be more uniform and there should be little need to call anesthesia for "back-up".

During training we had that fiberoptic camera and monitor on the macs and millers so we could see what the residents were doing, and used it as a teaching tool. However, we didn't have the bronchoscope attatchment (they might have it now), so some attendings would call anesthesia down to do an anticapted horrible airway with the intubating fiberoptics, (and in those few cases anesthesia usally just did a direct intubation and it went fine, and in retrospect probably didn't need to be bothered). But to call someone for back-up I think is a waste of time and resources. We had a really good relationship with anesthesia and they were happy we didn't bother them other than a couple times a year.

I feel with all the training I've done I'm maybe as good as an average anesthesiologist and respect that there's should be someone in the hospital at any time with more skill. I've had one failed airway that it took 2 anesthesiologists to get, but we could always bag, and they needed to use a combination of an intubating LMA with fiberoptic. (Pt was 300lbs and had a tumor on his cords which we didn't know at the time). So there are those bizarre cases which will make any operator wet the pants a little.

Overall, if your at a hopsital with a good emergency department, you should really only get a called a handful of times through the year. Otherwise, they need to review what they are doing and remediate the ER docs that can't manage a difficult airway, because they are out there. (In some small hospitals they're only doing 2 airways a month.) If you're repeatedly called for failed airways this is really something that needs to be brought up and investigated by both department heads.

It's kind of ironic in medicine how every specialty craps on every other specialty. Surgery says anesthesia is boring, anesthesia says the ED can't manage an airway, the ER says GI is lazy because they won't come in and scope the UGI bleed, and down the line. There needs to be more of a team approach and realization we're all here for patient care and resident education if you're in an academic setting. (Sorry for the rant.)

 

[Planktonmd]

I'm curious what other technique would have worked? when chords are swollen to not allow passage of any ETT through them? Nasotracheal wouldn't work, and I can't think of any other technique. I personally would love to never have to do a surgical airway again. however, I imagine I will. (what do you do when a massive gi bleeder is outpacing your suction? ) These are rare rare cases, but they happen. I do think that 99% of pt's are intubatable. however, like all things in medicine, there are no absolutes, including 'intubatability'.

So you are saying that your patient had "swelling of the vocal cords" that wouldn't allow the passage of any size ETT but you were still able to bag ventilate through these cords long enough for someone to try to intubate 10 times?
In my experience when there is a passage that allows ventilation you can usually insert a tube through it with some determination.
Don't get me wrong, I am not saying that there is never an indication for a surgical airway, actually a surgical airway is by itself an intubation technique.
And I do agree with you: There is no absolutes in medicine and this is why there is no such a thing as an absolutely unintubatable patient.

 

[Planktonmd]

I feel with all the training I've done I'm maybe as good as an average anesthesiologist

I highly doubt that.

 

[roja]

So you are saying that your patient had "swelling of the vocal cords" that wouldn't allow the passage of any size ETT but you were still able to bag ventilate through these cords long enough for someone to try to intubate 10 times?
In my experience when there is a passage that allows ventilation you can usually insert a tube through it with some determination.
Don't get me wrong, I am not saying that there is never an indication for a surgical airway, actually a surgical airway is by itself an intubation technique.
And I do agree with you: There is no absolutes in medicine and this is why there is no such a thing as an absolutely unintubatable patient.

Perhaps its a language issue, then? I tend (perhaps incorrectly) to consider intubation to be passing a tube through the vocal cords, as opposed to a surgical airway. If surgical airway=intubation technique, then you are correct. There are no unintubatable patients.