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EM residents claiming they are better at trauma/difficult airway management than anesthesiologists??

Discussion in 'Anesthesiology' started by operavore, Aug 7, 2017.

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  1. operavore

    operavore ASA Member 2+ Year Member

    Dec 10, 2013
    Recently ran across an interesting conversation on reddit, started off by this quote from a third year EM resident:

    "Almost any trauma that requires intubation by definition should be considered a difficult airway and require anticipation of a difficult airway. Similarly with medical resuscitations in the ED. These are precisely the patients that should be intubated by an emergency physician or intensivist, as they are the most competent airway team member in the room in those situations, not the anesthesiologist who intubates under ideal conditions."

    I've never run into this line of thinking in real life, but still...

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  3. G-Man82

    G-Man82 Physician 10+ Year Member

    May 16, 2005
    The Southeast
    Haha, I guess because I'm an Intensivist AND an Anesthesiologist, that makes me the KING of airways

    Sent from my iPhone using SDN mobile
    frosted2, sally23, ranvier and 9 others like this.
  4. Man o War

    Man o War 2+ Year Member

    Apr 13, 2015
    Meh. 3rd year EM resident. Consider the source.
  5. nimbus

    nimbus Member 10+ Year Member

    Jan 13, 2006
    And he says trauma airways should be considered difficult when 99.9% of them are easy. Maybe he's never encountered a real difficult airway. Hopefully he won't ever wake up an anesthesiologist in the middle of the night for a difficult airway. I hate those calls, so annoying. Our ER docs must be clowns.
    Last edited: Aug 7, 2017
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  6. acidbase1

    acidbase1 5+ Year Member

    Jul 28, 2011
    I regularly bailed out the ED docs in residency
    Soccer171983 and MaximusD like this.
  7. Physio Doc 2 Be

    Physio Doc 2 Be Supratentorial problems Physician 10+ Year Member

    Sep 4, 2007
    This is clearly someone who doesn't know what they don't know speaking.
  8. 0kazak1

    0kazak1 ASA Member 7+ Year Member

    Nov 30, 2009
    Well, I don't care if they want to intubate, just don't eff it up. If intubating is all we did, we wouldn't have jobs. I think if an anesthesiologist was really concerned they would've spoken up and taken over it. I am sure we've seen enough to know what is/isn't difficult.
  9. dr doze

    dr doze To be able to forget means to sanity Lifetime Donor Classifieds Approved 10+ Year Member

    Dec 6, 2006
    good for them. whatever gets them through the night.
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  10. thinkorswim

    thinkorswim Mr. Monster 10+ Year Member

    Dec 11, 2006
    This was the culture of the EM residents/attendings at my training institution. They even thought they were better at chest tubes than our fellow surgeons (of course no one told them when they put it through the liver).

    Last time I was called down to help them, they were so far up **** creek without a paddle that they were redosing the rocuronium. Young guy didn't make it. Wasn't their fault, obviously.
    Last edited: Aug 9, 2017
  11. AdmiralChz

    AdmiralChz ASA Member 7+ Year Member

    Sep 8, 2008
    "He who knows best knows how little he knows." - Thomas Jefferson

    Overreach by a PGY-3, but it's not uncommon to see some arrogance/over confidence in new CA-2s and even some CA-3s - I know many of us can think of a time when we were totally humbled with an unexpectedly terrible situation. Maybe this ER resident hasn't had that angioedema case yet, or even the bloody mess after a bad wreck with a poorly-sealing King tube in place. He will get humbled eventually.
    Swamp Gas, plick, sally23 and 5 others like this.
  12. IlDestriero

    IlDestriero Ether Man Physician Faculty 10+ Year Member

    Nov 24, 2007
    The ivory tower.
    He doesn't even know what a difficult airway really is.
    It's like the .mil CRNAs thinking they're bad asses because they can manage the healthiest of all patients who had a trauma overseas somewhere. 10 bullets and an IED can't kill them.

    Il Destriero
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  13. teeva

    teeva 2+ Year Member

    May 21, 2015
    I'm more likely to believe more reputable sources that say the earth is flat.

    If ER residents were so great they would have left me alone instead of forcing the anesthesia team to attend trauma codes. We always stood back and let them try the airway, though occasionally they didn't even want to and left it to us. I trained at an institution with a top rated EM program and they didn't take us for granted. More often they were battling trauma surgery residents for turf and management decisions.

    Let me know when EM residents cover codes and manage airways solo throughout the hospital. Lots of f'ed up situations with patients who nobody knows nothing about, nurses running around aimlessly like the apocalypse was coming, medicine residents pulling up EMR/labs, and patients dying while in weird locations and lying in weird positions with literal diarrhea spewing out the mouth and chest compressions going on.
  14. IlDestriero

    IlDestriero Ether Man Physician Faculty 10+ Year Member

    Nov 24, 2007
    The ivory tower.
    Nice visuals.

    Il Destriero
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  15. pgg

    pgg Laugh at me, will they? Moderator 10+ Year Member

    Dec 14, 2005
    Home Again
    I'm sure the airways he couldn't get or had trouble getting were difficult to him.

    More to the point, he probably made them more difficult than they had to be with his hurried "it's in the ER so it must be an emergency" approach to them.

    EM residents are commonly people who thrive on excitement and chaos, and revel in the adrenaline of the moment. I abhor excitement and adrenaline. If I'm making a visible dramatic save it's probably because I screwed up and did something (or failed to do something) that made that save necessary. I feel a dumb twinge of shame when that happens. Some people feel like heroes.

    This EM resident sounds like a real hero.

    And the definition of a hero is ...
  16. VisionaryTics

    VisionaryTics Señor Member 7+ Year Member

    Jan 13, 2009
    I'm an ENT resident and I readily admit that anesthesia is the king of the airway. We deal with plenty of bad airways (trauma/cancer/airway malformations), but we represent the end of the algorithm. It's the anesthesiologist that makes management of those airways routinely smooth and safe. That's the real skill.

    One of my favorite idioms: "Surgery [or airway management] is lot a like sailing. The worse you are at it, the more exciting it is."
  17. MaximusD

    MaximusD Anatomically Incorrect Physician 10+ Year Member

    Aug 8, 2006
    State of Delirium
    But only after they've traumatized the airway.
    Moose A Moose likes this.
  18. ZzzPlz

    ZzzPlz ASA Member 7+ Year Member

    Dec 2, 2010
    Doesn't surprise me. I bet if you polled EMTs, most of them would also claim to be the king of the airway too :bored:
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  19. caligas

    caligas ASA Member 5+ Year Member

    Aug 17, 2012
    Good, stop calling me to help.
  20. aneftp

    aneftp 7+ Year Member

    Mar 23, 2010
    ER resident hasn't intubated the "easy" 120 pound s/p radical neck dissection patient with palliative radiation treatment who can't open their mouth.

    And I guess not too many 350-400 plus BMI 50 plus 50 year old male trauma patients come in for airway for him

    Most real trauma patients are pretty healthy.

    Anyways. There is confidence in airway skill. And there is arrogance in airway skill.

    Respect the airway. Doesn't seem the ER resident respect the airway.
  21. Ezekiel2517

    Ezekiel2517 Anesthesiologist Physician 10+ Year Member

    Jan 21, 2005
    There was a thread many months back in the em forum where one of them described how they managed a recent difficult airway. Everyone was giving him kudos for successfully getting the airway. I couldn't help but cringe at the flaws and missteps that were made and just the lack of knowledge in general. Didn't have the heart to tell em tho. Sometimes ignorance is bliss
  22. Ronin786

    Ronin786 ASA Member 5+ Year Member

    Mar 27, 2011
    That line of thought is par for the course when it comes to a lot of EM trainees and even attendings. I just shrug it off.
  23. Neogenesis

    Neogenesis Certifiable 10+ Year Member

    Dec 10, 2005
    Reminds me of a story about one of the residents from my program. Got called down to ED for a trauma. After multiple failed attempts at intubation by the ED intern.....followed by the ED resident.....and then the ED staff....finally they relinquished. This resident took one look, and loudly proclaimed to the room "GRADE 1 VIEW!", placed the tube and walked away. Yes, he got in trouble for his attitude/actions, but it was kinda funny.
  24. ranvier

    ranvier I can't anesthetize a rumor. 10+ Year Member

    Jul 17, 2006
    An ENT surgeon told me sailing is taking an ice cold shower while tearing up 100 dollar bills.
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  25. Psai

    Psai Account on Hold Physician 2+ Year Member

    Jan 2, 2014
    If they're so good at it maybe they can stop waking me up to watch them do it
    Wiscoblue likes this.
  26. Robotic Wis-Hipple

    Robotic Wis-Hipple ASA Member

    Feb 25, 2016
    I love that idea that we only deal with ideal condition airways when most floor or ED tubes I've had to assist or outright save could've been helped a lot by ideal positioning. Or ideal timing/planning rather than waiting until it got bad. My favorite is the residents attempting to intubate with their face 0.5" from the patient's mouth using a laryngoscope like it's an otoscope.

    It's a funny thing those ideal conditions, it's almost like some people know how to create those things....
    Last edited: Aug 8, 2017
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  27. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

    Aug 10, 2007
    Closer to Mexico

    We used to have paramedic interns come through to learn some airway skills. I always told them it was their job to optimize everything and create controlled/ideal conditions regardless of the situation. Always make it as good as it can be before you start.
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  28. anbuitachi

    anbuitachi ASA Member 7+ Year Member

    Oct 26, 2008
    lol what did he get in trouble for? whats wrong with saying grade 1 view? haha
  29. Mad Jack

    Mad Jack Critically Caring Gold Donor Classifieds Approved 2+ Year Member

    Jul 27, 2013
    4th Dimension
    What is scary is one day he'll have a real difficult trauma airway, and then he don't know what to do, and he will be too arrogant to call anesthesia fast enough, and the patient will die.
    Last edited: Aug 11, 2017

    BLADEMDA ASA Member 10+ Year Member

    Apr 22, 2007
    If only I could post the stuff I have seen Board Certified EM Physicians do to patients at my facility you would be shocked.
    sally23, ToldYouSo, PharmD500 and 2 others like this.
  31. IlDestriero

    IlDestriero Ether Man Physician Faculty 10+ Year Member

    Nov 24, 2007
    The ivory tower.
    They won't die. He'll call anesthesia when he's way way down the rabbit hole. He won't do a rescue surgical airway when he had the chance. Then we'll finally get there drop the tube one way or the other after the anoxic brain injury, and as a final going away present his note will say how long it took us to get there and imply that we caused the brain injury because it took so long to intubate.
    Fortunately we have a pretty good relationship with our intensive care people and ED, HOWEVER if you want me to be there for your attempts, it's my way or the highway. If you want me to be there while 4 people line up to try to intubate, you're on your own. If I really think the airway will be difficult, it's not a good teaching case for them. If I feel good about it, that's a different story. We aren't paid to be their back up.

    Il Destriero
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  32. IlDestriero

    IlDestriero Ether Man Physician Faculty 10+ Year Member

    Nov 24, 2007
    The ivory tower.
    The private forum is only a few clicks away...

    Il Destriero
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  33. acidbase1

    acidbase1 5+ Year Member

    Jul 28, 2011
    This is an understatement. One night I went down to the ED after being called by a frantic nurse around 3am. Walk in, blood everywhere, blood pressure through the roof bc he used incubating dose of rocuronium without redosing hypnotic. Airway a complete disaster after he attempted to intubaed this lady for 30 minutes. Finally got a 6.0 tube in with a fiber optic scope 2/2 to all the airway edema.

    I get a kick out of this study bc we were at a major academic institution with a solid ED program
  34. AdmiralChz

    AdmiralChz ASA Member 7+ Year Member

    Sep 8, 2008
    Fight fire with fire - at my residency institution the ED docs were taught to input times when they called/received a call back/filled note or decisions from consulting services. When you put in your intubation note, do the same: "Was called by Dr. X for assistance at Y time, arrived at Y+3 minutes and found..."

    Probably won't fully protect you but I can't see it hurting to put in the note if you have a poor relationship with your ED.
    Swamp Gas likes this.
  35. Neogenesis

    Neogenesis Certifiable 10+ Year Member

    Dec 10, 2005
    It was a combination of snarky attitude (he was still a resident) and the fact that he just walked away after placing the tube without securing it, etc. It was pretty much an intubating version of a mic drop.
  36. Hoya11

    Hoya11 Senior Member 10+ Year Member

    Sep 4, 2004

    Here's one that happened to me from less than a month ago:

    60 year old guy gets in an MVA while visiting another state 2 hrs away.

    He goes to the local ER, he feels fine, gets a tetanus shot, negative head CT. He is discharged home and drives back to his home state with his wife.

    On the ride home he notes trouble speaking, some pain in his throat. He decides to go to right to his home ER after the drive home.

    He walks into the ER, gets a regular room, tells his story, says he thinks he is having an allergic reaction to the tetanus booster.

    Starts to have difficulty breathing, increasing throat swelling, decision to intubate him by the ER attg after about 1-2hrs in ER room.

    Then, my beeper goes off: Surgical Airway Code ER

    I enter the room to find the ER attending attempting to intubate with a Miller 3, a bloody mouth, bloody glidescope blade, and a pale white patient who is being coded.

    He places the tube and gets condensation but no CO2. Listen to the chest and its likely in the esophagus. Pull it out.

    I put the glidescope blade that he was using back into the guys mouth. Nothing but red blood everywhere, no view of anything, ENT preparing to cut.

    I change glidescope blades to a new one, see a clear picture now of a massively swollen oropharynx with barely visible tip of the epiglottis.

    I managed to intubate him with one pass, and upon intubation pulse returned and he became less cyanotic and HD stable.

    Good save, I thought. Next day, EEG shows brain death.
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  37. WholeLottaGame7

    WholeLottaGame7 10+ Year Member

    Jul 10, 2005
    Right here.
    Back when I was on my surgery AI in med school (had to choose surgery or IM), went to a trauma in the ED around 0400. 20-something year old guy, super altered, was found in a ditch somewhere after being on the losing end of a fight. Vomiting/aspirating burgers and beer everywhere. ED tried for awhile, paged anesthesia. Attending rolled in, half-asleep, casually crossed the room, DL'd, held out his hand for the tube, placed the tube, and casually strolled out. I remember thinking "what a boss, I want to be that guy."

    Also, I can't believe we've gotten this far in the thread without this being mentioned:

    It's only funny because it's true...
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  38. turnupthegas

    turnupthegas 2+ Year Member

    Jan 10, 2014
    Van down by the river
    I bailed out the MICU attendings and ED attendings routinely as a resident. The ED docs thinks they are good at everything. In reality, everything they do someone else in the hospital is specialized and can do it much better.

    Sent from my iPhone using SDN mobile
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  39. pgg

    pgg Laugh at me, will they? Moderator 10+ Year Member

    Dec 14, 2005
    Home Again
    The "tracheal vomiting syndrome" gets me every time. :)
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  40. 0kazak1

    0kazak1 ASA Member 7+ Year Member

    Nov 30, 2009
    I like to tell people that, yeah anesthesia can get exciting, but like a airline pilot I'm okay with 'boring' day, there's only so much excitement I (or the patient for that matter) can take.

    There only been a few people that have made me say that since I started medicine. And one of the first was why I changed my mind from going into surgery (which those guys are cool and all), but damn that anesthesiologist is the man. (The others who were not anesthesiologists, were in crit care.)
  41. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

    Jun 20, 2005
    Save the drama for you Momma.
  42. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

    Jun 20, 2005
    We are a rural setting and therefore we feel it is our duty to train our EMT-P/ Paramedics to manage an airway since the vast majority of my group can easily see themselves needing their services in the field. When these individuals first started coming to us they had the gall to act as if they only needed to show up and get their intubation. After a couple visits they realized how much they lacked in the area of airway management. It took a couple years to get these paraprofessionals to realize why they were in our OR. We also had a few ER docs claim that they were the real airway specialists. But after time and a few bailouts plus more than a few laughs from our surgical colleagues they realized the absurdity of that stance. Now the paraprofessionals are much more eceptive to our guidance. Or else they are not invited back.
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  43. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

    Jun 20, 2005
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  44. ballinsncbirth

    ballinsncbirth Junior Member 10+ Year Member

    Feb 23, 2005
    as an ER doc who loves reading the anesthesia forum (EM and anesthesia are the only interesting ones) , I am trying suppress my knee reactionary defense of EM and "anesthesia suxors!!! " response. But truthfully I can easily admit that the 3rdyear resident is an idiot for saying that. A 3rd year resident EM resident training at some trauma center has very little idea of actual emergency medicine as it is practiced in the real world. Being in that environment where you are constantly getting crapped on , and [email protected]@k measuring by every other service in the hospital , sometimes they feel the need to defend themselves against constant belittling

    anesthesia is the king of airway(especially in most trauma centers or level 3/teaching programs) however this is not where the majority of EM docs or anesthesia docs practice. I have noticed an interesting correlation in the difference between private docs and ivory tower docs.

    In emergency medicine docs who practice exclusively in the ivory tower for a prolonged period of time , without any private practice are not practicing emergency medicine and usually pretty....les than ideal . . When you have every consultant on call 24/7 , residents doing all your grunt work , a full service trauma service, and can consult ent for every scratchy throat, optho for every conjunctivitis and anesthesia "just to come take a look " at a "difficult airway" , you get complacent . New grads, and docs who have practiced a long time at these places are usually in for a rude awakening when they try and join the private world.

    Whereas private docs in most places are "the only docs in the hospital "at times especially at night. I do not have any specialist in the hospital at night (anesthesia including), and they are at least 30-60 minutes away (that's if they call back at all) in this environment you learn real emergency medicine. you do not have the crutch of and specialist that can come save you.

    The opposite is true for every other specialty . docs in private practice in these small hospitals usually have not maintain the breath of skills they had in residency .(and nor should they ) If I call my surgeon who has done nothing but gallbladders and appys for 20 years, to put in an chest tube they will look at me like I am crazy . Have you ever scene a private practice cardiologist try to run a code on the floor ? its quite laughable. I once had to stop an anesthesiologist during a code who stopped cpr for 5 minutes while he furiously was trying to get an abg in a guy with no heartbeat. Our ortho haven't reduced shoulders or ankle or placed a splint in years since residency (especially not under sedation) . and don't get me stared on almost every private doc sending patients to the ER for emergent blood pressures of 160/80 or blood sugars of 220 .

    We all have our strengths and weakness of your specialties.

    So yes if I get hit by a car I would rather be at a trauma center and intubated by anesthesia as they are better at the airway . however unfortunately if I am brought anywhere else than trauma center I would much rather be seen by an er docs , than a combination of surgery , medicine, and anesthesia coming own from the ob suite.
  45. ranvier

    ranvier I can't anesthetize a rumor. 10+ Year Member

    Jul 17, 2006
    OB has crash intubations just as gnarly as trauma.
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  46. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

    Jun 20, 2005
    Not exactly. But close.
  47. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

    Jun 20, 2005
    Lots of good points to consider here. But the bottom line is that when the chips hit the table and the cards are laid, chances are that the anesthesiologist and vpeven the crna is a better option than just about any ER doc, period. I'm not trying to be disruptive at all. I appreciate everything you ER guys/gals do but strictly taking the odds like I. A good poker game I'm going with the anesthesia team. The on,y thing more dangerous is overconfidence from the ER person(and anesthesiaperson as well). But we always know that we are attending end of the algorithm for intu Atkin and then it's off to the ENT. AND you saw the response from the one ENT on this post. I always bring them when I can to a bad airway. And it eases my mind if nothing else. I've even used them twice n my career. I'm very very thankful for them. But to have someone like this ER "resident" spew nonesense like this is disturbing to say the least.
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  48. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

    Jun 20, 2005
    Ohad ballinsrbirith, don't get me wrong. I (we) love having you participate in this forum and I hope everyone realizes the the benefit of your presence. Thanks.

    But if I may be blunt, I think your name here should be "BALLSNSRCH".

    Unless of course you are a chick. In with case you should be "BALLSINSRT".

    poor taste of course.
  49. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

    Jun 20, 2005
    I guess this could even be reversed.
  50. dchz

    dchz Avoiding the Dunning-Kruger Gold Donor Classifieds Approved 5+ Year Member

    Sep 25, 2012
    These are all good points, and I do appreciate the perspective that you offer and it has made me see more of the world.

    However, this is hardly justification for the original comment by the EM resident, or any of this BS that's propagated in many EM training programs.

    The key to forging good graduating residents is at minimum a level of conscious competence:


    By the EM resident's comment, he's literally at the unconscious incompetence stage; that means this resident has to get to conscious competence in less than 1 year!!!! Imagine how scary that is to the pts hes going to be seeing. Imagine if that pt is your loved one.

    Imagine if the trauma surgeon stepped in front of the CT surgeon and said he was the king of emergent chest tubes since all of the CT surgeons' chest tubes are in a controlled environment.

    Or the Ortho spine fellow saying he is the king of suturing dura because all the dura he sews are unintentional and all the neurosurgeon's dura cuts are all planned.

    Or even better yet, imagine the family medicine care doctor saying he's better than the EM doctor at running a ER because his FM residency is an unopposed residency, where they don't have the "luxury" of consults.

    I believe all 3 above examples are logically analogous to this airway situation, which really reveals the absurdity of this whole mentality. As you said, we all have strengths and weaknesses, but if we are so delusional that we don't know our weaknesses. Patients suffer.

    I openly welcome any ED resident to take any of my airways any day they want, no one ever shows up. May be they busy saving lives in their 8 hour shift to have any time to come by the OR or may be they Allen Iverson this thing - too good for practice
    Last edited: Aug 8, 2017
  51. ballinsncbirth

    ballinsncbirth Junior Member 10+ Year Member

    Feb 23, 2005
    I agree . EM resident In this case is dumb . It sometimes is hard to criticize our own , but I have no problem with it. Some EM residents (and most 3rd year residents of all specialties) tend to think they are invincible until they get out in the real world. That first difficult airway (with no backup) usually has a gut checking experience in the community .

    I also agree that anesthesia is better at the airway than most EM docs, especially in tertiary hospitals. (I mean that is your specialty I hope you'd be better)

    but the reality is that most intubations in this country (sans the OR ) are done in the ER , And 100 percent of these intubations are emergent, stomach full of Cheetos and mcdonanlds . 99 percent of these are accomplished without any problems. The reality is that either an anesthesiologist or EM doc wouldn't make any different in those.

    Now for the real difficult intubations , would an anesthesiologist do better? yep ..they would. I have no problem admitting that .
    But EM still good. And in most private hospitals in this country there is no such thing as anesthesia backup for the emergent airway, and ER docs do a fine job.

    So if there was an option of putting an anesthesiologist in every ER 24/7 , to get the .01 percent of emergent intubations that cant be managed by EM , that would be great.... but unfortunately (well fortunately for me ) that isn't the case.

    Also my name is ballinsncbirth ie ( balling since birth )

    was cool when I came up with it when I was 13 , and just stuck .
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