How did you learn to intubate and from whom?

[aspergilloma]

There seems to be a lot more variability among Pulm-CC programs than I had anticipated. Many of them have required anesthesia months during F1 year where anesthesiology attendings teach you, while other programs have a much less formal process where essentially you tube your MICU patients with the oversight of whatever CC attending happens to be there. Some programs fall in the middle of that spectrum, obviously.

What was your experience in fellowship? What are your feelings about it in hindsight? Does it even matter?

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[Hamhock]

What will your practice environment be afterwards?

Academic Pulm/CCM (usually Pulm-focused)? Mostly CCM in the community?

Large university? Busy community hospital?

How much airway experience do you have entering fellowship?

Answering your first question is a bit difficult without a better sense of your incoming experience and your eventual plans.

HH

 

[aspergilloma]

What will your practice environment be afterwards?

Academic Pulm/CCM (usually Pulm-focused)? Mostly CCM in the community?

Large university? Busy community hospital?

How much airway experience do you have entering fellowship?

Answering your first question is a bit difficult without a better sense of your incoming experience and your eventual plans.

HH

Staying academic, hopefully at a large center but if a smaller one has the research opportunities, that'll do just as well.
I'd like to be comfortable teaching residents/fellows in the MICU as a faculty member; ideally will have mixed pulm/CC clinical teaching duties
Never intubated anything besides a dummy

 

[Hamhock]

I think my answer hinges on what you mean by, "I'd like to be comfortable teaching residents/fellows in the MICU". Does that mean you would like to be comfortable teaching airway management to these residents/fellows (presumably mostly IM-trained) or does that mean you would like to be comfortable teaching the rest of medical CCM while letting them learn airway from others and having "airway backup"?

If it is the former, I can not emphasize enough the importance of obtaining training FAR beyond intubating MICU patients under the typical supervision of an IM-CCM-trained intensivist. Spending a month in the OR "learning" from an anesthesiologist is equally inadequate, although better than "learning in the MICU".

I would be happy to expand my response further, but I am still not sure what your airway and teaching goals are.

I will say that the highest-risk procedure an intensivist performs -- by far -- is endotracheal intubation...and sticking the plastic into the hole is the easiest part. I will also say that any anesthesiologist who claims OR airway training is adequate for ICU airway management is kidding themselves and you.

As you can tell, I have strong opinions about this and am considering study of standardization of airway management part of my career. Perhaps you will benefit from hearing from others before I continue.

Please don't minimize airway training,
HH

 

[aspergilloma]

I think my answer hinges on what you mean by, "I'd like to be comfortable teaching residents/fellows in the MICU". Does that mean you would like to be comfortable teaching airway management to these residents/fellows (presumably mostly IM-trained) or does that mean you would like to be comfortable teaching the rest of medical CCM while letting them learn airway from others and having "airway backup"?

If it is the former, I can not emphasize enough the importance of obtaining training FAR beyond intubating MICU patients under the typical supervision of an IM-CCM-trained intensivist. Spending a month in the OR "learning" from an anesthesiologist is equally inadequate, although better than "learning in the MICU".

I would be happy to expand my response further, but I am still not sure what your airway and teaching goals are.

I will say that the highest-risk procedure an intensivist performs -- by far -- is endotracheal intubation...and sticking the plastic into the hole is the easiest part. I will also say that any anesthesiologist who claims OR airway training is adequate for ICU airway management is kidding themselves and you.

As you can tell, I have strong opinions about this and am considering study of standardization of airway management part of my career. Perhaps you will benefit from hearing from others before I continue.

Please don't minimize airway training,
HH

I'm mainly glad that my perseveration on this question apparently isn't for naught haha. I wasn't sure if it was a meaningless detail that works itself out by F3 year.

To answer your question: I'm OK if, someday, I'm not the one teaching intubations to my pulmonary fellows as long as it wouldn't prohibit me from attending in the MICU. If Anesthesia intubates everybody in whatever academic MICU I end up attending, that's fine by me.

That being said, if it's expected that academic MICU attendings at my future university teach/oversee 90% of the tubes that get placed on their service, then yes, I would want sufficient training over the course of fellowship.

 

[Hernandez]

I think my answer hinges on what you mean by, "I'd like to be comfortable teaching residents/fellows in the MICU". Does that mean you would like to be comfortable teaching airway management to these residents/fellows (presumably mostly IM-trained) or does that mean you would like to be comfortable teaching the rest of medical CCM while letting them learn airway from others and having "airway backup"?

If it is the former, I can not emphasize enough the importance of obtaining training FAR beyond intubating MICU patients under the typical supervision of an IM-CCM-trained intensivist. Spending a month in the OR "learning" from an anesthesiologist is equally inadequate, although better than "learning in the MICU".

I would be happy to expand my response further, but I am still not sure what your airway and teaching goals are.

I will say that the highest-risk procedure an intensivist performs -- by far -- is endotracheal intubation...and sticking the plastic into the hole is the easiest part. I will also say that any anesthesiologist who claims OR airway training is adequate for ICU airway management is kidding themselves and you.

As you can tell, I have strong opinions about this and am considering study of standardization of airway management part of my career. Perhaps you will benefit from hearing from others before I continue.

Please don't minimize airway training,
HH

I was going to be snarky and say YouTube but this is a damn good reply and I agree, my last gig the icu primary team were hospitalists dedicated to the icu and they were so very cavalier with intubations and looked at me as if I was crazy when I said intubations and bronchs are the only procedure that I have a constant level of concern and forethought about what I'm going to do next if **** hits the fan.

There needs to be a structured approach in how intubations are managed yet it isn't a one size fits all approach. I rsi many but don't for others, I frequently start with a videoscope but don't on some, I always have a 2nd if not a 3rd tool nearby to help out and I'm still paranoid enough I carry a scalpel and tongue depressor for every intubation. I like the Difficult Airway Course's approach to how they airway and mine mirrors there's in many aspects.

 

[tartesos]

I have been lucky, I learned a lot in residency, Intubated over 45 people in residency( no fellows, 10 months of Icu), about at my 15th intubation one went terribly wrong( still remember everything about it) and I took it upon myself to get better, did an anesthesia elective and went to a difficult airway management course, read about it and today after well over a 150 and Pulm/Ccm training, I still get chills down my spine before each and everyone of them.

It is always better to prepare for a complication( who's your back up, boogie, Bronchoscope, LMA etc) and never need it, than be caught with your pants down in a crucial moment where less than 60 seconds can mean the difference between a good outcome or CPR.


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[tartesos]

Another thing, once you are doing bronchoscopies under conscious sedation, you learn the anatomy so well that it will become second nature to you when you there, even from the side of the bed when supervising.


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[MirrorTodd]

I know this is an old thread but I'm branching out from the lounge. Anyway, med student perspective: we had a half hour class on intubations during second year and practiced on a dummy once. Now, I'm a fourth year and have done 5 months of anesthesia (yay for picking your own schedule) where I've had people watch/coach me and picked up tips as I've gone along.
Naive surprise: I kinda thought I'd be intubating all the time in residency at least during internship. Is that not the case?

 

[gutonc]

I know this is an old thread but I'm branching out from the lounge. Anyway, med student perspective: we had a half hour class on intubations during second year and practiced on a dummy once. Now, I'm a fourth year and have done 5 months of anesthesia (yay for picking your own schedule) where I've had people watch/coach me and picked up tips as I've gone along.
Naive surprise: I kinda thought I'd be intubating all the time in residency at least during internship. Is that not the case?

In IM? I think I dropped 3 or 4 tubes total during my intern year. None after. Did 3x that many during my 2 weeks of Anesthesia as med student.

If you want them, you can get them. I didn't want them.

 

[tartesos]

I know this is an old thread but I'm branching out from the lounge. Anyway, med student perspective: we had a half hour class on intubations during second year and practiced on a dummy once. Now, I'm a fourth year and have done 5 months of anesthesia (yay for picking your own schedule) where I've had people watch/coach me and picked up tips as I've gone along.
Naive surprise: I kinda thought I'd be intubating all the time in residency at least during internship. Is that not the case?

As gutonc said it depends on interest and training institution( some places Anes intubates, ridiculous!!)

It's fun.


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[deleted547339]

If you do CCM, you need to find a place where you intubate all of your own patients. I interviewed at one program (with a very good reputation) where they could "ask anesthesia" if it was OK to intubate. That was a hard no for me.

Seek them out. Rotate in the ICU and ED and try to rotate with senior fellows and residents, respectively. Let them know you're interested.

Do an anesthesia rotation in residency and fellowship.

Go to an airway course. Rich Levitan puts on a great one.

Read about airway. Listen to podcasts.

Know that taking an airway is one of the few ways you can kill a patient. Give it the respect it deserves.

 

[AdmiralChz]

Interesting discussion, as someone who is almost done with Anesthesiology residency and seen some disasters it would make me pretty nervous if you are at a place where only Anesthesiology intubates. What if we are busy, in the OR, doing an epidural in the middle of the night, or simply far away? An intensivist MUST have a reasonable skill set to deal with airway emergencies. Just like any other physician, though, they should be able to identify potential difficult airways and not be conceited enough to not know their limitations.

 

[Raryn]

In IM? I think I dropped 3 or 4 tubes total during my intern year. None after. Did 3x that many during my 2 weeks of Anesthesia as med student.

If you want them, you can get them. I didn't want them.

I know this is an old thread but I'm branching out from the lounge. Anyway, med student perspective: we had a half hour class on intubations during second year and practiced on a dummy once. Now, I'm a fourth year and have done 5 months of anesthesia (yay for picking your own schedule) where I've had people watch/coach me and picked up tips as I've gone along.
Naive surprise: I kinda thought I'd be intubating all the time in residency at least during internship. Is that not the case?

As an IM resident, this is extremely program dependent. There's programs (especially in the northeast) where pulmonary fellows barely get to intubate floor patients, and a second year anesthesthia resident can over-ride a PGY6 fellow on the floor. And at those programs, anesthesia is typically in house 24/7 and goes to all codes. At those programs, residents typically graduate with zero intubations, unless they do an anesthesia elective and get a few OR intubations.

OTOH, at my residency program (a university affiliated community program on the west coast), we had no anesthesia program, and the MICU team got first shot at all code intubations. Intubating was an optional procedure, so plenty of my classmates graduated with 2 or 3 tubes... but if you wanted to do them (and I did, just for the experience), it wasn't that unusually to graduate with 20-30 tubes as a resident without too much extra effort, and some people tried to seek out even more.