Intubation difficulties

[GasMD]

I just rotated through the 2 week anesthesia rotation during my M3 year and had a terrible time with intubations (got 1 of 6). I know my technique is not perfect yet. I am strongly considering anesthesia for the residency. Does this mean my problems will continue and I should think of something else? I think I might be over-reacting but any advice will be good. Thanks

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[jwk]

I just rotated through the 2 week anesthesia rotation during my M3 year and had a terrible time with intubations (got 1 of 6). I know my technique is not perfect yet. I am strongly considering anesthesia for the residency. Does this mean my problems will continue and I should think of something else? I think I might be over-reacting but any advice will be good. Thanks

Six isn't very many. They may have been tough patients. Did the person with you just pop the tube in like it was nothing or did they have to work a little as well? Did they make any attempt to help you figure out what you were doing wrong? How long did your attempts take? Did you stick in the scope, look and not see anything and assume you failed, or did you move the scope around and try to find something that looked familiar? If your patient was pre-oxygenated well (they should be) and if the anesthesia provider made sure they had an adequate mask airway before they gave any muscle relaxant (they should have unless it was an RSI, in which case you shouldn't have been doing it anyway), you should have had plenty of time to manipulate the scope and look around.

You're definitely over-reacting. It's a technical skill that takes repeated practice. And ANY experienced anesthesia that tells you they NEVER miss is lying through their teeth.

 

[xampower]

Don't even second guess yourself for one minute. If you like the specialty and see yourself practicing anesthesia for the next 20 years the go for it. You will develop the skills. In residency you will do thousands if intubations. It is all about practice and repitition. During my elective when I would miss and intubation my attending would say "that is why residency is three years...don't sweat it".

 

[soon2bdoc2003]

Takes about 100 intubations before you really BEGIN to understand what it means to manage an airway. Even attendings with 15 years experience have to pass the tube to a more experienced person every once in a while. I have had lots of students rotate through and what I like to see is enthusiasm and willingness to learn. After all, respiratory therapists and EMT's can throw in a tube.. its not rocket science, but dont expect to become a master after 6 tries.

 

[gaslady]

I agree. Your experience with intubating so far shouldn't play any part in your decision making process. It's tough early on and there is a steep learning curve initially. Don't sweat it.

 

[snowman8]

Don't get frustrated! One attending said to me once, "it's all about patient setup and technique". If the patient is not at the proper height, position, and if you are not using proper form.....it will make the whole procedure a lot harder. I sat down for 20 mins and read about the proper technique and since then as a medical student, I have been pretty successful. Any procedure takes practice! Even the most experienced physician will miss an intubation or arterial stick now and again.

 

[heartICU]

I agree. I am still learning, and last semester was having the same problem as you...didn't seem like I was making any progress. Then, one day it suddenly clicked, and I learned to 'lift.' My success rate has been much better since then! Experience is all you need.

 

[DenRock]

Certainly don't base your choice of specialty based on SIX attempts! Getting good at airway management takes time. First, you need to understand the basics of proper patient and operator positioning, including the basics of bag-mask ventilation. It sounds easy, but it's a skill that most health care providers can't do properly. Second, you need a basic understanding of the anatamy to know exactly what you are seeing and going to see when doing laryngoscopy. This doesn't come from doing just 6 intubations as a student. Some reading is necessary, along with good instruction. Third, you need to more fully understand how to use the equipment. Again, this comes with good instruction, reading, and lots of practice (many more than 6). With time and practice will come the necessary skills.

I guess the take home message is that intubation/airway management takes much more time than simply a fourth year elective - it takes arguably a lifetime. Also consider all the other aspects of anesthesiology before giving up on it.

 

[OldManDave]

I just rotated through the 2 week anesthesia rotation during my M3 year and had a terrible time with intubations (got 1 of 6). I know my technique is not perfect yet. I am strongly considering anesthesia for the residency. Does this mean my problems will continue and I should think of something else? I think I might be over-reacting but any advice will be good. Thanks

GasMD;

According to several of our staff - to become facile at intubation requires b/t 25 & 50 attempts based upon sort article out I should have already read... So, I would certainly not be stressing over missing 5 of your first 6. Now, if you were a CA-3 finishing up & missed 5 of 6 unchallenging intubations - it is past time to fret!

Best of luck in making your career choice!

 

[timtye78]

GasMD;

According to several of our staff - to become facile at intubation requires b/t 25 & 50 attempts based upon sort article out I should have already read... So, I would certainly not be stressing over missing 5 of your first 6. Now, if you were a CA-3 finishing up & missed 5 of 6 unchallenging intubations - it is past time to fret!

Best of luck in making your career choice!

The idea of being a CA3 in this position is self-contradicting. I don't think they would hardly let you in the heart room if you cannot intubate.
The student surely shouldn't let these miniscule (sp?) experiences in any way shape their career choices. However, as a side note, someone once told me about an article that found that a lot of people were drawn to specialties that they felt the the MOST inadequate at knowledge or skills-wise, hence you have cardiologists who weren't exactly heart whizzes until they finished.

the idea of someone being 'born for the specialty' is rarely the case. Somehow, magically med students assume that if they were 'destined' to be an anesthesiologist, they would get the airway on every single attempt, and if they miss even one, they eliminate themselves from being an anesthesiologist or whatever. If that were true, I would not be in a gas residency. Honestly, I was fully matched into gas, and into my intern year (just several months ago) before my confidence with intubation was any better-the more you try, the better you will get.
To the OP-You will be fine-keep trying!

 

[OldManDave]

The idea of being a CA3 in this position is self-contradicting. I don't think they would hardly let you in the heart room if you cannot intubate.
The student surely shouldn't let these miniscule (sp?) experiences in any way shape their career choices. However, as a side note, someone once told me about an article that found that a lot of people were drawn to specialties that they felt the the MOST inadequate at knowledge or skills-wise, hence you have cardiologists who weren't exactly heart whizzes until they finished.

the idea of someone being 'born for the specialty' is rarely the case. Somehow, magically med students assume that if they were 'destined' to be an anesthesiologist, they would get the airway on every single attempt, and if they miss even one, they eliminate themselves from being an anesthesiologist or whatever. If that were true, I would not be in a gas residency. Honestly, I was fully matched into gas, and into my intern year (just several months ago) before my confidence with intubation was any better-the more you try, the better you will get.
To the OP-You will be fine-keep trying!

Relax Tim - it was a facetious comment implemented to stress a point.

 

[timtye78]

Relax Tim - it was a facetious comment implemented to stress a point.

 

[zreagle]

Takes about 100 intubations before you really BEGIN to understand what it means to manage an airway. Even attendings with 15 years experience have to pass the tube to a more experienced person every once in a while. I have had lots of students rotate through and what I like to see is enthusiasm and willingness to learn. After all, respiratory therapists and EMT's can throw in a tube.. its not rocket science, but dont expect to become a master after 6 tries.

Point of correction: EMTs do not intubate, paramedics intubate. What is the difference? About 1100+ hours of training. EMTs take a semester long course of 130 hours, paramedics attend a year or more of training that takes 1250-3000 hours. As a physician in anesthia you should know the difference.

I was a paramedic for 12 years before attending medical school and can tell you from experience that 6 attempts is nothing. It took about about 2 years and close to 100 intubations before I had any skill - passing a tracheal tube is the easy part, deciding when it is necessary and ensuring effective ventilation and oxygenation is much more important.

If you like anesthia, go for it you will have plenty of time to develop your airway management skills.

peace out
Z

 

[mikecwru]

Point of correction: EMTs do not intubate, paramedics intubate. What is the difference? About 1100+ hours of training. EMTs take a semester long course of 130 hours, paramedics attend a year or more of training that takes 1250-3000 hours. As a physician in anesthia you should know the difference.

I was a paramedic for 12 years before attending medical school and can tell you from experience that 6 attempts is nothing. It took about about 2 years and close to 100 intubations before I had any skill - passing a tracheal tube is the easy part, deciding when it is necessary and ensuring effective ventilation and oxygenation is much more important.

If you like anesthia, go for it you will have plenty of time to develop your airway management skills.

peace out
Z

I was taught to intubate and did so as an EMT basic before med school.

mike

 

[gasgodess]

I was taught to intubate and did so as an EMT basic before med school.

mike

me too
goddess

 

[jwk]

Point of correction: EMTs do not intubate, paramedics intubate. What is the difference? About 1100+ hours of training. EMTs take a semester long course of 130 hours, paramedics attend a year or more of training that takes 1250-3000 hours. As a physician in anesthia you should know the difference.

I was a paramedic for 12 years before attending medical school and can tell you from experience that 6 attempts is nothing. It took about about 2 years and close to 100 intubations before I had any skill - passing a tracheal tube is the easy part, deciding when it is necessary and ensuring effective ventilation and oxygenation is much more important.

If you like anesthia, go for it you will have plenty of time to develop your airway management skills.

peace out
Z

Same here - was intubating as an EMT 30 years ago.

Also, paramedic courses in the 70's-80's were a lot shorter. Our course in Missouri was 200 hours, including intubations, IV's, meds, EKG and defib, etc. Obviously it's not as comprehensive as it is now, but we were also hospital-based and got tons of hands-on experience in a very progressive ED. At the time I left, they were teaching their paramedics to do trans-thoracic pacing. Intra-cardiac epi was a standard at the time, so threading a wire through the needle was not a big jump.

 

[Tenesma]

as an EMT- basic I intubated as well (initially with combitubes then on to endotracheal tubes) - of course, if paramedics were on the scene they got first dibs... (if they made it to the scene)....

I have intubated over 3,000 people so far - stopped counting after residency (darn acgme logs), and while I feel very confident - there are still a few that make your perineum knot up real tight

 

[Benjamin]

Dude, I couldn't buy a freakin intubation during my first 3 weeks in anesthesia. Now Im a pro. Dont even worry.

I just rotated through the 2 week anesthesia rotation during my M3 year and had a terrible time with intubations (got 1 of 6). I know my technique is not perfect yet. I am strongly considering anesthesia for the residency. Does this mean my problems will continue and I should think of something else? I think I might be over-reacting but any advice will be good. Thanks

 

[UTSouthwestern]

One of our CA-1's missed her first 30 intubation attempts. She hasn't missed since.

 

[Jalopycat]

I had the exact same problems on my 2 week rotation. I thought what made it difficult for me to intubate was having a high strung attending on one side of me and a nervous resident on the other side. After having the scope in for maybe 5 seconds, the attending starts yelling, "what do you see?". Hell, I'm trying to concentrate on what I'm doing. When I don't answer her, she screamed "answer me!" and hit my arm. After that experience, I was completely psyched out and didn't get another one that day.

I always thought anesthesia was known for it's relaxed attitude, but on this rotation, I've met more malignant attendings than any other rotation. During the two weeks, I successfully got about 2 out of 10 attempts. It's pretty frustrating. I'll try again next year when I do a longer rotation.

 

[UTSouthwestern]

I had the exact same problems on my 2 week rotation. I thought what made it difficult for me to intubate was having a high strung attending on one side of me and a nervous resident on the other side. After having the scope in for maybe 5 seconds, the attending starts yelling, "what do you see?". Hell, I'm trying to concentrate on what I'm doing. When I don't answer her, she screamed "answer me!" and hit my arm. After that experience, I was completely psyched out and didn't get another one that day.

I always thought anesthesia was known for it's relaxed attitude, but on this rotation, I've met more malignant attendings than any other rotation. During the two weeks, I successfully got about 2 out of 10 attempts. It's pretty frustrating. I'll try again next year when I do a longer rotation.

Where are you at?

 

[pharmer]

I feel everyone's pain. I'm a second year medical student and I plan on doing gas in the future too. I went through pharmacy school first and during my last year of pharm school I was on an OR pharm rotation. My preceptors knew I would be starting medical school the next year so they just let me follow around gas residents to the OR about everyday. On my second day of following around one of the residents (he was high strung but nice) after the first case of the day he turns to me and says "sorry we didn't get you an intubation." I was like whatever thinking he was kidding. The very next case I'm with him I find myself holding the scope with no anatomy classes ever and little more than a one minute crash course on intubation on my side. I start my attempt w/ no idea what I should be looking at and 5s later the attending is barking at me to tell her what I see. I have no idea, I've never had an anatomy course in my life and could be looking straint at the cords and still not know that's what I'm suppose to see. I jokingly looked up at her and said "throat". No one thought that was funny. I then proceeded to get yelled at until the attending learned I was a freakin' pharmacy student. Then the resident got a new a-hole torn. Needless to say I didn't get the intubation but I'm hoping my future experiences will be much different

 

[Jalopycat]

Hey UT, I'm up the road from you about 400 miles.

 

[juddson]

It seems to me that I'll do OK with tubes, but I'm certain I'm going to knock out a few teeth along the learning curve. How do you prevent this from happening? Why don't they make a device that protect the teeth?

judd

 

[UTSouthwestern]

Hey UT, I'm up the road from you about 400 miles.

Just curious.

 

[rhinosp_33]

I feel everyone's pain. I'm a second year medical student and I plan on doing gas in the future too. I went through pharmacy school first and during my last year of pharm school I was on an OR pharm rotation. My preceptors knew I would be starting medical school the next year so they just let me follow around gas residents to the OR about everyday. On my second day of following around one of the residents (he was high strung but nice) after the first case of the day he turns to me and says "sorry we didn't get you an intubation." I was like whatever thinking he was kidding. The very next case I'm with him I find myself holding the scope with no anatomy classes ever and little more than a one minute crash course on intubation on my side. I start my attempt w/ no idea what I should be looking at and 5s later the attending is barking at me to tell her what I see. I have no idea, I've never had an anatomy course in my life and could be looking straint at the cords and still not know that's what I'm suppose to see. I jokingly looked up at her and said "throat". No one thought that was funny. I then proceeded to get yelled at until the attending learned I was a freakin' pharmacy student. Then the resident got a new a-hole torn. Needless to say I didn't get the intubation but I'm hoping my future experiences will be much different

ha.. thats a funny story.

 

[Tenesma]

juddson...

i doubt you will knock out teeth... chipping is a lot more common. Some people where a difficult laryngoscopy is expected will use teeth-guards (same thing that pulmonologists or thoracic surgeons use to cover the teeth when they do rigid bronchs).

 

[NYCDawg81]

.

 

[apma77]

pharmar thats a great story..esp the part where the resident got his a hole torn!