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Med students shouldn't even be getting the opportunity to intubate. Interns and residents need that practice.
What is the expected intubation skill level for an incoming EM intern? Pre-COVID I had the chance to do an M4 anesthesia rotation for a couple of weeks before COVID fully hit and rotations got cancelled for the rest of the year. I'd say my proficiency rate was about 50% and even then most of the ones I managed to get weren't first pass, and these were on relatively normal/healthy patients that the CRNAs let me attempt.
Meh. Some places have enough to go around, but I agree that if the people with needs are ignored, then it's a problem. Med students don't have a need to intubate.Med students shouldn't even be getting the opportunity to intubate. Interns and residents need that practice.
I taught multiple medical students how to intubate in the ED as a PGY-3 chief resident. I was standing by the head of the bed with them the whole time, sometimes with my hand on the video laryngoscope as well if they were super nervous.Med students should never intubate in the ED, period.
I don't care how "procedure heavy" a residency program is, every single intubation should be done by a resident. It is one of those procedures, I have found, that requires over and over repetition. It is without a doubt, the highest risk intervention we perform on a daily routine basis. It is also deceptively simple and I find people get way overconfident. Dunning Kruger in full force.
I think an intern should understand some basic points such as "hold the blade in your left hand", and perhaps some very superficial understanding of RSI (the basic principles of it). But it is a pretty detailed procedure with a lot of minor adjustments that can make or break what happens to do the patient, and those details take years to implement, and even then, I've had my own attendings struggle with an airway that I could not secure.
Nothing is more humbling than watching a patient crash in front of you and watching your own attending with decades of experience nearly soil themselves.
Med students should never intubate in the ED, period.
I don't care how "procedure heavy" a residency program is, every single intubation should be done by a resident. It is one of those procedures, I have found, that requires over and over repetition. It is without a doubt, the highest risk intervention we perform on a daily routine basis. It is also deceptively simple and I find people get way overconfident. Dunning Kruger in full force.
I think an intern should understand some basic points such as "hold the blade in your left hand", and perhaps some very superficial understanding of RSI (the basic principles of it). But it is a pretty detailed procedure with a lot of minor adjustments that can make or break what happens to do the patient, and those details take years to implement, and even then, I've had my own attendings struggle with an airway that I could not secure.
Nothing is more humbling than watching a patient crash in front of you and watching your own attending with decades of experience nearly soil themselves.
Med students should never intubate in the ED, period.
The one tube I did as a student the 3 put their hands on mine and watched one the video as I did it DL. So she was able to show me the correct movement as I attempted to intubate the esophagus.
Seemed like a pretty reasonable way to teach a student while not endangering the patient.
I did an anesthesia rotation at a community hospital (no residents) in my fourth year. Did ~30 intubations.
I did 6 intubations in the ED on my 3rd and 4th year rotations. Each time, either no resident was around or they actively gave it to me and walked me through it. In speaking with my friends, it seems like I got very lucky because several of them had none in the ED. I don’t think having zero experience prior to starting intern year will matter.
And on my anesthesia rotation, I did more epidurals/spinals than intubations because of the CRNAs.
Just a week ago, had a drive up gunshot wound patient that that lost a pulse, could not secure the airway via DL (expanding hematoma over the neck with tracheal disruption) that required a surgical airway. The patient survived.2) If your attending is about to soil himself or herself, that is saying something else.
Just a week ago, had a drive up gunshot wound patient that that lost a pulse, could not secure the airway via DL (expanding hematoma over the neck with tracheal disruption) that required a surgical airway. The patient survived.
Maybe I'm weak, but I nearly soiled myself watching that unfold.
I think most well trained people respect the airway. And if you aren't nervous, I think it's a problem. I agree though, being nervous to the point that it incapacitates you is obviously detrimental.
But as Weingart refers to the "laryngoscope as a murder weapon", there is something about airway that is particularly nerve racking because it's an intervention you are performing that has the potential to kill the patient.
I stand by my position that med students don't need to be intubating in the ED. EM interns/residents should get first crack at every airway. I've done 100+ airways in residency, and I still want to do more, and would frankly be annoyed if I saw it being given away to a med student. ED airways are different than the OR, more challenging, and less routine. Let med students intubate on anesthesia all day.
What is the expected intubation skill level for an incoming EM intern? Pre-COVID I had the chance to do an M4 anesthesia rotation for a couple of weeks before COVID fully hit and rotations got cancelled for the rest of the year. I'd say my proficiency rate was about 50% and even then most of the ones I managed to get weren't first pass, and these were on relatively normal/healthy patients that the CRNAs let me attempt.
program variation - our school had a huge anesthesia residency and CRNA program. Students would get maybe 1-2 tubes on that rotation cuz the residents and crnas needed the numbers
One of the things you will notice about medical education when you get into residency is that procedural training doesn’t follow the sort of organized “train to proficiency” model you will see in other industries. It’s more like throwing a steak into a pack of hyenas. I would recommend taking an airway course as an intern, it will make up for any deficiencies your anesthesia rotation may have.
Now that's interesting. I can't think of anything more frustrating than supervising a medical student doing an LP...Sadly, zero intubations as a med stud, but a pretty serious number of lumbar punctures that (no surprise) the residents wanted nothing to do with. Probably 30+ MS4. I was shocked when plenty incoming PGY-1s hadn't done one before.
Sadly, zero intubations as a med stud, but a pretty serious number of lumbar punctures that (no surprise) the residents wanted nothing to do with. Probably 30+ MS4. I was shocked when plenty incoming PGY-1s hadn't done one before.
What’s been the cause of the change?It's crazy but even in the 5 years I've been doing EM the numbers of LPs have dropped significantly.
I remember as an intern we'd get 3-4 per month but the interns now are lucky to get 3-4 per year sometimes.
What’s been the cause of the change?
The biggest reason is the use of CTAs to rule out SAH in patients.
On the subject of tubes, this whole covid thing has really thrown a wrench in my ability to get intubations as an intern.
Before we intubated virtually every cardiac arrest that came in with CPR in progress. Now most of them come in with an LMA and we leave it in place cuz it’s not worth the risk.
Questions you should get answers to before ranking programs: Is there an anesthesia residency here? Do CRNA students train here? Because you’re going to be in line after them for tubes.
Was this on a Neuro/ICU rotation? I went to school at a really crazy high acuity hospital and even then we weren’t seeing anywhere close to those numbers in the ED/wards.
Just looked it up--jeez, 2.25 RVU (80 bucks) is flat out ridiculous compared to other things we do.Parkland, LA County, and some work in South Africa. Mostly places where the supervision is pretty notional haha.
I feel like all the trials in 2011/12 regarding the efficacy of NCHCT within 6 hours to rule out SAH in thunderclap headache is what really drove the numbers down. I certainly don't mind doing them on the ever-growing American body habitus, but it's ridiculous how little they're reimbursed for how frustrating and time consuming they can be. I can knock out a laceration that's 3x the RVUs in the same time.