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.
The only procedural skill I expect an EM intern to have is basic suturing.
The only way you'll go wrong is if you try and be all falsely confident and arrogant like a handful of interns do every year. Otherwise, what RustedFox said.
COVID has really done a number on what med students are allowed/not allowed to do, procedurally speaking, at my core site hospital. No intubations....can't even be in the room during ANY intubation. No chest tubes/observing chest tubes. No nasal/oropharyngeal epistaxis or drainage/FB procedures or observing them either. Can't eval or participate in the care of anyone who has sx suggesting a possible Covid infection is present either. As bad as this will be for EM auditions, those wanting to do a gas or ENT clerkship are really screwed because they haven't called off those clerkships....they've just been hamstrung.
Zero.
It's nice to have some practice (along with good underlying habits). If you're at zero, Dr. Levitan has some nice info online. Good preparation (positioning, oxygenation, resuscitation, medications, ? NG) make a big difference in how hard it is to "intubate" (i.e. pass the tube). Skip or mismanage the preparation, and intubation will be unnecessarily hard. The OR is a ok place to get a foundation, but not the same as the ED.
It's nice to have some practice (along with good underlying habits). If you're at zero, Dr. Levitan has some nice info online. Good preparation (positioning, oxygenation, resuscitation, medications, ? NG) make a big difference in how hard it is to "intubate" (i.e. pass the tube). Skip or mismanage the preparation, and intubation will be unnecessarily hard. The OR is a ok place to get a foundation, but not the same as the ED.
I never intubated as a student. First intubation was as a resident.
I except zero experience for everything.
I do expect you being open minded to how I explain the procedure.
I do expect you being open minded to how I explain the procedure.
My first intubation was as a resident on my NSICU rotation. I cranked back and knocked this guys tooth out. Attending...classic palm to the face.
Med students shouldn't even be getting the opportunity to intubate. Interns and residents need that practice.
They should in the OR. But I agree w/ you that ED intubation is not really a med student procedure (although I'll let students take a shot at easy appearing, stable patients as well as codes that I'm about to call). The culture at my residency was to let med students attempt intubation (attendings would let the resident make the call) and it kinda pissed me off, since our procedure numbers were really not out of the world at all (despite trying to project that we had more than enough)
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 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.
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.
Meh I let med students intubate all the time. If your senior residents have done so few procedures that giving away a few tubes is an issue then you've got much bigger problems to worry about before graduation. Also you shouldn't just be giving them away I expect all our senior residents to be right there with the med student guiding them through the entire procedure. Its a shame that many places have turned rotations into nothing more than glorified shadowing experiences where everyone just stands in the corner watching codes like they're still a pre med college student.
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.
Sometimes teaching is actually more beneficial than doing it solo because you watch mistakes happen and show how to correct them in real time.
So in a sense I still got to do the intubation as a resident, I just used someone else’s hands.
1) That’s a little dramatic. I’ve let plenty of med students intubate. Mind you, it’s not my IPF patient on 50lpm HFNC. It’s my 19yo GHB OD who you can DL for a week before desating.
2) If your attending is about to soil himself or herself, that is saying something else.
PAs and NPs 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.
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.
When I was a PGY-4 I think I let an internal medicine intern intubate. She was interested in doing so, it was a slow Sunday night in the ER, and we had literally no other residents around for some reason.
But I agree as a general policy unless your program has tubes coming out of the walls left and right and you have so many you don't know what to do with them, it should be something that EM residents do.
But I agree as a general policy unless your program has tubes coming out of the walls left and right and you have so many you don't know what to do with them, it should be something that EM residents do.
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
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.
And on my anesthesia rotation, I did more epidurals/spinals than intubations because of the CRNAs.
I will say that I thought LMA placement was lame when I was a med student/resident but it’s a very valuable skill that has saved my bacon more than once in the years since.
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.
As a PGY 3, I gave a large subset of my airways and CVLs to med students. Agree to disagree. I feel like after my CCM fellowship, there is very little that makes me sweat. Airways became much less intimidating when I became facile with the bronch and surgical airways - now, if I’m actually worried, I just awake bronch. Things still go badly for me, but I’m a lot more confident that they would have gone badly for anyone else in my shoes.
10 shifts left in residency here; I intubated exactly one human prior to residency beginning. At my program I guess we still have the "tubes up to your eyeballs" because I think I did somewhere around 50-60 intubations intern year alone. In the past 6 months I probably have done 10 intubations. If we had interested medical students I would give them the chance, but in the age of COVID they just go to the interns.
Was doing anesthesia rotation during medschool where they didn't have residents but the CRNAs were a**holes so I snuck off to the ED (also without residents) for a couple hours. Chopped it up with one of the docs, saw a couple patients with him, and he let me tube an incoming acute respiratory patient. Went off without a hitch and I knew EM was for me lol. Also learned that experience was exceedingly rare.
Was also able to get a couple during surgery rotation if I went directly down with the patient.
Was also able to get a couple during surgery rotation if I went directly down with the patient.
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I watched a resident set up for a tube gripping the blade handle with their hand fully pronated, ie palm out thumb down. Never seen such a thing
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.
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.
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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.
Now that's interesting. I can't think of anything more frustrating than supervising a medical student doing an LP...
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.
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.
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.
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I think the only two emergent reasons to perform a LP are to evaluate for SAH and meningitis. NPH, IIH and other conditions don’t really need emergent evaluation.
I’d guess decreasing rates of LP are due to combination of reasons. There isn’t much clinical utility in chasing after head CT negative SAH. I almost never perform LPs to evaluate for SAH any more. CTA, CTV and MRI/MRA are becoming increasingly utilized in general to evaluate neuro complaints (not specifically for SAH). I think we also better recognize that there are very few patients with meningitis with decreased need to perform LPs in the ED. True meningitic patients usually present super sick with sepsis as well and typically get empiric treatment anyways.
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.
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.
If you can mostly rule out SAH with an image, and let IR’s do the LPs for presumptuous meningitis that you covering for . . . you don’t have to do any LP’s. It’s a skill that most IM docs have lost. I really like them, but they are a time sink and don’t pay hardly at all.
Theoretically it should be opposite. Previously there was enough evidence to leave the LMA in and not intubate until you get ROSC due to reductions in high quality CPR. Now with COVID, AHA and others prioritize intubation over chest compressions to reduce exposure
If you want to get a leg up: read a few articles/summaries about the pharmacology of various induction cocktails and learn this stuff cold. Watch videos about proper bag mask technique.
These 2 things will give you a great start!
These 2 things will give you a great start!
Seriously. My 2 week anesthesia “rotation” was a complete waste of time. Pretty much was told on the first day that CRNA students had priority. Only one of the anesthesiologists would routinely grab me and kick the students out of the way so I could get procedures. I even tried to weasel a couple of central lines and A-lines for transplant patients. Nope...they’d grab the CRNA students and give those to them as well.
Our departments are busy enough, we get most of ours on shift
Don’t even get me started on our policy of “CRNA’s intubate everywhere except the ED”
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.
Just looked it up--jeez, 2.25 RVU (80 bucks) is flat out ridiculous compared to other things we do.