Intubation training on cadavers

[Perrotfish]

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Could anyone recommend a good intubation course that uses unembalmed cadavers? I'd really like to take a weekend to improve my airway skills (I'm a military doc/pediatrician). Ideally I'd like a course that focuses on bread and butter intubation, rather than a lot of fancy toys that I won't have access to. Thoughts?

 

[Jay K]

You won't improve your skills intubating cadavers. Look into rotating through the OR with an anesthesia group. On occasion we'll have internists, paramedics, EMT's and the like rotate through for airway experience. If you want airway experience with neonates, look into rotating through a NICU. Spend your weekend there vs at a paid cadaver XP which sounds fairly useless (like intubating mannequins).

 

[Perrotfish]

You won't improve your skills intubating cadavers. Look into rotating through the OR with an anesthesia group. On occasion we'll have internists, paramedics, EMT's and the like rotate through for airway experience. If you want airway experience with neonates, look into rotating through a NICU. Spend your weekend there vs at a paid cadaver XP which sounds fairly useless (like intubating mannequins).

I have lots of NICU scheduled, so that's already taken care of (whether I like it or not). I may use an elective for anesthesia, but that's a long way off. However I've heard great things about unembalmed cadavers as practice for intubation from those who have done it, especially for people with no previous experience. I know of two courses: one in MD and one in SoCal, I really just want to know if there are any more.

 

[periopdoc]

This is going to sound snarky, but it isn't meant to be... Are you going to listen to folks with no experience or those of us who manage multiple airways every day?

Jay K's post reflects my exact sentiments. You say that you are interested in the bread and butter, not the toys. That is what you are going to get in the OR, and you are going to get a lot more of it than you will at a course, plus our subjects are not specially prepared to mimic real live tissue. Unless you are just dying to spend some CME money, save it and spend some time in your ORs. Not a elective rotation, just a couple of days. I know this might seem intimidating to someone who is somewhat unfamiliar with the ORs, but for those of us who work there every day, it is very common to have other docs, paramedics, etc drop by for intubations. Typically they go from room to room to make the best use of their time. In a typical day I might spend five minutes per case with one of these trainees before they are off to another room to do another intubation.

It really is a better use of your time, and the cost can't be beat. Our price free, cheap!

-pod

 

[leviathan]

I did a month in the OR and found that on the airways I missed, I never had a chance to play around with different positions with the blade (e.g. am I too far in, not far enough, not in the vallecula? etc), or using cricoid pressure or repositioning the head, or switching blade types, or using a bougie.

If I couldn't get a view of the cords in about 10 seconds the staff would take over. I feel like practicing on cadavers would give you the chance to practice changing your technique slightly to see what works/doesnt work without someone breathing down your neck trying to take over. Plus cadavers will have varying airway anatomy.

Thoughts?

 

[Dwindlin]

I did a month in the OR and found that on the airways I missed, I never had a chance to play around with different positions with the blade (e.g. am I too far in, not far enough, not in the vallecula? etc), or using cricoid pressure or repositioning the head, or switching blade types, or using a bougie.

If I couldn't get a view of the cords in about 10 seconds the staff would take over. I feel like practicing on cadavers would give you the chance to practice changing your technique slightly to see what works/doesnt work without someone breathing down your neck trying to take over. Plus cadavers will have varying airway anatomy.

Thoughts?

Did you have this problem with all the anesthesia staff? I ask because where I am this is a common complaint with the anesthetists. On the occasions I get to be in a room with an MD/DO they are generally much better about letting me actually take a look and "trouble shoot." I am at a community based program with no anesthesia residency, so no residents around.

 

[Perrotfish]

Did you have this problem with all the anesthesia staff? I ask because where I am this is a common complaint with the anesthetists. On the occasions I get to be in a room with an MD/DO they are generally much more better about letting me actually take a look and "trouble shoot." I am at a community based program with no anesthesia program, so no residents around.

I did a two week anesthesia rotation and had that exact problem with both the anesthesia staff and the anesthetists. I got pretty good at bag masking but on the few occasions when there wasn't an Intern who needed the training more than I did I got about ten seconds to fumble around before someone grabbed the tools out of my hand.

I'm not saying I really blame them. Its a living person who needs to breath. I just need some practice before I do the real thing.

 

[MRW]

What you are going to get from working with cadavers and Mannequins is practice on the basic mechanics of intubation. You get to practice the steps and make them rote so when you get a real attempt, you can focus on what you are looking at rather than whether or not to open the mouth first or stick in the blade...

It's helpful, but NOTHING replaces live soft wet tissue and a time limit...

 

[leviathan]

What you are going to get from working with cadavers and Mannequins is practice on the basic mechanics of intubation. You get to practice the steps and make them rote so when you get a real attempt, you can focus on what you are looking at rather than whether or not to open the mouth first or stick in the blade...

It's helpful, but NOTHING replaces live soft wet tissue and a time limit...

Obviously nothing beats the real deal..but when you have people who won't let you play around then wouldn't it be good for the reasons I stated? I always had people take over but I felt like if I had the chance to just adjust my technique and learn what works/doesnt work I would have had a much better learning experience.

I often found I had a view of the epiglottis but no matter how much I lifted the blade, it didn't budge. Before I had a chance to really adjust my technique someone would always take over and immediately get the tube in without even trying. What a blow to my ego! 😛 I found my batting average was about 70% where I'd get a great view immediately, and I don't know what was different about the other 30% where I was missing it. There were only 2 cases where I couldn't get a view and both the CRNA+attending also had trouble.

 

[Bertelman]

I think an anesthesiologist's response to your fumbling has much to do with your motivation for being in the OR. I've been around enough half-assed med students to understand which ones are sincerely interested in learning the skill v. the ones that just heard anesthesia was a soft rotation, easier than another 4 weeks of surgery.

If I had an EM resident who showed a sincere interest in learning, listened to advice and implemented our plan correctly, I would give all kinds of leeway and extra time to safely get the tube in the hole. Same with med students.

Spend an hour with some manikins. Become adept at attaching the blade to the handle. Practice inserting without knocking teeth. Practice holding the tube comfortably. Reposition the manikin head, practice with & without cricoid. Then show up in the OR, not worrying about all that secondary stuff. If you look like you know how to handle 5 inches of curved, cold hard steel, I'll give you at least 60 seconds to land it in the glory hole. I'll even get my hands in there and help you position correctly for proper climax. I don't want you leaving unsatisfied.

 

[leviathan]

Did something I say make it seem like I wasn't sincerely interested in learning the skill? Or why are you implying my motivation of being in the OR was not sincere?

I always asked for feedback on good and missed tubes, on the missed ones I usually was told 'your technique is good, it just takes practice'.

 

[Bertelman]

Not at all. I was just implying that I am sure there are others like me, more than willing to teach a motivated learner how to intubate. Maybe you just got a bad draw on your last experience. Maybe you didn't look comfortable or confident with your actions.

I also don't know where you are exactly in your training, but I would guess that you would be given better instruction and opportunity if they understood you have committed your own personal time to learn this, as opposed to this being an assigned med school rotation.

In short, as everyone else has said above, try to arrange some time in the OR. Explain to them why you are there, and how your last experience was not as beneficial as you would have liked. I guarantee it would be a better use of your time than tubing a cadaver. Understand that there is a significant learning curve to the task, and it will take close to 100 or more intubations before you will begin to understand how to alter your technique to be successful on the variety of anatomy that presents itself to you. That's what you can't get on a cadaver.

 

[Mman]

Could anyone recommend a good intubation course that uses unembalmed cadavers? I'd really like to take a weekend to improve my airway skills (I'm a military doc/pediatrician). Ideally I'd like a course that focuses on bread and butter intubation, rather than a lot of fancy toys that I won't have access to. Thoughts?

Unembalmed cadavers? Am I the only one that finds this request a bit disturbing? I'm assuming a cadaver would be nearly impossible to intubate after rigor mortis sets in. Why not just practice on lifelike mannequins? Airway dummies are fairly realistic with normal airway anatomy. They tend to have a little stiffer tissue but still better than a cadaver.

 

[rsgillmd]

Did something I say make it seem like I wasn't sincerely interested in learning the skill? Or why are you implying my motivation of being in the OR was not sincere?

I always asked for feedback on good and missed tubes, on the missed ones I usually was told 'your technique is good, it just takes practice'.

Leviathan, there is definitely something to be said for practice. There are probably subtle movements we make that we don't think about/can't teach. It used to bug the heck out of me as a CA-1 when I was struggling, and then my attending would take over and say, "That's easy! It's right there!" Then a few months down the road I found myself thinking in my head what he was saying out loud as I watched my juniors struggle.

I went through a period of struggling with intubations, to succeeding incredibly regularly, to struggling again before it finally became second nature. Give it time, and ask for live guidance if needed, but you have to realize you will not succeed at every attempt.

 

[pgg]

It's helpful, but NOTHING replaces live soft wet tissue and a time limit...

Agree that a person is a far better learning object than a plastic dummy. One of the reasons the OR is the best place to learn how to intubate is that the elective setting and pre-oxygenation often takes the time limit out of the picture. I'll let people flail for a long, long time while making periodic suggestions, adjustments, etc.

And if the student flails long enough and the patient needs to be mask ventilated - well, that's just an opportunity for them to practice mask ventilation, arguably a more important skill than intubation.



Perrotfish, if you're near an MTF of any size, including "glorified surgicenter" size, I have zero doubt that the anesthesia department would trip over themselves getting you some airway time in the ORs. We do it all the time for other doctors including GMOs, nurses, anyone who's deploying.

 

[Bertelman]

Unembalmed cadavers? Am I the only one that finds this request a bit disturbing? I'm assuming a cadaver would be nearly impossible to intubate after rigor mortis sets in. Why not just practice on lifelike mannequins? Airway dummies are fairly realistic with normal airway anatomy. They tend to have a little stiffer tissue but still better than a cadaver.

Rigor sets in around 24 hrs, then it relaxes.