intubation

[gasman654]

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Hello,

I am a 3rd yer med student interested in anesthesiology and am currently near the end of my 2 week core anesthesiology rotation.

Thanks

 

[pgg]

It takes dozens of intubations to begin to be comfortable. There is no one on earth who can't, with practice and good instruction, become proficient at it. Profiency in procedures is not expected in rotating 4th year med students. 4th year students who come in thinking that they're proficient worry us more than the ones who come in knowing they're not good at it. Don't sweat it.

Two suggestions
1) Take the time to get the patient in good position before induction, including table height. Preoxygenate well, so you don't feel hurried.
2) Give the muscle relaxant time to work. Succ is quick, but give roc a minute+ to work. One of the reasons 2nd attempts by someone else can look so easy after your initial flail is because the drugs have had time to work. And take this time to practice mask ventilation, when appropriate - it's a more important skill than intubation, but underappreciated.

 

[norwood]

4th year students who come in thinking that they're proficient worry us more than the ones who come in knowing they're not good at it.

+1

I'm far more interested in med students being involved and interested in learning than I am in whether they've already achieved procedural competence.

Best advice I can give you is to sign up for a 4 week elective. I agree with each thing pgg wrote (with the caveat that people who just don't care about learning won't become good - that's the one thing we can't teach trainees about intubating!) but hands-on advice from someone who can watch what you're doing is priceless.

Personally, what I love to do with beginning trainees is to put them on a Glidescope, so that I can do one or two intubations while pointing out the anatomy that they should look for, and then so that I can see what they're seeing. I have them use it like a Mac blade at that point - the screen is for me, not them. Then they go to a Mac blade, and we get the Glidescope back out once they're more proficient. But that's just me. What's critical is to keep doing intubations and keep asking for advice.

 

[deleted171991]

Agree with pgg. Intubation has a steep learning curve until you reach your aha moment. Don't sweat it.

To quote my attendings: "There is a reason anesthesia residency is 3 years."

 

[countingdays]

I was worse at it than you as a med student and now I'm amazing 😉.
Don't sweat it. You'll get it.

 

[deleted171991]

The glidescope is amazing. 😉

 

[Bostonredsox]

Hello,

I am a 3rd yer med student interested in anesthesiology and am currently near the end of my 2 week core anesthesiology rotation. The problem is, I am horrible at intubating and have only been successful a handful of times. How bad is it that I am still so bad at them? My away rotations are not until August so I am worried by then my skills will have decreased even more and I will not be competent. I go to a D.O school and do about 2-3 intubations per day. I am trying to do MD anesthsiology and my step 1 ws 228.

Thanks

It's a procedure. Just like any other procedure, skill comes with practice. Don't sweat it.

 

[gasdoc77]

Agree with the aforementioned, particularly masking. No matter what specialty, the ability to mask well is indispensible. If you can master using 2 hands, gripping tightly behind the angle of the mandible and pulling the jaw firmly into the mask with a snug seal, you can ventilate any patient under any condition any day of the week; oral and nasal airways helping all the more. That comfort will completely alleviate the angst surrounding airway procurement. When time is no longer of the essence, intubation becomes more of a game of how slick you can make it look.

 

[gasthrowaway]

I am trying to do MD anesthsiology and my step 1 ws 228.

I assume you're mentioning to gauge your chance of matching. Apply broadly and cover all the mid and low tiers and you'll be fine.

 

[deleted87051]

MS3s are all horrible at intubation. You're supposed to be. If any of your classmates say they are good at it, they are lying or have no self awareness. That you recognize you are horrible is an attribute. As others have said don't sweat it.

 

[Planktonmd]

There is one important thing to remember: This is the OR, it's done under very controlled conditions, you are not going to kill the patient, and no one is expecting you to be quick or slick... take your time and insert the scope slowly, there should be zero excitement and zero anxiety.
Most new people fail because of stress and anxiety.

 

[Druggernaut]

Just to give you another student's perspective, I did four weeks of anesthesia. I'm not good at intubating, but at two weeks I was abysmal. It seemed to get a lot better in weeks three and four (I think I had a run where I was 0/9 in my second week, then finished something like 7/8 on my last two days). Everyone I've spoken with has had a similar experience. Just keep trying, and try to get in on as many things as you can, not just intubations.

Hopefully you have cool attending/residents. I had one who would pimp me while I was at the head of the bed ventilating the patient, really rip into me when I whiffed on his questions, then mock me in front of everyone in the OR when I (surprise!) missed the tube. Others would let me take my time as long as I thought I had a shot and the patient wasn't desatting, and I did much better and learned much more.

 

[Twptophan]

I had zero successful intubations my MS3 year because I kept going on the wrong side of the epiglottis.

 

[gasman654]

Hey all,

Thank you so much for the encouragement I really appreciate it! I got kind of siked out after hearing fellow classmates but after reading this thread I feel way better. You guys are awesome!

Thanks,
Sacredlearner

 

[Consigliere]

CRNAs will be doing all the intubating in the future so don't sweat it.

 

[countingdays]

CRNAs will be doing all the intubating in the future so don't sweat it.

Or a robot

 

[deleted87051]

I had zero successful intubations my MS3 year because I kept going on the wrong side of the epiglottis.

Hahaha!

And in all seriousness, watching a couple done with a glidescope is really useful for beginners learning what things are supposed to look like and which hole the tube goes in.

 

[Spinach Dip]

...and which hole the tube goes in.

Mouth: Yes.
Ear: No.

Got it.

 

[deleted87051]

Got it.[/quote]

Mouth: Yes.
Ear: No.

Got it.

It's a lot harder than I thought. Always thought of intubation as a 50% shot but it is actually 25%. Left ear, right ear, trachea or esophagus.

 

[Sublimazing]

Pre-oxygenate well, ramp up if necessary, assure no twitches, get in a good sniffing position, have the circulator hold cricoid...then get 10 feet away from head of bed, running start, jam tube in mouth (mid air is best...air jordan pose if you're cay3 or better), it will end up somewhere that can be ventilated

 

[epidural man]

It takes dozens of intubations to begin to be comfortable. There is no one on earth who can't, with practice and good instruction, become proficient at it. Profiency in procedures is not expected in rotating 4th year med students. 4th year students who come in thinking that they're proficient worry us more than the ones who come in knowing they're not good at it. Don't sweat it.

Two suggestions
1) Take the time to get the patient in good position before induction, including table height. Preoxygenate well, so you don't feel hurried.
2) Give the muscle relaxant time to work. Succ is quick, but give roc a minute+ to work. One of the reasons 2nd attempts by someone else can look so easy after your initial flail is because the drugs have had time to work. And take this time to practice mask ventilation, when appropriate - it's a more important skill than intubation, but underappreciated.

Two WONDERFUL suggestions.

Bed height is KEY. PLEASE PLEASE PLEASE remember positioning. Even experienced intubators forget this and I see them bending over, etc. I just got back from the ER - they called a pediatric code and asked us to come down. They never do this so I was a little surprised. Anyway, we arrived. The place was in a frenzy. The first thing I noticed was they were providing adequete oxygenation and ventillation through a bag and mask. This completely calmed me down - unlike everyone else there. The point is - if the kid is oxygenating and ventillating...relax. 02 sats were 100%.

After the story - it sounded as if they had tried 4 times. An ER physician (a very tall guy) was setting up for attempt #5. The bed (I am 5'11) was just below my waist - so way too low for me. I didn't say anything because at the time, I felt like it might have been an A-hole move, but as I type this - I probably should have said something just to help them in their field and practice...but I don't know if it would have seemed that way. (I guess I could have pulled him aside afterward.....)

Anyway, he barely eeked the tube in, but he was bent over like he was trying to touch his toes. Also, he didn't have a roll under the shoulders - and for small kiddos, this is key. So to reiterate...position is HUGE.

Second - kind of on the positioning side - and MANY intubators never get this their whole carreer - but stand back! Don't shove your face right up next to their mouth as if getting your eyes closer to the mouth helps. IT DOESN'T. It makes your view much much worse. When you are looking, your hand holding the laryngoscope should almost be straight, with elbow locked - with you standing almost straight up. Try it. It is amazing how much leaning your head BACK gives you a much greater persepctive on the airway. Try move your head in and see how the view changes. (I know some people sit to intubate....that might change what I am saying...) I hope that made sense. I wish I had pictures to illustrate.

 

[deleted171991]

Hint about positioning: if you prefer not to change the height of the bed, sit down while intubating. 😉

 

[Spinach Dip]

It's a lot harder than I thought. Always thought of intubation as a 50% shot but it is actually 25%. Left ear, right ear, trachea or esophagus.

Hey, all I know is that if you're standing at the head of the bed you're off to a good start.

 

[HalO'Thane]

If you have access to a sim lab or mannequins that is also a great way to practice. Intubating a mannequin is nothing like intubating a real person but it can help you out with a few things: 1. Proper technique, particularly if an experienced laryngoscopist is with you (this can even be an EMT) 2. A general idea of landmarks and anatomy 3. The ability to practice these things in a low stress environment where you won't have to worry about being judged or harming a patient. Good luck. The fact that you even care about getting better already puts you far ahead of the curve for your upcoming anesthesia rotations.

 

[Laryngophed]

Hey, all I know is that if you're standing at the head of the bed you're off to a good start.

Wut? I always thought we put the tube in caudad aiming cephalic.



Edit - Obviously just kidding. I'm glad this thread was posted. I "missed" an intubation two weeks ago, despite "knowing" the steps. The attending told me that to "get it" you just have to do a bunch and start "getting it." It sounded a bit convoluted at the time, but I think I understand now.

 

[Mapleson D]

Agree agree agree with previous advice.

1) Intubation is sexy and all but definitely also concentrate on mask ventilation skills. Do they do ECTs at your hospital? Can you get in on the anesthesia for those? Great mask ventilation practice.

2) Positioning - adjusting the height of the OR table to put the plane of the patient's face at about your xiphoid is a good height. Using a ramp for obese patients is hugely helpful. Elevating the head of nonobese patients into a good sniffing position is also hugely helpful.

3) Agree with straightening your left arm. The elbow doesn't have to be locked, but stand back and use your binocular vision.

 

[gasman654]

Agree agree agree with previous advice.

1) Intubation is sexy and all but definitely also concentrate on mask ventilation skills. Do they do ECTs at your hospital? Can you get in on the anesthesia for those? Great mask ventilation practice.

2) Positioning - adjusting the height of the OR table to put the plane of the patient's face at about your xiphoid is a good height. Using a ramp for obese patients is hugely helpful. Elevating the head of nonobese patients into a good sniffing position is also hugely helpful.

3) Agree with straightening your left arm. The elbow doesn't have to be locked, but stand back and use your binocular vision.

Unfortunately we dont have ECTs at my hospital.

But thanks so much for the advice everyone! This has all been extremely helpful. I am definitely rereading this thread before my next anesthesia rotation, there are so many gems on here! One of the attendings me to give lifting force by elevating my shoulder and locking my wrist - this way I am less likely to damage teeth and will have the proper vector. Being able to stand back I think helps ALOT!! My head was always right at the patient's mouth.

 

[Freak]

Also I found the miller to be easier to get for a view. You have to find a blade you are comfortable with and then switch as you get more proficient.

I would suggest you watch a few intubation as well to see the technique ( the tongue sweep, blade insertion and even where to open the mouth from ). This can really help.