Is it true that there are CC docs out there who can't/won't intubate?

[anesussy]

Saw this in an old thread:

The ED doc or the Anesthesiologist coming in from home if the ED doc is unavailable. In my old hospital.
Been there done that. I remember saying, “it will take me 5-7 minutes to get there.” And they said that’s fine. Cuz the patient was already dead anyway.
Honestly, Intensivists are hard to come by. Intenisvists who intubate, even rarer. That ICU had pulmonary running it but didn’t incubate.
Oh well... what can you do.

Terrifying. Legit seems morally wrong to be running an ICU where no one is there who can intubate in an emergent situation.

Is this as common as the poster says? CC docs who intubate are extremely hard to come by?

If I was a CC doc who saw a patient die in front of me because nobody (including myself) could intubate them, I would 100% devote myself to learning how to intubate. I mean, come on. Even EMTs learn how to intubate. There's really no excuse imo.

---

Members don't see this ad.

 

[NicMouse64]

Not even remotely true from the various ICUs I've rotated through.

 

[nimbus]

Saw this in an old thread:

Terrifying. Legit seems morally wrong to be running an ICU where no one is there who can intubate in an emergent situation.

Is this as common as the poster says? CC docs who intubate are extremely hard to come by?

If I was a CC doc who saw a patient die in front of me because nobody (including myself) could intubate them, I would 100% devote myself to learning how to intubate. I mean, come on. Even EMTs learn how to intubate. There's really no excuse imo.

If that was ever the case, COVID fixed that.

 

[SpacemanSpifff]

There are a handful of attendings at both my residency and fellowship institutions who did not intubate. People who trained at big name academic shops like Penn and UW.

 

[POW16]

Of course it's true. Some of those shops have 4 anesthesia personnel in house at all times. (Call team with residents and or CRNAs) They just call anesthesia for all their airways.

 

[CCM-MD]

I see and hear about rural hospitalists and even ICU midlevels intubating. Even saw a midlevel write on their CV that they are credentialed to bronch. Never heard of an intensivist that doesn't intubate. Maybe some old pulmonary guys that cover units by "managing the vent", but I don't really consider them intensivists.

 

[gro2001]

There are two types of places where you could encounter intensivists not intubating:

1) Smaller/sleepier community hospitals where old time Pulm docs or 'critical care hospitalists' run an open ICU. They will just have the RT or CRNA deal with it. It's not like the intensivist wouldn't get credentialed to do it if they wanted to, it's just they don't want to get involved with stuff like that. These are also the type of places where they would do crazy outdated stuff because 'they've been doing it like that for decades'. This is not all or even majority of small community hospitals, but isn't uncommon either. These are not the type of places that have trainees, so residents/fellows typically don't know this exists until they maybe they go on a job search and visit some community places.

2) Some specific high end academic places don't have intensivists intubate. They all deny this because I guess in theory they could. However, in reality at some of these places the median number of intubations in a year by a critical care attending is zero and fellows graduate with like ~10 non-OR intubations. Obviously not all high end academic places, but there are a few famous institutions that fall into this category.

 

[Lexdiamondz]

Never heard of an intensivist who flat out couldnt intubate.

Now, there are many PCCM programs that have mediocre airway training for a variety of reasons. Something like 40% of PCCM fellowships have no dedicated airway training and in 20% the MICU fellow isnt the primary airway person in the ICU. So it likely isn't uncommon to find an intensivist who isn't particularly good at intubating, but one who flat out can't tube is probably rare.

Variation in Intensive Care Unit Intubation Practices in Pulmonary Critical Care Medicine Fellowship - PubMed

There is significant variation in whether PCCM fellows are the primary operators to intubate medical ICU patients during training. Further work should explore how this variation affects fellow career development and competence in intubation.

pubmed.ncbi.nlm.nih.gov

A call for collaboration and consensus on training for endotracheal intubation in the medical intensive care unit - Critical Care

Endotracheal intubation (EI) is a potentially lifesaving but high-risk procedure in critically ill patients. While the ACGME mandates that trainees in pulmonary and critical care medicine (PCCM) achieve competence in this procedure, there is wide variation in EI training across the USA. One...

ccforum.biomedcentral.com

 

[coffeebythelake]

Saw this in an old thread:

Terrifying. Legit seems morally wrong to be running an ICU where no one is there who can intubate in an emergent situation.

Is this as common as the poster says? CC docs who intubate are extremely hard to come by?

If I was a CC doc who saw a patient die in front of me because nobody (including myself) could intubate them, I would 100% devote myself to learning how to intubate. I mean, come on. Even EMTs learn how to intubate. There's really no excuse imo.

Video larynogscopes make it so easy to intubate most patients nowadays. And presumably these ICU docs know how to manage the physiologic changes that occur w induction and intubation.

 

[grt398]

Video larynogscopes make it so easy to intubate most patients nowadays. And presumably these ICU docs know how to manage the physiologic changes that occur w induction and intubation.

Agree with the VL making it easy enough to get a view in many cases, but I have seen people get into an airway in patients who were on BiPAP for 5-7 days, not anticipate all the dried out secretions etc basically blocking the airway, and not be prepared to clean it out/have alternative tools bedside to help out. Or not having a smaller ETT readily available b/c the 7.5 they defaulted too was too big. And then being too anxious to step back and bag the patient or otherwise support them with an LMA etc while you regroup. It's that kind of stuff that I think trips people up.

And maybe it's just where I am right now, but some people really seem to underestimate the physiologic changes of pushing RSI meds in critically ill patients, double that for those with underlying cardiac issues like significant HFrEF, HOCM, PHTN, severe RV dysfunction etc. Here's an article on the "physiologically difficult airway" that I always liked:

The Physiologically Difficult Airway

Airway management in critically ill patients involves the identification and management of the potentially difficult airway in order to avoid untoward complications. This focus on difficult airway management has traditionally referred to identifying anatomic ...

www.ncbi.nlm.nih.gov

And to the OP, there are big name programs for sure like UW/BWH where anesthesia is always primary unless they give permission to the ICU fellow to intubate, so it's one of those things you have to ask about and try to figure out before you train somewhere. If your goal is academic research where you're only doing 8-12 weeks/year or something, and you have multiple anesthesia residents + attending in house 24/7, it's probably fine, but you'll struggle going into the community.

 

[vector2]

My hospital has a decently busy 20 bed academic MICU and maybe half of the pulm CCM folks intubate their own pts.

 

[DrOwnage]

I agree that this is uncommon. However, it needs to be addressed in training. As an anesthesiologist my job isn't to come for potential difficult airways and just stand there while said uncomfortable individuals give it a go. If I'm there I'm gonna do the thing.

 

[SurfingDoctor]

Between training fellows and requiring them to have the first go to clinical effort reduction through grant funding... I get to intubate a patient once a year or so.

The easy ones are like riding a bike, but I'm quite in tune to the fact that I'm not what I used to be (graduating fellowship a decade or so ago, I think I was +100 emergent intubations) and am perfectly fine letting the person whose sole job it is to intubate do just that when I know that I'm out of my element.

After all, the patient doesn't care about ego... all they care about is staying alive to fight another day. From an intensive care standpoint, that's usually remedied by proactiveness and calling the right reinforcements. That's also not specific for airways, but medicine in general.

 

[chocomorsel]

I was the one quoted in the OP. That's when I used to work in the OR of a small shop of 100 beds ran by this CCM/pulmonogist who did not intubate or do lines. We would intubate and the surgeons did the lines. In fact the nurses had no clue that anesthesiologists could do lines, so it was quite amusing.
Anyway I work in a much bigger shop now of about 500 beds and all of us CCM docs intubate no problem. I however suspect that there are still many small shops where the ICU docs be it pulmonogists, or IM in an open unit don't intubate and call the anesthesia or ER department to come do it. And also in residency, the anesthesia department did all the intubations in the SICU. So the surgeons never got to intubate. Depending on the location, it's probably more common than it should be.

 

[chocomorsel]

I agree that this is uncommon. However, it needs to be addressed in training. As an anesthesiologist my job isn't to come for potential difficult airways and just stand there while said uncomfortable individuals give it a go. If I'm there I'm gonna do the thing.

If you are being called, it isn't to be there on standby. It's to do the thing. Otherwise you shouldn't be bothered. This is something that young anesthesiologists and ER docs should ask about when interviewing.

 

[SurfingDoctor]

I agree that this is uncommon. However, it needs to be addressed in training. As an anesthesiologist my job isn't to come for potential difficult airways and just stand there while said uncomfortable individuals give it a go. If I'm there I'm gonna do the thing.

If you are being called, it isn't to be there on standby. It's to do the thing. Otherwise you shouldn't be bothered. This is something that young anesthesiologists and ER docs should ask about when interviewing.

While I have no problem with this, in academics, I do see a difficult airway attending give the teaching to the CRNA and not the MD in-training. It actually happens more frequently than not. I've never personally understood this approach or who it really being helped by. I guess if the goal is to have CRNA work on difficult airways independently... that's the only reason I could foresee. But I don't do private practice medicine to know if that is a thing.

 

[Hamhock]

Widely variable.

Choose widely.

HH

 

[DrOwnage]

While I have no problem with this, in academics, I do see a difficult airway attending give the teaching to the CRNA and not the MD in-training. It actually happens more frequently than not. I've never personally understood this approach or who it really being helped by. I guess if the goal is to have CRNA work on difficult airways independently... that's the only reason I could foresee. But I don't do private practice medicine to know if that is a thing.

That's complete garbage. Either that anesthesia resident was shy or incapable, or that attending should be scrapped (if its a regular occurrence).

 

[grt398]

While I have no problem with this, in academics, I do see a difficult airway attending give the teaching to the CRNA and not the MD in-training. It actually happens more frequently than not. I've never personally understood this approach or who it really being helped by. I guess if the goal is to have CRNA work on difficult airways independently... that's the only reason I could foresee. But I don't do private practice medicine to know if that is a thing.

Unfortunately this seems to happen not just with airways, but with all ICU procedures including lines/chest tubes/paras/thoras etc b/c in certain units the attendings are more concerned with keeping the NP's/PA's happy b/c otherwise there's high turnover amongst the midlevels.

 

[psychbender]

Unfortunately this seems to happen not just with airways, but with all ICU procedures including lines/chest tubes/paras/thoras etc b/c in certain units the attendings are more concerned with keeping the NP's/PA's happy b/c otherwise there's high turnover amongst the midlevels.

In fellowship, there was a push started by the department chief to get the NPs credentialed to do all common ICU procedures. The stated rationale was that with ACGME supervision rules, the attending had to actually be present when a resident or fellow does them, but the NP can bill independently. He didn't even try to make up an excuse about keeping them happy, or having a constant rotation of residents every month.

 

[SurfingDoctor]

That's complete garbage. Either that anesthesia resident was shy or incapable, or that attending should be scrapped (if its a regular occurrence).

If it’s the anesthesia resident, that’s fine with me, but I would say only 1/2 the time does the airway team have a resident instead of a CRNA.

 

[Siggy]

In fellowship, there was a push started by the department chief to get the NPs credentialed to do all common ICU procedures. The stated rationale was that with ACGME supervision rules, the attending had to actually be present when a resident or fellow does them, but the NP can bill independently. He didn't even try to make up an excuse about keeping them happy, or having a constant rotation of residents every month.

There has to be "supervision" but indirect supervision is still supervision.

The only thing I'm not sure is how billing is supposed to work with fellows and indirect supervision.

 

[grt398]

In fellowship, there was a push started by the department chief to get the NPs credentialed to do all common ICU procedures. The stated rationale was that with ACGME supervision rules, the attending had to actually be present when a resident or fellow does them, but the NP can bill independently. He didn't even try to make up an excuse about keeping them happy, or having a constant rotation of residents every month.

I was told recently this is why I'm no longer able to teach residents procedures in a particular unit if there's a midlevel available to do the procedure. It's absurd that training programs that supposedly exist to train the next generation of physicians (and receive significant tax breaks and many other benefits from trainees) are allowed to do this kind of thing. The system is very very broken on many levels.

 

[chocomorsel]

I was told recently this is why I'm no longer able to teach residents procedures in a particular unit if there's a midlevel available to do the procedure. It's absurd that training programs that supposedly exist to train the next generation of physicians (and receive significant tax breaks and many other benefits from trainees) are allowed to do this kind of thing. The system is very very broken on many levels.

So did you abide by their rules? Or ignore?

 

[grt398]

Not sure what other people's experiences have been, but it was made clear to me that part of my job as a fellow is to follow the official and unofficial rules. People who bring up issues that faculty/leadership would like to avoid discussing find themselves labeled as "difficult." Similar to how medical schools use "professionalism" to "encourage" certain behavior in med students. Which is a hard position to find yourself in as a trainee with massive debt.

 

[cchoukal]

I work in two places where (most of) the pulmonologists don't intubate. True, there is always an anesthesia provider in-house, so it's not like someone isn't available. In these shops, there has always been a mix of pulm and anesth in the ICUs, and I think over time, because there was always someone "better" at it, the pulm people just stopped doing it, and now no longer feel confident.

Edit: Just today was called to intubate a patient in the ICU with a pulmonologist as the attending. So this definitely happens.

 

[Radetzky]

Embarrassing. Like being a mechanic who doesn’t know how to drive. What if the anesthesia cover is tied up in theatre? What if a patient needs intubation immediately? Cardiac arrest?

The expected failure rate of extubation if you’re doing it aggressively enough is 10-15%. How can you extubate patients appropriately if you know you can’t back your own self up if it fails?

 

[Lexdiamondz]

Honestly in the context of overall institutional inertia coupled with ubiquitous use of noninvasive ventilation and HFNC, I'm not surprised at the overall relative lack of airway skills among some subsets of Pulm-Crit folks. Even among ER folks there have been similar issues with newer trainees (especially from newer programs) having poor airway skills just because fewer patients are needing to be intubated.

 

[lunaire]

Reminds me of the time when my anesthesiology attending had a broken arm, and we had to emergently intubate the patient on the table. Also the few times when I had to bail out failed intubations by other CCM attendings, that turned out to be quite easy.

My experience in the last few years have taught me that there are various deficiencies in various healthcare system - including the occasional intensivist that is bad at intubating. As long as there is a process to overcome that deficiency safely, then it isn't really a big problem... I'd rather have the second intensivist covering the unit be a wiz at oncologic emergencies (my weakness) than another anesthesiology/CCM that is good at airway.

 

[Siggy]

Reminds me of the time when my anesthesiology attending had a broken arm, and we had to emergently intubate the patient on the table. Also the few times when I had to bail out failed intubations by other CCM attendings, that turned out to be quite easy.

It's one of the reasons why you're supposed to change the person doing the intubation quickly in a failed airway. Sometimes there's a subtle difference between technique that might make getting a grade 1 view hard for one person, but easy for the second. I've been on both sides of these intubations.

 

[BreathDeep]

Saw this in an old thread:

Terrifying. Legit seems morally wrong to be running an ICU where no one is there who can intubate in an emergent situation.

Is this as common as the poster says? CC docs who intubate are extremely hard to come by?

If I was a CC doc who saw a patient die in front of me because nobody (including myself) could intubate them, I would 100% devote myself to learning how to intubate. I mean, come on. Even EMTs learn how to intubate. There's really no excuse imo.

I'd never seen a facility where CC didn't intubate 24/7 (I've seen intensivists who panic and refuse to even try without the glidescope, but they still try at least) until my current job.

The intensivists in my 200 bed community hospital are only in house from 0600-1200, then they leave to cover the other sister hospital from 1300-1900.

So I guess they do intubate, but only for 6 out of 18 hours. Our patients tend to be polite and mostly try and die after lunch is finished, which means most of the time the intensivist is 40 miles away when the reaper comes calling.

Once the intensivist is gone ICU management is by the hospitalist. They absolutely love having ICU privileges except for intubating, which they hate doing apparently, so they have RT do it while they run the rest of the code/rapid/whatever it is. If RT can't get the tube then they roll out the glidescope and say a little prayer. It's an, uh, interesting set up.

 

[CCM-MD]

I'd never seen a facility where CC didn't intubate 24/7 (I've seen intensivists who panic and refuse to even try without the glidescope, but they still try at least) until my current job.

The intensivists in my 200 bed community hospital are only in house from 0600-1200, then they leave to cover the other sister hospital from 1300-1900.

So I guess they do intubate, but only for 6 out of 18 hours. Our patients tend to be polite and mostly try and die after lunch is finished, which means most of the time the intensivist is 40 miles away when the reaper comes calling.

Once the intensivist is gone ICU management is by the hospitalist. They absolutely love having ICU privileges except for intubating, which they hate doing apparently, so they have RT do it while they run the rest of the code/rapid/whatever it is. If RT can't get the tube then they roll out the glidescope and say a little prayer. It's an, uh, interesting set up.

That’s a horrible set up. I’m sure some dirtbag hospital administrator got a good bonus to make it happen.

 

[DrDrummer]

I'd never seen a facility where CC didn't intubate 24/7 (I've seen intensivists who panic and refuse to even try without the glidescope, but they still try at least) until my current job.

The intensivists in my 200 bed community hospital are only in house from 0600-1200, then they leave to cover the other sister hospital from 1300-1900.

So I guess they do intubate, but only for 6 out of 18 hours. Our patients tend to be polite and mostly try and die after lunch is finished, which means most of the time the intensivist is 40 miles away when the reaper comes calling.

Once the intensivist is gone ICU management is by the hospitalist. They absolutely love having ICU privileges except for intubating, which they hate doing apparently, so they have RT do it while they run the rest of the code/rapid/whatever it is. If RT can't get the tube then they roll out the glidescope and say a little prayer. It's an, uh, interesting set up.

You don’t have anesthesia or EM in-house? Or they just don’t call for help? Scary.

 

[psychbender]

I'd never seen a facility where CC didn't intubate 24/7 (I've seen intensivists who panic and refuse to even try without the glidescope, but they still try at least) until my current job.

The intensivists in my 200 bed community hospital are only in house from 0600-1200, then they leave to cover the other sister hospital from 1300-1900.

So I guess they do intubate, but only for 6 out of 18 hours. Our patients tend to be polite and mostly try and die after lunch is finished, which means most of the time the intensivist is 40 miles away when the reaper comes calling.

Once the intensivist is gone ICU management is by the hospitalist. They absolutely love having ICU privileges except for intubating, which they hate doing apparently, so they have RT do it while they run the rest of the code/rapid/whatever it is. If RT can't get the tube then they roll out the glidescope and say a little prayer. It's an, uh, interesting set up.

I used to moonlight for anesthesia at a tiny, rural, central Georgia hospital. The hospital had a pair of Pulm/CC docs (father and son team) that were there from 0700-1900 alternating weeks. Any critical needs after hours were called to hospitalists, and all procedures were called to either the surgeon or anesthesiologist on call, regardless of time of day. I recall several times getting called to intubate and line up someone, while the intensivist stood there and thanked me for coming, while I was covering the ORs.

I also had all kinds of crazy stories from the OR there. Care at those tiny places can be very interesting.