Question!!!!

[Funniman250x]

---

Members don't see this ad.

I'm a Paramedic intern as well as a Pre-Med student and I was sort of thrown back the other day by what an Anesthesiologist had said to me. After waiting 5 hours in pre-op a case had finally came around that needed to be intubated. I had seen the anesthesiologist who would be taking care of the patient about 20 minutes before the surgery and asked very politely if he would mind if I could come in with him and watch, maybe even perform the intubation whereas I had intubated just over twenty times so far. He looked me up and down and said "sorry you can... this is an RSI." I held my tongue and sat back down but what I REALLY felt like saying was that the majority of intubations I will be performing in the field are RSI's!!!! Maybe he was having a bad day .... I don't really know to tell you the truth... Think I should try to talk to him?

 

[mcgreen]

I'm a Paramedic intern as well as a Pre-Med student and I was sort of thrown back the other day by what an Anesthesiologist had said to me. After waiting 5 hours in pre-op a case had finally came around that needed to be intubated. I had seen the anesthesiologist who would be taking care of the patient about 20 minutes before the surgery and asked very politely if he would mind if I could come in with him and watch, maybe even perform the intubation whereas I had intubated just over twenty times so far. He looked me up and down and said "sorry you can... this is an RSI." I held my tongue and sat back down but what I REALLY felt like saying was that the majority of intubations I will be performing in the field are RSI's!!!! Maybe he was having a bad day .... I don't really know to tell you the truth... Think I should try to talk to him?

He might be afraid about getting sued.

Patient claims battery over botched procedure

September 27, 2006 INDIANAPOLIS - The Indiana Supreme Court is considering whether a woman who had to have a second surgery after a medical student tore her esophagus during a botched procedure was a victim of battery.

Attorneys for W- Ruth Mullins say she signed documents saying she didn't want students in the operating room, but doctors ignored her wishes.
Her attorney, Sherrill Colvin, says the case fits the definition of battery because harm resulted after the student inserted a tube in Mullins' throat.

But Justice Frank Sullivan argued that the law requires that harm be intended to fit the definition of battery.

The court heard oral arguments in the case yesterday.

(Copyright 2006 by The Associated Press. All Rights Reserved.)

 

[veetz]

From my experience, attendings typically will not allow someone who they are not familiar with their capabilities to manage the airway during a RSI. Don't take it personally. During my first week as an anesthesia resident, I was denied a chance at a RSI b/c of my inexperience.

 

[huktonfonix]

no offense dude, but 20 isnt that many intubations. Im sure youre good at your job, but if Im gonna do a RSI for a patient theres usually a good reason that dictates the most experienced laryngoscopist be doing it (in a typical non teaching environment anyway). Unless Ive seen you intubate before, I have no idea what your skill level is and Im certainly not gonna have the first one I watch be an RSI. Sorry, I wouldve said the same thing.

 

[Jeff05]

when you're intubating in the field - the patient is sick as crap already. so if you knock out a tooth or there is some aspiration - no one is going to mind.

if you mess up in the OR (20 intubations? i do that during 2 busy ENT days) you get your ***** handed to you.

i wouldn't let you touch my patients either.

 

[Licoricestick]

...the majority of intubations I will be performing in the field are RSI's!!!!

There can be a significant difference between a theatre RSI and a field RSI. The most obvious difference occurs when you consider tubing people in cardiac arrest - their greatest aspiration risk actually exists during compressions not intubation, and if you stuff up the intubation you almost certainly haven't made the situation any worse - we all know what the survival rates for out of hospital cardiac arrest are like. That is the main difference between theatre (even for an urgent/emergent case) and the field - in theatre we take people who are awake, alert and maintaining their own airway and breathingand completely remove their ability to do either. In the field patients generally require intubation because they are having difficulty maintaining their airway or breathing - the gap between their current situation and the situation imposed by you attempting to intubate them is MUCH smaller.

And I agree with what everyone else has said - an RSI is not appropriate for someone with very limited experience when the supervisor has never seen them tube before. My main fear wouldn't be being sued, it would be having to take over an airway following a likely traumatic attempt at intubation, in a patient who is desaturating and is a high aspiration risk. As has been mentioned on this site many times the most important thing in an RSI is the rapidity of it.
20 tubes is very limited experience - most people are doing well at that point to put the blade down correctly, avoid damaging teeth/levering on teeth and get a good view of a grade 1 larynx; they generally can't do all that and put the tube down quickly. What would you have done if the patient had a grade III or IV larynx?

I'm a first year anaesthetics registrar. I've done maybe 100-150 intubations and would therefore consider myself of limited experience. It's only in the last couple of months I have started to regularly succeed with intubation where the patient has a grade III or borderline grade II/III larynx. Haven't yet had an unanticipated grade IV so although I have a concept of how I would proceed - I don't know how successful I would be, particularly in an RSI situation.

 

[Bertelman]

... After waiting 5 hours in pre-op a case had finally came around that needed to be intubated. ...

Agree with what everyone else has said. There's no way you're touching that patient if that were me. Maybe you can look over my shoulder, but that's about it. If I've just met you, I probably wouldn't even let you hold cricoid.

Sounds like you're just as upset that you had to wait 5 hours. Unfortunately, the patient having surgery couldn't care less about how long you have waited. They just want someone to put the tube in the first time, skillfully.

 

[coprolalia]

I'm sorry, but just to clarify... Does your comment/question/concern center on why he wouldn't let you intubate or why he was doing an RSI after the patient sat there for 5 hours?

-copro

 

[Funniman250x]

First off I'd like to say thank you for all of those who have responded to what I had posted. For being so young and new to the field I am not able to see or hear how the anesthesiologists actually feel about letting paramedic students intubate their patients. Though we are taught the basics of intubation in an emergency setting, we are not educated about the people who will be training us under supervision to obtain our required clinical time intubations for the state. In Massachusetts we are required 10 intubations, I obviously do not believe this is enough. I completely understand what everyone is saying about how these people barely even know me and I expect them to take me in with open arms and let me intubate their patients under their liability. Honestly you have all really put things into perspective for me so thank you all... I really do appreciate it. Now I guess the true question is how do I earn that trust without any shot at a first try? Besides my knowledge which is limited to EMS, I guess just time and patience will tell.

 

[SleepIsGood]

First off I'd like to say thank you for all of those who have responded to what I had posted. For being so young and new to the field I am not able to see or hear how the anesthesiologists actually feel about letting paramedic students intubate their patients. Though we are taught the basics of intubation in an emergency setting, we are not educated about the people who will be training us under supervision to obtain our required clinical time intubations for the state. In Massachusetts we are required 10 intubations, I obviously do not believe this is enough. I completely understand what everyone is saying about how these people barely even know me and I expect them to take me in with open arms and let me intubate their patients under their liability. Honestly you have all really put things into perspective for me so thank you all... I really do appreciate it. Now I guess the true question is how do I earn that trust without any shot at a first try? Besides my knowledge which is limited to EMS, I guess just time and patience will tell.

A RSI is definitely not where most anesthesiolgists would let you learn. An old guy male/female with no teeth is likely where they would like you to start. Then healthy, skinny males/females.

 

[Bertelman]

First off I'd like to say thank you for all of those who have responded to what I had posted. For being so young and new to the field I am not able to see or hear how the anesthesiologists actually feel about letting paramedic students intubate their patients. Though we are taught the basics of intubation in an emergency setting, we are not educated about the people who will be training us under supervision to obtain our required clinical time intubations for the state. In Massachusetts we are required 10 intubations, I obviously do not believe this is enough. I completely understand what everyone is saying about how these people barely even know me and I expect them to take me in with open arms and let me intubate their patients under their liability. Honestly you have all really put things into perspective for me so thank you all... I really do appreciate it. Now I guess the true question is how do I earn that trust without any shot at a first try? Besides my knowledge which is limited to EMS, I guess just time and patience will tell.

You're right to believe that 10 tubes is not enough. It should be closer to 100 before you feel comfortable intubating most patients. The easiest way to obtain that trust with an anesthesiologist is to work with the same one for an extended time. That would be difficult given our erratic schedule, and your limited available time for the OR. You also may have been assigned to a hospital with not enough surgical cases, or too many trainees. I'm at a mid-size academic center, and an eager ED resident can get 10 tubes in a day.

 

[proman]

This brings up the issue whether paramedics should be intubating at all. Vast majority of paramedics have no where near 100 tubes, even after a few years in the field. Many hospitals are reluctant to train students due to perceived risk. And, skill atrophy is a major issue. I used to work in a very busy 911 system in Atlanta. I averaged maybe 1-2 tubes per MONTH (and to be honest sucked at intubating).

 

[McPoyle]

You're right to believe that 10 tubes is not enough. It should be closer to 100 before you feel comfortable intubating most patients. The easiest way to obtain that trust with an anesthesiologist is to work with the same one for an extended time. That would be difficult given our erratic schedule, and your limited available time for the OR. You also may have been assigned to a hospital with not enough surgical cases, or too many trainees. I'm at a mid-size academic center, and an eager ED resident can get 10 tubes in a day.

We also needed ten during my paramedic training, I think most got slightly over this. In the five years since then, however, I've grown to truly believe that this is nowhere near enough tubes. More importantly for a skill we use maybe 10-12 times per year, we certainly do not get enough training to maintain a proficient skill level. I know at least around here in MN there has been slow push towards limiting the effects of this by using alternative airways such as the King airway. We for instance are allowed one attempt at DL and if we are unable to see cords/pass the tube then we go to the King. While I prefer intubating I feel its not really fair to the pt. to be in a constant state of remediation and generally use the King-I find it be quick, easy, and perfect for a rescue airway.

 

[urge]

What is you relationship with said anesthesiologist? Did you introduce yourself before asking? 10 seconds is not enough time.

I'm sure if he knew who you were from meeting you A FEW DAYS before, and had seen you intubate, then it would have been different.

He just takes his job seriously.