Surgeons intubating

[europeman]

I thought the title would get your attention 🙂

Here's my question. What do you guys think about non-anesthesiologists intubating in the hospital - in particular, the ICU?

Obviously airway skills is something an intensivist should have some facility in, but I'm wondering how appropriate it is for them to routinely intubate their patients in the ICU. At the insitution I'm at, if the patient isn't thought to be a difficult airway, the intensivist will intubate (or more often walk a fellow through it).

I don't know how I feel about it, because, honestly, I think it's playing with fire.

Let me tell you where I'm coming from. I'm a senior general surgery resident who will be doing a fellowship in trauma/acute-care/critical-care. Therefore, starting this year (so for about 11 months now), I decided to be more proactive learning from the anesthesia staff during intubation/extubation, in particular when there is no resident. It has been fantastic how willing and eager anesthesia attending are to teach! I have kept a log, and logged 52 intubations (all with mac, no miller yet), 3 LMAs, and most importantly, I have practiced BVMing them all of course, placing appropriate oral/nasal airways when needed, etc. In the beginning I was ******ed, like anyone starting, but now I'm getting more of the hang of it and I'm reasonably successful at getting it in the first time around.

BUT NOW I RESPECT THE AIRWAY *SO* MUCH more than before. I said reasonably successful... well.... in the few cases recently I couldn't get the tube in, they were SURPRISES! They were *NOT* thought to be difficult airways. One of them ended up being very difficult to BVM also once the roc hit. SCAREY.

Then I go back, and I routinely make an effort to watch the ICU guys do their thing now that I have some more background. And it's just NOT ideal. They often don't have everything readily available in case they get into trouble (for example, a rescue device like an LMA, or a bougie. Most of the time, granted, they do have a glidescope around, but that's not fullproof either), they don't use wave capnography, etc. I have to say though, I've also been a bit surprised how sorta less prepared and less-organized even the anesthesia residents sometimes are when called to floors for urgent (but not emergent) intubations... so maybe it's just an organization, training thing?

On the other hand, in order to maintain a skill, of course, you have to do it at some reasonable frequency also. That's what ER docs would say - understandably.

So I'm sorta caught wondering what I'll be doing once I'm an attending intensivist. The last thing I want to do is seem like the surgeon who is trying to do everything. That's not the case at all. However, as an intensivist, I need and want to have airway facility, not just for emergencies but also for conscious sedation, etc.

What are your thoughts? Thanks!

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[jetproppilot]

I'm all for you dudes doing whatever you feel comfortable with.

WANNA INTUBATE? WANNA RULE THE ROOST?

That's fine with me man.

Do your thing.

Here's some advice:

Don't get in over your head.

Are you confident with airway management?

IF SO,

great.

IF NOT,

there's no heroes in this business man, even if you've been lead to think so.

We're all good at what we're good at, and venturing beyond your expertise puts you and the patient at risk.

Despite what academic medicine promotes,

The practice of medicine is not a Dick Swinging Contest.

Do what you do comfortably.

If you're not comfortable with something,

CALL A COLLEAGUE.

We're all here to help.

 

[PMPMD]

As always, great post Jet!

 

[countingdays]

As always, great post Jet!

One of my favorite moments in residency was as a ca1 getting called to icu and finding a Pulm/cc attending from my intern year struggling to intubate. My attending came along too and the cc guy tried to give him the scope. Attending say gypsy take a look then I reposition the patient and pop in the tubr in about 2 seconds. Not especially difficult. Just a passive f u to an a hole from my internship.

There's a difference between should and can do it. I'm all for letting people do the tube. I usually don't even mind standing there as backup. Just don't tear things up then call and pass the buck.

 

[Lightwand]

I think what's you've done (learning in the OR) is the best thing to do. It's much easier to develop skills in a controlled setting and then have a level of comfort when you have to manage an airway in the ICU.

We have a rule at our institution that surgical residents MUST call the airway pager before drugs are pushed. (I think this is the result of cavalier surgical residents pushing drugs, looking, not being able to intubate and then paging anesthesia emergently). But when we show up, there's usually a turf war about who's actually going to manage the airway. My usual response is that unless I am 1,000,000% sure that I can rescue the airway after they jack it up, I manage the airway myself. I invite the residents to ask in the OR if they can intubate in appropriate cases.

I think it's important for an intensivist to be able to manage basic airways (I'm not talking awake FOI or retrograde wire), but what is more important is to recognize the situations where you may need help. Know what you're getting into and know when you're in over your head and need help. Jet's spot-on, as usual, with this one.

 

[Idiopathic]

look, ill say it. pulmonologists/medicine CC docs are the worst larymgoscopist/airway technicians. they have phenomenal understanding of the physiology of the human body, pathologic and normal, but really all that knowledge begins below the cords. three of the four worst airway situations ive ever encountered were elective procedures done by pulm/CCM that culminated in lost airways. tube "change outs" are the worst, everyone seems surprised when the tube doesnt simply follow the cook catheter back into the trachea.

edit: i guess my point is that, as a surgeon, its imperative that you develop good laryngoscopy skills. you may be called upon to intubate/reintubate in the OR in some situation and you should be well versed in the techniques. might save someone a slash trach or even their life.

 

[sevoflurane]

Get yourself a glidescope for the ICU. Go down to anesthesia land after rounds and put in as much PVC as you possibly can. Understand the airway exam and learn to recognize potential disasters. We are always available to help... we just like to be there before the AW is all mucked up. Nothing worse than seeing a fat lip, a mouth full of blood and ongoing edema. Stay safe and know your limitations... O/W, I'm happy to give up emergency AW's. At our hospital, ED does them and we like that. We get called when they can't lay down some pipe.

Here is a story from this past weekend. Wife gets called from home.... 350 lb fatty with emergent AW... ED needs help. She gets there and sees a mess of intubating LMA's, glidescopes, boogies, proseals.... patient is blue. This AW has been going on for 45 minutes. My wife is 5'4. 6'6" ED attending wants another crack at it.... she takes over the airway and realizes that he is easily maskable with an OA she stealthy places....So she says OK... Go for it but first let's get the patient to at least 98%.... Hands over the AW to ED guy who thinks he's got it this time......PVC goes into the goose... god knows how many times this happened in the last 45 minutes.....

Anywho... she does the stuff we do... repositions/pillow/reverse Tburg, propofol + ROC (since she now knows he is maskable) and gets ETCO2 in seconds flat. Room full of nurses and docs start clapping as my 5'4'' wife is taping in the tube. 😍😍😍

There is a reason we are AW experts. Don't let your testosterone get in the way of patient care. O/W go for it dude. 🙂

 

[Birdstrike]

I thought the title would get your attention 🙂

Here's my question. What do you guys think about non-anesthesiologists intubating in the hospital - in particular, the ICU?

Obviously airway skills is something an intensivist should have some facility in, but I'm wondering how appropriate it is for them to routinely intubate their patients in the ICU. At the insitution I'm at, if the patient isn't thought to be a difficult airway, the intensivist will intubate (or more often walk a fellow through it).

I don't know how I feel about it, because, honestly, I think it's playing with fire.

Let me tell you where I'm coming from. I'm a senior general surgery resident who will be doing a fellowship in trauma/acute-care/critical-care. Therefore, starting this year (so for about 11 months now), I decided to be more proactive learning from the anesthesia staff during intubation/extubation, in particular when there is no resident. It has been fantastic how willing and eager anesthesia attending are to teach! I have kept a log, and logged 52 intubations (all with mac, no miller yet), 3 LMAs, and most importantly, I have practiced BVMing them all of course, placing appropriate oral/nasal airways when needed, etc. In the beginning I was ******ed, like anyone starting, but now I'm getting more of the hang of it and I'm reasonably successful at getting it in the first time around.

BUT NOW I RESPECT THE AIRWAY *SO* MUCH more than before. I said reasonably successful... well.... in the few cases recently I couldn't get the tube in, they were SURPRISES! They were *NOT* thought to be difficult airways. One of them ended up being very difficult to BVM also once the roc hit. SCAREY.

Then I go back, and I routinely make an effort to watch the ICU guys do their thing now that I have some more background. And it's just NOT ideal. They often don't have everything readily available in case they get into trouble (for example, a rescue device like an LMA, or a bougie. Most of the time, granted, they do have a glidescope around, but that's not fullproof either), they don't use wave capnography, etc. I have to say though, I've also been a bit surprised how sorta less prepared and less-organized even the anesthesia residents sometimes are when called to floors for urgent (but not emergent) intubations... so maybe it's just an organization, training thing?

On the other hand, in order to maintain a skill, of course, you have to do it at some reasonable frequency also. That's what ER docs would say - understandably.

So I'm sorta caught wondering what I'll be doing once I'm an attending intensivist. The last thing I want to do is seem like the surgeon who is trying to do everything. That's not the case at all. However, as an intensivist, I need and want to have airway facility, not just for emergencies but also for conscious sedation, etc.

What are your thoughts? Thanks!

If you're going to be an intensivist, taking care of critical care patients, how could you even consider NOT becoming skilled in airway/RSI/intubations? One of the few things we do as docs, that allow us to walk away and say "I saved that guys life", are airway maneuvers. Forget all the ego wars about who's THE BEST at airway, be a good as you can be. The more you do, learn and know, the better. Does that mean you'll never need to ask for help, with a procedure/airway, or whatever? No. You may not always be sheltered at a tertiary referral teaching hospital where, with one push of the code button, you can have an anesthesiologist, 2 anesthesia residents, a surgery resident, in house trauma attending, ent resident and ER resident/attending rush to help you. You may be the only doc in the hospital. Do you really want to forego learning critical skills because you're afraid you'll bruise someone else's ego that thinks they own a certain procedure? Let them say they're the experts, and get so good you never have to call them. But also know that calling for help is good. It's NOT, I repeat it's NOT a sign of failure. Especially with procedures, airway included. I've had airways that were very difficult, tough getting a tube in, but bagging well, sat's OK. You know what I do? "Hey Joe, would you mind giving this intubation a shot? You try, and if you have trouble, I'll come back at it with the Glidescope, fiberoptic scope..." or whatever. And guess what, Joe gets the tube in like it's no big deal. And it is no big deal because you kept things under control, you know how to BVM an airway and keep the sat up, and let your partner have a lucky day. I've turned right around with roles reversed and gotten a tough airway from the same guy who helped me out before. Who's better? Who cares. Be the best doc you can be, attain the most skills you can, and let the ego's think they're the best......and you know what, after you've been somewhere 5 years quietly killing it, racking up win after win without asking your ego to be stroked, the "ego's" will look at you and say, "you know what? That guy know's his s---"

 

[loveumms]

I agree with sevo. As long as I'm not getting a call to help after 20 attempts with a blood airway and a patient who is dying due to hypoxia.

I'm actually a little disturbed that the ICU guys at my institution don't know how to intubate. Yes, we are always around and go to all airways but, all of these trainees will likely have to intubate when they are finished with training.

Honestly, you can teach anyone how to intubate. It's not a skill that is difficult to learn well after doing it enough. You just have to be humble and know your limits. That is what I try to teach "off service" residents when they are coming to learn airway management.

 

[RemyMcswain]

Get yourself a glidescope for the ICU. Go down to anesthesia land after rounds and put in as much PVC as you possibly can. Understand the airway exam and learn to recognize potential disasters. We are always available to help... we just like to be there before the AW is all mucked up. Nothing worse than seeing a fat lip, a mouth full of blood and ongoing edema. Stay safe and know your limitations... O/W, I’m happy to give up emergency AW’s. At our hospital, ED does them and we like that. We get called when they can't lay down some pipe.

Here is a story from this past weekend. Wife gets called from home.... 350 lb fatty with emergent AW... ED needs help. She gets there and sees a mess of intubating LMA’s, glidescopes, boogies, proseals.... patient is blue. This AW has been going on for 45 minutes. My wife is 5’4. 6’6” ED attending wants another crack at it.... she takes over the airway and realizes that he is easily maskable with an OA she stealthy places....So she says OK... Go for it but first let’s get the patient to at least 98%.... Hands over the AW to ED guy who thinks he’s got it this time......PVC goes into the goose... god knows how many times this happened in the last 45 minutes.....

Anywho... she does the stuff we do... repositions/pillow/reverse Tburg, propofol + ROC (since she now knows he is maskable) and gets ETCO2 in seconds flat. Room full of nurses and docs start clapping as my 5’4’’ wife is taping in the tube. 😍😍😍

There is a reason we are AW experts. Don’t let your testosterone get in the way of patient care. O/W go for it dude. 🙂

Does your wife have a sister??

 

[europeman]

thanks for the comments everyone.

first, my goal is to never be like that ER doc that sevo described - i.e. not starting with the basics, slowing down, putting an airway in and bagging until help gets there! sounds like this ER doc forgot the basics, and went on to ten thousand crazy manuvers in a panic (hence the blue patient until the wife/anesthesiologist got there).

Anyway, yes, obviously I agree that it's an important skill to have, especially being an intensivist. WHAT I AM SAYING/ASKING, however, is given I'll be in a tertiary trauma center as an attending trauma/acute-care/critical-care doc, it's hard for me to justify EVER doing semi-elective (i.e. non EMERGENT) intubations in the ICU.

On the one hand, I recognize that even with an airway which appears easy, trying to do it as intensivist inevitably is somehow putting the patient more at risk - because, no matter what, I'm just never going to be as good as the anesthesia guys.

On the other hand, obviously, an intensivist really should have airway skills and ability, and, maintaining those skills I think has some virtue.

Thus.. from you guys'/gals' perspective.... what is your preference to scenarios like this? Say a patient in respiratory distress that needs an intubation soon, that I want to intubate.... say I get to a skill level where I'm pretty confident in my skills with this patients airway exam, etc.... do you really want me to call you after my resident failed, and I failed? Two missed tries sometimes can really mess up an airway if they are done traumatically. I dunno... i just want what's best for the patient, while at the same time, not waisting your time calling you for every airway. Or is that the solution? "Hey, we are going to intubate a patient soon, we don't anticipate any problems, but if you could kindly make yourself available in the event we need you please be nearby. thanks"? that mabye better?


thoughts? thanks!

 

[sevoflurane]

Start here 🙂

99% of patients you will be able to ventilate with proper technique. So you should first learn to mask ventilate all comers.

Just remember to call early if you've overestimated your chances, DL'd and all you see is a pink abyss... early is key and I'm pretty sure you know that.

Think twice before paralyzing somebody who may be difficult to ventilate.... Can't intubate and can't ventilate is a BIG problem that needs to be addressed immediately.

No reason you can't become excellent at laryngoscopy. In general, it takes about 300 intubation attempts to be considered proficient. Learn from others... a lot of little tricks that may help you with the difficult intubation.

As for Burns....well those burn patients can be very difficult to ventilate due to eschar encasing their chest wall, ards etc... and can also become difficult intubations... with contraindications to depolarizing muscle relaxants which, if used, may ultimately cause cardiac arrest. There are little pitfalls in AW management you want to avoid. This is one.

Lastly... it's a procedure... so HAVE FUN! 😉

 

[IlDestriero]

We have a 3 attempt policy. On the 3rd attempt they have to call us. When we arrive, we're in charge. Obviously this doesn't apply to known or apparently difficult airways. Unfortunately they often call us on try #3 and still try a couple more times instead of just bagging. They're usually not difficult at all. Once in a blue moon the ED will dick around with a known difficult airway. That just pisses me off.
It's getting better though.👍

 

[michigangirl]

Speaking from the pediatric intensive care unit standpoint, the majority of our fellows are not anesthesia trained, only pediatric residency trained. They get one month in the OR with peds anesthesiologists and learn the difficult airway algorithm, know their limits, and intubate almost 98% of the children in the PICU. There is no peds anesthesia in house overnight only on call, and our adult anesthesia team has no interest in intubating the little ones unless it's a life or death situation and noone more skilled is around....this is a VERY rare event. All of our fellows are proficient at intubation of the non-difficult airway, and placement of LMA's. I am proud of how well our PICU fellows manage airways-- can't speak to MICU/SICU-- I think the focus is not as intubation based in these locations, more of a reliance on anesthesia on-call?

 

[jetproppilot]

...also know that calling for help is good. It's NOT, I repeat it's NOT a sign of failure. Especially with procedures, airway included. I've had airways that were very difficult, tough getting a tube in, but bagging well, sat's OK. You know what I do? "Hey Joe, would you mind giving this intubation a shot?"

This is serious.

SERIOUSLY THE WAY TO HANDLE YOU, YOUR PRACTICE, YOUR COLLEAGUES, YOUR WIFE, YOUR KIDS, YOUR

LIFE.

Yeah, ok, I got all philisophical on you dudes but Bird's post speaks above the clinical message sent:

1) EVERYONE NEEDS HELP AT SOME POINT IN THEIR LIFE. CALL EARLY RATHER THAN LATER. YOU ARE NOT ALONE.

2) YOUR COLLEAGUE (Bird's metaphorical "Joe") WILL PROBABLY SUCCEED WHERE YOU FAIL. IN THE FUTURE YOU WILL SUCCEED WHEN SOMEONE ELSE FAILS.

Thats the beauty of medicine practiced the

RIGHT WAY.

AS ONE.

Jet's advice:

WATCH YOUR COLLEAGUE'S BACK. COLLEAGUE MEANING ANY PHYSICIAN. CUZ KNOW WHAT? you WILL need help at some point. It very well may come from THAT COLLEAGUE'S BACK you had a long time ago.

PLAY IT FORWARD.

 

[jetproppilot]

Thus.. from you guys'/gals' perspective.... what is your preference to scenarios like this? Say a patient in respiratory distress that needs an intubation soon, that I want to intubate.... say I get to a skill level where I'm....!

DUDE...

Reflecting on the feedback sent to you, then reading what you posted above...

WTF?

TAKE TO HEART WHAT IS POSTED...THINK ABOUT THE REPLIES...

Use your COMMON SENSE,

man.

You're fishing for SPECIFIC ANSWERS for

AMBIGUOUS SITUATIONS!!!

Dude, do you watch

ESPN? The part where the commentators say

"C'MON, MAN!!"

Thats how I feel about your followup post.

Apologies if you are in a far off land that doesn't get the ESPN reference. Nothing I can do about that. Google ESPN.

 

[IlDestriero]

thanks for the comments everyone.

first, my goal is to never be like that ER doc that sevo described - i.e. not starting with the basics, slowing down, putting an airway in and bagging until help gets there! sounds like this ER doc forgot the basics, and went on to ten thousand crazy manuvers in a panic (hence the blue patient until the wife/anesthesiologist got there).

Anyway, yes, obviously I agree that it's an important skill to have, especially being an intensivist. WHAT I AM SAYING/ASKING, however, is given I'll be in a tertiary trauma center as an attending trauma/acute-care/critical-care doc, it's hard for me to justify EVER doing semi-elective (i.e. non EMERGENT) intubations in the ICU.

On the one hand, I recognize that even with an airway which appears easy, trying to do it as intensivist inevitably is somehow putting the patient more at risk - because, no matter what, I'm just never going to be as good as the anesthesia guys.

On the other hand, obviously, an intensivist really should have airway skills and ability, and, maintaining those skills I think has some virtue.

Thus.. from you guys'/gals' perspective.... what is your preference to scenarios like this? Say a patient in respiratory distress that needs an intubation soon, that I want to intubate.... say I get to a skill level where I'm pretty confident in my skills with this patients airway exam, etc.... do you really want me to call you after my resident failed, and I failed? Two missed tries sometimes can really mess up an airway if they are done traumatically. I dunno... i just want what's best for the patient, while at the same time, not waisting your time calling you for every airway. Or is that the solution? "Hey, we are going to intubate a patient soon, we don't anticipate any problems, but if you could kindly make yourself available in the event we need you please be nearby. thanks"? that mabye better?


thoughts? thanks!

If you consult me, I'm doing the airway. If I arrive, and you're about to try one more time, I'm still doing the airway. Practice, learn your limits, optimize what you can optimize, call early. If you think it may be difficult, don't be a hero, because help might NOT be 2 minutes away ready to go. If I'm with a sick neonate, unstable trauma, etc, I'm not coming anytime soon.

 

[Birdstrike]

This is serious.

SERIOUSLY THE WAY TO HANDLE YOU, YOUR PRACTICE, YOUR COLLEAGUES, YOUR WIFE, YOUR KIDS, YOUR

LIFE.

Yeah, ok, I got all philisophical on you dudes but Bird's post speaks above the clinical message sent:

1) EVERYONE NEEDS HELP AT SOME POINT IN THEIR LIFE. CALL EARLY RATHER THAN LATER. YOU ARE NOT ALONE.

2) YOUR COLLEAGUE (Bird's metaphorical "Joe") WILL PROBABLY SUCCEED WHERE YOU FAIL. IN THE FUTURE YOU WILL SUCCEED WHEN SOMEONE ELSE FAILS.

Thats the beauty of medicine practiced the

RIGHT WAY.

AS ONE.

Jet's advice:

WATCH YOUR COLLEAGUE'S BACK. COLLEAGUE MEANING ANY PHYSICIAN. CUZ KNOW WHAT? you WILL need help at some point. It very well may come from THAT COLLEAGUE'S BACK you had a long time ago.

PLAY IT FORWARD.

Thanks bro

 

[Ignatius J]

Thanks bro

I've seen some surgeons intubate and it really kind of made me cringe. I once watched a surgery resident take about 45 minutes to get a radial art line in the ICU, cussing, making excuses, etc.

This isn't to diminish what they do. I just think specialties need to stick to specialties unless you have gone out of your way to make sure you know what you're doing.

If you're a surgeon and haven't intubated since residency, I would recommend at least getting some supervision if you want to learn. In the same way I'm not going to suture a dude's fascia together, I don't like seeing surgeons try and wing an intubation. Just me, though.

 

[Birdstrike]

... unless you have gone out of your way to make sure you know what you're doing..

Yes. That's the whole point. It's called being a professional (going out of your way to make sure you know what you're doing). No one is suggesting that you should fly by the seat of your pants, like a cowboy, trying a little bit of this, and a little bit of that.

Should a surgeon waltz into the ICU and say, "He guys, I haven't intubated in five years, I think tonight's the night to give it a shot"? No. Should a surgeon who is going to be running an ICU, calling himself an intensive care specialist be an expert in airway. Hell, yes. HELL, yes.

The whole point of my post above, at least, was exactly that. If everyone "went out of their way to know what they were doing", we wouldn't have a discussion would we? However, if someone is advancing their skills and going out of their way to advance and excel, why should the "turf gods" put their hand down and stop them?

(Wait, I know the reason. Money, money, and money. And, turf protection, ego protection, and lastly, money. Different thread.)

There's going to be plenty of sick patients for all of us. Let's worry a little bit more about being the best doctors we can be, and a little bit less about turf protection.

 

[europeman]

Ignatius,

I don't think anyone would disagree that people shouldn't be doing what they aren't properly trained/skilled at w/o appropriate supervision.

That example of a surgeon who couldn't get an a-line and was swearing though sounds like a bad doctor and practioner overall... and not illustrative of surgeons, in general.

 

[jwk]

Speaking from the pediatric intensive care unit standpoint, the majority of our fellows are not anesthesia trained, only pediatric residency trained. They get one month in the OR with peds anesthesiologists and learn the difficult airway algorithm, know their limits, and intubate almost 98% of the children in the PICU. There is no peds anesthesia in house overnight only on call, and our adult anesthesia team has no interest in intubating the little ones unless it's a life or death situation and noone more skilled is around....this is a VERY rare event. All of our fellows are proficient at intubation of the non-difficult airway, and placement of LMA's. I am proud of how well our PICU fellows manage airways-- can't speak to MICU/SICU-- I think the focus is not as intubation based in these locations, more of a reliance on anesthesia on-call?

All due respect...but that's crap.

 

[Ignatius J]

Ignatius,

I don't think anyone would disagree that people shouldn't be doing what they aren't properly trained/skilled at w/o appropriate supervision.

That example of a surgeon who couldn't get an a-line and was swearing though sounds like a bad doctor and practioner overall... and not illustrative of surgeons, in general.

I totally agree. I was really just trying to use it as an example to illustrate a point. Something that can become almost second nature to one specialty can still be very dangerous in the hands of another physician that doesn't do it routinely. No knock on surgeons at all.

🙂

 

[Arch Guillotti]

All due respect...but that's crap.

Why?

If they can manage the airway safely and know their limits, let em have it.

 

[jennyboo]

Bottom line is, if you do any procedure including intubations, you own any consequences or complications that follow.

Not all intensivists do their own intubations (I have tubed for surgical, neuro, pediatric & pulmonary intensivists and the ER) so even if some of your colleagues intubate without backup, it doesn't mean you have to. You can decide for yourself whether you want to intubate routinely or whether you want to call someone else to intubate routinely. You can do both. Same as I can decide for myself whether I want to do none, some, or all chest tubes or perc trachs.

Learn to recognize when you're in vs out of your depth. Listen to that little voice that tells you "Ahhh, I don't want to do this by myself" and bump it to someone else.

 

[jwk]

Why?

If they can manage the airway safely and know their limits, let em have it.

"...our adult anesthesia team has no interest in intubating the little ones..."

This was the part I thought was absurd.

 

[IlDestriero]

"...our adult anesthesia team has no interest in intubating the little ones..."

This was the part I thought was absurd.

Why? Do you work there? My buddy is in a PP in town, there are 3 peds guys, the other 30 won't touch a kid under 3 at all. Good job security for him.

 

[jwk]

Why? Do you work there? My buddy is in a PP in town, there are 3 peds guys, the other 30 won't touch a kid under 3 at all. Good job security for him.

Sorry, I just don't get it. We've got 42 docs, but only 2 bonafide peds guys. Not one of those 40 non-peds docs would shy away from taking care of a peds patient, emergent, urgent, or otherwise because "....nah, I'm just not interested...".

 

[proman]

Sorry, I just don't get it. We've got 42 docs, but only 2 bonafide peds guys. Not one of those 40 non-peds docs would shy away from taking care of a peds patient, emergent, urgent, or otherwise because "....nah, I'm just not interested...".

These aren't OR cases. Michigangirl is referring to emergent PICU intubations which is sometimes a different ball game:

And anyway the vast majority of attendings and fellows at her PICU are anesthesia trained. Some adult attendings aren't comfortable taking care of kids since it's not part of their routine case load. Regardless, life threatening peds emergencies are taken care by the in-house adult call team until the peds attending arrives.

 

[CambieMD]

We have a 3 attempt policy. On the 3rd attempt they have to call us. When we arrive, we're in charge. Obviously this doesn't apply to known or apparently difficult airways. Unfortunately they often call us on try #3 and still try a couple more times instead of just bagging. They're usually not difficult at all. Once in a blue moon the ED will dick around with a known difficult airway. That just pisses me off.
It's getting better though.👍

I think that two attempts are enough.I would advocate one attempt. After someone with a rough touch has been manipulating the airway an easy airway can beocome difficult secondary to swelling and increased secretions. I have seen other providers cause aspiration because they masked the patient for a long period of time with a great amount of force. They miss easy intubations.

What none of us want to see is brain damage from prolonged hypoxia. At the end of the day we all want to see our patients discharged home were they can resume their lives at their pre-hospital functional capacities.

We have to be advocates of whatever is best for our patients.

Cambie

 

[IlDestriero]

Sorry, I just don't get it. We've got 42 docs, but only 2 bonafide peds guys. Not one of those 40 non-peds docs would shy away from taking care of a peds patient, emergent, urgent, or otherwise because "....nah, I'm just not interested...".

Different strokes. That's how they operate. His partner's response would be, "call the peds call person, thanks, zzzzzzz...". Under 3 goes to the peds trained guys. If they were 30 minutes away in bed and the ED could not intubate, I'm sure they would try. NICU, etc, they wouldn't touch them. Could they? Probably, they all did peds a few years ago before they hired a few peds fellowship trained people. They all do 3+ as far as I know.