TEE Advice

[Steeeeeve]

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Hi All,

I am a new non-invasive attending at a small-ish community hospital. Mostly outpatient, some inpatient consults. For whatever reason, I have always struggled with TEE intubations. I only did 140-150 as a fellow since my center was very advanced imaging-heavy and would do a ton of CT/MRI. I feel like I can intubate smoothly like 60-70% of the time, but it often takes me several tries for the rest of them. I try staying mid-line, using my finger, left lateral decubitus, jaw thrust, neck flexion, etc. I've also tried to really learn the oropharyngeal anatomy to see if that helps. When I am getting resistance, I can usually feel that I am slipping into the right piriform fossa for whatever reason. I always use extremely gentle pressure so I don't cause injury. Eventually, I keep repositioning and then it will go, but I definitely feel like others are much better at it and can get it first try most of the time.

Is this normal? I feel like when I was a fellow and would be struggling like this, the attending would take over and get it immediately almost every time. Has anyone else experienced this? Any tips or advice? I tried asking for feedback and advice during fellowship and never really got much technical advice on how to become facile.

Thank you

 

[shouldigomd]

It is normal but hard to give advice without watching you. Seems like you are doing all the right things and this is largely a skill that comes by practice. It is really just a feel thing. You probably have done more TEE's than your average fellow coming out of training and intubating smoothly 70% of the time is great. I felt like I did a ton and I finished with 300ish. I am in my 2nd year as attending and I still "struggle" on 20% of them or so requiring a few attempts. Everyone has different neck anatomy. Just be patient / don't push too hard and if it doesn't work on a couple attempts in one position just swap to another. Vary the angle on your probe tip. I usually start pretty steep around 80-90 degrees as that works on most I feel. Laying the probe handle down between the patients legs while you intubate can help you ensure you are going in straight too. I usually do that when I am using my finger. Obviously the worst thing you can do is push hard and cause injury but maybe your lack of confidence is causing you to not apply enough pressure vs the attendings that intubated with ease. They also got to see your attempts and learned what wouldn't work before they tried. It will come with time but I think you are fine!