what to do with M3s?

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pillowhead

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new CA1 here. i've started having m3s rotating through with us this week. they're only there for a one week break from their surgery rotations. any suggestions as to what to teach, how to keep them interested? at this point, they basically know nothing and so can't really useful like an M4, but i want them to have a good experience even if it is only a few days.
 
new CA1 here. i've started having m3s rotating through with us this week. they're only there for a one week break from their surgery rotations. any suggestions as to what to teach, how to keep them interested? at this point, they basically know nothing and so can't really useful like an M4, but i want them to have a good experience even if it is only a few days.

I teach them how to mask, how to start an IV, what the different numbers on the monitor and ventilator mean, the basic roles of the different anesthetic drug classes, and a down and dirty talk about oxygenating versus ventilating and how to achieve each by varying vent parameters. That's the stuff they learn nowhere else.
 
teach IV. but they don't start unless pt is asleep.
teach mask ventilation.
teach some basic pulm and CV physio
go over drugs in cart

NO intubation attempts.
 
teach IV. but they don't start unless pt is asleep.
teach mask ventilation.
teach some basic pulm and CV physio
go over drugs in cart

NO intubation attempts.

I'm a 4th year, and i loved my gas rotation. The residents talked to me about all of the stuff mentioned above and I got experience with IVs and blood draws that was very useful later on in the year. I didn't work with any of the new CA-1s however. They put us with 2nd and 3rd years who were comfortable in the OR and running their own cases. I thought that was ideal (not that you won't do a great job too).

However, I strongly disagree with the no intubation attempts suggestion. This is the only time some of us will get a chance to try it out. Its a big part of what anesthesiology is about. To limit us and refuse to let med students try it out is ridiculous. After the first day on the service where i watched how it was done and had it carefully explained to me and my residents and attendings let me try almost every intubation attempt even if they thought it was gonna be a difficult tube. I'm not suggesting that you let the med student do a rapid sequence induction or anything dangerous, but as long as you can bag mask them, and you trust that the med student won't be irresponsible, whats the harm in letting him or her try it under careful supervision?

Its fun and my experience with the anesthesiology service is a big reason I'm considering going into the field. So what if I didn't get the tube into the obese patient with a difficult airway? At least I tried and I got a whole new respect for how hard it can be.

Again, as a CA-1 it may be different because you are still learning and need practice on all of the intubations. I respect that, but maybe that's another reason not to have med students until the second half of the year....
 
teach IV. but they don't start unless pt is asleep.
teach mask ventilation.
teach some basic pulm and CV physio
go over drugs in cart

NO intubation attempts.


Why no intubation attempts? When I was in med school I was starting central lines, doing chest tubes, learning how to intubate. I think it really helps them stay intersted and learn self confidence with manual procedures.

I tell them that what they should walk away from the one week is a better feel for mask ventilation and the basics of how to start IVs and do ABGs. But I always let them attempt more.
 
I let students do postop femoral nerve blocks under ultrasound as well. We do so damn many anyways, and with u/s those blocks are like shooting fish in a bucket.
 
Where I am rotating right now, the neighboring medical school has its students do two weeks of Anesthesiology during their M3 Surgery rotation. They all have their little procedure logs to keep track of successes and attempts at things like IVs, intubations, mask ventilations, and NG/OG tubes. They are also given a topic list to cover with their residents or attendings that include such things as cardiac drugs, local anesthetics, inhalational and IV anesthetics, NMB, card/pulm physiology, and anesthetic monitoring.

I strongly disagree with only allowing M3s to start IVs after induction, and disallowing intubation attempts. There is a time and place for learning these skills, and that is now.

As far as what skills to teach, I believe that the most important procedures for them to do on their brief stop-over with you are IVs and mask ventilation. The rest are gravy.

If you meet them in the afternoon, tell them when you set up, and ask them to help you get your room ready the next day. You can walk them through the check-off, and explain what drugs you are using, and why. During the cases themselves, take a few minutes and review some basic pharmacology as it pertains to the surgical patient. Talk a little about the vent (this is probably the only time they'll get any vent experience outside of ICU) and pulmonary physiology (PEEP, TV, EtCO2, etc).

Finally, just because they are brand new does not mean that they cannot be useful. At the very least, they can draw up drugs for you and can chart vitals once shown how. Challenge them a little, and offer a reward (a crack and intubating, perhaps), and you may be pleasantly surprised.
 
M3's know more than you think. I know I knew a ton more physio and basic pharm as at the beginning of m3 than the end b/c I just got finsihed w/my boards and it was all fresh in my head. Anesthesia utilizes m1 and 2 knowlege moreso than almost any other field in medicine, part of the reason i like it so much. I'm physio dork :laugh:
 
i think if u think the kid is a knucklehead dont let him do it. There is a policy at my hospital that students dont do procedures especially if they are dangerous but the interns and residents during my surgery rotation let you prove yourself capable and then give you leeway. I got to put in Quintons, triple lumens, a-lines, even got to excise a mass today during surgery with assistance (like yelling at me for cutting some "small" veins by mistake haha).

aka.....give us a chance haha
 
M3's know more than you think. I know I knew a ton more physio and basic pharm as at the beginning of m3 than the end b/c I just got finsihed w/my boards and it was all fresh in my head. Anesthesia utilizes m1 and 2 knowlege moreso than almost any other field in medicine, part of the reason i like it so much. I'm physio dork :laugh:

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Anyone else out there paying for a portion of your tuition sitting in poker rooms?😱

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Not let M3s intubate? What is gonna change once they become m4s? They are gonna all of the sudden become brilliant and able to intubate? Nonsense
 
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As an MS4 I can say that there is a huge amount you can do and teach the MS3s.

1) I definitely agree that they should get to do some of the small procedures but I think the key is to teach them. I have a few great residents and attendings teach me how to start and IV (not just point me to the patient and say try) and it made a huge difference

2) Talk to them about why you are doing what you are doing. I.e. what are you looking at while you mask the patient? Why phenylephrine instead of ep?, Why sux and not vec or roc? When you wake up the patient was signs are you looking for?

3) They can also help prep IV bags, draw up drugs, I even got to take a shot at a few preop H&Ps.

Overall part of what I like about gas is that a good MD has a reason for everything he does, every vent setting he changes, each time he chooses a drug. Try to convey to the student what you know, at the least they will appreciate what you (hopefully soon we) do.
 
teach IV. but they don't start unless pt is asleep.
teach mask ventilation.
teach some basic pulm and CV physio
go over drugs in cart

NO intubation attempts.

I agree on the IV part, but if their veins are the size of the tires on Jet's Monster Truck and there is at least one vein I can hit in case they blow this one, I let them try. However, if their hand shaking makes me suspect Parkinson's and the pt. is anxious, I stop them there. When the patient is asleep, as long as you have access to the arms, you have all the time in the world.

As far as intubation goes, if they show me they can mask ventilate and I am confident it will be an easy airway, I'll give them one shot (especially if the pt. is edentulous). If they can't mask ventilate despite my guidance, they don't earn the right to intubate. This may make some med. students angry, but they eventually learn that their is more to anesthesia than being a tube jockey. You don't get to Step 2 or 3 without doing Step 1.
 
...Its fun and my experience with the anesthesiology service is a big reason I'm considering going into the field. So what if I didn't get the tube into the obese patient with a difficult airway? At least I tried and I got a whole new respect for how hard it can be.

Again, as a CA-1 it may be different because you are still learning and need practice on all of the intubations. I respect that, but maybe that's another reason not to have med students until the second half of the year....

If I think an airway is going to be truly difficult the med. student does not get to try. In that setting I wouldn't let a rotating resident or paramedic student try, so I'm certainly not going to make an exception for a med. student.

With a true possible difficult airway, your first shot is your best shot. After that you increase likelihood of having blood/edema in the airway(especially if a novice is trying). This makes repeat laryngoscopies more difficult. Multiple laryngoscopies can increase secretions if an insufficient dose of glyco was given (or if glyco was not given at all). This makes your rescue fiberoptic more challenging.

Trust me, I've seen ER residents bloody up super easy airways with just one attempt. If a resident can do it, med. students can do it. Usually it's "I see the cords! Give me the tube." --> +/- "Give me more cricoid pressure." --> "I'm in" --> NOT (Esophageal intubation). I do DL --> Class 1 view of cords + bloodied up posterior pharynx (by esophagus).

I remember being a med. student and being told I couldn't get a chance to intubate. It sucked then, but I understand now why I was told that.

As far as rotating in med. students in the beginning of the year -- no problem. Just put them with a senior resident or an attending without a resident. Elective anesthesia rotation for an M4 can be hard to fit in as it is and still get a letter in time for the applications. Why make that process more difficult by limiting when the rotation can be done?
 
new CA1 here. i've started having m3s rotating through with us this week. they're only there for a one week break from their surgery rotations. any suggestions as to what to teach, how to keep them interested? at this point, they basically know nothing and so can't really useful like an M4, but i want them to have a good experience even if it is only a few days.

I am all for giving med students proceedures.

Question: What is difference between a med student doing a proceedure for the first time and a resident doing a proceedure for the first time?

Answer: As a resident you are sleep deprived and thus less focused.

Manual skills are learned by doing. The first time a resident intubates, they have no advantage over an MS3 intubating for the first time as well.

This is a problem at alot of medical schools. They do not teach med students proceedures. It is really a same.

Ender
 
I am not defending the statement to not let MSIIIs intubate but if you have ever had a not so great experience you might think twice.

Was teaching a med student how to intubate. I first showed her what the view should be like. Grade I view, nice big mouth. I said, do you see it? Yes. OK, you take a look and put the tube in. After fumbling for about two minutes the patient starts to desat. Mask for a little bit. Back up to 100%. I take the blade and get the view again. Do you see it? Yes. Put the tube through the VCs. Understand? Yes. Ends up putting the tube in the goose. Next day I go to see the patient and she can barely talk from all the manipulation of her airway. She has tons of throat pain too. I was the one that had to explain ... and no, I didn't tell her a med student intubated.

I understand that it's hard at first and I have intubated the esophagus too but, it made me loose my confidence in the students. This occured with a student who wanted to do anesthesia. Point being that sometimes it is difficult to let others do procedures when you've got burned in the past.
 
I am not defending the statement to not let MSIIIs intubate but if you have ever had a not so great experience you might think twice.

Was teaching a med student how to intubate. I first showed her what the view should be like. Grade I view, nice big mouth. I said, do you see it? Yes. OK, you take a look and put the tube in. After fumbling for about two minutes the patient starts to desat. Mask for a little bit. Back up to 100%. I take the blade and get the view again. Do you see it? Yes. Put the tube through the VCs. Understand? Yes. Ends up putting the tube in the goose. Next day I go to see the patient and she can barely talk from all the manipulation of her airway. She has tons of throat pain too. I was the one that had to explain ... and no, I didn't tell her a med student intubated.

I understand that it's hard at first and I have intubated the esophagus too but, it made me loose my confidence in the students. This occured with a student who wanted to do anesthesia. Point being that sometimes it is difficult to let others do procedures when you've got burned in the past.


I can understand that. Maybe giving them one try per patient is a little safer. I am just saying that if she were a resident learning from you, the experience would have been no different. She has to go through the learning curve just like everyone.

Ender
 
I intubated as a 3rd year medical student.

Made me really appreciate the rotation that the attending would entrust such a task to me. (Obviously, for difficult airways, the attending would do the intubation)
 
M3's know more than you think. I know I knew a ton more physio and basic pharm as at the beginning of m3 than the end b/c I just got finsihed w/my boards and it was all fresh in my head. Anesthesia utilizes m1 and 2 knowlege moreso than almost any other field in medicine, part of the reason i like it so much. I'm physio dork :laugh:

this is very true and when i said m3s don't really know anything, it was more like they don't even know where the oxygen tanks are and don't know what supplies i need for an a-line (or what and a-line even is) rather than they don't know pharm or physio. these guys just took step 1 so they've got way more book knowledge than practical knowledge right now!
 
this is very true and when i said m3s don't really know anything, it was more like they don't even know where the oxygen tanks are and don't know what supplies i need for an a-line (or what and a-line even is) rather than they don't know pharm or physio. these guys just took step 1 so they've got way more book knowledge than practical knowledge right now!

Unfortunately, that material is not evaluated on Step 1. Neither are vital other delivery-of-medicine items like how to write for an insulin sliding scale, how to write for a bowel regimen, dealing w/ social work, etc, etc.

I attribute the this to the fact that nearly all MS1 and MS2 courses are taught by faculty who don't physically DO anything for/to patients - biochemists, pathologists, IM specialists. Learning how the hospital physically works (pts going to and fro, invasive tests, where stuff is kept) comes way behind discussing ad nauseam the ddx for cough.

Hence, clumsy MS3's.
 
As a third year student, I had appreciated anything I could do to be helpful. - Setting up IV bags
- drawing up basic drugs
- IV lines (actually i preferred for these to be done initially while the patient was under because there was less fear of hurting the patient with repetitive attempts - in anesthesia as opposed to fields like EM, this is definitely possible)
- hooking up patients to monitors
- mask ventilation. It wasn't until 4th year that I was really taught how to do this properly. During 3rd year it was just "okay ventilate him/her" without instructing how to properly do so resulting in difficulty.
- intubation was taught initially as baby steps. first i was allowed to intubate while the attending showed me the cords. As time progressed, I was allowed to do it on my own. A few failures, a few successes but I became more comfortable with them.

With one week rotation, I think these should be done with the student.
 
FRIKKIN NICE, DUDE.

Poker room where?

You and ME45455 need to hook up.

He's helped my game.👍

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Don't worry dude, I'll make it out casinos sometime and we'll play some big NL
 
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