# Intubation Experiance



## mikie (Oct 13, 2011)

When you first started intubation (which maybe a LONG time ago from some of you geezers  ) , field/clinical/OR, wherever; were you successful, unsuccessful?  Found it easy, difficult?  At what point in time did it take you to "think" you were competent in ETI?  

Obviously every patient has different airway anatomies and circumstances surrounding the reason for intubation, I'm just looking for some general impressions, per se.  

thanks!


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## MSDeltaFlt (Oct 13, 2011)

Intubations are like IV's. It is a skill that is easy to learn, hard to master.  I have been told to my face and overheard some brag that they haven't missed a tube.  Either they are lying or not as experienced as they would like or think.  Because the operative word in that phrase is "yet".

I've been intubating since 1992.  I have gotten tubes some would never get and I have missed tubes some would never miss.  I have acquired enough experience to be comfortable enough to admit I may need help on some difficult airways.  I don't consider myself good, reliable, or whatever.  All I can say is that I'm experienced. 

When did I begin to feel comfortable on airway?  Can't say.  That's a blur.


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## fast65 (Oct 13, 2011)

I missed the first couple intubations in the OR, but then I finally relaxed and went a little more slowly, and my success rate shot up. I can't say I really found it to be difficult, nor easy, it just depends on the patient. I think I'm decent at intubation, but I still have a long way to go before I feel like I would be competent in intubation.


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## Shishkabob (Oct 13, 2011)

I have 3 field intubations, 2 of which were RSIs.  100% first pass success rate.




Still don't think I'm competent at it... just lucky, despite the grade 3/4 airways I've had.


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## mikie (Oct 13, 2011)

Linuss said:


> I have 3 field intubations, 2 of which were RSIs.  100% first pass success rate.



You cheated and used a bougie   jk, that's awesome!


and thanks for the replies


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## Shishkabob (Oct 13, 2011)

mikie said:


> You cheated and used a bougie   jk, that's awesome!



Hey, just like the EZ-IO, I have no issue using the bougie on the first attempt if I think it will help. ^_^


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## mikie (Oct 13, 2011)

Linuss said:


> Hey, just like the EZ-IO, I have no issue using the bougie on the first attempt if I think it will help. ^_^



I know, just hasslin'.   I didn't have it available for my attempts and haven't had much practice with it (we were drilled on stylettes).  Though using on a simman recently it does seem to be easier (with an additional set of hands)


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## JPINFV (Oct 13, 2011)

If a bougie improves intubation rates, is there any reason not to use one? 

If a bougie would improve intubation rates when used as a matter of practice, how is not using one, as a matter of practice, anything other than malpractice? 

If a bougie would improve intubation rates when used as a matter of practice, shouldn't services be held liable for putting their patients needlessly at an increased risk? 

/Channeling my inner-Roguemedic.


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## fast65 (Oct 13, 2011)

JPINFV said:


> If a bougie improves intubation rates, is there any reason not to use one?



Yes, there is...because we don't carry them


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## Shishkabob (Oct 13, 2011)

My last agency required bougies to be used on the first attempt after internal studies showed massive first pass success rates getting increased.


The stylettes were backup (we carried adult and pedi bougies)


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## ArcticKat (Oct 13, 2011)

I missed my first real one in the OR back in 1993 and haven't missed one since.  I'm still not competent.


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## MasterIntubator (Oct 14, 2011)

In the 80s I first learned with an anesthesiologist, who happened to be our medical director.  After playing with plastic, he brought me to the OR and we went over the gadgets.  My first view inside was just that... a view.  He had me look in under direct laryngoscopy and describe the structures, position, etc.  After about 20 seconds, I pulled out and did a a little BVM.  Then back to viewing the structures again, gently moving around and getting comfortable with the sights.  Another round of BVM vents, and then I passed the tube.  
Memorable as if it were yesterday.
After that, we would go over "what-ifs" and "what would you do" scenarios.  I did about 10 intubations that day.
Over the years, I stopped documenting tubes as a supplemental log after 100 in the field somewhere around 93/94.  Since then its just been on the PPCRs and a couple or so for re-registry.  I feel quite comfortable with them, and like to hum a tune while doing it now, maybe some sound effects or something. 
I love that tube... and will always fight to keep it in our profession.  No doubt.


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## usafmedic45 (Oct 14, 2011)

mikie said:


> You cheated and used a bougie   jk, that's awesome!
> 
> 
> and thanks for the replies



If it secures an airway, there is no such thing as cheating. Ego is the quickest way to :censored::censored::censored::censored: up an otherwise recoverable failed airway scenario (or get yourself into one in the first place).


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## fast65 (Oct 16, 2011)

usafmedic45 said:


> If it secures an airway, there is no such thing as cheating. Ego is the quickest way to :censored::censored::censored::censored: up an otherwise recoverable failed airway scenario (or get yourself into one in the first place).



Agreed.

Don't think of it so much as "cheating" as it is a "helping tool". We have a multitude of tools and techniques that we can use to secure an airway, and we have such a plethora of options because everyone's airway is different. Don't be afraid to go straight to the bougie if you predict it to be a difficult airway, and my the same measure, don't be afraid to go to your backup airway.

However, lately I've had two Kings that I just couldn't ventilate through, it must be me


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## NomadicMedic (Oct 16, 2011)

I've been a medic for just under 2 years and have 7 RSIs and about 15 tubes in the field, all told. Everyone still makes me nervous. Preperation is the key.

And I use a bougie 90% of the time. 

And I'm only baseline competent.


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## firecoins (Oct 16, 2011)

what is a bougie?


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## JPINFV (Oct 16, 2011)

Think of an extra long stylet that is designed so that the stylet is introduced into the trachea first, confirmed by feeling the cartilaginous rings circling the trachea, then the ET tube is slide down the bougie and into the trachea. 







It can be used both both with a larygnoscope or as a blind technique.


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## Shishkabob (Oct 16, 2011)

You'll feel the tracheal clicks AND hopefully tracheal lock when the tip of the bougie hits the carina and sticks on the right mainstem.


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## Chief Complaint (Oct 16, 2011)

Has anyone ever used one of these?  Seems gimmicky at first, but who doesnt like a little extra light in there?  FF to 1:58 to see it in action.

[youtube]WBBoEmObqX4[/youtube]


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## Fish (Oct 17, 2011)

At my previous Service, the Bougie was an option and we only used it on difficult airways. At my current service we do not even have stylettes. It is Bougie all the way, the increase in success with a Bougie shown in studies was so large that it only seemed reasonable to make this the standard. I have never missed with a Bougie, have missed maybe 4 times with a stylette? However 2 of them required an ant. to come down from the OR to intubate in the ER as the ER Doc could not place the tube either. Also we added the LED Larygnoscope Blades, when you add this super bright blade with the Bouge it is almost impossible to miss! And that Bougie works even when you can't see the Cords due to anatomy or Blood/Vomit/Etc.


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## dfib (Oct 17, 2011)

Bougie or Bust!!!


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## mikie (Oct 17, 2011)

Chief Complaint said:


> Has anyone ever used one of these?  Seems gimmicky at first, but who doesnt like a little extra light in there?  FF to 1:58 to see it in action.



Lol I have one sitting in my apartment from last years EMS Expo, waiting for a power outage.......I used one on a dummy there, it was a nice "adjunct" but think about it, if you can't already see your cords, should you really be passing the tube (where the only the tip is illuminated)?


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## Shishkabob (Oct 17, 2011)

mikie said:


> if you can't already see your cords, should you really be passing the tube (where the only the tip is illuminated)?



If with the bougie, sure, why not?  Just confirm placement by other means than direct visualization.  

One of my intubations was on a grade 4 patient, yet I felt the clicks, felt the lock, got good EtCO2, good chest rise and good breath sounds.


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## Fish (Oct 17, 2011)

Linuss said:


> If with the bougie, sure, why not?  Just confirm placement by other means than direct visualization.
> 
> One of my intubations was on a grade 4 patient, yet I felt the clicks, felt the lock, got good EtCO2, good chest rise and good breath sounds.



I'll second that, I have got tubes when I could not visualize the cords. Even as a last ditch effort if you are not able to feel the rings or see the cords you can shoot for where the cords should be and push the bougie in, if you feel it stop and hit the corina pass the tube confirm with Capnography Breath sounds. If you are pushing it in and it keeps going down down down, you probably in the esophagus, don't pass the tube. Like I said, this is not an exact science and a last ditch method if all else fails before you have to place a king or combitube.


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## Chief Complaint (Oct 17, 2011)

mikie said:


> Lol I have one sitting in my apartment from last years EMS Expo, waiting for a power outage.......I used one on a dummy there, it was a nice "adjunct" but think about it, if you can't already see your cords, should you really be passing the tube (where the only the tip is illuminated)?



Tis a good point.  I was so enamored by the bright colors that i didnt even think about that!


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## Fish (Oct 17, 2011)

Chief Complaint said:


> Tis a good point.  I was so enamored by the bright colors that i didnt even think about that!



It was originally designed for Intubation attempts that did not yield cord visualization, in other words it was originally ment for a Blind Intubation device or Difficult airway device(the bougie that is, not sure about this other thing)


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## mikie (Oct 18, 2011)

Linuss said:


> If with the bougie, sure, why not?  Just confirm placement by other means than direct visualization.
> 
> One of my intubations was on a grade 4 patient, yet I felt the clicks, felt the lock, got good EtCO2, good chest rise and good breath sounds.



I was referring strickly to the OmniGlow Styette.


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## Chief Complaint (Oct 18, 2011)

Fish said:


> It was originally designed for Intubation attempts that did not yield cord visualization, in other words it was originally ment for a Blind Intubation device or Difficult airway device(the bougie that is, not sure about this other thing)



I was referring to the Omniglow Stylite.

The bougie is a great tool, have yet to use one though.


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## ArcticKat (Oct 18, 2011)

Is anyone familiar with the LEMON score for difficult airways?  I've been trying to self teach myself and although I can find out what the components of LEMON are and how to evaluate them, I don't know how to score them.

I've determined that the overall score is 10, but is 10 a good airway or a bad one?

Does each letter get a score of 0, 1, 2 or are they scored differently like the GCS.

Is the lower number a good thing or bad?  For example, if a Mallampati is level IV, is that a score of 2 or 0?


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## Shishkabob (Oct 18, 2011)

I had never been taught it with a score, but more an evaluation as to the proposed difficulty.

L-Look-  facial trauma, large incisors, beard or moustache, and large tongue? (Max of 4 points)
E-Evaluate-  3-3-2 rule.  3 fingers fit in mouth opening?  3 fingers from tip of chin to neck?  2 fingers from mouth to thyroid?  (max of 3 points)
M-Mallampatti- This is where the grades come in...1,2,3 or 4? (1pt)
O-Obstruction- False teeth? etc (1pt)
N-Neck- How is the neck mobility?  Good?  Stiff?  Obese patient? (1pt)




It's scored out of 10.  A score of 5 or higher is claimed to be a difficult intubation.  You assign one point for each of the items listed above that are not "optimal".  IE if you can only do 3/1/1, they would get a score of 2 for the E section.


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## ArcticKat (Oct 18, 2011)

Thanks Linuss


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## xrsm002 (Oct 19, 2011)

I am a Paramedic student and have been to the OR twice and have yet to get a successful intubation.  I am going back again on the 31st to attempt again  Maybe Halloween day will bring me luck haha My advice keep trying you will eventually get there. I agree its easily learned yet hard to master!!


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## xrsm002 (Oct 21, 2011)

My last OR rotation I had a patient with a difficult airway, the anesthesiologist with me then gave it a try with their mac 3 (which is what they seem to like), then he called for a c-mac glide scope (laryngascope with a very small camerac attached, being viewed on a small monitor, pretty sweet actually)  was struggling with that, so he called for a fiibrscope or something like that, he finally got it with the c-mac.  So just goes to show you this Doctor whose been practicing awhile even has a difficult time every now and then.  My instructor has told me if you can't get a tube bag the patient, they don't die from lack of being intubated but rather a lack of oxygen.  The anesthesiologist even told me the same thing!! ^_^.  To this day I have been to the OR twice and still have not gotten a successfull tube, although I was close last time.  I am going back soon, to try a third time.  It doesnt' benefit me being at a universty's teaching hospital.  Like everyone said its an easy skill to learn, but hard to master.


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## NomadicMedic (Oct 21, 2011)

I'm curious how many intubation attempts you've made. If you've been to the OR twice, and not competed a successful intubation, perhaps you need some additional instruction in technique. How many mannequin or simulator intubations have you performed? Are you familiar with all of the anatomy? Were you given the opportunity to use a bougie if you couldn't visualize the cords? Did you get assistance in fine tuning your technique from the anesthesiologist?

Seriously, 2 shots at the OR is all many paramedic students get, you should be. Using every minute there to work on this low frequency, high acuity skill.


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## Smash (Oct 21, 2011)

N7's comment about low frequency, high acuity made me wonder: how many intubations are people performing per week? Or should it be month/year?  It's pretty relevant to this thread, so would people like to chime in?


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## ArcticKat (Oct 21, 2011)

I get in about 6 per year, that probably accounts for my stellar success rate.


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## medicsb (Oct 21, 2011)

When I was a medic in NJ, I'd get 8-10 per year.  

(I worked 16-20 hours per week on average.)


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## fast65 (Oct 21, 2011)

Eh, I maybe get two per month, not very many at all.


Sent from my iPhone using Tapatalk


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## ArcticKat (Oct 21, 2011)

fast65 said:


> Eh, I maybe get two per month, not very many at all.



That's 4 times more than I get.


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## medicsb (Oct 21, 2011)

ArcticKat said:


> That's 4 times more than I get.



I'm willing to bet that 6 is twice what the average US medic gets in a year.  In PA, it is something like 2.


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## NomadicMedic (Oct 21, 2011)

I get about two per month as well. Plus I have access to the OR anytime I need it. It seems as if some of our medics get several tubes every shift, some people just luck into it.


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## 325Medic (Oct 22, 2011)

I average about  <12 a year. Some people get more, depends on luck I guess.

325.


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## Fish (Oct 22, 2011)

10 or less a year


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## Smash (Oct 22, 2011)

Thanks.  I find it quite fascinating, and it does throw into perspective some of the opposition to Paramedic intubation that exists.  I usually get 2-5 tubes a week, and I think that I really don't get enough to maintain competence.


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## Handsome Robb (Oct 23, 2011)

Smash I don't want to derail your thread but after reading this I'm wondering how many medics are provided the opportunity to score OR time to maintain and practice this skill in a controlled environment under direct physician/advanced provider supervision? I can start another thread if you would like me to rather than changing the direction of yours.


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## Chief Complaint (Oct 23, 2011)

NVRob said:


> Smash I don't want to derail your thread but after reading this I'm wondering how many medics are provided the opportunity to score OR time to maintain and practice this skill in a controlled environment under direct physician/advanced provider supervision? I can start another thread if you would like me to rather than changing the direction of yours.



I wish I could have had some chances in the OR but its really luck of the draw there.  Depends on how nice the hospital staff is feeling that day.  All of my tubes have come from internship hours but that is pure luck on my part.  I've been very lucky to get so many chances, my preceptors have been great for the most part.

We do not get placed in the OR for intubations by our program.


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## fast65 (Oct 23, 2011)

Smash said:


> Thanks.  I find it quite fascinating, and it does throw into perspective some of the opposition to Paramedic intubation that exists.  I usually get 2-5 tubes a week, and I think that I really don't get enough to maintain competence.



Smash, I'm not exactly sure what you do, are you a CRNA? I'm just curious 

 I know that with my paramedic program, we needed at least 4 shifts and 10 intubations in the OR, if there were spots open we were allowed to schedule more as well. Now, that is a very, very tiny amount, but I suppose it's a lot better than getting no OR time like some programs.

 I haven't actually heard if we're allowed some OR time with my current company, but most ER docs will let us have a shot at intubating if we happen to be around when they're about to do it. That being said, I will ask around today and see if we actually get any OR time.


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## Smash (Oct 23, 2011)

I'm just a medic in a large service.  2-5 is an average.  Last week I got none at all.  The week before I got 6, so it comes and goes obviously.  I'm not intending to denigrate anyone's abilities, but I've always been confused as to why there was a distinct anti-ETT sentiment from some quarters and this certainly sheds some light on that.


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## Chief Complaint (Oct 23, 2011)

The lack of opportunity for students to practice intubation in the field isn't because of any anti ETT sentiment.  Unfortunately its because none of the counties or hospitals feel comfortable allowing it.  Can't say that I blame them though.  For every 1 student who seems competent with the skill, there are 3 who would surely make matters worse.

If you look like you know what you are doing, preceptors may give you a shot in the field.  But most medic students will never get a chance outside of the classroom.


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## Handsome Robb (Oct 23, 2011)

Chief Complaint said:


> If you look like you know what you are doing, preceptors may give you a shot in the field.  But most medic students will never get a chance outside of the classroom.



Then they shouldn't be  graduating from medic school. If you can't demonstrate competence in the classroom and the field in a skill they shouldn't be graduating, personally. 

The Preceptors job is to be a teacher, they should be helping the student develop the competence.


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## Chief Complaint (Oct 23, 2011)

NVRob said:


> Then they shouldn't be  graduating from medic school. If you can't demonstrate competence in the classroom and the field in a skill they shouldn't be graduating, personally.
> 
> The Preceptors job is to be a teacher, they should be helping the student develop the competence.



Couldn't agree more, things are just wacky here.  You should see some of the clowns that passed registry with me.  Like you said, many of these folks shouldn't even have been able to test.  It's quite frustrating.

These students are the ones that ruin it for the rest of us when it comes to field intubations.  If the hospitals and counties saw that only competent students were allowed to attend clinicals/internships, they would probably be more likely to work with us.

I agree that its a preceptors job to teach, and most of them do a great job, but I can't blame then for not wanting students to tube patients on their watch when some of them clearly have no clue what they are doing.


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## Handsome Robb (Oct 23, 2011)

Very true. I'm very blessed with my school and how our internship is set up. We have the same preceptor for the entire internship unless you are extended, then your preceptor changes at the extension. It allows you to gain your trust of the preceptor. Interns here run the entire show for the most part while the preceptor just hangs out with the FD Officer and watches or helps if we delegate something to them. They will step in if your struggling or things are going south. I am not to my internship phase yet, we do didactic then clinical then internship, I have 2 months let of didactic. 

From what I have heard from talking to other medic students on here is that they have multiple preceptors.


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## Chief Complaint (Oct 23, 2011)

NVRob said:


> Very true. I'm very blessed with my school and how our internship is set up. We have the same preceptor for the entire internship unless you are extended, then your preceptor changes at the extension. It allows you to gain your trust of the preceptor. Interns here run the entire show for the most part while the preceptor just hangs out with the FD Officer and watches or helps if we delegate something to them. They will step in if your struggling or things are going south. I am not to my internship phase yet, we do didactic then clinical then internship, I have 2 months let of didactic.
> 
> From what I have heard from talking to other medic students on here is that they have multiple preceptors.



You're a lucky sonovabitch, I haven't had the same preceptor twice.  Some are happy to let you run the show, others would prefer if you just do the simple tasks....which does very little to help the student.

Medic students here (I and P) do internships with 2 rather large counties so scheduling can be a nightmare.  It's very common to have a different preceptor every time.


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## Handsome Robb (Oct 23, 2011)

Chief Complaint said:


> You're a lucky sonovabitch, I haven't had the same preceptor twice.  Some are happy to let you run the show, others would prefer if you just do the simple tasks....which does very little to help the student.
> 
> Medic students here (I and P) do internships with 2 rather large counties so scheduling can be a nightmare.  It's very common to have a different preceptor every time.



Thats nuts. I don't get how that is an effective education model :wacko:

I'm definitely spoiled. I work for the agency as a per diem Intermediate that also runs my school and is where we do our internship, so most of the preceptors already know me and let me do more ALS assessments before they will start doing their thing when I'm working. They'll let me interp 12 leads then check it to make sure its correct and bounce ideas for treatment and differentials off me when they are stuck.


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## Shishkabob (Oct 23, 2011)

NVRob said:


> Then they shouldn't be  graduating from medic school.



I got 0 tubes in clinicals and 0 in my field internship.  I was a Paramedic for a year before my first field intubation, and it also happened to be my first RSI.  Passed it, and the subsequent tubes, all on first try.  Should I not have graduated?   Some people just aren't there when the tubes are, always the wrong place at the right time.  I can't tell you how many tubes there were at locations I was doing clinicals, but I was off doing some menial tasks for a nurse that could have waited.

Infact, I went though all of EMT school, all of Paramedic school, clinicals, and up until my final 2 shifts of Paramedic internship before I had my first cardiac arrest... and I was in urban Ft Worth and Dallas for these. (And with my luck, the patient was not an ETI candidate due to neck cancer)



What about crics (surgical / needle)?  Chance of you getting one during your internships is minimal, which is why they spend so much time teaching on mannequins and pig trachs. 

Same with pacing.  Or synchronized cardioversion.  My first pacing of a patient was this past July.  Hell, I've never shocked a cardiac arrest, as all of mine (and I've had my fair share in recent months) have all been asystole.  Should I not be trusted with defibrillation, either?



Or any of the other high acuity / low frequency Paramedics do.  Just because you don't do one on a real live patient doesn't mean you're incompetent in it, just inexperienced.  Inexperience doesn't mean failure.  Some people get multiple births in one year, some never get on in their whole career.  Right place at right time is all it equates to.


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## Handsome Robb (Oct 23, 2011)

NVRob said:


> Then they shouldn't be  graduating from medic school. If you can't demonstrate competence in the classroom and the field in a skill they shouldn't be graduating, personally.



I definitely specified competence. It should have said "the classroom *or* the field" instead of and. Sorry english was never my strong suit I should have worded it better.

If a preceptor isn't allowing an intern to perform skills because they are comfortable with the way the student is acting, talking or for whatever other reason there's an issue there that needs to be addressed prior to graduation...


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## Chief Complaint (Oct 23, 2011)

Our preceptors have no affiliation with the school so they have no say as to whether a student graduates.  What they should be doing is reporting to the school when a student shows up who clearly needs some more training/education, and suggesting that they try again once they have grasped the basics.

Linuss' post makes sense to me. There are quite a few bright medics in my program that unfortunately will get zero intubation attempts before they get out in the field.  They will be fine when their time comes to drop a tube.  It's the douche who still can't figure out how to start an IV (but somehow passed that station at registry) who is going to smash all of the patients teeth out when they go in for their first attempt.


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