# Intubations in the OR



## chaz90 (Apr 2, 2013)

I went to the OR for intubation practice for my new job today. Let me preface the rest of this post by saying what a good move I think that is. This obviously doesn't fix all the controversy about paramedic intubation, but sending all new hire medics to prove competency in the OR prior to being released seems like a great commitment to quality service to me.

I am looking for some feedback from others though now that I have done intubations in several hospitals.

What is everyone's thought on the narrow range of patients most hospital staff are comfortable letting the paramedic intubate? I really can see the Anesthesiologist's side of the equation, as I understand the patient is their responsibility and having someone they just met step on their toes cannot be comforting. At the same time, I wonder how smart it is to only let paramedics intubate the easiest patients in the OR. Let's be honest, the 25 year old athlete with a Mallampati of 1 who is already paralyzed doesn't really present any challenge. I don't really see consent being much of an issue either. Most consents can be acquired just by the way it is presented to the patient. They obviously shouldn't be forced at all, but the anesthesiologist asking if the patient minds if they supervise a paramedic as they intubate will most likely be met with approval 9/10 times.

In some ways, I wonder if paramedics should only be attempting intubations on at least moderately difficult airways in the OR. This can certainly leave out extremely high risk patients or those that are deemed to be too difficult for the paramedic to even attempt. This should only occur after familiarization with normal airways and anatomy of course, and only under the direct supervision of the anesthesiologist. Realistically, most airways we manage in the field are difficult in some way. What better place to get practice on varying airway anatomy and pt. size than in a controlled environment with an expert immediately available to correct mistakes, teach, and obtain an airway if necessary? The current model of teaching on simple patients and then throwing new medics to the wolves by intubating elderly, obese patients or children seems intrinsically flawed.


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## VFlutter (Apr 2, 2013)

chaz90 said:


> Most consents can be acquired just by the way it is presented to the patient. They obviously shouldn't be forced at all, but the anesthesiologist asking if the patient minds if they supervise a paramedic as they intubate will most likely be met with approval 9/10 times.



I doubt that the anesthesiologist even mentions that a paramedic student may be intubating during the consent process. If they are an inpatient then consent is sometimes even obtained the night before the surgery. 

I also think 9/10 is very optimistic. A decent percentage of patients refuse to allow CRNAs do procedures let alone SRNAs. I don't think 9/10 people will be on board with allowing a paramedic student to intubate them. Especially if it is a know difficult intubation. But I could be wrong.


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## Dwindlin (Apr 2, 2013)

Chase said:


> I doubt that the anesthesiologist even mentions that a paramedic student may be intubating during the consent process. If they are an inpatient then consent is sometimes even obtained the night before the surgery.
> 
> I also think 9/10 is very optimistic. A decent percentage of patients refuse to allow CRNAs do procedures let alone SRNAs. I don't think 9/10 people will be on board with allowing a paramedic student to intubate them. Especially if it is a know difficult intubation. But I could be wrong.



We consent here for students managing the airway.  Honestly that's a bigger hurdle here than the OR staff.  Though, I do agree most the docs here are leery letting students/medics intubate anything other than the healthy ASA1's.  I am a future anesthesiologist and even I struggle at times to convince them to let me to tackle tougher airways.


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## Carlos Danger (Apr 2, 2013)

chaz90 said:


> They obviously shouldn't be forced at all, but the anesthesiologist asking if the patient minds if they supervise a paramedic as they intubate *will most likely be met with approval 9/10 times*.



Unfortunately, this is untrue. Many patients will refuse to consent to a student. 



chaz90 said:


> The current model of teaching on simple patients and then throwing new medics to the wolves by intubating elderly, obese patients or children seems intrinsically flawed.



Yep, that is a problem. It is not a new problem, either.

Like lots of things, it comes down to liability. The MDA or CRNA who is letting you intubate their patient is financially responsible for any damage that occurs to the teeth or pharynx, and those complications are not rare. We don't think about it much in EMS, because the emergent and difficult nature of prehospital airway management insulates us from liability pretty effectively. But in an elective surgery it is a significant consideration.

The other thing that lots of people don't realize is how fast-paced the OR is. OR and anesthesia staff are under a lot of pressure to turn rooms over as quickly as possible, and, right or wrong, taking the extra few minutes that it takes to have a paramedic student do the intubation is not looked upon kindly by some.

It only takes one or two bad experiences with a paramedic or paramedic student for an anesthesiologist and nurse anesthetist to decide that they aren't going to waste their time and take on the liability of teaching. A couple medic students show up acting like they don't know what they are doing, and next thing you know they aren't allowed in that OR any more.


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## Nova1300 (Apr 2, 2013)

It helps to find the anesthesiologist who is also a paramedic


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## NomadicMedic (Apr 2, 2013)

Interesting. During my last OR rotation I had no difficulty in directly asking patients for consent, nor did I have any issues with the staff allowing me to intubate patients with various degrees of difficulty. The anesthesia chief of staff  introduced me to the patients and then I would explain that I visit the OR every year to learn and maintain my skills. I explain that I have performed several dozen intubations in the field and working with the anesthesia staff was a vital part of my continuing education. Only one refusal, and that was a woman who was so nervous about her upcoming surgery I felt guilty about even asking. 

I believe your success in working with the OR staff is a matter of confidence and poise. If you walk into the to the OR and are visibly nervous around the staff, they will know you're inexperienced and won't give you the opportunities that a confident medic may be offered. 

I had the luxury of a significantly higher number of intubations, including field RSIs, than most students normally see. When I did my student OR rotations, the anesthesia chief of staff took me under his wing and took lots of extra time to teach me various techniques, worked on perfecting my bagging skills and took  the time to show me rather than just say "get the tube and get out". I was invited to stay longer than my regular rotation shift, did extra rotations and was allowed to intubate emergent cases. 

I consider myself very lucky that I had that experience, as I learn that most paramedics don't and most are woefully underprepared to truly mange an airway in the field. And yes, there's a lot more to managing an airway than just "getting a tube". 

Even today, if I don't RSI a patient in the field, but know a tube might be in the patient's future, I'll stay and ask to intubate the patient in the ED. I've never been denied. Trust from the docs and a calm, confident attitude will get you into places that the average medic doesn't go.


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## Clipper1 (Apr 2, 2013)

DEmedic said:


> Interesting. During my last OR rotation I had no difficulty in directly asking patients for consent, nor did I have any issues with the staff allowing me to intubate patients with various degrees of difficulty. The anesthesia chief of staff  introduced me to the patients and then I would explain that I visit the OR every year to learn and maintain my skills. I explain that I have performed several dozen intubations in the field and working with the anesthesia staff was a vital part of my continuing education. Only one refusal, and that was a woman who was so nervous about her upcoming surgery I felt guilty about even asking.



Asking and having it in writing are two different things when it comes to consent for any procedure in the OR. Also, it is the responsibility of the Physician or the CRNA to explain intubation and other procedures which will happen in the OR and not a student, Paramedic or even an RN.


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## NomadicMedic (Apr 2, 2013)

Oh, please don't think that a verbal consent was all that we got. There is a comprehensive consent form for paramedic intubations. I just found that once I was introduced and I explained why I was there, patients were much more receptive than if a CRNA just said, "we have a student, can he do it?"


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## Carlos Danger (Apr 2, 2013)

Clipper1 said:


> Asking and having it in writing are two different things when it comes to consent for any procedure in the OR. Also, it is the responsibility of the Physician or the CRNA to explain intubation and other procedures which will happen in the OR and not a student, Paramedic or even an RN.



A student intubating does not generally require a separate consent. 

It's usually in the language of the facility and surgical consents that you "consent to the supervised participation of students in your care".


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## chaz90 (Apr 2, 2013)

The facility we go to has the pt. sign a separate written consent. The consents today really weren't a problem at all, and neither was the OR staff. I'm just curious how intubation training could be improved and strike a compromise between protecting the patient and anesthesiologist, and allowing medics to get more real world opportunities.


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## chaz90 (Apr 2, 2013)

I do appreciate your input btw Halothane. I get the impression from your username that you spend some time around anesthesia.


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## jwk (Apr 2, 2013)

Ah, a topic near and dear to my heart  

I taught airway management to paramedics for years at my previous gig, and am getting ready to do it again at a new hospital.

Both our hospital and anesthesia consents contain language regarding students.  It's up to the patient to read their consent, and if they want to take the time to do that, that's fine.  There is no need to have a separate consent, oral or written, for students.  That's pointless and will create far more problems than it will solve.  A "comprehensive consent form for paramedic intubations" is, sorry to say, kinda stupid in my view.  (what on earth do you tell them anyway?)  As Clipper1 pointed out, it's up to the the anesthesia staff to talk to the patient about anesthesia issues, and nobody else.  Written consents generally aren't worth the paper they're printed on, but of course we do them anyway.  A student is under the direction and supervision of the anesthesiologist and/or anesthetist in the OR at the time, and that's the important thing.  The same goes for nursing students, radiology students, etc.  No separate consent is necessary for them when they do their thing in other parts of the hospital.  Now of course if the patient specifically requests "no students" we will of course honor that request.

It's not even necessary to specify that a student will be involved, but if they're around before the patient goes to sleep, I'm happy to introduce them to the patient and let them know they're in the OR to learn about airway management.  There's not need to get more specific than that.  The decision to allow students (of any kind) in the OR, or anywhere else in the hospital for that matter, is one made by the hospital and medical staff.  
Most patients don't have an issue with students, but again, there's no need to burden them with lengthy explanations of exactly what the student will be involved with.  Not sure where one gets the idea that patients frequently object to a CRNA (or in my case, an AA) doing their case either.  That is a rare event in most locales.  You can have MD anesthesia at my place - but unless you made arrangements weeks ahead of time, you won't get it on the day you show up for surgery.  We don't staff that way.  We're an anesthesia care team practice and about 99% of our anesthetics are done by anesthetists directed by an anesthesiologist.

Until I see a student intubate, I'm not likely to let them start out with one I know is going to be difficult.  But the only way they're going to know the difference between a difficult one and an easy one is to try, so it definitely doesn't help giving them just the easy ones.  Plus, the ones I think are easy don't always turn out that way.  I rarely get thrown by a difficult airway because I'll prepare for it, but an unexpected difficult airway can be much different.  And honestly, it's not just intubating that a student should be learning - this is the best place to learn how to manage an airway with a mask, because 99% of those that aren't in anesthesia do it poorly (that includes ER docs, respiratory therapists, and yes, paramedics).  They should also be learning how to use LMA's (we generally don't use King airways in the OR).


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## FLdoc2011 (Apr 2, 2013)

I agree with everything said above.  It's going to be tough to get "difficult airway" experience like you said and I don't know a good answer to that.   

I certainly think initially the OR experience is good because you need to start with the basics on straight forward, controlled airways to get the mechanics of it down.   

Not sure if its possible,  but if you're able to prove your skills there and continue to go back to the same OR then over time they may build trust in you and gradually allow you to do more difficult intubations.  

Or I would suggest spending time in the ED and getting in on intubations there where their airways are going to be more indicative of what you may see in the field.

In residency whenever I heard I code called in the ED I'd run down there (even if I wasn't in ER that month) as the ED attending would let me know do whatever procedure needed to be done and I got a lot of central lines, chest tubes, and intubations that way.


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## NomadicMedic (Apr 2, 2013)

Unfortunately, all of the studies have shown, there's no way to get good at intubating patients aside from doing it a whole bunch. Paramedic students just aren't afforded enough opportunity to get the practice needed to reach a level of baseline competency. One of the studies I've read shows that it takes 40+ intubations before reaching a competency level of 80%. That is, being able to manage the airway without asking for assistance, 80% of the time. Of course, I'm on my phone and don't have access to that study now… But if anybody's really curious I'll dig it up when I get home.

Today's litigious society prevents paramedics from achieving competency at the skills that they place in our hands. That's pretty damn frightening. Think about it, "we don't want you to practice it here in this controlled environment, with lots of people around who can help you, because we might get sued." Yet paramedic programs put students into the field with five or fewer intubations. Many with no live intubations, only Fred the head.

Paramedics need to intubate on bariatric surgery day. Paramedics need to intubate on pediatric surgery day. Paramedics need to intubate old people. We need to intubate young people. The only way we get good at it is to do it a lot. And I don't know about you, but if I'm in a car wreck, I don't want the paramedic who's only put the tube in the plastic head to try his first "live tube" on me. 

I agree with FLdoc. Really, the best way to get access to difficult airways is to prove yourself to the staff and be in the right place at the right time.


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## JPINFV (Apr 2, 2013)

Halothane said:


> A student intubating does not generally require a separate consent.
> 
> It's usually in the language of the facility and surgical consents that you "consent to the supervised participation of students in your care".




That's how the hospitals I rotate at work. There is no separate consent process even if we know a paramedic student or medical student is getting the first crack at the intubation.


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## Clipper1 (Apr 2, 2013)

Halothane said:


> A student intubating does not generally require a separate consent.
> 
> It's usually in the language of the facility and surgical consents that you "consent to the supervised participation of students in your care".



Not a separate consent. 

A Physician or CRNA must be the one to obtain the consent and explain the procedure to the patient. A Paramedic can not take a valid consent for the OR.  This is one duty which can NOT be delegated.  It does not matter if a student will be doing the intubation for the purpose of consent for the procedure.


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## JPINFV (Apr 2, 2013)

chaz90 said:


> In some ways, I wonder if paramedics should only be attempting intubations on at least moderately difficult airways in the OR. This can certainly leave out extremely high risk patients or those that are deemed to be too difficult for the paramedic to even attempt.



You're assuming that there's a high volume of those tubes. All of the patients I've seen (regardless of whether I'm intubating or not... and the anesthesiology preop is done just before we go into the OR) have been Mallampati 1 or 2. I few have had anterior airways that have increased the difficulty, but it's not like the OR is getting a ton of 3s and 4s every day.


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## NomadicMedic (Apr 2, 2013)

Clipper, you once again managed to misunderstand and/or misconstrue what I am saying. Obviously, the anesthesiologist or CRNA must get the signed consent. I was simply stating that it makes it easier to gain permission from a patient if the paramedic who will be performing the intubation introduces himself and explains why he is in the OR performing intubations.


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## JPINFV (Apr 2, 2013)

DEmedic said:


> Clipper, you once again managed to misunderstand and/or misconstrue what I am saying. Obviously, the anesthesiologist or CRNA must get the signed consent. I was simply stating that it makes it easier to gain permission from a patient if the paramedic who will be performing the intubation introduces himself and explains why he is in the OR performing intubations.




...and I'll hold that it's completely unnecessary for the student to request special permission when the hospital admission packet or outpatient surgery packet includes such language notifying the patient that students will be involved in their case. If intubation requires special notification, shouldn't the students scrubbing in on the case likewise require special permission?


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## AtlasFlyer (Apr 2, 2013)

As a patient, I would say no to a student of any kind intubating me.  The thought of intubation on ME is bad enough but I just don't want a student doing it. Yeah, I'm one of the 1 out of 10 I guess.  Speaking as a patient, please ask if they're comfortable with it. Many will probably be fine with it, others may not be, and it's their right not to be.

Which is funny, because at my last OB/GYN yearly checkup, my doc had a student and asked if the student could do the internal "girly check" of things. My response, "Sure, I've had two kids, what are you going to do, hurt me?"  It made the nervous student laugh and relax (the poor girl seemed REALLY nervous, I think it was the first actual internal exam she'd ever done), and it may seen backwards but the student doing the girly internal exam didn't bother me but the thought of a student intubating me does. I'm weird I guess.


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## blindsideflank (Apr 2, 2013)

i was always introduced as a `student` it was sneaky i guess but i think people assumed i was a med student. I had no problems with consent.

I didnt get an opportunity for difficult airways in patients that were likely to desaturate quickly (obese copd) but my anesthetist pushed me to experience difficult airways by holding c-spine and doing some ELM (more like reverse BURP or jaw manipulation) to make it hard. He really pushed for me to use a bougie to the point that it is almost my go to (make your first chance your best chance).

he would also paralyze when i was preoccupied then walk away and say `hey, your patient is desatting, i hope you already assessed  if he will be easy to bag``... haha it was always mild panic but it sure boosted my skillséconfidence


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## JPINFV (Apr 2, 2013)

AtlasFlyer said:


> Which is funny, because at my last OB/GYN yearly checkup, my doc had a student and asked if the student could do the internal "girly check" of things. My response, "Sure, I've had two kids, what are you going to do, hurt me?"  It made the nervous student laugh and relax (the poor girl seemed REALLY nervous, I think it was the first actual internal exam she'd ever done), and it may seen backwards but the student doing the girly internal exam didn't bother me but the thought of a student intubating me does. I'm weird I guess.




The worst a student can do with a speculum exam is pinch the inside of your vagina. 

The worst a student can do with an intubation (because... in all honesty if anything goes wrong the supervisor is going to step in quickly) is knock a tooth out. 


Of course the counter argument is that the paramedic student is going to be a paramedic soon. Do you want to be their first tube ever when it's in a much less controlled environment? Also, the resident at my hospital always takes a first look before handing the laryngoscope over to the student.


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## joshrunkle35 (Apr 2, 2013)

I just finished doing a bunch in the OR for paramedic school. I introduced myself as "an EMT who was continuing training to become a Paramedic and was practicing multiple intubations under the direct supervision of the anesthesiologist". I obtained verbal and written consent from every patient, and no one even hesitated. 

I skipped 2 patients that I was uncomfortable doing. The goal is not just to complete intubations, it is to learn how to do them, and how to do them well. The ones I skipped, I still learned a TON about. 

The biggest lesson I learned was how important the "sniffing position" is, and why. Every mannequin I practiced on, I really opened the airway wide. I was dumbfounded when the CRNAs made me do them with pillows still under the patient's heads. All my mannequin practice told me it would be easier to pull the pillow out from under their head. Then I learned how to do it right. 

The goal of practice should not be merely "successful attempts", but how to make them as efficient and perfect as possible, and WHY something is done a certain way.


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## AtlasFlyer (Apr 2, 2013)

JPINFV said:


> The worst a student can do with a speculum exam is pinch the inside of your vagina.
> 
> The worst a student can do with an intubation (because... in all honesty if anything goes wrong the supervisor is going to step in quickly) is knock a tooth out.
> 
> ...



I know. A hospital is a MUCH more controlled setting than anything in the field. I'm just really, really squeamish about being intubated. I absolutely HATE surgeries and everything that goes along with it... Entirely a dumb, stupid thing I know. Just trying to present a patient's side, that while it may be silly, they may be very anxious about a surgery, and just not be comfortable with a student doing it. And it's not something that should be taken "personally", it's not an insult or anything like that at all against the student. They may just be really really nervous.


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## Dwindlin (Apr 2, 2013)

JPINFV said:


> ...and I'll hold that it's completely unnecessary for the student to request special permission when the hospital admission packet or outpatient surgery packet includes such language notifying the patient that students will be involved in their case. If intubation requires special notification, shouldn't the students scrubbing in on the case likewise require special permission?



Sorry going to disagree with you here.  Patients have a right to know who is doing what and should have the opportunity to say no.  Next year when I have students I will absolutely let the patient know ahead of time and ask their permission, even though we have the same deal (this is a teaching center and every consent has students mentioned in them).


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## JPINFV (Apr 2, 2013)

AtlasFlyer said:


> I know. A hospital is a MUCH more controlled setting than anything in the field. I'm just really, really squeamish about being intubated. I absolutely HATE surgeries and everything that goes along with it... Entirely a dumb, stupid thing I know. Just trying to present a patient's side, that while it may be silly, they may be very anxious about a surgery, and just not be comfortable with a student doing it. And it's not something that should be taken "personally", it's not an insult or anything like that at all against the student. They may just be really really nervous.




As I always mention, it's an issue of different views and different positions. When on your paramedic internship, do the paramedics always get permission before the paramedic student does something, or is it a matter of, "The student is a member of the team." Similarly, as a medical student on anesthiology, the team consists of the student, the resident or SRNA, and the attending anesthiologist. It's not an intubate and run, I'm involved with the case from pre-op all the way through dropping the patient off in post op. This includes pushing medications, intubating, setup, maintaining the anesthesiology chart, etc as needed. 

I think the bigger issue with student consents is that it removes the student from the healthcare team. It gives the appearance that the main reason that specific intervention is that it's for education, not because it's right for the patient.


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## JPINFV (Apr 2, 2013)

Dwindlin said:


> Sorry going to disagree with you here.  Patients have a right to know who is doing what and should have the opportunity to say no.  Next year when I have students I will absolutely let the patient know ahead of time and ask their permission, even though we have the same deal (this is a teaching center and every consent has students mentioned in them).



Should the resident physician (who is still arguably a student in a graduate medical education program) require special consent as well?


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## Carlos Danger (Apr 2, 2013)

DEmedic said:


> Unfortunately, all of the studies have shown, there's no way to get good at intubating patients aside from doing it a whole bunch. Paramedic students just aren't afforded enough opportunity to get the practice needed to reach a level of baseline competency. One of the studies I've read shows that it takes 40+ intubations before reaching a competency level of 80%. That is, being able to manage the airway without asking for assistance, 80% of the time. Of course, I'm on my phone and don't have access to that study now… But if anybody's really curious I'll dig it up when I get home.
> 
> Today's litigious society prevents paramedics from achieving competency at the skills that they place in our hands. That's pretty damn frightening. Think about it, "we don't want you to practice it here in this controlled environment, with lots of people around who can help you, because we might get sued." Yet paramedic programs put students into the field with five or fewer intubations. Many with no live intubations, only Fred the head.
> 
> ...



You are 100% right that paramedics need experience managing airways, and the OR seems like the perfect place to do it.

The problem is, there are only so many patients to go around, even in the OR. 

In an urban area you might have dozens of paramedics in school at any given time. How do you get them to spend enough time in the OR to get enough intubations to really be good at it? What about medical students? Anesthesia and ER residents? CRNA students? Paramedics who are out of school but need some skills maintenance? 

The other thing is, as JWK said, paramedics really need to do more than just walk in, stuff the ETT down the trachea, and walk away. They need to practice airway assessments, positioning, mask-ventilating, using different types of blades and adjuncts, etc. This is important stuff but it adds significantly to the time requirement.

I'm in CRNA school now, and I've always planned on doing as much as I can to help paramedics learn airway management once I start practicing. I still plan to, but now that I'm on the other side of the fence, I can see why so many anesthesia folks are squeemish about letting paramedics do it. 

There is a lot that paramedics can learn from anesthesiologists and CRNA's, and I think many would like to teach, but time and liability are big problems.

It is a dilemma. 


As an aside, I have a good friend who was my parter on the helicopter years ago, and we intubated more than a few tough airways when we worked together. He's been a CRNA for a little while now, and even with the background he went into school with, he'll tell you "I didn't really know what I was doing managing airways until I'd done at least a few hundred of them, using lots of different techniques."


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## Carlos Danger (Apr 2, 2013)

Dwindlin said:


> Sorry going to disagree with you here.  Patients have a right to know who is doing what and should have the opportunity to say no.  Next year when I have students I will absolutely let the patient know ahead of time and ask their permission, even though we have the same deal (this is a teaching center and every consent has students mentioned in them).



That is completely impractical. In a large teaching hospital, there might be a few hundred residents and students of various types all participating in every aspect of patient care.

There's simply no way you could possibly get consent for everything a student does on every patient.


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## Dwindlin (Apr 2, 2013)

JPINFV said:


> Should the resident physician (who is still arguably a student in a graduate medical education program) require special consent as well?



That's tricky.  Just out of curiosity how are you going to introduce yourself when you're a resident?  Because personally I'll introduce myself as "I'm Dwindlin, one of the anesthesia residents."  And if they ask what that is I'll explain it.  Again, if it were my family and they were uncomfortable with students of any level they should have the right to voice those concerns.


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## Dwindlin (Apr 2, 2013)

Halothane said:


> That is completely impractical. In a large teaching hospital, there might be a few hundred residents and students of various types all participating in every aspect of patient care.
> 
> There's simply no way you could possibly get consent for everything a student does on every patient.



I can on my patients for my portion of care.  When patients are pre-oped I talk about the risk/benefits of the anesthesia.  The surgeons talk about the surgery.  You act as if it's difficult to say to the patient "Also, I have a xxxx student with me today, would it be okay if they help with taking care of you?"

If they have more questions as to what that entails answer them, if not we're good to go.


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## Dwindlin (Apr 2, 2013)

And for the record I'm at a major teaching institution and this is how it works here.


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## medicsb (Apr 2, 2013)

Getting medics experience in the OR can be done with time.  But, how many paramedic students are willing to hang out in the OR for a couple weeks?  I think I did 30-35 hours in an OR over a week (the majority of cases start between 7 and 1pm) and placed 15 tubes, which I was able to do by bouncing from room to room and scrutinizing the OR schedule for cases using general anesthesia.  I only had to compete with 2 other medical students, one SRNA, and one anesthesia resident.  At a larger academic center, it probably would have been fewer tubes as one would have to compete with more students and more residents.   (My classmates, who had never intubated, got approx. half the number of tubes I got.)  

I think the OR is ideal for initial training, but ongoing competency is best done in the field and the only way to do that is reduce the number of paramedics or the number of paramedics allowed to intubate.  Being allowed to use the OR for ongoing training is a luxury and I don't think ORs should have to open their doors for already practicing medics (but it is great if they do).

What isn't really known (not just limited to paramedics) is how frequently does one need to be intubating to maintain skills after initial training?


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## Carlos Danger (Apr 2, 2013)

Dwindlin said:


> I can on my patients for my portion of care.  When patients are pre-oped I talk about the risk/benefits of the anesthesia.  The surgeons talk about the surgery.  *You act as if it's difficult to say to the patient "Also, I have a xxxx student with me today, would it be okay if they help with taking care of you?"*
> 
> If they have more questions as to what that entails answer them, if not we're good to go.



It can be quite difficult, in fact.

There can be a dozen or more residents or students involved in the care of an ICU patient in a given day.

Would you say we should call an ICU patient's family at home to get permission every time a different resident or student writes an order or starts an a-line or looks at an image?


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## jwk (Apr 2, 2013)

Dwindlin said:


> And for the record I'm at a major teaching institution and this is how it works here.



Weird.    At a major teaching institution, it's kind of a given that students are involved.  That's why it's called a teaching institution.

Using that rationale, every person who comes in contact with the patient would need to obtain an informed consent for whatever they do - IV, foley catheter, chest x-ray, etc.  Pointless and unnecessary.


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## Dwindlin (Apr 2, 2013)

Halothane said:


> It can be quite difficult, in fact.
> 
> There can be a dozen or more residents or students involved in the care of an ICU patient in a given day.
> 
> Would you say we should call an ICU patient's family at home to get permission every time a different resident or student writes an order or starts an a-line or looks at an image?



If you're talking emergent conditions obviously that's different.  For the most part these cases going to the OR are elective, thus time can taken, and as I said in this facility is in fact done with no problem.


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## joshrunkle35 (Apr 2, 2013)

Halothane said:


> That is completely impractical. In a large teaching hospital, there might be a few hundred residents and students of various types all participating in every aspect of patient care.
> 
> There's simply no way you could possibly get consent for everything a student does on every patient.



I obtain written consent from every patient to "allow paramedic student to provide services as part of the care team" and obtain verbal consent which is witnessed by a proctor for every procedure performed. As a student, I note every procedure I perform in the nursing notes. "Paramedic Student IV start, 1 attempt, RH, 125 mL/hr 0.9% NS" might be an example. 

Unconscious patients are a different story, but generally, I do nothing but watch on an unconscious patient unless they are skills that the team is beyond comfortable with me doing, and they feel that the patient would allow me to perform them, could they give consent. Generally, the only skills I do on an unconscious patient are already EMT skills, unless it is truly necessary that I perform the skill to save the person's life...which has only happened once, and I can guarantee the person would have given consent.

I can say that, yes, it is possible to almost always obtain consent, and, with a very small amount of exceptions, anything else is not really due to being "practical", but being lazy.


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## AtlasFlyer (Apr 2, 2013)

When I went in to have my 2nd baby I was asked if it was okay if a nursing student started my IV. I reluctantly agreed.  6 sticks later I was in tears and asked her (nicely) to leave. Another nurse came in and got the IV in on the very next stick, no problem (I'm not hard to stick, no one else has EVER had a problem getting an IV in me).

I would have been a LOT more angry with her incompetence if I HADN'T been told she was a student. I cut her a lot of slack in her failed attempts because I'd been told she was a student. It didn't make it hurt any less, but I was still nice to her even though she had reduced me to tears and I hadn't even been in the building 15 minutes.  I was more patient with her because I had been told she was a student.

There's NOTHING WRONG with admitting to being a student, or being fully open about students doing something. It can actually be to all parties' benefit, as in my example above where knowing she was a student explained her inexperience at starting IVs and it made me less mad as the PT. Sure, I still asked her to leave when I had enough and she'd hurt me too many times, but I didn't get mad about it. I could tell she felt bad too, and it was not my intention to cause her embarrassment, but 6 sticks was enough.


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## Carlos Danger (Apr 2, 2013)

joshrunkle35 said:


> I note every procedure I perform in the nursing notes. "Paramedic Student IV start, 1 attempt, RH, 125 mL/hr 0.9% NS" might be an example.



Documentation and consent are not the same thing.



joshrunkle35 said:


> Unconscious patients are a different story, but generally, I do nothing but watch on an unconscious patient unless they are skills that the team is beyond comfortable with me doing, and they feel that the patient would allow me to perform them, could they give consent. Generally, the only skills I do on an unconscious patient are already EMT skills, unless it is truly necessary that I perform the skill to save the person's life...which has only happened once, and I can guarantee the person would have given consent.
> 
> I can say that, yes, it is possible to almost always obtain consent, and, with a very small amount of exceptions,* anything else is not really due to being "practical", but being lazy.*



Let me get this straight....you are a _basic EMT_, yet you are qualified to proclaim that the way every teaching hospital operates is _lazy?_

An ICU patient or their family could easily have to sign 5 or 10 or more separate consents each day, if they had to sign a consent for every student or resident involved in their care. 

That's not how it's done. 

It's all covered in the general consent for treatment that they signed when they were admitted. If they didn't like what that form said, they didn't have to sign it.


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## jwk (Apr 2, 2013)

joshrunkle35 said:


> I obtain written consent from every patient to "allow paramedic student to provide services as part of the care team" and obtain verbal consent which is witnessed by a proctor for every procedure performed. As a student, I note every procedure I perform in the nursing notes. "Paramedic Student IV start, 1 attempt, RH, 125 mL/hr 0.9% NS" might be an example.
> 
> Unconscious patients are a different story, but generally, I do nothing but watch on an unconscious patient unless they are skills that the team is beyond comfortable with me doing, and they feel that the patient would allow me to perform them, could they give consent. Generally, the only skills I do on an unconscious patient are already EMT skills, unless it is truly necessary that I perform the skill to save the person's life...which has only happened once, and I can guarantee the person would have given consent.
> 
> I can say that, yes, it is possible to almost always obtain consent, and, with a very small amount of exceptions, anything else is not really due to being "practical", but being lazy.



This is where your concepts go haywire.  You can't possible "guarantee the person would have given consent" had they been conscious, and "the team is beyond comfortable" hardly qualifies as consent.

This is purely a CYA move that some attorney has come up with that really has no point outside of hoping it will deter the patient from filing a suit if something bad happened.  Any competent attorney will tell you that a written consent to do ANYTHING by ANYONE is absolutely worthless, even though we all do them every day.  And it's a pretty arrogant attitude, ESPECIALLY for a basic EMT, who barely has a concept of true informed consents and the legal ramifications of one, to think that not getting a separate consent for every individual for every procedure qualifies as being "lazy" on the part of someone.

Tell me - do you get a signed informed consent in the field when taking care of a patient before you do any type of procedure, assuming they're conscious, informing them of the risks and benefits as well as alternatives to the procedure you're doing and the risks and benefits of those as well?  Somehow I doubt it.  I don't think it's because you're lazy - it's because A) it's unnecessary and B) it's impractical.


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## Tigger (Apr 2, 2013)

Let's keep it respectful here folks.


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## JPINFV (Apr 2, 2013)

AtlasFlyer said:


> When I went in to have my 2nd baby I was asked if it was okay if a nursing student started my IV. I reluctantly agreed.  6 sticks later I was in tears and asked her (nicely) to leave. Another nurse came in and got the IV in on the very next stick, no problem (I'm not hard to stick, no one else has EVER had a problem getting an IV in me).
> 
> I would have been a LOT more angry with her incompetence if I HADN'T been told she was a student. I cut her a lot of slack in her failed attempts because I'd been told she was a student. It didn't make it hurt any less, but I was still nice to her even though she had reduced me to tears and I hadn't even been in the building 15 minutes.  I was more patient with her because I had been told she was a student.
> 
> There's NOTHING WRONG with admitting to being a student, or being fully open about students doing something. It can actually be to all parties' benefit, as in my example above where knowing she was a student explained her inexperience at starting IVs and it made me less mad as the PT. Sure, I still asked her to leave when I had enough and she'd hurt me too many times, but I didn't get mad about it. I could tell she felt bad too, and it was not my intention to cause her embarrassment, but 6 sticks was enough.



I think there's two different issues at play.


I'll use my OB/Gyn rotation as an example because it had the most procedural things (namely pelvic, breast, paps, wet mounts). I knock, enter the room, introduce myself as JPINFV, the medical student with the team, so what can we help you with today?" I do a history and physical (and my documentation is cosigned by the attending after I present). If, say, a wet mount is needed (speculum exam to obtain a sample of vaginal discharge), I say, "Ok, we're going to need to do a vaginal exam and a wet mount. There will be a nurse present as a chaperone [ed: standard regardless of if it's a student, resident or attending doing the exam]. Any questions? [reach into cabinet under exam table to get a paper sheet] Ok, I need you to get changed. I'm going to go get the nurse and get setup."

What I don't do is, "Hi, I'm a student, can I do the exam on you?" 



By the way, no one has yet answered the question about whether paramedic students on ambulances require explicit permission before any action is done. I'm willing to place money that the paramedic is just told to start the IV [or other random invasive or non-invasive intervention or skill] while the patient person is doing the H&P.


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## Dwindlin (Apr 2, 2013)

Just so we're clear, the patients here aren't signing anything extra.  The actual consent form has the fact that students will be included in care.  I am talking about actually talking to the patients, again it adds very little time (if any), and personally I think it's the right thing to do.  If it were me or my family I would want to know is doing what (that goes beyond students).


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## VFlutter (Apr 2, 2013)

Are you even legally allowed to witness and obtain consent as a paramedic student?


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## Dwindlin (Apr 2, 2013)

JPINFV said:


> I think there's two different issues at play.
> 
> 
> I'll use my OB/Gyn rotation as an example because it had the most procedural things (namely pelvic, breast, paps, wet mounts). I knock, enter the room, introduce myself as JPINFV, the medical student with the team, so what can we help you with today?" I do a history and physical (and my documentation is cosigned by the attending after I present). If, say, a wet mount is needed (speculum exam to obtain a sample of vaginal discharge), I say, "Ok, we're going to need to do a vaginal exam and a wet mount. There will be a nurse present as a chaperone [ed: standard regardless of if it's a student, resident or attending doing the exam]. Any questions? [reach into cabinet under exam table to get a paper sheet] Ok, I need you to get changed. I'm going to go get the nurse and get setup."
> ...



If it's a relatively stable patient, I introduce the student and ask if they have any issues with them helping me out.  If the patient is cool, student runs the call. 

I'm surprised this is so shocking to people.  I find it disrespectful to do anything else.


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## FLdoc2011 (Apr 2, 2013)

Chase said:


> Are you even legally allowed to witness and obtain consent as a paramedic student?



Doesn't sound like he's obtaining the actual consent or signing anything in the medical record, but more of introducing himself to the patient and what his role is.   By that time I'm sure the anesthesiologist or CRNA has already obtained the official consent.


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## JPINFV (Apr 2, 2013)

Dwindlin said:


> If it's a relatively stable patient, I introduce the student and ask if they have any issues with them helping me out.  If the patient is cool, student runs the call.



...but that's not what's being advocated. You're saying that each intervention the student does needs specific permission for the student to perform it. Not necessarily the general knowledge that the student's a part of the team. Using the "no objections to knowing that a student is involved" argument, than every one I've done pre-op on has given tacit permission for me to intubate just as your students have their tacit permission to do any indicated procedures.

On a side note, unlike the paramedic students, I'm not room hopping most days... and when I do room hop I still stay for the entire case.


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## jwk (Apr 2, 2013)

Dwindlin said:


> If it's a relatively stable patient, I introduce the student and ask if they have any issues with them helping me out.  If the patient is cool, student runs the call.
> 
> I'm surprised this is so shocking to people.  I find it disrespectful to do anything else.



We do a LOT of things every day for which there is no consent, no introductions, etc.  That being said, the various students I work with frequently introduce themselves to my patients, which is simply being respectful.  However, asking permission is generally not involved because it's already covered in the written consents.  By and large, patients who have problems with students participating in their care make sure EVERYBODY knows about it before they even start undressing and put on their hospital gown.

When I come in to do a procedure on a patient, I tell them what I am going to do.  I don't ask permission - it's implied.  But if they say no, or indicate they don't want me doing something, they'll speak up and I'll stop.  I'd guess you do the same thing on your EMS calls.


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## NomadicMedic (Apr 2, 2013)

FWIW, the hospital where were do our OR rotations is not a teaching hospital. I've found that introducing myself to patients and explaining why I'm there works for me. YMMV.


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## hogwiley (Apr 3, 2013)

If you were going for surgery and were likely a tough intubation, would you want some Paramedics practicing on you?

I bet many Paramedics and students would say no. Its one thing to be intubated pre hospital when there arent any good alternatives and its life or death, its another thing to be someones guinea pig when you are in the hospital for shoulder surgery or to have your gall bladder removed.


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## JPINFV (Apr 3, 2013)

hogwiley said:


> If you were going for surgery and were likely a tough intubation, would you want some Paramedics practicing on you?



If it was likely to be a tough intubation than a few things are true. First, the student wouldn't be intubating. Second, the anesthesiologist (or resident) would be hauling out their toys like glide scopes (we've got 4 of them at my current hospital) or fiber optics. This is besides the fact that each OR comes with a bougie in the anesthesia machine.


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## hogwiley (Apr 3, 2013)

JPINFV said:


> If it was likely to be a tough intubation than a few things are true. First, the student wouldn't be intubating. Second, the anesthesiologist (or resident) would be hauling out their toys like glide scopes (we've got 4 of them at my current hospital) or fiber optics. This is besides the fact that each OR comes with a bougie in the anesthesia machine.



I understand that, but it seems the OP was complaining about the fact Paramedic students are generally only allowed to do easy tubes in the OR. I just wonder if theyd feel the same way if they were the one being intubated.

I say this as someone who did knowingly consent to it when having surgery, but I'm also not someone who was likely a hard tube. I survived the procedure with all teeth and fillings intact, but I did have one hell of a sore throat for a long time afterward.


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## AtlasFlyer (Apr 3, 2013)

hogwiley said:


> I understand that, but it seems the OP was complaining about the fact Paramedic students are generally only allowed to do easy tubes in the OR. *I just wonder if theyd feel the same way if they were the one being intubated.*
> 
> I say this as someone who did knowingly consent to it when having surgery, but I'm also not someone who was likely a hard tube. I survived the procedure with all teeth and fillings intact,* but I did have one hell of a sore throat for a long time afterward.*



Exactly. 

And following my tubal ligation, I had the worst sore throat of my LIFE for two weeks. I'm just really touchy about being intubated myself.


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## usalsfyre (Apr 3, 2013)

Chase said:


> Are you even legally allowed to witness and obtain consent as a paramedic student?



I'm not sure if your speaking of the OR specifically, or just in general...but if an EMT/Paramedic can't obtain a consent then how do we operate in the field? 

Most of the consents I've signed have been done by admitting.


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## epipusher (Apr 3, 2013)

I like DEmedics experience. To hone our skills in the entire experience, better bagging and what not,not just sliding a tube in. I will pass what should be an obvious idea along.


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## Christopher (Apr 3, 2013)

hogwiley said:


> If you were going for surgery and were likely a tough intubation, would you want some Paramedics practicing on you?
> 
> I bet many Paramedics and students would say no. Its one thing to be intubated pre hospital when there arent any good alternatives and its life or death, its another thing to be someones guinea pig when you are in the hospital for shoulder surgery or to have your gall bladder removed.



I always ask for students when I come in for medical care. If a student is there, typically folks go into teaching mode. It is a different frame of thought, and a lot of the time they ask more questions then they normally would. I honestly feel like you get more comprehensive care (and perhaps a blown IV or two, but hey, comprehensive care may come at a price).


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## NomadicMedic (Apr 3, 2013)

hogwiley said:


> If you were going for surgery and were likely a tough intubation, would you want some Paramedics practicing on you?



You'd rather have the paramedic's first live intubation be on your mom or your kid on the side of the road after a motor vehicle accident? There is absolutely no logic in preventing paramedic students, or currently certified paramedics who need to demonstrate competency, from practicing intubation in a controlled environment like the operating room. 

Most paramedics I've spoken with have intubated a relatively small number of children, usually they can count that number on one hand. Many paramedics have limited experience with intubation of bariatric patients. Let's face it, we either intubate young trauma patients or old, mostly dead people. 

It only makes sense to give paramedics varied experiences in the controlled setting of the OR.


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## AtlasFlyer (Apr 3, 2013)

DEmedic said:


> You'd rather have the paramedic's first live intubation be on your mom or your kid on the side of the road after a motor vehicle accident? *There is absolutely no logic in preventing paramedic students, or currently certified paramedics who need to demonstrate competency, from practicing intubation in a controlled environment like the operating room.*
> 
> Most paramedics I've spoken with have intubated a relatively small number of children, usually they can count that number on one hand. Many paramedics have limited experience with intubation of bariatric patients. Let's face it, we either intubate young trauma patients or old, mostly dead people.
> 
> It only makes sense to give paramedics varied experiences in the controlled setting of the OR.



I couldn't agree more, and I'm in NO WAY at all trying to advocate for preventing paramedic students from doing intubations in OR environments. I, as a patient, would just like to be ASKED first, before an invasive procedure like that is performed on me by a student. 

A great many people will not have any issue at all with it. A few will, and in a non-emergency environment like an OR there is time to talk about it with the patient. 

I had no problem letting a OB/GYN student do an internal exam on me, and given the same set of circumstances I'd allow a student to do that again. Just be open with the patient and give them the chance to say no if their anxiety level is such that they're not comfortable with it.


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## jwk (Apr 3, 2013)

AtlasFlyer said:


> Exactly.
> 
> And following my tubal ligation, I had the worst sore throat of my LIFE for two weeks. I'm just really touchy about being intubated myself.



Sorry boys and girls - a sore throat is the most common complaint following intubations and is pretty much the rule, not the exception.  It is what it is - a rigid plastic pipe going down your trachea that is usually only filled with...nothing.  And we get tons of complaints about LMA's as well.  Most of the time it has nothing to do with who is placing the airway - it's the fact that something was put there to begin with.


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## AtlasFlyer (Apr 3, 2013)

jwk said:


> *Sorry boys and girls* - a sore throat is the most common complaint following intubations and is pretty much the rule, not the exception.  It is what it is - a rigid plastic pipe going down your trachea that is usually only filled with...nothing.  And we get tons of complaints about LMA's as well.  Most of the time it has nothing to do with who is placing the airway - it's the fact that something was put there to begin with.



Compassion much? :unsure:  I understand that in healthcare, things are going to be done to people that are going to hurt and are going to be uncomfortable. That is unavoidable. Yes, I understand what intubation is, and I understand the mechanics of WHY I could barely talk for two days and hurt like HELL for two weeks. I get it. That doesn't mean we shouldn't show some sympathy for someone in pain, or suffering from some massive anxiety, for whatever reason they may be hurting. Isn't that part of what being a healthcare provider is? 

When I went back to that same hospital for my hysterectomy 4 months later I mentioned (nicely!) the raging sore throat I'd had from the tubal, and the nice anesthesiologist listened, made a note (which may very well have just been chicken scratching to make me feel better) and when I woke up from that operation my throat didn't hurt at all, and I could actually talk within a few minutes. He even stopped by later to ask how my throat was, which was, I thought, kind, nice of him and completely above and beyond what he needed to do.


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## Carlos Danger (Apr 3, 2013)

AtlasFlyer said:


> I couldn't agree more, and I'm in NO WAY at all trying to advocate for preventing paramedic students from doing intubations in OR environments. I, as a patient, would just like to be ASKED first, before an invasive procedure like that is performed on me by a student.
> 
> A great many people will not have any issue at all with it. A few will, and* in a non-emergency environment like an OR there is time to talk about it with the patient.*



Not necessarily.

When I did my OR intubations as a paramedic student and later as a flight paramedic and flight nurse, I never had any opportunity for interaction with the patient. 

In a busy surgical suite first thing in the morning, you may have 5 or 10 cases starting at pretty much the same time, and the time I was instructed to arrive was usually just few minutes before that. As someone who is there to get practice intubating, I would get shuffled from one room to the next with just enough time to walk in as they were giving propofol, mask for a minute, place the tube, tell the anesthesiologist or CRNA "thanks" and then get shuffled to the next room. It's not ideal, but I think it's pretty common.

You can make the argument that I _should have_ gotten there early enough to introduce myself to all 5 or 10 patients and ask them if they'd mind me doing their intubation, but again, I think that's impractical. 

And I also think it's unnecessary, given that these were teaching hospitals where students are the norm and where the patients already signed a consent saying it was OK with them if students were involved in their care. 




AtlasFlyer said:


> Compassion much? :unsure:
> 
> Yes, I understand what intubation is, and I understand the mechanics of WHY I could barely talk for two days and hurt like HELL for two weeks. I get it. That doesn't mean we shouldn't show some sympathy for someone in pain, or suffering from some massive anxiety, for whatever reason they may be hurting. Isn't that part of what being a healthcare provider is?



The point is that a sore throat is common and has nothing to do with students.

It has nothing to do with compassion, or lack thereof.


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## jwk (Apr 3, 2013)

Halothane said:


> The point is that a sore throat is common and has nothing to do with students.
> 
> It has nothing to do with compassion, or lack thereof.



Bingo!  

Some risks are assumed with anesthesia.  In addition to sore throat, nausea, vomiting, etc., dental injury is also an assumed risk.  Far more likely than not, if a tooth or dental work is damaged, it's not going to be paid for by the hospital or anesthesia group.  The risk is there and we warn every patient of the possibility.  Again - it has nothing to do with compassion or lack thereof - sometimes unavoidable things happen despite our best efforts.  It doesn't happen often, but it does happen.


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## VirginiaEMT (Apr 11, 2013)

This is a completely different experience than I had. I was allowed to intubate every patient I came in contact with. I would say that learning how to ventilate a person properly is the biggest thing a paramedic student can take away from the O.R. experience.




chaz90 said:


> I went to the OR for intubation practice for my new job today. Let me preface the rest of this post by saying what a good move I think that is. This obviously doesn't fix all the controversy about paramedic intubation, but sending all new hire medics to prove competency in the OR prior to being released seems like a great commitment to quality service to me.
> 
> I am looking for some feedback from others though now that I have done intubations in several hospitals.
> 
> ...


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