# my OR clinicals



## mikeN (Mar 9, 2009)

so I am currently doing my clinicals for medic school and other  OR.  I have 5 tubes so far, but I need a total of 10 tubes. I'm not having any trouble actually  intubating. The problem is the hospital I am at uses LMA's and tries to avoid ETTs. The docs are more than happy to let me put LMAs in but now it's tithe point where I don't want to miss a tube in another room if I'm plaing an LMA especially side I only need tubes. I was wondering if anyone else has had a problem getting tubes in the OR.


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## Sasha (Mar 9, 2009)

mikeN said:


> so I am currently doing my clinicals for medic school and other  OR.  I have 5 tubes so far, but I need a total of 10 tubes. I'm not having any trouble actually  intubating. The problem is the hospital I am at uses LMA's and tries to avoid ETTs. The docs are more than happy to let me put LMAs in but now it's tithe point where I don't want to miss a tube in another room if I'm plaing an LMA especially side I only need tubes. I was wondering if anyone else has had a problem getting tubes in the OR.



At least you have an OR rotation! We lost our privledge to go into the OR due to some other school's students flubbing it up pretty bad and all of our intubations must be done in the field or five intubations on a mannequin equals one field intubation, so be happy for what ya got!


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## Scott33 (Mar 9, 2009)

It's a tough one with ETI being used less often in the OR.

You could either ask ahead what cases are going to use ETI, or look at the schedule of any cases with surgery over the nipple line - basically ENT cases which should favour ET tubes. I got ALL my OR tubes from pediatric myringotomies, tonsillectomies, adenoidectomies etc. 

It doesn't help your case, but I predict that ET intubation is going to become a thing of the past, in all but a few instances in the years ahead, and that includes in EMS. The benefit of having a secure airway _some_ of the time, will eventually give way to having a reasonably secure airway which provides ventilation to the lungs _all_ of the time, with supraglottic airways such as the King LT, I-gel, Combi, and of course the LMA being the norm.


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## Outbac1 (Mar 9, 2009)

I had the same problem. I found they had a list of the surgeries for that day and if you talked to the anesthetist they would tell you which ones were going to need an ETT and not a LMA. Then I would talk to the other anesthetist to see if I could get in on their surg. for the ETT. It involved a bit of juggling but it was good to see how different anesthetists worked. I worked with four of them and they all did things differently. I always went out and did the pt. interview with them so I could examine the pt prior to intubating them. I found it was also a good time to learn some different drugs for sedation, and paralysis and the ventilator settings. The anesthetists are very smart Drs. and you can learn a lot from them. 

  I had 20 tubes to do and did about 12 LMA's. I actually found the LMA's to be not quite as easy to put in as I was told in school. Sometimes you need a bit of force and wiggle to get them down, or deflate the cuff and prebend them a little. For my tubes I didn't use a stylet but did get to use a bougie a couple of times. 

  All in all the OR was a very interesting and educational experience.


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## VentMedic (Mar 9, 2009)

mikeN said:


> so I am currently doing my clinicals for medic school and other OR. I have 5 tubes so far, but I need a total of 10 tubes. I'm not having any trouble actually intubating. The problem is the hospital I am at uses LMA's and tries to avoid ETTs. The docs are more than happy to let me put LMAs in but now it's tithe point where I don't want to miss a tube in another room if I'm plaing an LMA especially side I only need tubes. I was wondering if anyone else has had a problem getting tubes in the OR.


 
Do NOT pass up the opportunity to learn any alternative airways or anything extra about airways.   Unfortunately, some students just do their checklist and say FINISHED.   Make time to see and do as much as possible between your ETIs.



Scott33 said:


> It doesn't help your case, but I predict that ET intubation is going to become a thing of the past, in all but a few instances in the years ahead, and that includes in EMS. The benefit of having a secure airway _some_ of the time, will eventually give way to having a reasonably secure airway which provides ventilation to the lungs _all_ of the time, with supraglottic airways such as the King LT, I-gel, Combi, and of course the LMA being the norm.


 
ETI will NOT become a thing of the past because the supraglottic tubes can not be placed on a ventilator with any degree of safety.  Hospitals also use a wide variety of different ETTs for a wide range of disease processes and gases.   

However, for some places, ETI is already a thing of the past for EMS especially with pediatrics.


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## Scott33 (Mar 9, 2009)

VentMedic said:


> ETI will NOT become a thing of the past because the supraglottic tubes can not be placed on a ventilator with any degree of safety.  Hospitals also use a wide variety of different ETTs for a wide range of disease processes and gases.



Stop replying to posts you have merely scanned. I deliberately included the words _"*in all but a few instances*"_ for the pedants among us. Your (real) job is safe...for now 

And yes, it is already _"becoming"_ a thing of the past in some of the more progressive EMS systems. The lack of tubes in the OR as time goes on, will also make live practice with endotracheal intubation a distant memory, as is already evident by other posts.


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## VentMedic (Mar 9, 2009)

Scott33 said:


> Stop replying to posts you have merely scanned. I deliberately included the _"in all but a few instances"_ for the pedants amoung us. Your (real) job is safe...for now


 
A few? Do you know how many intubated patients are on life support in hospitals throughout the world? It is definitely more than a few. Unfortunately, some in EMS never get to see the world of critical care or even care much about what happens past the ED entrance.

Yes, I do prefer a secure tube by ETI for Flight but if an LMA is present and there have been multiple attempts by the ground crew to intubate, I may elect to keep the LMA. But that in not way makes my job not secure since alot more goes into advanced life support than being able to put a plastic tube through the cords.


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## Scott33 (Mar 9, 2009)

VentMedic said:


> A few? Do you know how many intubated patients are on life support in hospitals throughout the world? It is definitely more than a few.



My comment was in reference to the number of professions and systems using ETI, not the number of individual patients.

But while we are on the subject, maybe you can run the exact number by me as I have no idea.


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## VentMedic (Mar 9, 2009)

Scott33 said:


> My comment was in reference to professions and systems using ETI, not number of patients.
> 
> But while we are on the subject, maybe you can run the exact number by me as I have no idea.


 
Today, we currently have 120 adult ventilator patients and 75 in the neo/peds section.  I have 4 intubated adults on ventilators in the ED awaiting space in an ICU.  

Throughout the city with the many hospitals, I would say there may be another 300 - 400 ventilators in use just in the immediate area.  That does not include the sub-acutes where a tracheostomy (below the cords not supraglottic) must be done for long term.   My area is large but nothing compared to LA, NYC or even Boston. 

Small community hospitals of 200 beds may average 12 - 30 adult ventilators per day.


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## mikeN (Mar 9, 2009)

I go in at 630am and I find the anesth charge for the day to look at the schedule and he'll tell me which cases are tubes. Then I'll go to that anesthesiologist and find out most of the time that they are just going to use an LMA. They even invite me to do the LMA but now it getting to the wire and I need tubes, not LMAs. I understand it's good to sit in on the surgeries and I have but I can't chance a doc deciding he wants to do a tube on someone while interviewing a pt and I'm off watching a surgery. Another annoyig thing is I have to get a consent form signed by patients to let me put a tube or LMA in. I haven't had anyone refuse but people can't sign if they have been medicated before the procedure. I've had one doc come out of the surgical room to get me to tell me that he needs to tube instead of using an LMA but I can't tube if hey can't sign. That also goes for someone that's been given fentynal while waiting.


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## mikeN (Mar 9, 2009)

Excuse spelling and grammar. I'm working from an iPod here.


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## Silverstone (Mar 9, 2009)

Just tell your preceptor you NEED ETT's and not LMA's.  I'm sure they'll work with you.  When I did my OR clinicals I mostly did ETT's on kids that were getting T&A's out.


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## TransportJockey (Mar 9, 2009)

Sasha said:


> At least you have an OR rotation! We lost our privledge to go into the OR due to some other school's students flubbing it up pretty bad and all of our intubations must be done in the field or five intubations on a mannequin equals one field intubation, so be happy for what ya got!



I know the feeling! The one major healthcare system in NM has decreed no students in the OR, period. Their one hospital that was letting my colleges students in was found out and lots of their staff got in trouble.


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## mikeN (Mar 9, 2009)

haha! Preceptor. You're funny. 
I'm kind of on my own in their. Most of the dogs know I'm there for tubes but they can tube everyone. A few wouldn't mind tubing everyone, but the lady that runs the gig wants LMAs and no unnessessary intubations. It's just the frequency of tubes is rare or it decided to intubate someone after I can get a signature.


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## Wee-EMT (Mar 9, 2009)

When I was in the OR, I got to do 9 LMA's. Didn't see any ETT at all.


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## vquintessence (Mar 10, 2009)

I know MA is a pain in the explitive when it comes to requirements... but it can all easily be done and shouldn't deter you from enjoying the OR.  What hospital are you doing OR time at?  Can you choose your own?  Try to get to a learning hospital, preferably UMASS or in Boston.  They have lots of scheduled and unscheduled surgeries alike, but the problem lies with competing with med students.

_If it takes you longer to get the minimum, so what?_  You're still being given a front row seat to surgery procedures, getting the importance of sterilization further hammered into you, contingency planning, etc.  If you run into a set where all pts will get LMA's, try to find the most interesting surgeries and ask the pts/surgeons/anesthesiologists if you can watch from the corner, instead of sitting in the break room until the next round.

If you happen to be lucky enough to see a tracheostomy case, TAKE IT (sorry cannot remember the procedural name for it).  It is truly amazing to see it undertaken.  People pay HUGE amounts of money AFTER school to witness/experience airway cases.  I wasn't allowed to touch the airway in that case, you probably won't be allowed to either, but it will be hugely beneficial nonetheless.

Have you been with the anesthesiologists and CRNA's when they do their airway assessment with the pts?  Their size up may seem quick and non-essential but it will be a huge asset for you in the field, when you can see a difficult tube BEFORE you attempt it.  That may save your pt.  Seriously, "extra" OR time isn't a bad thing.


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## mikeN (Mar 10, 2009)

I stopped sitting in on surgeries on day 2 after 2 instances of a doc trying to find me to intubate patients that were still in holding. I also stopped hanging out in the breakroom and hang out by the pre-op rooms where the interveiws are done and will ask the doc if that case will e a tube or LMA. 

I'm not going to name my hospital but it is west of Boston and not a teaching hospital so I have to get consent forms signed which is really working against me right now. The rest of my classmates are at teaching hospitals so they don't need consent forms signed by a patient. I got denied by a patient literally 10 minutes ago.


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## MSDeltaFlt (Mar 10, 2009)

MikeN,

There is another solution to your predicament, *but* it does require your anesthesiologist/anesthetist being *very* lenient and not apposed to thinking/working outside the box.

You may have already tried, *but*...

Explain your situation and ask them if it would be possible to intubate them with ETT, confirm proper placement, then change back to LMA for the surgery.

Granted, you're not likely to be allowed to do this, but it couldn't hurt to ask.


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## mikeN (Mar 10, 2009)

I that last post, yeah that wouldn't fly. So I got denied by that patient a bit ago. Literally right after I posted that a doc decided during an interview that he was going to tube a patient and got me.  I was outside of the room. Patient consented and success. Now the next one is in a half hour so I need to hunt that one down.


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## jason152318 (Mar 22, 2009)

Thats interesting. A lot of hospitals and even EMS providers are switching over to the king LT which they say is better and is faster. When I did my OR time the hospital I was at used both lms's and ET's but only on certain pt's. are there any other hospitals in your area that use ET's?


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## VentMedic (Mar 22, 2009)

jason152318 said:


> are there any other hospitals in your area that use ET's?


 
If you look for a hospital that does cardiac surgery, they will use ETTs since these patients will be on a ventilator once outside of the OR.  

If you can shadow an ED doctor in a busy hospital, they will use ETTs since these patients will also be on a ventilator.


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## sdchargersfan (Mar 23, 2009)

I had a hard time getting tubes in my clinical rotation as well.  10 tubes is a big requirement.  We were only required to do 3, but I got lucky and had 6 in my internship.  It sounds like you need to talk with your teacher or your clinical cordinator and tell them the issue that you are having, and maybe they can talk with the medical director or MD.  LMAs are also great practice though, and I can see them replacing ETs in the near future.


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## mikeN (Mar 23, 2009)

alright, update. I got my 10 tubes. I went to extra days to get them. I only missed one tube and I used a miller blade on that one.  I missed a tube in the ER this morning on a woman that looked easy. She was anterior and her stomach contents kept coming up. A traumatic arrest came in today too and the doc was kind of mad the crew used an LMA instead of a tube. The doc tubes that guy due to messed up anatomy from the accident.  I did get a bunch of med pushes on that one. 
On an unrelated note, I swear I'm a black cloud for stuff.


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## Ridryder911 (Mar 23, 2009)

sdchargersfan said:


> I had a hard time getting tubes in my clinical rotation as well.  10 tubes is a big requirement.  We were only required to do 3, but I got lucky and had 6 in my internship.  It sounds like you need to talk with your teacher or your clinical cordinator and tell them the issue that you are having, and maybe they can talk with the medical director or MD.  LMAs are also great practice though, and I can see them replacing ETs in the near future.



Just to think, the new NHTSA scope/curriculum will require Paramedic students to achieve 5 live intubations. No exceptions. 

R/r 911


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## tydek07 (Mar 23, 2009)

Ridryder911 said:


> Just to think, the new NHTSA scope/curriculum will require Paramedic students to achieve 5 live intubations. No exceptions.
> 
> R/r 911



We had to have 10 successful live tubes in order to pass the class. From the looks of it, we had more requirements then some other services have for their paramedic program(s). I know that some have even higher requirements, but from what I have seen, a lot do not.

tydek07


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## reaper (Mar 23, 2009)

Dang, I was required 30 live intubations, when I was in school. We were also required to have 100 iv sticks. I guess things are getting to easy, now a days!


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## mikeN (Mar 23, 2009)

10 is challengin to get but not impossible.  I would have like to do more and my teacher would like me to have some more. If I don't get a couple more in the ED my teacher is going to put me in another OR for a week.  As for IV's. My requirement is 75 by the end of my clinicals and I have 73 and I'm no where near done. I sucked at them at first and now I can stick almost anyone in one or two shots. I will definatly have well over 200 by the time I'm done.


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## paccookie (Mar 26, 2009)

OR clinicals were fun.  We had to do 20 successful intubations.  That seems to be high based on what the other schools in my state require (5 - which is the state minimum).  By far the most useful experience was learning how to properly bag the patient.  Don't pass up learning anything they are willing to teach you.  Ask for tips and be ready to listen.  Ask questions.  I've done two field intubations since my OR rotation and that experience has been very valuable.


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## NESDMEDIC (Mar 26, 2009)

I was required to have 15 adult, 15 child and 15 infant live intubations.


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## fma08 (Mar 26, 2009)

reaper said:


> Dang, I was required 30 live intubations, when I was in school. We were also required to have 100 iv sticks. I guess things are getting to easy, now a days!



Would have been nice. From the sound of it when I started school, it seemed like some people were going through school without having to perform even 1 live intubation... Something wrong there in my opinion...<_<


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## medic417 (Mar 26, 2009)

Maybe Vent can post how many CRNA's are required before they are turned loose.  Would bet we don't even come close yet we are working alone while they have doctors, etc around if things go bad.


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## VentMedic (Mar 26, 2009)

medic417 said:


> Maybe Vent can post how many CRNA's are required before they are turned loose. Would bet we don't even come close yet we are working alone while they have doctors, etc around if things go bad.


 
We don't use many CRNAs at my hospital so I'll have to get back to you on that. Considering the length of the program and the intensity of their clinicals, I wouldn't even want to guess because it may come up short.

For RRTs, the programs can average 1-5 for adults, 1-5 for kids and 1-5 for infants. Once hired at a hospital where RRTs intubate, another 10 - 20 may be required depending on the area you are working in and may need to maintain 10 - 20+ per year. For L&D, it is preferred you have no less than 25 per year (preferably more) since meconium babies require that you do not miss with each pass of the tube. For specialty teams, you need at least 100 intubations for the age group the team specializes in before being allowed to apply for the team. If you are on both a Neo and Pedi team, you will need to meet the proficiency requirements in both. RNs may also intubate on these teams and are expected to get at least 10 intubations during their training once they are accepted on the team and maintain competency throughout their time with the team. For transport we will probably not have doctors around and may be 100s or 1000s of miles from home in the middle of nowhere. 

At some hospitals, if an RRT has 3 patients in a quarter where it takes you 2 or more tries, you may be told to work under supervision for the next 5 - 10 intubations.


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## Ridryder911 (Mar 26, 2009)

medic417 said:


> Maybe Vent can post how many CRNA's are required before they are turned loose.  Would bet we don't even come close yet we are working alone while they have doctors, etc around if things go bad.



Most nurse anesthetist programs are at the minimum of two years graduate to closer of three years. I know it varies from program to program as well as most hospitals that do use them as a sole provider they have privileges similar to physicians. Most do clinical/fellowship for years usually all year long (M-Fri or more). That is why many have a stipend for those in the program. For those that are under an anesthesiologist, many have to still have the physician present when placing the patient under and intubating them; even decades later.


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## VentMedic (Mar 26, 2009)

Ridryder911 said:


> Most nurse anesthetist programs are at the minimum of two years graduate to closer of three years. I know it varies from program to program as well as most hospitals that do use them as a sole provider they have privileges similar to physicians. Most do clinical/fellowship for years usually all year long (M-Fri or more). That is why many have a stipend for those in the program. For those that are under an anesthesiologist, many have to still have the physician present when placing the patient under and intubating them; even decades later.


 

But the physician presence is during clinicals while still in training, correct?

I know once they get their CRNA, they can be in the OR without an anesthesiologist.

That is not much different than the residents having a higher level resident, fellow or attending at their side.  Or, in the case of our residents, they may get an RRT beside them to take over after two attempts.


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## Sasha (Mar 26, 2009)

fma08 said:


> Would have been nice. From the sound of it when I started school, it seemed like some people were going through school without having to perform even 1 live intubation... Something wrong there in my opinion...<_<



The two other students in my class never got a live intubation. Very wrong! That's not a skill you wanna be trying for the first time for real all by yourself.


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