Intubations in the OR

[blindsideflank]

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

 

[JPINFV]

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.

 

[joshrunkle35]

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.

 

[AtlasFlyer]

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.

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.

 

[Dwindlin]

...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).

 

[JPINFV]

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.

 

[JPINFV]

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?

 

[Carlos Danger]

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.

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."

 

[Carlos Danger]

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.

 

[Dwindlin]

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.

 

[Dwindlin]

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.

 

[Dwindlin]

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

 

[medicsb]

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?

 

[Carlos Danger]

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?

 

[jwk]

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.

 

[Dwindlin]

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.

 

[joshrunkle35]

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.

 

[AtlasFlyer]

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.

 

[Carlos Danger]

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.

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.

 

[jwk]

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.