Intubations in the OR

[Tigger]

Let's keep it respectful here folks.

 

[JPINFV]

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.

 

[Dwindlin]

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).

 

[VFlutter]

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

 

[Dwindlin]

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.

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.

 

[FLdoc2011]

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.

 

[JPINFV]

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.

 

[jwk]

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.

 

[NomadicMedic]

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.

 

[hogwiley]

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.

 

[JPINFV]

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.

 

[hogwiley]

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.

 

[AtlasFlyer]

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.

 

[usalsfyre]

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.

 

[epipusher]

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.

 

[Christopher]

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).

 

[NomadicMedic]

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.

 

[AtlasFlyer]

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.

 

[jwk]

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.

 

[AtlasFlyer]

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.