Paramedic students in the OR

[Carlos Danger]

I know we've touched on this topic in the past, and in fact may have had a thread about this exact topic, but to be honest, I'm too lazy to look very far back to find it.

Anyway......we recently started getting paramedic students in the OR. We have one pretty much every day for most of the day, and I usually end up spending more time with them than anyone else.

Besides the obvious things like getting them as many airways as possible, and stressing the importance of good mask ventilation technique, use of simple adjuncts, patient positioning during intubation, and solid, basic laryngoscopy technique, what else should I be focusing on with them?

I find myself trying to talk to them about the (not-necessarily airway related) drugs that we use in the OR that might have application to general resuscitation and emergency situations, but I find that more often than not I end up getting blank stares back. I've tried to show a couple of them a few basic things with the ultrasound just to get them a little exposure to a tool that is becoming more and more important in EM and in healthcare in general, but again it seems to be a pretty low-yield exercise.

I don't always have a lot of time to spend with them, but whatever amount of time I do have, I want to make count for as much as possible.

Any suggestions?

 

[NPO]

Recent paramedic school graduate here.
I did 5 days in OR.

You hit the major things, as many airways as possible, pharmacology, etc.

For me, OR was the best rotation I did. It was very educational.

Some key things I would stress are:
- Proper Face Mask seal. I had no idea how crappy my seal was until day one in the OR.
- BLS airway menuvers. Again, I always got by just fine, but a CRNA corrected my scissor technique, and it was like night and day getting the blade in the mouth safely same with head tilt, I was not putting the head back nearly far enough.
- Proper use and technique with the laryngoscope.
- Anatomy review and major structures
- Proper blade and tube sizing. I always had a tube and blade given to me; I never had to figure out what to use.

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[VentMonkey]

When, and why not to intubate an individual. All those things taught are great, but oftentimes we do our students a disservice by never explaining why one could potentially inflict harm on a patient (e.g., and unconscious salicylate OD, or DKA patient) with choosing to intubate solely to "protect their airway".

I think where we fall short in initial paramedic training still is teaching them all of the advanced skills, but not properly introducing advanced (critical) thinking skills that display restraint, and could very well impact a patients outcome for better, or worse depending on their choice of care.

In other words, perhaps when one should be less aggressive with their airway management vs. not.

 

[StCEMT]

NPO and vent monkey gave some great suggestions I definitely agree with. I would have blanked stared the ultrasound too, but I would have appreciated the chance for sure.

I think the only thing I would add to this list is have them practice all the methods. Nothing pissed me off more than the "a stylet is a crutch" line or whatever similar answer to me trying to familiarize myself with all the tools/methods. All the blades, DL/VL, naked tube/stylet/bougie, positioning, etc. That would have been nice to have.

I really like your med idea. Getting a crash course in different meds would be really good and when one is more appropriate.

Thanks for taking the time. Would have been glued to your hip if I had someone willing to go this in depth.

 

[Handsome Robb]

I wasn't allowed to intubate until I could demonstrate a proper mask seal and ventilate a patient correctly.

Surgeon was less than pleased but they can deal with the extra minute or two. I had a cool anesthesiologist for that rotation though who actually stood up for us against the surgical teams. The other providers seemed to just kowtow to the surgeon.


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[Tigger]

I found the pharmacology and vent crash course from the anaesthesiologists was even more beneficial than the actual placing of airways. Using an anaesthesia bag was also super helpful, you really don't know how hard is until you aren't using a BVM.

 

[EpiEMS]

I wasn't able to find a minimum CAAHEP or CoAEMSPrequirement for OR hours. Is there such a thing? Interestingly, CoAEMSP says that:

The paramedic student should have no fewer than fifty (50) attempts at airway management across all age levels, with a 90% success rate utilizing endotracheal intubation models in their last ten (10) attempts. The paramedic student needs to be 100% successful in the management of their last twenty (20) attempts at airway management. The majority of airway attempts should be emphasized with live intubations, realistic simulation labs, or both. As with all other required skills, terminal competency needs to be validated by the program medical director’s signature.

Seems a little...low, no?

 

[E tank]

I think assessment of difficult airway gets passed over a little when training folks in the OR, no matter who they are. A thorough assessment isn't practical in the field, but general principles might be helpful, I think. Feeding some pertinent questions to ask family if they're around, about previous problems with intubation, previous neck problems, surgery, RA, stuff like that. I know I don't hammer it a whole lot. There's enough to talk about, but it might be worth a couple of minutes.

Scene conditions and frequency of intubation might make every intubation difficult, but forewarned is forearmed.

 

[DesertMedic66]

Not many programs in CA have you go to OR. For us it was only 1 4-6 hour shift. My first shift there was ehhh. Second shift (needed more tubes) was amazing. At the medic student level I was more than satisfied with just the airway help. If they dive into meds I would have probably been a little overwhelmed.

 

[VentMonkey]

If they dive into meds I would have probably been a little overwhelmed.

What kind of meds are you referring to specifically? RSI meds, pre and post?

I agree with what you said re: CA programs, and it only further serves to exemplify why intubation either A) does not belong in our scope, or B) needs an all inclusive, and restructured airway lecture approach, similar to the "seriousness" we see taken with cardiology modules.

 

[DesertMedic66]

What kind of meds are you referring to specifically? RSI meds, pre and post?

I agree with what you said re: CA programs, and it only further serves to exemplify why intubation either A) does not belong in our scope, or B) needs an all inclusive, and restructured airway lecture approach, similar to the "seriousness" we see taken with cardiology modules.

If it's the very basic airway meds (roc, sux, etom) then I would have been fine with that. Anything more and who knows. If I had more time in the OR then sign me up. For the small amount of time I had I was able to grasp some very basic techniques.

 

[VentMonkey]

If it's the very basic airway meds (roc, sux, etom) then I would have been fine with that. Anything more and who knows. If I had more time in the OR then sign me up. For the small amount of time I had I was able to grasp some very basic techniques.

There are only a handful of prehospital induction agents that are kept as a constant for various reasons, be it cost, storage, medical director preference, etc. There are some seen most commonly in hospital that have similar properties, and/ or offer different advantages (e.g., precedex, and propofol).

I still can't fathom in this day and age why we don't approach a respiratory module similar to cardiology, but I digress and don't want to devalue or derail this thread.

I liked @E tank's point about going over difficult airways, and going over positioning of a predicted difficult airway patient. I also think at the very least (and I don't know if programs do this enough, or collectively enough) there needs to be a "first pass should be the only pass" mentality, with the obvious caveat of having, and damn well knowing where, and how to use your back ups rapidly.

 

[NPO]

Not many programs in CA have you go to OR.

When I went and did my NREMT skills in Orange County, my class was astonished by what other students said their class included. Some reported as little as a week in the ER.

I guess fire department paramedics don't need to know all that fancy medicine stuff.


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[VentMonkey]

I guess fire department paramedics don't need to know all that fancy medicine stuff.

I vote for trying to keep this thread on topic. I'm all for razzing and such, but this seems like a decent topic worth input from prehospital providers asked by an in-hospital provider that can benefit our fellow prehospital providers, granted in another region, but nonetheless...

...help a brutha' out.

 

[Carlos Danger]

I appreciate everyone's input. I really enjoy teaching and haven't really gotten to do it in a while, as a result I know that my enthusiasm leads me off into the weeds a little bit at times. I want to make the best use of the limited time these guys have with us.

What I take away from this thread so far is that, in addition to mask ventilating and placing airways, people find the following things beneficial:

- airway assessment
- indications / when to think twice about intubating
- talking about basic ventilator management
- going over the tools of airway management (different blades, stylet vs. no stylet, etc)

Any other suggestions?

 

[VentMonkey]

Any other suggestions?

Maybe adding other resources that have helped you as references, be it podcasts, EMS forums (ahem), or any material you've found helpful over the span of your career.

Oftentimes when we start out we're working off of what's been drilled into us via textbooks in class and not a whole lot more (thus the overwhelming feeling, and "deer in the headlights" reactions).

This is fine, as it builds fundamentals, but knowing where to pick up where you left off that isn't laterally equivalent, but instead will guide their thought processes with regards to airway management can propel not only their decision making abilities, but a whole slew of other things including their confidence, and probably even their competence to a degree.

We really need to do better as a whole with the privileges and a better understanding of the responsibilities placed on us with airway management. It really is a serious thing far beyond just intubating. If we can instill this in just one bright-eyed student, then maybe they'll in fact take it in, and in turn pay it forward.

 

[StCEMT]

A pharm crash course would be cool. I know you can't delve deeply into receptors and all that type of stuff. The basics of what we carry like versed, ketamine, etomidate, roc/sux, etc. would be helpful. Dosing, push rates, side effects, choosing the appropriate one, and continuing sedation would all be helpful.

 

[captaindepth]

When I was in paramedic school a couple of years ago we did three 8 hour shifts in the OR. It was all about getting as many tubes as possible and not a lot other than that. Since we are part of an academic hospital there were lots of "students" of varying levels of care and P-students were definitely the lowest on the totem pole. You had to be aggressive with finding patients in the pre-op area and asking to assist the anesthesiologists with their cases. The three shifts were a blur of dozens of intubations with significant assistance from staff, and pretty much no self reliance. About 6 months after I graduated and was working as a field paramedic and I hit a "rough patch" with intubations, my confidence plummeted, that clock in my head got louder and louder every time I put the blade in for a look, and finally I'd just hand the tube off to my partner. I asked for another rotation in the OR and it was incredible. I spent 8 hours talking to every anesthesiologist, CRNA, med student, and anyone else who knew anything about airway techniques. The biggest "aha moment" was when we focused on proper positioning of the pt BEFORE attempting to intubate, we really focused on different body types, head types, body habitus, and how to set yourself up for success. We also went over secondary and tertiary steps to take when the first attempt wasn't a good view. After that one shift my confidence soared, success rate shot up, and now walk into those scenarios mentally and physically prepared to be more successful.

Sorry that was long winded but that experience has changed the way I think students should approach their OR clinical time. Of course solid mechanics need to be established with face/mask seal and pre-oxygenation, BLS adjuncts, "basic laryngoscopy technique", blade manipulation, positioning, and anatomy recognition. But I think students should be taught and prepared for what to do WHEN things don't go as planned. How long are you going to look? Are you going to use B.U.R.P? What positional changes to the patient will improve your next view? What can you use to position the patient, blankets? couch pillows? a roll of paper towels from the kitchen? Can you BLS the airway effectively and appropriately? All of these thoughts were never introduced in my first round of clinicals because, "of course Ill just get the tube" or we'll just put in a SGA, no big deal. Well when I was in dark basements, on sidewalks, or in the middle of a church with 100 people standing around I sure wish I had thought of some of those back up plans then. So yeah, teach them to be ready for WHEN things dont go as planned is my point.

 

[agregularguy]

When I was in paramedic school a couple of years ago we did three 8 hour shifts in the OR. It was all about getting as many tubes as possible and not a lot other than that. Since we are part of an academic hospital there were lots of "students" of varying levels of care and P-students were definitely the lowest on the totem pole. You had to be aggressive with finding patients in the pre-op area and asking to assist the anesthesiologists with their cases. The three shifts were a blur of dozens of intubations with significant assistance from staff, and pretty much no self reliance. About 6 months after I graduated and was working as a field paramedic and I hit a "rough patch" with intubations, my confidence plummeted, that clock in my head got louder and louder every time I put the blade in for a look, and finally I'd just hand the tube off to my partner. I asked for another rotation in the OR and it was incredible. I spent 8 hours talking to every anesthesiologist, CRNA, med student, and anyone else who knew anything about airway techniques. The biggest "aha moment" was when we focused on proper positioning of the pt BEFORE attempting to intubate, we really focused on different body types, head types, body habitus, and how to set yourself up for success. We also went over secondary and tertiary steps to take when the first attempt wasn't a good view. After that one shift my confidence soared, success rate shot up, and now walk into those scenarios mentally and physically prepared to be more successful.

Sorry that was long winded but that experience has changed the way I think students should approach their OR clinical time. Of course solid mechanics need to be established with face/mask seal and pre-oxygenation, BLS adjuncts, "basic laryngoscopy technique", blade manipulation, positioning, and anatomy recognition. But I think students should be taught and prepared for what to do WHEN things don't go as planned. How long are you going to look? Are you going to use B.U.R.P? What positional changes to the patient will improve your next view? What can you use to position the patient, blankets? couch pillows? a roll of paper towels from the kitchen? Can you BLS the airway effectively and appropriately? All of these thoughts were never introduced in my first round of clinicals because, "of course Ill just get the tube" or we'll just put in a SGA, no big deal. Well when I was in dark basements, on sidewalks, or in the middle of a church with 100 people standing around I sure wish I had thought of some of those back up plans then. So yeah, teach them to be ready for WHEN things dont go as planned is my point.

We too had that problem during clinicals. Our OR time was spent at a great hospital, but again us medic students were lowest on the totem pole. We got bumped by any doctors, nursing students, hell you could have had me convinced a janitor could have bumped me out of an intubation at one point.
Proper positioning of the neck was what really did it for me though. I'd love to do more clinical time in the OR now.. I'll have to see if that's possible.

 

[StCEMT]

Proper positioning of the neck was what really did it for me though.

This really helped me I think too. Depending on your comfort, maybe you could take a minute to show the anatomy with different positioning with them looking over your shoulder so they can see the difference it can make.