Wheelchair Intubationist

[RocketMedic]

So, I haven’t intubated a real human in six months, and I have to fight to keep an appropriate 911 mindset in my desolate wheelchair kingdom. I’ve played with Fred a fair bit, and I still remember how to intubate, but I feel like I’ve lost the edge and a lot of the blade of my skills. Can someone be good at a skill they don’t use except on a rubber head?

 

[akflightmedic]

I think so. I went years without a tube, then jumped right back in the saddle and nailed several in a row, no issue. Muscle memory is a powerful thing. Same with my IVs.

 

[VentMonkey]

Two words: Kovacs Kata.

 

[StCEMT]

I've had periods where I have went months without one and then I'll do one a week every week on the first attempt for a few weeks without difficulty.

 

[NomadicMedic]

Yes. I went awhile with no tubes... no issues here. Of course I use a KV,so it’s like intubation on an Xbox.

 

[hometownmedic5]

Intubation frequency is the primary argument used against field intubations, so I’m guessing there is at least some traction to the idea that, if we don’t do it often, maybe we shouldn’t do it at all...

Sure, even after along hiatus, people have been able to demonstrate success. I would hazard a guess that a far greater number of people have ****ed up their once a year tube than have been successful at it. With the proliferation of easy, safe, and effective alternative airways, my commitment to the “I’m a paramedic damnit, give me the tube” mentality is starting to wane. And of course, generically not specific to anybody here, there is the propensity to juke the stats, or outright lie to make the numbers look good.

Finally, there’s the famous and always popular “walk a mile” thought process. If your or your’s required emergency airway management, would you rather the medic go right to a nearly sure shot, or use you as their “slump buster”, or at least attempt to...

 

[KingCountyMedic]

Can someone be good at a skill they don’t use except on a rubber head?

Simple answer is nope. 12 tubes a year on real humans is our requirement. This was the minimum standard agreed upon by our Medical Directors including several world renowned Anesthesiologists. There is no substitute for human tissue in real prehospital environments. Going to the OR is awesome, it's good to spend time there with the true airway experts and have them critique your technique and offer input and advice. If you can't get real tubes on a regular basis you probably should have a box of iGels and a fast rig.

 

[NomadicMedic]

Is King County using video yet?

 

[Carlos Danger]

So, I haven’t intubated a real human in six months, and I have to fight to keep an appropriate 911 mindset in my desolate wheelchair kingdom. I’ve played with Fred a fair bit, and I still remember how to intubate, but I feel like I’ve lost the edge and a lot of the blade of my skills. Can someone be good at a skill they don’t use except on a rubber head?

I think it depends on how you define "good". If by "good" you mean "a very basic level of competence", then yes, you are probably still fine. But keep in mind that the only way to become and remain very highly skilled at anything is to study it thoroughly and do it a lot.

What degrades much faster than the psychomotor part of any skill is the cognitive aspect of the performance. Airway management is about more than placing a tube between the cords, which is easy 99% of the time. It's the overall act of managing a sick patient's airway - especially when difficulty is encountered - that I would be concerned about if I were away for a while.

 

[KingCountyMedic]

Is King County using video yet?

Yes, there are several agencies using a combination of old school and new video tech. Lot's of folks are using the Glide Scope now as an additional tool in the airway kit.

 

[Tigger]

For me too much fred the head action creates bad peri-intubation habits. You don't really have to position the head, you just tube it. I find that while I have complete muscle memory from placing the blade into the mouth through placing the tube, I do not have this for positioning, setting things up, and securing the tube. I am perfectly competent with these things but have to actually think about them. When a call is going sideways is not when you want to be thinking about these things, you should have already done them. I think this is where checklists really shine through for EMS.

 

[CANMAN]

I think it depends on how you define "good". If by "good" you mean "a very basic level of competence", then yes, you are probably still fine. But keep in mind that the only way to become and remain very highly skilled at anything is to study it thoroughly and do it a lot.

What degrades much faster than the psychomotor part of any skill is the cognitive aspect of the performance. Airway management is about more than placing a tube between the cords, which is easy 99% of the time. It's the overall act of managing a sick patient's airway - especially when difficulty is encountered - that I would be concerned about if I were away for a while.

Agree 110% with Remi here. I also think it depends on what level of "mastery" you achieve prior to hitting your stagnant point. Someone with 200+ career intubations is going to be much better off with a 6 month or one year period between tubes if they had to then someone who has 40 or 60 lifetime tubes for example. I also think exposure and what type of experience and/or training you have is huge as well.

Personally I can't preach enough about O.R. experience, and how much it improves your skill. I was a very active medic, working in a high volume system and volunteering as well out of medic school. At year 8 in my career when I got hired for my first HEMS job I had about 100 field tubes, and felt like I was "really good". It wasn't until I started to rotate into the O.R. on a quarterly basis that I learned I wasn't nearly as good as I had previous thought, and although I had gotten those prior 100 tubes, my technique was fairly sloppy and I lacked the finesse of the CRNA's I was intubating with that day. Which I feel like is super common coming out of P school, but that's how a lot of schools breed us, we are badass airway managers after a couple of Harry the Head tubes and maybe a handful of live tubes in school in an OR. After a year in that flight program and going to the OR multiple times, I had sought out enough feedback and coupled my newly learn finesse with my previous knowledge and I think I graduated into a much better airway manager at that time. Reason I bring this up is it's very difficult for most people to give an adequate assessment of how good they are at something, certainly something such as intubation as a Paramedic. I think the fact you realize that you haven't have the opportunity to maintain the skill in a live patient in a while, and at least are seeking out other ways to maintain the muscle memory is great. I think to answer your question adequately only you can give an accurate assessment of where you are at on that "mastery" scale, and how long you may be able to go and maintain solid skills.

 

[RocketMedic]

I was average at best, 80ish career tubes before this transfer exile began. ;(

 

[akflightmedic]

This brings up an interesting question...and no judgement being passed here.

Do you guys really count your tubes? Like maintain a log?

I never did that and I could not even hazard a guess at career tubes, just never thought to do it. The only log of any type I maintained was my flight log during my years in Alaska.

 

[CANMAN]

This brings up an interesting question...and no judgement being passed here.

Do you guys really count your tubes? Like maintain a log?

I never did that and I could not even hazard a guess at career tubes, just never thought to do it. The only log of any type I maintained was my flight log during my years in Alaska.

I don't count them to an exact number, but almost all of them are researchable in the two reporting systems I have used for many year. I also kept records of the yearly O.R. one's in my old program because not having your quarterly tubes would get you taken off the schedule. Minimum there was 12 tubes a year (3 per quarter) and whatever else you got on flights. So it was pretty easy to do the math.

Where I currently work we do our intubations in the trauma bays, rotate off with the ED residents every other day as far as who is managing the airway. We have to write a progress note post intubation, that is co-signed by the Attending, so I do keep a copy of those in case of any discrepancy.

 

[StCEMT]

This brings up an interesting question...and no judgement being passed here.

Do you guys really count your tubes? Like maintain a log?

I never did that and I could not even hazard a guess at career tubes, just never thought to do it. The only log of any type I maintained was my flight log during my years in Alaska.

Only because I have been told by QA/QI that I won't be shown mine again and I like to have some reference for progress.

 

[VentMonkey]

By far the biggest thing I’ve learned with ETI and advanced airway management from my paramedic infancy up until now is finesse.

I can’t count the times I’ve seen another paramedic, or even done myself (eegad!), obliterate an airway with lack of finesse which is all too commonly not emphasized enough, or at all with most paramedic programs/ students that I’ve seen.

Having learned smoother, more finessed airway entry has more often than not yielded a much higher success rate. But also, this may come with time for some, if not many.

All in all I feel technique is simply lost on too many to render the skill “day-to-day” salvageable.

Also, I’d say with my current program I average ~12 or so intubations in a year, sometimes more. But they also seem to come in clusters that depend on the time of year with often large breaks in between. So, where does this leave someone like myself on the competency level?

I do practice with our “Fred” almost everyday of our rotation and have kept a log on him for the past year and a half.

But also, as @Remi mentions, including the overall bigger picture of advanced airway management regardless of repetitive motor skills has not only made me a more confident airway manager, but has also made the overall management of often critically ill patients who may so happen to require intubation much smoother for me.

There is just not enough that can be said about cognitive offloading, and if it’s one skill that parallels its importance, it’s ETI.

 

[GMCmedic]

This brings up an interesting question...and no judgement being passed here.

Do you guys really count your tubes? Like maintain a log?

I never did that and I could not even hazard a guess at career tubes, just never thought to do it. The only log of any type I maintained was my flight log during my years in Alaska.

CAMTS says I have too

 

[akflightmedic]

I see, are you able to show me exactly where or tell me which category that specifically it is under?

And my question was a bit more broad than a CAMTS program, as several comments stated "career" count...

 

[johnrsemt]

I went from working 2 busy services in Indiana, averaging approx. 18 tubes a year: to working a very S L O W service for the Government (Dept of the Army) in Utah; worked there for 8 years before I finally went crazy and had to get more patient care and went to work PT for a service 115 miles away, and 110-130 miles to the closest hospitals.
No tubes for 8 years, 3 tubes in the 1st year at new PT job. 7 tubes in 3 years. No problems with any of them. So muscle memory does work, and practice does work.