Intubations in the OR

[chaz90]

I went to the OR for intubation practice for my new job today. Let me preface the rest of this post by saying what a good move I think that is. This obviously doesn't fix all the controversy about paramedic intubation, but sending all new hire medics to prove competency in the OR prior to being released seems like a great commitment to quality service to me.

I am looking for some feedback from others though now that I have done intubations in several hospitals.

What is everyone's thought on the narrow range of patients most hospital staff are comfortable letting the paramedic intubate? I really can see the Anesthesiologist's side of the equation, as I understand the patient is their responsibility and having someone they just met step on their toes cannot be comforting. At the same time, I wonder how smart it is to only let paramedics intubate the easiest patients in the OR. Let's be honest, the 25 year old athlete with a Mallampati of 1 who is already paralyzed doesn't really present any challenge. I don't really see consent being much of an issue either. Most consents can be acquired just by the way it is presented to the patient. They obviously shouldn't be forced at all, but the anesthesiologist asking if the patient minds if they supervise a paramedic as they intubate will most likely be met with approval 9/10 times.

In some ways, I wonder if paramedics should only be attempting intubations on at least moderately difficult airways in the OR. This can certainly leave out extremely high risk patients or those that are deemed to be too difficult for the paramedic to even attempt. This should only occur after familiarization with normal airways and anatomy of course, and only under the direct supervision of the anesthesiologist. Realistically, most airways we manage in the field are difficult in some way. What better place to get practice on varying airway anatomy and pt. size than in a controlled environment with an expert immediately available to correct mistakes, teach, and obtain an airway if necessary? The current model of teaching on simple patients and then throwing new medics to the wolves by intubating elderly, obese patients or children seems intrinsically flawed.

 

[VFlutter]

Most consents can be acquired just by the way it is presented to the patient. They obviously shouldn't be forced at all, but the anesthesiologist asking if the patient minds if they supervise a paramedic as they intubate will most likely be met with approval 9/10 times.

I doubt that the anesthesiologist even mentions that a paramedic student may be intubating during the consent process. If they are an inpatient then consent is sometimes even obtained the night before the surgery.

I also think 9/10 is very optimistic. A decent percentage of patients refuse to allow CRNAs do procedures let alone SRNAs. I don't think 9/10 people will be on board with allowing a paramedic student to intubate them. Especially if it is a know difficult intubation. But I could be wrong.

 

[Dwindlin]

I doubt that the anesthesiologist even mentions that a paramedic student may be intubating during the consent process. If they are an inpatient then consent is sometimes even obtained the night before the surgery.

I also think 9/10 is very optimistic. A decent percentage of patients refuse to allow CRNAs do procedures let alone SRNAs. I don't think 9/10 people will be on board with allowing a paramedic student to intubate them. Especially if it is a know difficult intubation. But I could be wrong.

We consent here for students managing the airway. Honestly that's a bigger hurdle here than the OR staff. Though, I do agree most the docs here are leery letting students/medics intubate anything other than the healthy ASA1's. I am a future anesthesiologist and even I struggle at times to convince them to let me to tackle tougher airways.

 

[Carlos Danger]

They obviously shouldn't be forced at all, but the anesthesiologist asking if the patient minds if they supervise a paramedic as they intubate will most likely be met with approval 9/10 times.

Unfortunately, this is untrue. Many patients will refuse to consent to a student.

The current model of teaching on simple patients and then throwing new medics to the wolves by intubating elderly, obese patients or children seems intrinsically flawed.

Yep, that is a problem. It is not a new problem, either.

Like lots of things, it comes down to liability. The MDA or CRNA who is letting you intubate their patient is financially responsible for any damage that occurs to the teeth or pharynx, and those complications are not rare. We don't think about it much in EMS, because the emergent and difficult nature of prehospital airway management insulates us from liability pretty effectively. But in an elective surgery it is a significant consideration.

The other thing that lots of people don't realize is how fast-paced the OR is. OR and anesthesia staff are under a lot of pressure to turn rooms over as quickly as possible, and, right or wrong, taking the extra few minutes that it takes to have a paramedic student do the intubation is not looked upon kindly by some.

It only takes one or two bad experiences with a paramedic or paramedic student for an anesthesiologist and nurse anesthetist to decide that they aren't going to waste their time and take on the liability of teaching. A couple medic students show up acting like they don't know what they are doing, and next thing you know they aren't allowed in that OR any more.

 

[Nova1300]

It helps to find the anesthesiologist who is also a paramedic

 

[NomadicMedic]

Interesting. During my last OR rotation I had no difficulty in directly asking patients for consent, nor did I have any issues with the staff allowing me to intubate patients with various degrees of difficulty. The anesthesia chief of staff introduced me to the patients and then I would explain that I visit the OR every year to learn and maintain my skills. I explain that I have performed several dozen intubations in the field and working with the anesthesia staff was a vital part of my continuing education. Only one refusal, and that was a woman who was so nervous about her upcoming surgery I felt guilty about even asking.

I believe your success in working with the OR staff is a matter of confidence and poise. If you walk into the to the OR and are visibly nervous around the staff, they will know you're inexperienced and won't give you the opportunities that a confident medic may be offered.

I had the luxury of a significantly higher number of intubations, including field RSIs, than most students normally see. When I did my student OR rotations, the anesthesia chief of staff took me under his wing and took lots of extra time to teach me various techniques, worked on perfecting my bagging skills and took the time to show me rather than just say "get the tube and get out". I was invited to stay longer than my regular rotation shift, did extra rotations and was allowed to intubate emergent cases.

I consider myself very lucky that I had that experience, as I learn that most paramedics don't and most are woefully underprepared to truly mange an airway in the field. And yes, there's a lot more to managing an airway than just "getting a tube".

Even today, if I don't RSI a patient in the field, but know a tube might be in the patient's future, I'll stay and ask to intubate the patient in the ED. I've never been denied. Trust from the docs and a calm, confident attitude will get you into places that the average medic doesn't go.

 

[Clipper1]

Interesting. During my last OR rotation I had no difficulty in directly asking patients for consent, nor did I have any issues with the staff allowing me to intubate patients with various degrees of difficulty. The anesthesia chief of staff introduced me to the patients and then I would explain that I visit the OR every year to learn and maintain my skills. I explain that I have performed several dozen intubations in the field and working with the anesthesia staff was a vital part of my continuing education. Only one refusal, and that was a woman who was so nervous about her upcoming surgery I felt guilty about even asking.

Asking and having it in writing are two different things when it comes to consent for any procedure in the OR. Also, it is the responsibility of the Physician or the CRNA to explain intubation and other procedures which will happen in the OR and not a student, Paramedic or even an RN.

 

[NomadicMedic]

Oh, please don't think that a verbal consent was all that we got. There is a comprehensive consent form for paramedic intubations. I just found that once I was introduced and I explained why I was there, patients were much more receptive than if a CRNA just said, "we have a student, can he do it?"

 

[Carlos Danger]

Asking and having it in writing are two different things when it comes to consent for any procedure in the OR. Also, it is the responsibility of the Physician or the CRNA to explain intubation and other procedures which will happen in the OR and not a student, Paramedic or even an RN.

A student intubating does not generally require a separate consent.

It's usually in the language of the facility and surgical consents that you "consent to the supervised participation of students in your care".

 

[chaz90]

The facility we go to has the pt. sign a separate written consent. The consents today really weren't a problem at all, and neither was the OR staff. I'm just curious how intubation training could be improved and strike a compromise between protecting the patient and anesthesiologist, and allowing medics to get more real world opportunities.

 

[chaz90]

I do appreciate your input btw Halothane. I get the impression from your username that you spend some time around anesthesia.

 

[jwk]

Ah, a topic near and dear to my heart

I taught airway management to paramedics for years at my previous gig, and am getting ready to do it again at a new hospital.

Both our hospital and anesthesia consents contain language regarding students. It's up to the patient to read their consent, and if they want to take the time to do that, that's fine. There is no need to have a separate consent, oral or written, for students. That's pointless and will create far more problems than it will solve. A "comprehensive consent form for paramedic intubations" is, sorry to say, kinda stupid in my view. (what on earth do you tell them anyway?) As Clipper1 pointed out, it's up to the the anesthesia staff to talk to the patient about anesthesia issues, and nobody else. Written consents generally aren't worth the paper they're printed on, but of course we do them anyway. A student is under the direction and supervision of the anesthesiologist and/or anesthetist in the OR at the time, and that's the important thing. The same goes for nursing students, radiology students, etc. No separate consent is necessary for them when they do their thing in other parts of the hospital. Now of course if the patient specifically requests "no students" we will of course honor that request.

It's not even necessary to specify that a student will be involved, but if they're around before the patient goes to sleep, I'm happy to introduce them to the patient and let them know they're in the OR to learn about airway management. There's not need to get more specific than that. The decision to allow students (of any kind) in the OR, or anywhere else in the hospital for that matter, is one made by the hospital and medical staff.
Most patients don't have an issue with students, but again, there's no need to burden them with lengthy explanations of exactly what the student will be involved with. Not sure where one gets the idea that patients frequently object to a CRNA (or in my case, an AA) doing their case either. That is a rare event in most locales. You can have MD anesthesia at my place - but unless you made arrangements weeks ahead of time, you won't get it on the day you show up for surgery. We don't staff that way. We're an anesthesia care team practice and about 99% of our anesthetics are done by anesthetists directed by an anesthesiologist.

Until I see a student intubate, I'm not likely to let them start out with one I know is going to be difficult. But the only way they're going to know the difference between a difficult one and an easy one is to try, so it definitely doesn't help giving them just the easy ones. Plus, the ones I think are easy don't always turn out that way. I rarely get thrown by a difficult airway because I'll prepare for it, but an unexpected difficult airway can be much different. And honestly, it's not just intubating that a student should be learning - this is the best place to learn how to manage an airway with a mask, because 99% of those that aren't in anesthesia do it poorly (that includes ER docs, respiratory therapists, and yes, paramedics). They should also be learning how to use LMA's (we generally don't use King airways in the OR).

 

[FLdoc2011]

I agree with everything said above. It's going to be tough to get "difficult airway" experience like you said and I don't know a good answer to that.

I certainly think initially the OR experience is good because you need to start with the basics on straight forward, controlled airways to get the mechanics of it down.

Not sure if its possible, but if you're able to prove your skills there and continue to go back to the same OR then over time they may build trust in you and gradually allow you to do more difficult intubations.

Or I would suggest spending time in the ED and getting in on intubations there where their airways are going to be more indicative of what you may see in the field.

In residency whenever I heard I code called in the ED I'd run down there (even if I wasn't in ER that month) as the ED attending would let me know do whatever procedure needed to be done and I got a lot of central lines, chest tubes, and intubations that way.

 

[NomadicMedic]

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.

 

[JPINFV]

A student intubating does not generally require a separate consent.

It's usually in the language of the facility and surgical consents that you "consent to the supervised participation of students in your care".

That's how the hospitals I rotate at work. There is no separate consent process even if we know a paramedic student or medical student is getting the first crack at the intubation.

 

[Clipper1]

A student intubating does not generally require a separate consent.

It's usually in the language of the facility and surgical consents that you "consent to the supervised participation of students in your care".

Not a separate consent.

A Physician or CRNA must be the one to obtain the consent and explain the procedure to the patient. A Paramedic can not take a valid consent for the OR. This is one duty which can NOT be delegated. It does not matter if a student will be doing the intubation for the purpose of consent for the procedure.

 

[JPINFV]

In some ways, I wonder if paramedics should only be attempting intubations on at least moderately difficult airways in the OR. This can certainly leave out extremely high risk patients or those that are deemed to be too difficult for the paramedic to even attempt.

You're assuming that there's a high volume of those tubes. All of the patients I've seen (regardless of whether I'm intubating or not... and the anesthesiology preop is done just before we go into the OR) have been Mallampati 1 or 2. I few have had anterior airways that have increased the difficulty, but it's not like the OR is getting a ton of 3s and 4s every day.

 

[NomadicMedic]

Clipper, you once again managed to misunderstand and/or misconstrue what I am saying. Obviously, the anesthesiologist or CRNA must get the signed consent. I was simply stating that it makes it easier to gain permission from a patient if the paramedic who will be performing the intubation introduces himself and explains why he is in the OR performing intubations.

 

[JPINFV]

Clipper, you once again managed to misunderstand and/or misconstrue what I am saying. Obviously, the anesthesiologist or CRNA must get the signed consent. I was simply stating that it makes it easier to gain permission from a patient if the paramedic who will be performing the intubation introduces himself and explains why he is in the OR performing intubations.

...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?

 

[AtlasFlyer]

As a patient, I would say no to a student of any kind intubating me. The thought of intubation on ME is bad enough but I just don't want a student doing it. Yeah, I'm one of the 1 out of 10 I guess. Speaking as a patient, please ask if they're comfortable with it. Many will probably be fine with it, others may not be, and it's their right not to be.

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.