learning curve for intubations?

[secretasianman]

I am an ms4 just finishing our first week of the anesthesia rotation. I'm getting much better at nailing IVs but I've only intubated 1 out of 4 times successfully. I'm a bit frustrated, but will keep trying. Are there residents who just "never get it" despite practice? What is the learning curve like really?

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[Noyac]

I'm still learning, seriously.

 

[dhb]

if you want to be ahead of the curve learn how to position the patient properly:

 

[jennyboo]

What's the difference between an anesthesiologist and any other specialist who sometimes intubates (say, a pulmonologist or a surgeon or an ER physician)?

It's a difference of degrees.

Those other guys either get the tube in or they can't. Can they put a tube in the patient? It's either YES or NO. If it's yes, great, but if it's no, they're not so empowered to do much more.

In anesthesiology, eventually you will reach the point where the choices are many and more varied than simply YES and NO, will the tube go in or won't it. THEN you will be able to make decisions about HOW that tube is going INTO THE TRACHEA for sure. If you are one of the other guys (medical student, pulmonologist, ER doc, surgeon) you won't have the training or experience to plan factors such as:
- Awake or asleep?
- Spontaneously breathing or not?
- Patient positioning
- Choosing a laryngoscope blade (most of the other guys use the same thing all the time)
- What drugs to use if doing it asleep and why
- What to do next if you take a look and can't see anything

Et cetera. I probably did 100-150 in the first few months of residency before even beginning to feel comfortable thinking about the subtleties and using adjuncts.

You can intubate patients without doing that many intubations, but there's a certain relatively high number you need to do before you get beyond just YES OR NO.

 

[Gimlet]

What's the difference between an anesthesiologist and any other specialist who sometimes intubates (say, a pulmonologist or a surgeon or an ER physician)?

It's a difference of degrees.

Those other guys either get the tube in or they can't. Can they put a tube in the patient? It's either YES or NO. If it's yes, great, but if it's no, they're not so empowered to do much more.

In anesthesiology, eventually you will reach the point where the choices are many and more varied than simply YES and NO, will the tube go in or won't it. THEN you will be able to make decisions about HOW that tube is going INTO THE TRACHEA for sure. If you are one of the other guys (medical student, pulmonologist, ER doc, surgeon) you won't have the training or experience to plan factors such as:
- Awake or asleep?
- Spontaneously breathing or not?
- Patient positioning
- Choosing a laryngoscope blade (most of the other guys use the same thing all the time)
- What drugs to use if doing it asleep and why
- What to do next if you take a look and can't see anything

Et cetera. I probably did 100-150 in the first few months of residency before even beginning to feel comfortable thinking about the subtleties and using adjuncts.

You can intubate patients without doing that many intubations, but there's a certain relatively high number you need to do before you get beyond just YES OR NO.

Great post.

OP, it took me 5 tries on my 3rd year rotation before I even had one success, so I don't think you're doing so bad. Things will start falling into place soon.

 

[Planktonmd]

I'm still learning, seriously.

Me too.

 

[drfeelgood]

Great post.

OP, it took me 5 tries on my 3rd year rotation before I even had one success, so I don't think you're doing so bad. Things will start falling into place soon.

I missed my first ten intubation attempts!!!!

 

[Arch Guillotti]

Don't sweat missing them at first. Took me about 50 my CA-1 year before I started feeling good about things.

 

[cgcrz8]

In theory, you could read and look at diagrams all day long about how to intubate (like i did), but it really is just practice practice practice. Be confident and just do it. I now think IVs are harder than tubes.

 

[me454555]

positioning is everything here and its usually the key to any procedure

1) Make sure the ear canal is lined up w/the anterior portion of the patients chest before you start to tilt his head back. Use pillows of blackets to prop if necessary

2) Make sure the patients face is just below your xiphoid process - gives you the best angle to see the cords

3) Get a good scissor and open the mouth real wide - sounds simple but you wouldn't believe how important this is

4) Go in deep before applying your anterior pressure - make sure you see the posterior oropharynx when you go in and put your blade down there

5) Don't be afraid to reposition the blade after you lift up and don't see what you want

6) After the blade is in the mouth, use your right hand to help position the head for a better view

7) Ask for a bit of cricoid, can often make a difference

8) Remember that you have more time than you think you do - most med students, myself included, rush the first few times b/c the patient isn't breathing. You've got a solid 4 mintues before anything goes wrong if you've preoxygenated this patient well. Don't panic if you don't see the cords when you first put the blade in. Just take a deep breath and think about the anatomy and where you are.

The above tips aren't anything groundbreaking but as with most procedures you'll find out that the key is the little things. If you do the little, easy things, correctly, you'll succeed more often than not.

 

[Gas]

It does take a lot of practice. Look for patients with dentures. I remember as a med student I was so scared of breaking teeth that I could not focus. I also thought I had a few seconds to get the tube in, but you do have some time in a fully pre-oxygenated patient.

The key is practice and don't let missed attempts rattle your confidence. Position, pre-oxygenation, and poise.

 

[Jeff05]

gotta love opinions of seasoned medical students.

In theory, you could read and look at diagrams all day long about how to intubate (like i did), but it really is just practice practice practice. Be confident and just do it. I now think IVs are harder than tubes.

 

[centrino]

2) Make sure the patients face is just below your xiphoid process - gives you the best angle to see the cords

After sturggling with a few intubations, I realized this is where I was wrong. One day while doing an intubation I reached the epiglottis and lifted it up but still couldn't see the vocal cords(as in many of the previous intubations) . The Tech person standing just behind me bent down and said hey there are the cords. Push it in. I still couldn't see and had to hand over the intubation. That day I realized my line of sight was not well aligned with the vocal cords and the other person was able to see it becasue he bent down. For the next two intubations I tried to keep the head of the patient atleast at my stomach, and I was actually successful in seeing the cords. Being in the Gyae/Ob OR I have fewer intubations on my hand but I will try this tip everytime I do intubations cause I have found it damn helpful.

3) Get a good scissor and open the mouth real wide - sounds simple but you wouldn't believe how important this is

Opening the mouth is the first step where I get tense as many a times I am unable to open it correctly and the attending or the resident standing beside me helps me do it. Hope to do it totally independantly soon.

7) Ask for a bit of cricoid, can often make a difference

Yes that has been really helpful.

8) Remember that you have more time than you think you do - most med students, myself included, rush the first few times b/c the patient isn't breathing. You've got a solid 4 mintues before anything goes wrong if you've preoxygenated this patient well. Don't panic if you don't see the cords when you first put the blade in. Just take a deep breath and think about the anatomy and where you are.

This is the first thing that comes to the mind of a newcomer like me. For the first few intubations I attempted, my biggest concern was the patient might die since he/she is not breathing. I tried to do everything in haste and usually became nervous. However one day my attending explained to me don't panic while intubating. We preoxygenate the patient and have plenty of time to get the tube in. Haste makes waste. I however didn't know about having "4 solid minutes"

 

[militarymd]

and yes, some people never get it.

 

[Dejavu]

I did my first intubation in 1976 and I still learn stuff every day.

Wait until you have tried a couple of hundred intubations before you start worrying about your comfort level. Everybody has to climb the learning curve and it varies from person to person. If you are still 1 out of 4 after 200 tries, then you need to rethink your technique. Until then, relax, it will come.