Started Clinical Rotations

[emt217]

Long time lurker, occasional poster. Read this site ALOT, and have gathered numerous tidbits. My class started clinical rotations a couple weeks ago, and although it may sound stupid, I'm wondering if I'm putting too much pressure on myself. I'm not really good at IV's yet (blow about 30% of the time), and today I did my first OR rotation so I could get my intubations. I had 3 patients to intubate. The first one I did place correctly, but didnt advance far enough. When the cuff inflated, it popped it out of the cords. 2nd attempt was a good placement. 3rd attempt, the cords were angulated anteriorly, and I thought I'd gotten in, but it slipped of the posterior cords and went into the esophagus. I guess what I'm wondering is if I'm expecting more out of myself than I should be this early into clinicals. Did any of you guys/girls have a tough time at the start?? I'm doing really well in the classroom setting, as well as my assessments. It's the skills I'm not so hot at right now. Any comments or thoughts?

[EMT-Bgray]

Long time lurker, occasional poster. Read this site ALOT, and have gathered numerous tidbits. My class started clinical rotations a couple weeks ago, and although it may sound stupid, I'm wondering if I'm putting too much pressure on myself. I'm not really good at IV's yet (blow about 30% of the time), and today I did my first OR rotation so I could get my intubations. I had 3 patients to intubate. The first one I did place correctly, but didnt advance far enough. When the cuff inflated, it popped it out of the cords. 2nd attempt was a good placement. 3rd attempt, the cords were angulated anteriorly, and I thought I'd gotten in, but it slipped of the posterior cords and went into the esophagus. I guess what I'm wondering is if I'm expecting more out of myself than I should be this early into clinicals. Did any of you guys/girls have a tough time at the start?? I'm doing really well in the classroom setting, as well as my assessments. It's the skills I'm not so hot at right now. Any comments or thoughts?

Just found this site and it looked good so i joined. I am an EMT-B in Mississippi and im in paramedic school as well. Assuming that your still in the early stages of school, you can't put too much pressure on yourself. Everyone has to start somewhere. Mastering skills is something that comes with time. Don't pressure yourself to the point of nervousness.

[emt217]

Yes, it's only week 3 of clinicals. One thing I have noticed about my IV issue is the difference in angiocaths between the ER and the service I do

ridetime with. The caths on the ambulance have about 1/16th of an inch between needle and cannula. The ER's is about 3/16ths. I wasn't advancing far enough before trying to canulate. Blew the vein everytime.

[AnthonyM83]

Make best friends with the nurses at the ER. Have them teach you everything they know about IVs. Watch them closely, have them watch you. See how they try to salvage yours when you can't get a flash. Ask them what you think went wrong with each one. Start an IV on every single patient that comes into the ER.

Don't be tentative. Not pushing the cuff past cords makes me think you're tentative, since you should know to push it past, hold it hard, don't let a single mm of it come out, and inflate the cuff all the way.

Other than talking through it with the ER doctors and instructors and reviewing your intubation chapters, I might recommend practicing on the dummies several dozen times (50-100). Get extremely confident with the dummies. Know that if you can't visualize cuff going completely past cords, then don't even try it. Confidence with the dummies will (to an extent) translate to confidence with a real patient.

I also used to miss IV's because I was tentative when advancing the catheter, either because I thought I was being too rough or because the patient winced in pain when I started advancing. Now, I don't hesitate and I find there's less resistance to advancing and usually no wincing.

[emt217]

Make best friends with the nurses at the ER. Have them teach you everything they know about IVs. Watch them closely, have them watch you. See how they try to salvage yours when you can't get a flash. Ask them what you think went wrong with each one. Start an IV on every single patient that comes into the ER.

Don't be tentative. Not pushing the cuff past cords makes me think you're tentative, since you should know to push it past, hold it hard, don't let a single mm of it come out, and inflate the cuff all the way.

Other than talking through it with the ER doctors and instructors and reviewing your intubation chapters, I might recommend practicing on the dummies several dozen times (50-100). Get extremely confident with the dummies. Know that if you can't visualize cuff going completely past cords, then don't even try it. Confidence with the dummies will (to an extent) translate to confidence with a real patient.

I also used to miss IV's because I was tentative when advancing the catheter, either because I thought I was being too rough or because the patient winced in pain when I started advancing. Now, I don't hesitate and I find there's less resistance to advancing and usually no wincing.

Yes, you are correct. I'm not apprehensive about the IV's, as I can get them quite often during ridetime, just difficulty in the ER. Intubation is a different story. I bet I've intubated our mannequin at least 40 times. I'm down to about 11 seconds on it. My problem is that I know if

I get it wrong on the dummy, the worst I can do is tear some plastic. On a patient, I can do much worse. I may not be applying enough upward lift, and it seems like the mouth just isn't big enough for the blade. The patient had a very short neck, and I didn't wanna go to far and intubate the right main stem. I'm hoping it's just inexperience, and will get better with practice. I will definitely take your advice. I'm well open to critique, as I want this very much, and I want to make sure I do the procedures right. Thanks again.

[AnthonyM83]

Get it down to 10 seconds from last ventilation pre-intubation to the first ventilation post-intubation without assistance.

(Basically, whatever time you posted, I probably still would have told you to better it.)

If you're getting too nervous about the stakes, pretend you're just doing another practice scenario in class (even though you're doing the real thing with a live patient). Detach....

[emt217]

I'll try that. I spoke to my instructor, and he told me it sounded like I wasn't placing enough pressure. He advised the same as you, to just imagine that I'm intubating the dummy. He said it takes as much pressure an a live patient as it does the dummy to visualize the cords, and that I'm not gonna do any damage so long as I use the technique we were taught, and that if the blade seemed too big for the mouth (Mac 3) then I just didn't have the mouth open enough. He chalked it up to being new, and nervous, and said it happens to most students first couple rounds. Thanks again for the advice.

Would anyone else chime in?

[Lone Star]

I'll try that. I spoke to my instructor, and he told me it sounded like I wasn't placing enough pressure. He advised the same as you, to just imagine that I'm intubating the dummy. He said it takes as much pressure an a live patient as it does the dummy to visualize the cords, and that I'm not gonna do any damage so long as I use the technique we were taught, and that if the blade seemed too big for the mouth (Mac 3) then I just didn't have the mouth open enough. He chalked it up to being new, and nervous, and said it happens to most students first couple rounds. Thanks again for the advice.

Would anyone else chime in?

The amount of hours for clinical rotations/ride times are the MINIMUM required to pass the course. There is absolutely NOTHING wrong with doing 'extra rotations' to gain more experience, which will equate to more confidence.

[WelshMedic]

You are right in assuming the catastrophic consequences of esophageal intubation. However, don't be too hard on yourself right away, everyone has to learn. That's the whole point of the rotation.

My own personal 5 point checklist usually stands me in pretty good stead (no failed intubations in the last 4 years):

1)Visualize the tube passing the chords

2)Note the "fogging"of the tube (not absolute, by the way...before anyone jumps on me!)

3)Listen for the absence of breath sounds over the stomach

4)Listen for breath sounds on both sides of the chest in at least 4 different places

5)Attach end-tidal capnometry for tube confirmation and maintenance

After intial intubation:

1)Use a good quality tube holder

2)Manually fixate the tube during any movement

3)Re-check breath sounds after said movement (eg. moving the pt. from the bed to the cot)

4)Place an OPA next to the tube as a bite block

5)Always assume the worst when a significant drop in etCO2 occurs.

Good luck!

WM

Edited July 8, 2009 by WelshMedic

[Jeepluv77]

We don't get to do rotations in the OR as EMT-I students here anymore for whatever reason. So goodness knows when I'll get my first live intubation. But I've been practicing the difficult airway scenarios so I can challenge the station for National Registry. Cricoid pressure has become my best friend. We were taught it for our EMT-B so, at least here, anyone on the medic or fire crew should be able to do it for you. Same for in the OR or ER. Next time if you are having trouble visualizing the cords ask some to help you out with cric pressure. From what I've been told the benefit of it on a live patient is even greater than on a dummy. And, no, you won't look silly or incompetent for asking. I wondered about that and was told you will actually gain more respect because you don't let your pride or insecurity compromise what you need to get done. Just a thought.