Frustrated

[Bieber]

So out of about the last five intubation attempts I've had I have only successfully intubated one patient. My last tube attempt before tonight was at least 2+ months ago. Tonight I completely blew it.

I can't successfully intubate. I need more attempts, more training, or more something because this problem isn't solving itself and I'm starting to get really depressed about it.

[Kiwiology]

Talk to your Clinical Standards Officer or local equivalent or medical director about seeing if they can help; do you haz Sim Man or something you can practice on? Are you using a bougie?

It might not be much consolation dude but without regular practice its one of those things anybody gets crap at, the ASA says ~200 tubes a year to be "minimally proficient"

Hope you feel better mate

Edited June 21, 2012 by Kiwiology

[island emt]

Patience young Jedi : Do an analysis of your recent failures and think about what is causing the issue.

Are you getting class 4 airways ?

Are you intubating pt's that truly need it? hence the pressure

or are you just not seeing the cords and trying to rush without proper prep?

The issue is a simple mechanical act brought about in times of sheer terror and usually in the heat of battle.

Can you nasally intubate in your system?

Do you have a backup airway such as the king that your comfortable with?

Do you have CPAP?

Time to hit the mannequins and practice , then go down to the hospital and try to get some time in the O R.

[DwayneEMTP]

So you've succeeded once out of the last five. What percentage of your total intubations does five attempts represent?

Out of the last five attempts you've been making some fundamental error, or like Island said, you've just been hosed by the EMS Gods.

Why did you fail in your latest attempt? The other three? As I know that you've analyzed this to death...

[nypamedic43]

If this is any consolation...I am SHIT with intubation. The company I work for does skills every month and this is the only one that I ever demand that I practice. And not just once or twice....dozens of times. ET in both adults and peds and LMA both adult and peds. And I still freeze up 90% of the time on a call.

island hit it on the head for me....heat of the battle and sheer terror. Ask me to decompress a chest or do a crich and I'm good....ask me to do an ET and I just go to pieces. I have no idea why but I get sooo frustrated with myself because this should be an easy skill. I have one partner on a regular basis that wishes a cardiac arrest on me so that I can get over....whatever this is. Bastard lol. But I know deep down that he wishes it on me to help me. As odd as that sounds.

I dont have the answer for you...but I feel your frustration.

[Bieber]

Kiwi, our training department is somewhat useless when it comes to getting us OR time for tubes and stuff. I might be able to get an airway mannequin--failing that, I know the directors of the two local paramedic programs that I was thinking of hitting up. And yeah, I know, I'm torn up about it but logically I know when I've only been getting the opportunity for a tube once every other month there's not a real easy way to stay proficient in it. Still frustrating, though.

Island, thanks for the kind words, man. If I was honest about it, all my recent airways have been kind of junky and not the most ideal. The most recent one I was sitting too far to the side (should have asked fire to move so I could sit directly in front of the head) and another one the patient started coming to (NOBODY should have attempted a tube after that; but you can imagine how that went). As far as necessity, none of them have been vital (all code blues), but it's still a bit of a pride thing (I know, stupid).

Dwayne, I got about 29 tubes during clinicals, 5 during internship, and one since I've been on the field. So out of those 35 successes + the last four misses isn't a tremendous percentage, it's just that they've pretty much all been in succession and they've all been since I've gone full time.

I guess the most frustrating thing is that our supervisor shows up on pretty much all of our code blues, and he's VERY tube aggressive, and because of that he's had probably about twenty tubes this year and is pretty damn good at getting them. It's a little frustrating having him always shows up because there is that pressure to get the tube before he swoops in and snatches it up.

NY, I don't think I'm freezing up necessarily, but like I said there's definitely added pressure to get a good tube since I don't have a great track record since I've been working with my regular partner and supervisor and the latter is always going for them tubes.

Thanks for the words, everyone. I'm gonna work on getting a mannequin or some OR time or something.

[Just Plain Ruff]

That's your issue. You need to discuss that with your supervisor. If he's taking all the tubes then he needs to butt out and let his field crews get the tubes and not push his way into the mix because this is what happens when he doesn't show up, his crews who don't get the practice they miss the tubes and then things go wrong.

The supervisor is seeing your track record and he's saying to himself, ahh that beiber, he sucks at tubes so I'll get it for him, thus perpetuating biebers crappy tube record and then when your evaluation comes up he can say "You've got a crappy tube record and you have until this time to get your record improved or your outta here" or something like that. You need to discuss this with this supervisor and if this gung ho asshole of a supervisor doesn't get the message then you need to go higher on the food chain because his attitude aint gonna change and he's going to conitnue to keep taking the tubes from you. Trust me I've been there. Or you can on the next call just tell the supervisor to butt the hell out and that this is your airway and he can take the other stuff.

The only way you can get your field tube success up is to either beat the supervisor to the call or to make the supervisor know that you got the airway on the codes or patients who need em and he needs to find something else to do.

I know he's the supervisor but seriously, the supervisor needs to learn boundaries. I'll bet you aren't the only crew he's pissing off.

If he continues to steal tubes then you need to go above his head and fix the issue. But remember, going above his head could have dire ramifications on your evaluations and career aspirations so tread lightly. First step is to talk to him man to man.

Good luck, I've been in your shoes before, it's not fun, but often a talk to this type of tube stealer is all it takes. But if not, you have te be willing to take it to the next level.

[Bieber]

Thanks, Mike. Yeah, it's kind of a tough situation around here when it comes to response standards and shit like that. Unfortunately, a lot of our supervisors have this crazy idea that having two paramedics and an engine of EMT's isn't enough for critical (code red) and code blue calls. We are seriously over-saturated on paramedics around here, and whereas two medics might be too many for most calls, adding that third just seems to make the whole situation worse. I'll try to see if there's anyway I can let him know that we don't really need his help on critical calls without being untactful.

[systemet]

Unfortunately, a lot of our supervisors have this crazy idea that having two paramedics and an engine of EMT's isn't enough for critical (code red) and code blue calls. We are seriously over-saturated on paramedics around here, and whereas two medics might be too many for most calls, adding that third just seems to make the whole situation worse.

This is one of the reasons why I liked being on a medic/EMT car, or being the only ALS provider on scene. In some ways it ramps up the pucker factor, as you've got no one to fall back on. But you get twice the exposure to running critical calls, and doing some of the psychomotor skills. [i won't say it doesn't often run smoother when you can just turn around to someone else and say "Can you intubate, when I do this here?", but it does mean you're doing half as much of everything.]

Not all of us play nice together, and sometimes multiple ALS providers on scene, especially >2 just means someone else tries to take over, making the entire call go sideways, especially if someone on scene is perceived as junior or weak.

I'll try to see if there's anyway I can let him know that we don't really need his help on critical calls without being untactful.

Depending on the culture in your workplace, and how this guy is as a human being, it might be worth saying something like, "I don't know if you've noticed, but I've been having some trouble with intubations recently. Do you think next time you back me up on a critical call you can watch while I'm intubating, and give me some pointers?".

I'm used to supervisors being there to be supervisors, and assist, not to try and poach skills and interfere with medical management or generally mess up the flow of things.

You should also look at the circumstances of the intubation attempts. Are these failures an issue with medication? Do you have inadequate relaxation of the jaw, are you using a sedation protocol where RSI might be better? If you're intubating without paralytics, are your drug doses too low, or is the population of patients you're intubating needing particularly high doses, e.g. closed head injuries. Are you not waiting long enough for the meds to take effect? Do you still have residual jaw tension.

You should consider your set up. Is the angle of the mandible aligned with the sternal notch? Is the neck flexed, head extended? Have you positioned both yourself and the patient in the best manner to succeed? Are you using the larygnoscope in a technically correct manner? Are you cranking on the jaw? Are you doing something silly, like taking a large blade, ramming in midline down the pharynx, and then pulling back to visualise --- or are you inserting it laterally, moving the tongue midline, and moving progressively deeper while identifying the structures? Are you modifying your approach to deal with poor visualisations e.g. C&L 3,4? Could you be using a Bougie in some circumstances? If using a stylet, is the tube curved appropriately? Are you doing something easily correctable, like pulling the tube back a bit as you remove the laryngoscope?

Is there some commonality amongst the small group of people that you're having trouble intubating? Obese? C-spine precautions? Inadequately medicated? Could it be specific circumstances that are causing you a problem?

Are you setting up well for the first attempt, and then varying your second and/or subsequent attempts based on what you see on the first pass? Or are you just repeating what didn't work the first time?

I think it's worth remembering that the population of patients we see in EMS often contain a lot of difficult airways, and we often have suboptimal training and equipment. The goal should be for atraumatic intubation, without incidences of profound desaturation, hypercapnia, arrhythmias, etc. Some of the guys going around boasting high rates are technicallly proficient, but a lot of others are just refusing to return to BLS measures, or a rescue device, and are stressing the crap out of their patients just so they can mark off that they got the tube, without mentioning it was on attempt 5.

Just some things to consider. I'm no expert, but perhaps something in there will be helpful. Also, I would suggest that while mannequins are not like real airways, regular practice on a mannequin is far superior to not doing anything.