OR/Intubation Clinical Frustration

[Spock]

I've been on both sides of this argument and don't have an easy answer. I've had paramedic students that couldn't mask ventilate a patient because of poor technique and medical students that made it clear they thought 4 intubations and 4 years of medical school made them more proficient than my 2 years of nurse anesthesia training and 4-5,000 intubations. Needless to say both picked their butts up off the floor before they touched a laryngoscope. I also had an emergency medicine resident walk into the OR once and announce he was going to do the intubation. I just chuckled while the anesthesiologist (who had served in Viet Nam as a medic) chewed him up and spit him out in little pieces.

My hospital is on of the few in our area that still allows paramedic students into the OR. We are a Catholic teaching hospital and really believe that education is a basic tenet of our mission. The anesthesiologists and CRNA's in my department feel strongly that if they or anybody in their families ever need an ambulance they want a well trained paramedic to show up and if advanced airway interventions are necessary they expect competence. They know they can't expect that if they won't commit to education. My active involvement in EMS certainly doesn't hurt. Somebody said it doesn't hurt to know someone in the anesthesia dept and unfortunately that is true. We had a paramedic student from my service come to the OR one day and I made sure she had a good experience. Yes that is unfair but so is life.

I think vs-eh really hit the nail on the head. You can't expect to get enough tubes in one day so plan on coming back. If I even think the airway is difficult you won't get a chance at it. Show me you can mask a patient and I'll let you touch a laryngoscope. Don't tell me you have done a dozen tubes and then go toward the patient with the scope in the wrong hand and no gloves. Demonstrate some proficiency with edentulous patients and you'll get a shot at people with teeth. There is a great deal of competition for tubes from paramedic students, flight crews, medical students, EM residents, medical resident and more so you will need to come around more than once if you expect to get a good experience.

There is no doubt that I have colleagues in anesthesia who are jerks but that occurs in every profession. Frankly there are days that I am a jerk because I'm tired of every Tom, Dick and Harry walking in and expecting to intubate my patient. I'd like to do some tubes also. Personally, my priority is nurse anesthesia students first, paramedic students second and everybody else last. The anesthesiologists I work with pretty much leave the decision on who intubates up to the CRNA.

Both the American Society of Anesthesiologists and the American Association of Nurse Anesthetists have position papers that "encourage" their respective members to be actively involved in the education of paramedics with regards to airway techniques. "Encourage" still may not get you into the door so you will need the medical director of the paramedic education program to deal with the anesthesia department directly in order to improve the educational experience.

Also, it helps to shower, shave and brush your teeth before you come into the OR. Believe it or not we have had trouble with this. Look and act professional and you have a better chance to be treated accordingly.

Live long and prosper.

Spock

[vs-eh?]

I've been on both sides of this argument and don't have an easy answer. I've had paramedic students that couldn't mask ventilate a patient because of poor technique and medical students that made it clear they thought 4 intubations and 4 years of medical school made them more proficient than my 2 years of nurse anesthesia training and 4-5,000 intubations. Needless to say both picked their butts up off the floor before they touched a laryngoscope. I also had an emergency medicine resident walk into the OR once and announce he was going to do the intubation. I just chuckled while the anesthesiologist (who had served in Viet Nam as a medic) chewed him up and spit him out in little pieces.

My hospital is on of the few in our area that still allows paramedic students into the OR. We are a Catholic teaching hospital and really believe that education is a basic tenet of our mission. The anesthesiologists and CRNA's in my department feel strongly that if they or anybody in their families ever need an ambulance they want a well trained paramedic to show up and if advanced airway interventions are necessary they expect competence. They know they can't expect that if they won't commit to education. My active involvement in EMS certainly doesn't hurt. Somebody said it doesn't hurt to know someone in the anesthesia dept and unfortunately that is true. We had a paramedic student from my service come to the OR one day and I made sure she had a good experience. Yes that is unfair but so is life.

I think vs-eh really hit the nail on the head. You can't expect to get enough tubes in one day so plan on coming back. If I even think the airway is difficult you won't get a chance at it. Show me you can mask a patient and I'll let you touch a laryngoscope. Don't tell me you have done a dozen tubes and then go toward the patient with the scope in the wrong hand and no gloves. Demonstrate some proficiency with edentulous patients and you'll get a shot at people with teeth. There is a great deal of competition for tubes from paramedic students, flight crews, medical students, EM residents, medical resident and more so you will need to come around more than once if you expect to get a good experience.

There is no doubt that I have colleagues in anesthesia who are jerks but that occurs in every profession. Frankly there are days that I am a jerk because I'm tired of every Tom, Dick and Harry walking in and expecting to intubate my patient. I'd like to do some tubes also. Personally, my priority is nurse anesthesia students first, paramedic students second and everybody else last. The anesthesiologists I work with pretty much leave the decision on who intubates up to the CRNA.

Both the American Society of Anesthesiologists and the American Association of Nurse Anesthetists have position papers that "encourage" their respective members to be actively involved in the education of paramedics with regards to airway techniques. "Encourage" still may not get you into the door so you will need the medical director of the paramedic education program to deal with the anesthesia department directly in order to improve the educational experience.

Also, it helps to shower, shave and brush your teeth before you come into the OR. Believe it or not we have had trouble with this. Look and act professional and you have a better chance to be treated accordingly.

Live long and prosper.

Spock

Bravo! =D>

I recommend picking up this book...

http://www.amazon.com/gp/product/078174764...6271944?ie=UTF8

I did and I read it prior to my OR rotations. I wanted, on an elevated level, to be able to discuss principals of advanced airway management and pharm. intervention outside of my traditional education. You know what? The doc's raised an eyebrow and gave a little smile of interest when I was discussing things with them. I didn't do my OR rotation in a teaching hospital, and I was the first to be educated in the OR at that hospital. I didn't want to let my school, the docs, or myself down.

My clinical hospital (and I assume all OR's) don't use the traditional EMS BVM (self inflating), they use a Flow-inflating bag (Anesthesia Bag). Lemme tell you, after the doc sedates, anesthetizes, and paralyzes a patient, they are going to want to see you do good BVM vents. (the cornerstone of airway management). The flow-inlating bag, requires a GOOD SEAL and GOOD BLS MANUAL AIRWAY MANAGEMENT or else it ummm, won't inflate... They don't see that, don't expecting to be intubating a patient. They also have the luxury of monitoring tidal volume with this, etc...

You will initially be intubating patients that doc's see as facile patients...Grade 1-2 airways, edentulous patients, etc... Know what those things mean too...

There is no way you can possible get any type of decent education rushing around in your one day of ORdom and hoping to tube every patient.

Baby steps.

[PrissyEMT]

I don't think there's really much I can add that hasn't already been said. Last semester during my OR time, we did have to compete with the CRNA students, and they were usually given precidence over us. I just went along with it, then scheduled more time later so I'd have more opportunities for tubes. But that's just the way it is- life's a competition sometimes. Just do the best you can, and make the best possible impression. You're more likely to have more chances for tubes if you show you're confident and that you know what you're doing. Don't whine and pout on the sidelines if someone else gets to do it, show an active interest in it anyway, and it might pay off next time.

[Ridryder 911]

First, feel lucky you have an OR rotation, we have lost nearly all the O.R.'s in my state, and now are thinking only mannequin cert is okay. The anesthesiologist group at the University teaching, wanted an $150 per intubation, per EMS student due to liability.

Welcome to EMS, you are at the lower end of the food chain, and always will be.. until we have a undergrad, grad then post grad level education... hmm they can not see why your 2 night a week class, is more important than their 8 years of University education would be. Especially, when the one that is the preceptor has the same level that they do...

Good luck, and continue to pursue.. get as much experience as you can...

R/r 911

[FormerEMSLT297]

on my one day to practice (they have weeks) and if his student will be around when he has that big MI.

Did anyone else in medic school have a similar experience? Any advice?

I'm confused and concerned ... when I went to EMT-P training 20 years ago, we spent a MINIMUM 1 week in the OR... why 20 years later are medics only spending 1 day in the OR?..... the training should have gotten longer, not shorter....

I would ask your instructor about rescheding the OR and also asking him or her to give you more time or a minimum number of tubes... I think we needed 10 or 15....

Good luck...

[fallout]

I know my upcoming airway practice consists of 36 hours in operating room with at least 5 successful LMA or ET tube placement. Realistically, I hope to have done more than that though as 5 advanced airway placements isn't that many.

[flightmedic608]

I am very amazed at what is being written here. Has paramedic education dropped so low as to have students only spend one day in an OR? Yes, intubation is a skill...but you still need to learn the reasons why, how to assess an airway and how to mask a patient way before you attempt at placing an airway. This needs to be done in an OR, not on mannequins. With all of the articles and literature being written about the negative sides of prehospital intubation, I would make it a point to spend as much time with an anesth or crna that I possibly could. This type of post makes me very depressed....I would hope that as a student or a ems provider you would advocate for increased education and OR rotations. My thoughts only....

[fallout]

36 hours isn't one day? It is roughly 6 days worth of OR time, since all the ORs around here do surgeries for a very limited amount of time (i.e. 6 hours per shift)

[thbarnes]

UPDATE: I relayed my frustrations with the OR to my clinical coordinator. She sympathized, but I still need a minimum of 12 hours in the OR and 5 successful intubations (ET or LMA) prior to graduation. I contacted a family friend who is a CRNA and I will be working with her next time I go in, she's great and promised me some hands-on time, that way I can get those intubations I need.

I feel like I should point that while our OR clinical is only 12 (not 8 ) hours long, the required number of clinical hours for Paramedic candidates in my state/in our program has increased almost every year for the past several years. The areas we orient in have expanded from the ambulance and ER to the Trauma ICU, Neonatal ICU, Labor and Delivery, Medical Psychiatry, Behavioral Psychiatry, Dialysis Clinic, Cardiac Cath Lab, and of course OR.

I should also point out I am in a 'bridge' program of sorts, an Accelerated Paramedic program for medical personnel with documented medical training and patient contact, incl. Army medics, Naval corpsman, experienced EMTs, and LPNs. Many of us not only have airway experience, but have intubation experience.

[mhicks]

I can sympathize with your concerns, however, nearly every Paramedic training program in the Country is faced with those same problems. First of all, many anesthesia groups don't want the liability or the hassle of having paramedic students. Secondly, the teaching hospitals also have the anesthesia physician and nurse students to accommodate and they usually have priority over us. Thirdly, depending on the type of surgery, most OR's are predominantly using LMA's and doing fewer intubations. All of these situations make it more difficult to get student paramedics live tissue intubations.