share!!
I had an OB, surgery, and medicine resident make me cry. They were all so mean.I had an OB resident nearly make me cry :'(. Whatevs.
But forreal - If I say I know/can do one, I'm not lying. And if my attempt isn't 100% perfect it's because you guys don't let us really try. Practice dummy's don't help...
Ugh... I've had a couple.
The recent one, though, are anesthesia attendings that are so... anti-letting med students do intubations.
First attending didn't even think to let me when the CRNA handed me the Mac. He took it from my hand and gave it back to her...
Today, tho, I was kinda annoyed because a different attending let me do it on one patient and I nailed it. Second patient - I get the blade in and see the epiglottis/cords. I insert the tube and KNOW I'm in. Unfortunately, when they pulled the guide wire, the tube came up a bit and the bag wouldn't inflate. I wanted to try again but he went ahead and did it. Sure enough - the nurse had forgot to inflate the cuff when I had the tube in...
But forreal - If I say I know/can do one, I'm not lying. And if my attempt isn't 100% perfect it's because you guys don't let us really try. Practice dummy's don't help...
Ugh... I've had a couple.
The recent one, though, are anesthesia attendings that are so... anti-letting med students do intubations.
First attending didn't even think to let me when the CRNA handed me the Mac. He took it from my hand and gave it back to her...
Today, tho, I was kinda annoyed because a different attending let me do it on one patient and I nailed it. Second patient - I get the blade in and see the epiglottis/cords. I insert the tube and KNOW I'm in. Unfortunately, when they pulled the guide wire, the tube came up a bit and the bag wouldn't inflate. I wanted to try again but he went ahead and did it. Sure enough - the nurse had forgot to inflate the cuff when I had the tube in...
But forreal - If I say I know/can do one, I'm not lying. And if my attempt isn't 100% perfect it's because you guys don't let us really try. Practice dummy's don't help...
Ugh... I've had a couple.
Sure enough - the nurse had forgot to inflate the cuff when I had the tube in...
...
Don't f**k with the airway.
As a surgery resident, I've done just enough intubations to be truly humbled/terrified by them.
Yea.... that is your responsibility to inflate the cuff. Intubations aren't just putting the ET tube passed the cords and then being all "Im done. If I say I did it then I did it, gosh". If you are at the head of the table, then you are the one in control.Ugh... I've had a couple.
The recent one, though, are anesthesia attendings that are so... anti-letting med students do intubations.
First attending didn't even think to let me when the CRNA handed me the Mac. He took it from my hand and gave it back to her...
Today, tho, I was kinda annoyed because a different attending let me do it on one patient and I nailed it. Second patient - I get the blade in and see the epiglottis/cords. I insert the tube and KNOW I'm in. Unfortunately, when they pulled the guide wire, the tube came up a bit and the bag wouldn't inflate. I wanted to try again but he went ahead and did it. Sure enough - the nurse had forgot to inflate the cuff when I had the tube in...
But forreal - If I say I know/can do one, I'm not lying. And if my attempt isn't 100% perfect it's because you guys don't let us really try. Practice dummy's don't help...
You were allowed to attempt. And on your second attempt, the attending did it when your tube came out because he didn't want to waste time. When a patient is being induced, it is critical to get the intubation right away because the patient has already received muscle relaxants and cannot breathe on his/her own without a ventilator. There is no time to screw around getting the tube in. And for that matter, how can you say you KNEW you were in? Did you auscultate the lungs and the trachea to make sure you were in? Did you check the end-tidal CO2 detector? This doesn't even come close to qualifying as a horrible attending/resident story.
Neutropeniaboy said:Classic Millennial!
You have no idea what problems you can encounter when dealing with an airway, even in controlled circumstances.
I suggest you take opportunities that are granted to you because you've earned them rather than to expect them because you feel entitled to them.
gators21 said:Yea.... that is your responsibility to inflate the cuff. Intubations aren't just putting the ET tube passed the cords and then being all "Im done. If I say I did it then I did it, gosh". If you are at the head of the table, then you are the one in control.
Sounds to me like a story of terrible med student
Tubing a sedated patient with health lungs is not an emergency and should not be treated like one.
BUT MOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOM
Or - I know I know. I'm being overzealous. And it's not about entitlement, it's about wanting to practice/perfect it. But like he said - you don't get good doing this stuff in med school. You get good after doing it 100x's.
Tubing a sedated patient with health lungs is not an emergency and should not be treated like one.
Yup, exactly. I never forget that. I don't feel entitled to this ****, I just want to do it.Be thankful for the opportunity, after all, the attendings easily could have never let you near intubating patients! Getting a chance to do a few as a med student is awesome in general! After all you are the guest, as a young buck.
I guess I should clarify - I wasn't holding the syringe in my hand, the nurse was. This wasn't a "Yeah, I got it in that's it". They were guiding/assisting me, like they should have and I'm thankful for. I wasn't mad at the nurse either. You guys are misinterpreting what I said as "OMG THIS GUY IS HORRIBLE" when it's more like "Meh, I don't really have much to share so I'll just say this is what I have". If that's the worst story I have, then that's a good thing. And since no one else is sharing... I had to say something.
Again - It wasn't me placing blame on the nurse. It was just what happened. I was just eager to do it and disappointed that it didn't work and I wasn't allowed to try again. Not because I feel entitled, but because if I fail - I at least like to rectify my mistake if I can. Yeah, I know med students don't get that opportunity, which I understand. But it doesn't mean I shouldn't want to try again/feel disappointed I wasn't allowed to try again. Some people fail and give up without trying again. I'm not like that.
The training of a resident who intubates patients routinely (ED, anesthesia, surgery) is, appropriately, a very different endeavor than the training of a med student.
Okay, no it's not a sense of entitlement. Read what I said above - I wanted to rectify my mistake. This has nothing to do with entitlement and everything to do with just learning to do something right. If I had tried again and failed - I would've gladly let them take over. I've failed putting an IV line and I stop at 2 tries. I never try more than that. I know when I should stop and let someone experienced try.During my third year out of residency I was about to do a tympanomastoidectomy on a healthy 38 year old woman. A second year anesthesiology resident dislocated one of the arytenoids, lacerated the posterior commissure and caused an obstruction with a lot of bleeding. Neither the attending nor I could incubate the patient after that and I performed a cric on the patient.
That's extreme.
I've seen plenty of blood tinged sputum in the ET tubes of healthy adults put through the ringer. I've seen chipped teeth. I've seen lip lacerations. I saw an attending put an ET tube through the soft palate. I've seen people develop asystole.
I've seen enough to make me believe that every airway procedure is one waiting to be a disaster and that while I am amenable to having students and residents learn, I have very little tolerance for mistakes in this area.
And while, yes, medical students need to learn, they have a lot of years to do so. As long as my name is listed as the attending surgeon, I'll make sure my patients are manipulated as little as possible and by as few as possible.
This is more of an issue of dealing with students like the OP who feel like they actually know what they are doing and feel this unearned sense of entitlement.
Only giving noobs 1 shot is SOP. Experienced residents that generally don't mess up but aren't the sharpest get two shots.Ugh... I've had a couple.
The recent one, though, are anesthesia attendings that are so... anti-letting med students do intubations.
First attending didn't even think to let me when the CRNA handed me the Mac. He took it from my hand and gave it back to her...
Today, tho, I was kinda annoyed because a different attending let me do it on one patient and I nailed it. Second patient - I get the blade in and see the epiglottis/cords. I insert the tube and KNOW I'm in. Unfortunately, when they pulled the guide wire, the tube came up a bit and the bag wouldn't inflate. I wanted to try again but he went ahead and did it. Sure enough - the nurse had forgot to inflate the cuff when I had the tube in...
But forreal - If I say I know/can do one, I'm not lying. And if my attempt isn't 100% perfect it's because you guys don't let us really try. Practice dummy's don't help...
I don't think people are trying to be too harsh on you. The nursing thing is an important point - as inmyslumber pointed out, when you are performing a procedure, you need to take control and responsibility over every aspect of it. You should build into your routine for the procedure both to (a) specifically ask someone to inflate the cuff for you or do it your self and (b) verify manually that the cuff is inflated
oh I know. Believe me - they asked me to do it and I got tunnel vision. Which is why the anesthesiologists said "I couldn't tell if you were placing an ETT or trying to make out with the guy at first"Only giving noobs 1 shot is SOP. Experienced residents that generally don't mess up but aren't the sharpest get two shots.
Just some tips for practicing so if you get another shot it goes really well. You should always be aware of where everything is when intubating. Have a system and a routine, make sure everything is laid out to your liking before you start (piss poor preparation leads to piss poor performance)- suction on one side, bag on the other, 10cc syringe attached to your ETT, capnometer on one side or the other where you can reach it, and tape or an ETT holder at the ready. Lay it out the same every time. After the intubation, you should have a set routine- have someone pull out your stylet while you hold the ETT in two fingers with the rest of your hand locked onto their face similar to how you hold when you bag, and use the other hand to bag while someone listens for breath sounds. While you're doing this, you WATCH them inflate the cuff, and you better look at that cuff and make SURE it's inflated. Give it a squeeze if you aren't certain.
Getting the tube in is only half the process. If you don't properly confirm placement, keep it in place, and secure it, you ****ed the whole thing up. Half an intubation is just as bad or worse than no intubation at all. Most people practice getting the tube in 100 times more than what comes after they get it in, when both parts of the process are equally important.
oh I know. Believe me - they asked me to do it and I got tunnel vision. Which is why the anesthesiologists said "I couldn't tell if you were placing an ETT or trying to make out with the guy at first"
And while, yes, medical students need to learn, they have a lot of years to do so. .
while I am amenable to having students and residents learn, I have very little tolerance for mistakes in this area.
[snip Airway is important, but we don't teach medical students how to manage the airway]
Short of requiring every 3rd or 4th year to do an anesthesiology rotation, how do we rectify the situation?
YES! I had one of those in medical school. Even told me she would write me a letter of recommendation for residency, then told me she couldn't. All this because a resident (who I didn't even work with) told her I was a slacker. I ASSURE you, I was there doing notes before everyone else, and never went home early. Anyway, nothing I could do about it. She said, if you will prove yourself in another month of rotation, I would consider it. Nevermind.the worst are the attnedings who are super friendly with you and then rip you a knew one on evaluations...ughhh snakes
Also, you can't be amenable to learning and not be tolerant of mistakes. If you're not making mistakes you're done learning.
It concerns me a bit. I did anesthesia at a very, very small hospital where I thought I had one of the best experiences of my rotation years. But now, I wonder if my attending was being too generous. I took as long as needed usually with intubations. If the patient dropped to the low 90s, we would bag them and I'd reattempt. The attending never seemed outwardly concerned. Hmm.Odd series of stories from attendings here - I was allowed multiple tries to intubate. God knows I needed them early on. I tried maybe 5 times on one of my earlier attempts. Doesn't a patient not even come into danger of desaturating for 3+ minutes? I'm wondering why my attendings are so different.
And never being allowed to intubate is crazy, especially if you're going into ER....that almost borders on dangerous in my mind.
Odd series of stories from attendings here - I was allowed multiple tries to intubate. God knows I needed them early on. I tried maybe 5 times on one of my earlier attempts. Doesn't a patient not even come into danger of desaturating for 3+ minutes? I'm wondering why my attendings are so different.
And never being allowed to intubate is crazy, especially if you're going into ER....that almost borders on dangerous in my mind.
I have never had the opportunity to intubate. Not once. I have three months of medical school left. Next year I will be an ER intern ( you know, one of those specialties that deals with airways a lot). O well, I guess I'll learn how to do it then on the fly.
I don't disagree with most of what you wrote, but I disagree with this strongly. In my opinion medical student don't have a lot of years to learn intubations, they have just the short span of time before they start residency. Intubation is a skill that residents need to come in competent and comfortable with., and the fact that basically none of them do is a major failure on the part of our medical education system. Even the most junior resident is responsible for resuscitations, and resuscitations mean being prepared to manage your patient's airway. Like most non-anesthesia residents I have never done a cric, and I came into residency with three attempt intubations (one successful), and I had precious little experience even bag-vale masking. Do you think that's enough to manage an airway in an emergency? To match your horror story (which ended with nothing worse then a cric and a stable, protected airway) I have stories of patients in respiratory failure who were hypoxic for minutes while awaiting definitive airway management from a night time code/rrt team that needs to sprint across a hospital because the resident couldn't intubate or even effectively bag mask.
Its easy to be protective of the patient in front of you, but like everything else in our medical training the minimal risk of harm in that patient can be outweighed by the much more real risk of producing a resident/attending who doesn't know what to do when he's on his own. Medical students need to learn airway management in the OR so that they can manage airways correctly outside of the OR when they are alone during Intern year, on night float, with a sleeping senior on the other side of the hospital and a home call attending on the other side of the city.
Also, you can't be amenable to learning and not be tolerant of mistakes. If you're not making mistakes you're done learning. You can be intolerant of inadequate preparation or inattentiveness, but mistakes are a non-negotiable part of education. If you're intolerant of them all you're doing is kicking the can down the road and letting the student/resident make his mistakes when there is no one around to correct him.
Jorts, with your limited experience doing just about everything that has to do with medicine, I think I'll rely on my acquired knowledge and experience as a teaching physician - who above all else has the patient's best interest in mind - to judge who has the privilege to perform any procedure on my patients when in front of me.
It's funny: I know a lot of your professed great teaching physicians (i.e., not the "crazy" ones like me who shouldn't be in a teaching institution) who pull me aside when they are having surgery to request that no students or residents touch them.
Yes, medical students need to acquire skills, but not before I've judged my residents to be competent and never for the sake of "practice" or if I deem the situation unsuitable for a student.
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I understand your reservations about patient safety and not letting med students touch your patients. Really, I do.
However, quick question - Do you think it is important for med students (especially future ER/Anesthesia/ENT residents but across all fields) to learn (and practice) how to intubate and/or bag-mask ventilate while they are in medical school?
As to how to change it? That's a really difficult question. Now that we've allowed procedural training/competency to slide uphill it is unlikely to slide back down anytime soon. Individually, I have no problem teaching a medical student a procedural skill - I've supervised students doing all of the activities I listed above. I will let them struggle, but only to a point, and only at steps in the procedure that are unlikely to harml a patient. And, the real kicker is, they only get to do it once my interns have done enough to be competent (or the interns aren't around).
It's a reflection on the state of medical education. I have zero expectation that our incoming interns can perform any procedure with competency.
I'm going to make up some statistics based on my anecdotal experience. I'd say currently less than 10% of interns that I've directly supervised can competently place a central line, arterial line, chest tube, or intubate. And that is among the interns that self-selected for a procedural specialty.
I think in theory in an ideal world medical schools would prepare students to do all of those things with competency. But I think at present, that is not the reality of medical school. Not saying I agree with that, but it is the present state of things.
Which is why the ACGME now explicitly requires direct supervision for interns to perform any of these tasks until they have demonstrated competency.
As to how to change it? That's a really difficult question. Now that we've allowed procedural training/competency to slide uphill it is unlikely to slide back down anytime soon. Individually, I have no problem teaching a medical student a procedural skill - I've supervised students doing all of the activities I listed above. I will let them struggle, but only to a point, and only at steps in the procedure that are unlikely to harml a patient. And, the real kicker is, they only get to do it once my interns have done enough to be competent (or the interns aren't around).
This is a fair assessment. If the prevailing thought process is that incoming interns are not expected to know what they are doing whatsoever in terms of procedural abilities, then fine. However, it seems like some attendings who post on this forum want to have their cake and eat it too. They want interns to come in with experience with basic procedures but don't want to allow their medical students to actually learn (and practice) how to do those procedures.
Also, if there is a discrepancy in how many procedures medical students have done, then doesn't that give an incoming Anesthesia PGY-2 with lots of intubations as a M3/M4 (even 1 year removed from doing intubations) an advantage over another anesthesia PGY-2 who didn't get the same ability to intubate as a medical student?
A graduating anesthesia resident will have performed hundreds and hundreds (thousands even? I have no idea) of intubations...does it particularly matter for their training whether they start residency with 1 or 20? Might make the first few weeks more painful but after that I doubt it matters.