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Do ENT's perform tracheotomies?
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are you serious?
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I guess they do, since a tracheotomy is performed in THEIR area, but still, it could be a procedure performed by general surgeons, becuase of them sometimes one can't really tell this things, you know...they actually do a lot of surgeries that could be done by a specialized surgeon.
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An otolaryngologist is one of many airway specialists in the hospital. The ENT should strive to be as good at intubating as the anesthesiologist--and may sometimes be better. He is occasionally better with surgical airways than is the general surgeon or the emergency physician. He is sometimes better at instrumenting the airway than the pulmonologist as well.
No one should try to be more adept at the airway in your hospital other than maybe another ENT.
With lots and lots of practice and a little luck with no other providers who have more experience you can intubate a 500lb heffer with retrognathia and a malampati IV oral airway, slash trach an epiglottitis in less than 45 seconds, bronch an 18 month old and remove the pistachio they aspirated within a minute or two if needed when your an ENT.
You are an airway expert. All else can be as good if they want
Yes, we do trachs.
No one should try to be more adept at the airway in your hospital other than maybe another ENT.
With lots and lots of practice and a little luck with no other providers who have more experience you can intubate a 500lb heffer with retrognathia and a malampati IV oral airway, slash trach an epiglottitis in less than 45 seconds, bronch an 18 month old and remove the pistachio they aspirated within a minute or two if needed when your an ENT.
You are an airway expert. All else can be as good if they want
Yes, we do trachs.
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When do ENTs have the opportunity to intubate difficult airways? Only asking because I've seen a lot of anes guys show up to codes, and in the OR obviously. But never seen an ENT . . .
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We frequently get called for difficult airways.
Last week, I had an ED call from anesthesia for an 8 month old that had significant biphasic stidor, severely increased work of breathing and was tiring out. Took him to the OR for intubation, which anesthesia defered to us, and formal arway evaluation.
Nearly all of our radiated head and neck cancer patients are difficult airways, due to radiation effects on mouth opening (trismus) and inability to extend their necks. We often obtain the airway for our anesthesia colleagues.
Yes, we rarely show up for codes - anesthesia is obviously very good at obtaining an airway, and have their own algorithms for a difficult airway (masking, LMA, etc) that can adequately ventilate a patient until they can call us, if needed.
At my insttution, general surgeons rarely do open trachs. They perform percutaneous trachs the vast majority of the time, and, indeed, recently had a chief GS resident ask if they could scrub a few trachs to get the experience before they graduate. Last year, GS nearly lost a patient on the table whle performing a trach when they hit the innominate.
Also, although we usually act as technitions when performing trachs for off-service patients (ie MICU patients), the critical care doctors choose ENT surgeons for their patients since we provide a "service" rather than just an operation - I can't tell you how any consults we've gotten for prevously placed perc trachs that they are unable to decannulate, and when we see the patient find the same cuffed trach place 6+ months ago (oftentimes still inflated) - no wonder they can't decannulate!
There are many areas where GS and ENT overlap within the neck - trachs, thyroids, neck dissections, etc. As long as they've received adequate training, both are equally qualified to perfom the operation. However, the ENT spends all of their time in the head and neck - and are far more comfortabl. An example would be thyroids, we both perform them at our institution. GS incisions are 10 cm. Ours are routinely 4 cm, and can be as little as 2.5 cm (with endoscopic assistance) - if you were referring your 29 y/o female for throidectomy, who would you choose?
Last week, I had an ED call from anesthesia for an 8 month old that had significant biphasic stidor, severely increased work of breathing and was tiring out. Took him to the OR for intubation, which anesthesia defered to us, and formal arway evaluation.
Nearly all of our radiated head and neck cancer patients are difficult airways, due to radiation effects on mouth opening (trismus) and inability to extend their necks. We often obtain the airway for our anesthesia colleagues.
Yes, we rarely show up for codes - anesthesia is obviously very good at obtaining an airway, and have their own algorithms for a difficult airway (masking, LMA, etc) that can adequately ventilate a patient until they can call us, if needed.
At my insttution, general surgeons rarely do open trachs. They perform percutaneous trachs the vast majority of the time, and, indeed, recently had a chief GS resident ask if they could scrub a few trachs to get the experience before they graduate. Last year, GS nearly lost a patient on the table whle performing a trach when they hit the innominate.
Also, although we usually act as technitions when performing trachs for off-service patients (ie MICU patients), the critical care doctors choose ENT surgeons for their patients since we provide a "service" rather than just an operation - I can't tell you how any consults we've gotten for prevously placed perc trachs that they are unable to decannulate, and when we see the patient find the same cuffed trach place 6+ months ago (oftentimes still inflated) - no wonder they can't decannulate!
There are many areas where GS and ENT overlap within the neck - trachs, thyroids, neck dissections, etc. As long as they've received adequate training, both are equally qualified to perfom the operation. However, the ENT spends all of their time in the head and neck - and are far more comfortabl. An example would be thyroids, we both perform them at our institution. GS incisions are 10 cm. Ours are routinely 4 cm, and can be as little as 2.5 cm (with endoscopic assistance) - if you were referring your 29 y/o female for throidectomy, who would you choose?
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redacted to prevent a flame war.
(planktonmd below accuses me of egomania and perhaps what I had written here demonstrated some egomania, but my purpose in posting these examples were to show extreme cases--and they were the extreme ones with which I've been involved--in which the ENT had to handle difficult airways when others failed.) I stand by my assertion that the ENT is the airway expert in the hospital simply because we (usually) have more methods for securing the airway than any other specialty. But others are right that the most important person for the pt is whoever is present with the most experience at the time. I will withold any further opinion on this subject. I'm sorry if I was inflammatory. I meant to educate, albeit I admit I have too much passion for what I do.
(planktonmd below accuses me of egomania and perhaps what I had written here demonstrated some egomania, but my purpose in posting these examples were to show extreme cases--and they were the extreme ones with which I've been involved--in which the ENT had to handle difficult airways when others failed.) I stand by my assertion that the ENT is the airway expert in the hospital simply because we (usually) have more methods for securing the airway than any other specialty. But others are right that the most important person for the pt is whoever is present with the most experience at the time. I will withold any further opinion on this subject. I'm sorry if I was inflammatory. I meant to educate, albeit I admit I have too much passion for what I do.
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Man, this guy is so green I can't believe it.
He must be either still a resident or in his first year of practice.
The fact that he went to such length in explaining why he is the ultimate airway champion is very funny.
And when he claims that 3 anesthesiologists were waiting for him to tell them that this was an esophageal intubation only shows that he is either lying or working with the crappiest anesthesiologists on earth!
Those young guys think of airway management always as an emergency, and they see themselves as heroes (this applies to many ER physicians as well).
They don't even have a clue that airway management is business as usual for us, we do it everyday, we manage difficult airways as well as easy ones and the fact that no one notices it is a proof that we are really good at we do.
He must be either still a resident or in his first year of practice.
The fact that he went to such length in explaining why he is the ultimate airway champion is very funny.
And when he claims that 3 anesthesiologists were waiting for him to tell them that this was an esophageal intubation only shows that he is either lying or working with the crappiest anesthesiologists on earth!
Those young guys think of airway management always as an emergency, and they see themselves as heroes (this applies to many ER physicians as well).
They don't even have a clue that airway management is business as usual for us, we do it everyday, we manage difficult airways as well as easy ones and the fact that no one notices it is a proof that we are really good at we do.
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oh boy... this thread started as a simple question and turned into some ego-issues
ENTs perform trachs... but it depends on the hospital/academic center on who performs trachs routinely (where i trained - mgh - gen surg did most of the trachs)
the next issue that comes up is how often does the average general surgery resident or ENT resident actually perform an emergency tracheostomy - actually very rarely.... frequently a bloody cric. occurs first with a real tracheostomy in the OR under more controlled circumstances...
who is the airway expert? well ER doctors think they are, ENT guys think they are and anesthesiologists think they are, Paramedics thinks they are... so who is right?
who cares - ATLS guidelines state that the most experienced laryngoscopist should perform the intubation....
I have just as many stories of saving ENTs (aka ORLs) asses... and never did i need/have an ENT to save mine... even though i wish I had an ENT next to me for a few of the trickier cases...
During my training i spent some time with an ENT and a thoracic surgeon who were world-famous for tracheal reconstruction - in fact that is all they did day in and day out - the thoracic surgeon always gaves deference to anesthesia... the ENT always wanted to manage the airway, but as soon as he got into trouble he would hand over the airway over to us while he got ready to perform a trach.... (he could do a trach from incision to tube placemetn - not a cric, a trach - in less than 25 seconds - you have to see it to believe it)
so who cares (other than Resxn) about who the airway expert is???
In my opinion it is whoever is at the bedside with the most laryngoscopy experience....
ENTs perform trachs... but it depends on the hospital/academic center on who performs trachs routinely (where i trained - mgh - gen surg did most of the trachs)
the next issue that comes up is how often does the average general surgery resident or ENT resident actually perform an emergency tracheostomy - actually very rarely.... frequently a bloody cric. occurs first with a real tracheostomy in the OR under more controlled circumstances...
who is the airway expert? well ER doctors think they are, ENT guys think they are and anesthesiologists think they are, Paramedics thinks they are... so who is right?
who cares - ATLS guidelines state that the most experienced laryngoscopist should perform the intubation....
I have just as many stories of saving ENTs (aka ORLs) asses... and never did i need/have an ENT to save mine... even though i wish I had an ENT next to me for a few of the trickier cases...
During my training i spent some time with an ENT and a thoracic surgeon who were world-famous for tracheal reconstruction - in fact that is all they did day in and day out - the thoracic surgeon always gaves deference to anesthesia... the ENT always wanted to manage the airway, but as soon as he got into trouble he would hand over the airway over to us while he got ready to perform a trach.... (he could do a trach from incision to tube placemetn - not a cric, a trach - in less than 25 seconds - you have to see it to believe it)
so who cares (other than Resxn) about who the airway expert is???
In my opinion it is whoever is at the bedside with the most laryngoscopy experience....
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Who cares?
I believe your response indicates that you care as well. Besides, you have your share of "who's better than who" threads:
http://forums.studentdoctor.net/search.php?searchid=2275883
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C'mon man, if you really are an attending who has been practicing long enough to take this things naturally, you must know that in medicine when you're new in something, you get that kind of excitement, it starts happening when you start med school, until your first years as an attending, it doesn't bothers me and if you were comprehensive enough it shouldn't bother you either.
I must admit I am still "green", currently a 4th year ENT resident but I've seen both sides of the story. We work at a few hospitals throughout our residency. And there is a whole spectrum of airway management depending on where we are. At our main hospital, anesthesia is actually pretty damn good and since we take home call, they obviously field alot of the emervgency airways. If they can't intubate it's usually gen surg on call that will perform a cric. If we're in house during the day we usually get called, and in my 2.5 years as an ENT resident have had may 5 urgent trachs (controlled, quickly done bedside trachs) and 1 "slash" trach on a coding patient that couldn't be intubated and was a big fat lady. Our county hospital is another story, and I really feel that even the anesthesia attendings are for the most part incompetent when it comes to a) head and neck patients, and more specifically cancer patients and b) the difficult airway. Even on healthy, non-cancer patients we regularly have to take over to intubate fiberoptically or even with a plain old Miller blade. And we've had them turn straight forward intubations into can't intubate, can't ventilate scenarios where we have to trach patients. So bottom line is we all think we're god's gift to the airway, but there is a vast spectrum of skills. The important thing to recognize is who is the most competent doctor in THAT particular room and let them do their thing...
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I think its kind of humorous people would actually debate over who gets the most trachs or what specialty does it best. I wouldn't consider it that glamorous of a procedure. I would like to comment though I am a little suprised at the comments related to anesthesia struggling with airways. At my institution the anesthesiolgists can intubate pretty much anybody that has an airway that can be physcially intubated. Where I am at it is almost never heard of for someone to require an emergent trach/cric in the OR.
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Which would pretty much fall in line with what is being said here. It doesn't happen often, but it does happen.
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I repaired a cleft palate on a kid about a year ago with Pierre Robin. When they extubated him, he turned blue. Anesthesia couldn't get the tube back in. Thank God that the ENT Chief Resident was literally next door. He got a rigid bronch in that they could ventilate through before he trached the kid. Makes me much more aware of the possible problems of operating in the airway.
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Wow, lots of anger. I like it.
SOoooo, at my training institution (Iowa), both g-surg and oto did trachs. If anesthesia couldn't intubate (seen it happen 2-3 times while in training), oto would be called bc/ we had someone in house 24/7. I did only one emergent trach while in training. Would have been a cric but the neurosurgeons (don't ask) had already exposed the trachea.
While in practice, have done one emergent trach. Have needed to managed one airway on an post-cancer pt who had no oral airway. G-surg does not do trachs where I practice. Don't know why, but oto does them all.
SOoooo, at my training institution (Iowa), both g-surg and oto did trachs. If anesthesia couldn't intubate (seen it happen 2-3 times while in training), oto would be called bc/ we had someone in house 24/7. I did only one emergent trach while in training. Would have been a cric but the neurosurgeons (don't ask) had already exposed the trachea.
While in practice, have done one emergent trach. Have needed to managed one airway on an post-cancer pt who had no oral airway. G-surg does not do trachs where I practice. Don't know why, but oto does them all.
I agree it's not a very "glamorous" procedure, and after having done nearly 100 in residency general surgery can gladly do as many as they want. Like I said before, it really is institution dependent and I agree if you're at a good hospital with good anesthesia it isn't usually a problem. But there are the rare instances where there is an unanticipated upper airway obstruction after extubation where a patient can't be re-intubated. That being said, Eclcell, not sure what specialty you are but head and neck patients represent a unique population of patients, and often their upper airway is distorted, whether from cancer or from chemo/XRT changes. If you operate on these patients, and anesthesia is sub-par (i.e. at my county hospital) then your sphincter tone is generally a little higher during intubation/extubation.
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From the gen surg perspective:
it definitely institution dependent. During my residency general surgery did all the trachs on the Trauma patients (most often PETs, but patient dependent..I always preferred a nice open operation [with a less than 10 cm incision
]...depending on anatomy and prior surgery in the area and to some extent, the resident's choice.)
ENT generally did the trachs on the Onc patients since the H&N cancers were in their arena.
I did one emergency cric during residency, an old guy who shot himself in the face and survived. ENT ended up taking him to the OR for some damage control of the face and converted the cric to a trach; so sometimes we even work together.
As for thyroids...well that could be ENT, gen surg, Endocrine surg and even one of the MIS guys who wanted to start doing them with a scope.
I'm sure the situation will be different in my new hospital...as far as I'm concerned, ENT can have them. Not glamorous, too much blood and potential for scary airway issues.
it definitely institution dependent. During my residency general surgery did all the trachs on the Trauma patients (most often PETs, but patient dependent..I always preferred a nice open operation [with a less than 10 cm incision
]...depending on anatomy and prior surgery in the area and to some extent, the resident's choice.)ENT generally did the trachs on the Onc patients since the H&N cancers were in their arena.
I did one emergency cric during residency, an old guy who shot himself in the face and survived. ENT ended up taking him to the OR for some damage control of the face and converted the cric to a trach; so sometimes we even work together.
As for thyroids...well that could be ENT, gen surg, Endocrine surg and even one of the MIS guys who wanted to start doing them with a scope.
I'm sure the situation will be different in my new hospital...as far as I'm concerned, ENT can have them. Not glamorous, too much blood and potential for scary airway issues.
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Its definitely institution dependant. At Carle Foundation Hospital our Oral & Maxillofacial Surgery Department performs close to 90% of the tracheostomies in the hospital (for more than 30 years now), mainly for the SICU, CVICU and Trauma Services as well as for our head/neck oncology patients. Average of about 80-100 cases/year. A good number of these are on 400-700 + pound patients.
The ENT department performed traches for patients on their service and for infant/pediatric cases.
Our attendings were not big fans for percutaneous & bedside trachs. I tend to agree... nothing better than having the control of the OR, lighting etc...
The ENT department performed traches for patients on their service and for infant/pediatric cases.
Our attendings were not big fans for percutaneous & bedside trachs. I tend to agree... nothing better than having the control of the OR, lighting etc...
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Just wondering if any you like to place any dressings around the trach stoma. At other hospitals where I rotated/externed the trach patients only had some gauze dressing and those old style trach ties.
We cut and customize a duoderm dressing, which we've found really helps protect the area. We keep that there for about a week or so and then remove it once we go to perform the first trach change. The tissues look great. No wound breakdown.
We cut and customize a duoderm dressing, which we've found really helps protect the area. We keep that there for about a week or so and then remove it once we go to perform the first trach change. The tissues look great. No wound breakdown.
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I do the same
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We sew them in too... Belts and Suspenders.
Usually a 2-0 Prolene for the Bjork Flap, and then we sew the trach in with another 4 sutures.
Usually a 2-0 Prolene for the Bjork Flap, and then we sew the trach in with another 4 sutures.
