Less than 10 lines?!?!
I doubt that anyone will ask numbers from a fellowship-trained person, as long as the ACGME requires that specific training for the fellowship.
We say that there is a reason anesthesia residency is 3 years.
We say that there is a reason anesthesia residency is 3 years.
To be good at intubating, you only need 2.
On the serious side, it doesn't matter only how many you do, but also the difficulty of the airway and the quality of the teacher. The latter is usually deficient in both ICU and ED, so one can have 200 intubations and still f up. We see it on a weekly basis.
Typical example (true story): 50 year-old patient with severe allergy to ACEI, swollen lips and airways, some SOB, but still conscious, breathing and satting 98%. Anesthesia team asks for ENT at bedside. ENT comes and asks for a cric kit and for the neck to be prepped, just in case. While people are still looking for a cric kit, the ED attending induces the patient on her own, without letting anybody know (at that point, there are 3 anesthesia and 2 ENT people at the bedside, waiting for the cric, patient still doing OK). Difficult glidescope intubation ensues and, thank God, succeeds. But the IQ and stupidity of the ED doc, OMG! I doubt the ED residents present learned a lot there, except how to be stupid macho.
The failed intubation rate after 200 was 7% which is probably fine for an academic place with anesthesia as 24hr in house backup. As single coverage in the community, 7% is probably an unacceptable miss rate. I'm not saying that nobody with less than 400 should be intubating unsupervised necessarily but that in a setting with frequent difficult airways with minimal time for optimization
Despite it being an OR setting, a quarter of the patients had some difficult airway characteristics. However, at some point, you need to define what people will consider competency (for credentialing and so on). The vast majority of ED residents graduate with less than 200 tubes, CC fellows often less than 50 - in that regard, it is interesting to see that in this studies, even anesthesiology residents achieved only 80% first pass success rate at 200 intubations
Ability to successfully execute your version of the difficult airway pathway probably matters more than monkey skills after certain point. I looked up the average number of intubations and was shocked by how low the average number of intimations for EM residents. On the other hand the ACGME only requires 35. Apparently I'm significantly biased by the airway environment I trained in.
Not NPO or emergent is not what makes an intubation difficult. I do most of my OR intubations in RSI mode, even if elective and NPO, as long as I don't expect a difficult airway. And planning shouldn't take more than a few minutes. So no, they are not commonly difficult.
You are misreading my post. I am not saying they are difficult because of NPO status or urgency. I just stated that in my experience (I work at a quaternary academic referral center), in addition to these two facts, they are commonly difficult. The average patient is 400 pounds, has a lot of comorbidities, underlying lung disease and will need control of their airway within minutes. I don't know when we last called somebody to come down and manage an airway for us, except if they needed an urgent, but not emergent, surgical airway. That's why I was questioning your post and wanted to explore your opinion on who you would like to see manage emergent airways. From your most recent post, it sounds like you don't necessarily advocate for mandatory anesthesia involvement for difficult airways, but for a well trained and competent clinician regardless of formal specialty background.
And it seems that you guys have it covered (and so has the ED in my academic hospital). A 400 pounder is not an easy cookie, even in an elective setting. But I would bet that most of your guys are way beyond the famous 200 number of intubations, and probably many difficult ones.
what are bronchs in icu used for?
