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SHOULD MEDICAL STUDENTS LEARN INTUBATION?? PHARM POLL SURVEY RESULTS ARE IN!!!

Medical students being taught intubation by James DuCanto

Medical students being taught intubation by James DuCanto

PHARM Poll survey 14-15th June 2013

PHARM Poll survey 14-15th June 2013

PLEASE OFFER SOME REASONS FOR YOUR ANSWER

  1. No resources to train properly No mechanism to maintain competence Unnecessary skill for JMOs Likely to be many patients harmed for the rare one who might be helped.

  2. It is a valuable, life-saving skill, which if I’m not mistaken is the fun part of medicine. Paramedics learn it (prob better than most at least in my experience). At least some PAs learn it (like me). Why should you graduate from medical school without knowing how to intubate?

  3. For all-comers I think no, only because it detracts from more important and life-saving skills like bag-mask ventilation and LMA insertion. Having said that, if a student is particularly keen, has chosen to do an elective in anaesthesia and is considering a career in anaesthesia/ICU/ED, I don’t see the harm. For example I was lucky as a med student to do 12 weeks of anaesthesia over various electives and did over 100 successful intubations. This helped me immensely and I don’t think it made me over confident.

  4. As part of oxygenation and other airways of course. You have to start somewhere. Even if they never do it again the exposure is helpful in some of the decisions they will make as they refer patients for surgery or anticipate problems with airways in other clinical situations. I don’t think it leads to overconfident juniors.

  5. Teach them in order to expose to ideas around difficulty, alternatives and traps. They need to know best practice – that is safe oxygenation strategies. This includes ETI but also a range of other option

  6. Haphazard attempts at intubation by those infrequently practicing and possibly with incorrect equipment may do more harm than safe and effective BVM. Save it for anaes/EM training.

  7. I did as a medical student, it was an excellent experience and I was a lot less scared the first time I had to do it in a less supervised context.

  8. Too little time as a student to become competent. Too few opportunities to practice after graduation to maintain skills. Effective bag/mask ventilation and placement of an LMA as per ALS should be taught, but that should be the limit.

  9. Not to learn ETI but to learn how diffucult it is.

  10. No possibility to adeguately mantain the skill

  11. They should learn about airway management. Most students won’t be competent in DL without advanced training and should mainly focus on more basic maneuvers, i.e. BVM, supraglottic techniques.

  12. Proper intubation is an advanced skill, requiring exposure to many attempts and differing situations in order to achieve competence. From my experience doctors need to be able to hold an airway first, providing effective ventilation. Nurses and doctors who are not exposed to even this skill on a regular basis do it poorly. Should we not first teach tme to manage the airway with the simplest techniques?

  13. SGA, SGA, SGA…

  14. If they have not had the opportunity and experience to perform this procedure, they will never know that they CAN do it

  15. Pointless trying to show a technique they will never gain competence in nor regularly practice. Focus instead on using theatre and sim slots on keeping skills up on regular but infrequent intubators – paramedics and EM docs

  16. Exposing medical students to intubation is great. They can get a feel for the skill. But making it an integral part of a program, I’m not so sure of. I would rather see a good strong grounding in the basic. Recognizing distress, Securing an airway,and appropriate O2 delivery, and suctioning. Skill that all health care providers could possibly need. I think this would go farther than teaching intubation.

  17. Students electing to participate in these elective do so, for the most part, because they plan to enter a specialty where the skills will absolutely be needed such as EM, anesthesia, or surgery. As long as respect for the airway is also emphasized these students should be taught to intubate. As mentioned in Twitter debate this skill takes years to master and learning as a student is a good job start – no one shows up the first day as a senior resident suddenly knowing how to manage airway; it is a skill that must be developed through earlier experiences. I do agree that medical students who will never intubate in practice should not be taught how unless they truly understand that they will not be able to do this independently just because they’ve touched a laryngoscope 10 times. Overall though I think it is a good experience for select students so they can at least get a feel for the technique and procedures in a controlled, closely supervised setting.

  18. We need to take a hard look at what really matters in education of students. Skills or knowledge?

  19. In a 6 year Australian undergraduate medical degree, I experienced two weeks of anaesthesia. This was obviously not long enough to learn anything other than observe things in action. I am aware of other post grad medical programs that provide a 3-4 week critical care elective which includes anaesthesia. But even though a student may do some I intubations during this period, I think that they would likely to have been closely supervised. Thus, I think that more emphasis to students should be on oxygenation and ventilation airway skills. It would give students a false sense of ability because they have been allowed to a perceived ‘cool’ procedure.

  20. I don’t feel all that strongly. 2) med school is more about learning cognitive steps (why we intubate) vs technical skills. 3) will they really learn enough about intubation to garner any meaningful skills? or just enough to gain false confidence? 4) we know that a lot of what med students learn in school is obsolete at the time they learn it. How many will be taught CP?

  21. First, I believe med students should have the opportunity to learn intubation if they want to. However I believe (and have seen this in practice) that some people aren’t aware of their limitations and have got themselves into trouble trying to intubate, when they were stable with good BVM ventilation. Therefore I believe med students should have practice at assessing the airway (both patency and potential difficulty), BVM ventilation both dual and single handed, and LMA insertion (iGel or SGA device of choice).

  22. Unlikely to gain the experience necessary. Should concentrate on basic airway and cardiac arrest management.

  23. We certainly had to at my Medical school in the UK. Im a junior resident and im not going to be attempting to tube patients in the ED without supervision. That is just not how it works. im no expert, but the time in theatre gives you an understanding of the positioning the equipment and variations in anatomy that you may encounter, which cannot be easily simulated. if gives you a solid background on which to build your skills later. its doesnt mean you are somehow ‘qualified’. if iwant to be an ent surgeon at med school I still learn anatomy of the GI tract, if I want to be a city GP I still learn to do blood gases at med school (which I will mever need to do again in the UK). intubation is a core background skill.

  24. Earlier to start learning the better

  25. Intubation is too specialised a skill, which not only requires years of training, but continuous practice to allow competence. Mask ventilation and LMA insertion should be taught. Not intubation.

  26. What is learning intubation?? Does it mean how to hold a laryngoscope? Does it mean in depth assesment of likelihood of difficult laryngoscopy? Certainly in the old days of ACLS (which as UK) medical students we did in our final year, we had to do skill stations involving intubation on a manikin. I don’t think this can be counted as learning intubation, and yet with these skills, prior to my anaesthetic career, I intubated several arrested patients (supervised by a senior doctor) without difficulty. If you are asking should all medical students graduate with a modicum of experience utilising various techniques to support the airway / ventilation in a patient with a decreased level of consciousness then I feel this is absolutely essential. I think that all medical students want to ‘stick a tube down’ during their time with an anaesthetist, and I do my best to facilitate this for the sake of their interest. However, the focus of my teaching is always on simple manoeuvres and adjuncts as is these skills that will buy time until a proficient airway operator can be mobilised. To teach intubation without the need for capnography is, especially post NAP4, probably a retrograde step. I thin that’s enough for a small comments box! Yours, liverpoolmedic.

  27. Four or five “easy” intubations will give “dangerous” confidence in own skills, and take focus away from important training in ventilation /oxygenation, preferably with SADs

  28. Gives exposure to a core skill and helps in recognition of an Anaesthetic risks

  29. Intubation? NO – needs >50 to get motor skill, plus many years to get clinical decision-making correct. And skills atrophy quickly Airway management – HELL YES! I’d teach ‘em the Vortex tim leeuwenburg kangaroo island

  30. Advanced Airwaymanagement is necessary during the rest of his medical life

  31. No, but I am not against them “having a go” under supervision should the opportunity arise, just like many other technical skills which they may have the opportunity to experience, and which may facilitate further career choices. Just need clear explanation of the purpose of the experience, and the potential problems.

  32. Learning how to perform laryngoscopy is a world away from learning how to perform RSI with safe doses of induction agent, correct team leadership, back up airways etc.

  33. Intubation is an advanced skill that requires continual practice to remain competent. It also requires sufficient experience to decide when and in whom it is appropriate

  34. It is a basic medical skill that is valuable to learn even if they end up in a specially that does not routinely intubate. Not everyone needs to be an expert, but all physicians should be familiar with the basic process.

  35. Airway mgt should be part of the basic training with special emphasis on bvm and surgical cric to get you out of the woods in dire straights

  36. After learning proper BVM technique the next logical step is to teach ETI- the additonal edu atipn will benefit those who need it later and won’t harm those who don’t do it in their practice because they won’t be credentialed for it and they won’t use it inappropriately- the benefits for those who need it in their future practice is immense

  37. PMMedical students are taught not to gain a mastery of any skill, but to have the raw knowledge and foundation to specialize in their field of choice. Being exposed to airway management can inspire the right sort of people to persue emergency medicine and is an essential portion of the curriculum.

  38. With the use of simulation there is no risk to patients.

  39. Impossible to achieve and maintain level of competence.

  40. 1. Anesthesia/OR offers a safe place to bag, intubate, assess airways, etc. 2. The nature of an elective is such that motivated learners who are likely to pursue specialties that will use intubation 3. Much of this skill set involves practice and simply, starting as a medical student helps in that endeavor.

  41. Better to learn it there than on their first arrest

  42. I did Part of exposure to all specialties

  43. Knowledge of risks, complications, alternatives.

  44. In the short amount of time that med students get exposed to anesthesia, they should learn how to open an airway, assist with oxygenation with devices like oral and nasal airways, learn how to insert LMAs, and how to do *good* bimanual bag mask ventilation. Doing less than 10 intubations on an anesthesia rotation will not help them in a crisis situation. A situation where they cannot bag/mask ventilate but can intubate would be extremely rare. For those who argue that early exposure/some exposure is good, there is no way that they will have any kind of competency with intubation, but can achieve basic competency with BMV. Also, if the student is keen/planning on going into anesthesia/emerg, then it can be argued that there will be plenty of time during residency to learn.

  45. yes -even if they never do it again, it may instill a respect for the airway and airway procedures.

  46. Advanced complex skill, they need to learn basics airway manoveurs and sga only!!!

  47. Inability to maintain adequate skill/safety level. Risk of conscious incompetence becoming unconscious incompetence. Better priorities in teaching juniors.

 

 

Minh’s comments : Thanks to all the readers and listeners of the PHARM in answering the poll! A small margin majority voted YES to the question of whether medical students should learn intubation. The open responses were very useful and many good reasons why or why not were given. I think this highlights to me one of the central problems of the quality of airway management training/education in our medical curriculum, both undergraduate and postgraduate. OUr very own attitudes and culture. We are both the problem and the solution. If we can come to no clear agreement as to when to start teaching airway management or even one part of it like intubation then no wonder it currently is a choose your own adventure style of self training. We focus on poor markers of competence such as number of intubations performed or time spent in anaesthesia terms. We dont even have a good objective method to assess competency of basic let alone advanced airway management. The real question is why? Why do we accept this? Is this the best we can do? Is this the best we can do for the public we serve? I believe we can and should do better.At no other time in our medical history do we now have such a wide range of open access resources for a comprehensive airway education. At no other time did we have such simulation training capability. At no other time did we have better devices to teach airway examination and procedures with. A small majority agree with me but its obvious there remains a significant reluctance to change what we are doing. Its called inertia. Its what we have done before and it was good enough for me.

Well I believe that the future should be better than us. That resuscitation skills including airway management should be a core part of becoming a doctor, a nurse, a paramedic, a physiciant assistant, a respiratory therapist..anyone who takes on the duty of clinical care. The level and scope of practice will vary of course but a minimum standard of knowledge and essential skills should be part of our life long learning in health care delivery for acute illness and injury.

Thanks again for your participation. It helped me understand.

3 Comments Post a comment
  1. I’m going to argue that this is not inertia. Of course I speak from anecdote data!

    I was given exposure to intubation as a medical student and a 3/12 anaes & ICU rotation as an intern, during which I intubated at arrests and elective OT cases under supervision

    Then moved overseas to Australia and spent 2 years on gen med and emerg rotations, during which ETT skills atrophied.

    Its probably taken several more years to appreciate how difficult ETI is and to get the cognitive skill set around decision making in the dynamic airway

    It’s a bit like some surgical procedures – I expect medical students and juniors to know about them, indications and contraindications – but I wouldnt expect them to do it

    Serioulsy, concentrate on the basics of ventilation, teach ‘em the Vortex. But til theyve got 50-100 under their belt and managed dynamic airways outside of OT, they are NOT safe to weild a laryngosocpe

    Double 0 7 and ‘licence to kill’ and all that…

    June 15, 2013
    • thanks Tim!
      Dont confuse laryngoscope skills with RSI. Sure Laryngoscope as murder weapon is a catchy phrase but if you look at pioneers of laryngoscopy and history of it, people been doing laryngoscopy for a long time without RSI.

      And how will your med student know how to extract that piece of chicken vindaloo from your larynx if they dont know how to do laryngoscopy? How will they know the difference between epiglottis and the chicken and how to find it if they have not at least practiced laryngoscopy on a mannikin at the very least? What is wrong with laryngoscopy practice on a mannikin? Dont you think the public expect a doctor, even a junior one to know how to save a life by clearing an obstructed airway due to chicken vindaloo? or the McHappy meal tool lodged in their child’s larynx?

      June 16, 2013
      • Hi Minh

        You are right of course – its not the laryngoscope per se….but it IS the decision-making and drugs around performing intubation that make this tiger territory for neophytes

        I have no problem (and indeed encourage) students to pick up a laryngoscope, visualise structures and appreciate how hard it can be to intubate a mannikin. Using video clips taken with the KingVision VL have also been useful to demonstrate epiglottoscopy and effect of blade tip in vallecula….VL accelerates the skills aquisition, I reckon.

        …but here endeth the lesson. Once we’ve demonstrated how hard laryngoscopy can be, and the subtelties of RSI, I encourage them to put the bloody thing down and dont play with it again until embarking on EM, crit care or anaes pathways (i include rural EM in this)

        - instead get students and juniors to focus on effective BMV, LMA insertion and basic airway management. They’ll do more good with this than the potential harm from pushing propofol, sux and attempting intubation on the crashing or dynamic airway.

        As for your obstructed airway ‘hamburger in the anaesthetic tea room’ – that lass needs a good ol’ “Hind Lick” manoeuvre, surely? :-)

        June 16, 2013

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