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How To Improve Intubation And Iv Techniques?


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Hello guys,

  I am currently in my mandatory anesthesia rotation. I am always clumsy with my hands and are having trouble intubating patients grade 2 and plus. At my school, we get daily feedback from the staff, and I almost failed my daily eval today :(

  Anyone has any advice to improve intubating techniques, and putting central lines?? Any references, or videos? I still have 1 week left in my mandatory rotation, I would love just to pass this rotation. 

  I will jump on every occasion to do things! I am really afraid of having a bad evaluation in anesthesia, even post-carms :mellow:

  My career goal is to become a family medicine in the community, learning to intubate and putting central lines are critical of my future ER rotations!

  Thanks so much guys :)

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Hey! 

 

Try not to be too hard on yourself. New skills take time to acquire. Two weeks is not enough to become great at intubating, in my opinion. It takes a lot of practice. I remember when I first started learning to intubate as a med student, I sucked. One thing that was a game-changer for me was actually watching lots of youtube videos on the proper technique. I realized that for the first week or so I had been doing it wrong (like, not putting the blade in the right anatomical place wrong). I recommend the youtube strategy. Watch many people intubate, watch some instructional videos, then try to apply what you learned in the OR. The other thing that is really important is positioning; try to have a pillow or two below the head so that the patient's head is lifted up and their ear is at the level of the sternum. You want a nice sniffing position, it will help. Especially important in obese patients. I realize you may not have much independence to position the patient yourself being that you're a med student, but if the attending lets you, do this. 

 

Keep practising and reflecting on where you think you're going wrong. Ask the more approachable attendings for direct feedback on how to improve your technique. Don't lose hope, it's a skill that can be learned with time and practise like anything else. 

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Common problem! Ask to be placed in high-turnover rooms for your last week so that you get to practice as much as you can. Also, see if they'll let you use the glidescope once. Sometimes visualizing the anatomy helps you get comfortable with the blade. 

 

Central lines are not the same as IV lines, and I've never seen a core clerk put one in. Are you referring to peripheral IVs or central venous access? The latter is a significantly more advanced skill. For peripheral IVs, I suggest going over your catheter handling technique in detail before your next attempt. A common problem is being too tentative about it and not making a nice smooth motion as you advance and retract the needle (and then you blow a vein). This is one case where doing things a bit faster and smoother may actually be better than going too slowly!

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Thanks guy I really appreciated it!

I was very down today, because my staff and resident kept saying that I would be a bad FM resident during my night calls, if I don't know how to intubate patients quickly and doing central lines, because often not able to reach the other senior residents quickly. I hesitated a long time between psychiatry and FM, and decided to rank FM first...

It were central lines and arterial lines. I guess that my staff and resident wanted me to be a future autonomous FM resident.

I am not the best person with my hands, but I will do my best and aiming just to pass my anaesthesia rotation :)

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None that I'm aware of. One of the staple books for med students is the Ottawa Anesthesia Primer by Sullivan. It's been re-done in colour but there's a free version of the old one (from the 90s) that you should be able to find online if you're interested. Outdated, but a lot of it will still be correct. 

 

It's a good book, especially the old version where they discuss propofol as a "promising new induction agent". (But it is actually good!)

 

Thanks guy I really appreciated it!

I was very down today, because my staff and resident kept saying that I would be a bad FM resident during my night calls, if I don't know how to intubate patients quickly and doing central lines, because often not able to reach the other senior residents quickly. I hesitated a long time between psychiatry and FM, and decided to rank FM first...

It were central lines and arterial lines. I guess that my staff and resident wanted me to be a future autonomous FM resident.

I am not the best person with my hands, but I will do my best and aiming just to pass my anaesthesia rotation :)

 

 

Oh please. There will always be RTs, staff ER docs, and (often) anesthesia and/or ICU residents and staff who will back you up. 

 

I absolutely didn't get good at central lines until I was a resident. 

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Thanks A-Stark, that's what I thought in my head. My resident and staff insisted that I learn how to intubate grade 2 + patients, and putting central lines, as I will be alone in the hospital as a R1 covering all the calls, and the senior residents will be hard to reach, and patients lives are dependent on my intubation skills!!!

I am reviewing youtube videos and reading the old 1999 Ottawa Anesthesia Primer now, propofol is a promising new induction agent. ;)

Thanks everyone for all your encouragement, I really appreciate it :)  :)  :)

It's a good book, especially the old version where they discuss propofol as a "promising new induction agent". (But it is actually good!)

 

 

 

Oh please. There will always be RTs, staff ER docs, and (often) anesthesia and/or ICU residents and staff who will back you up. 

 

I absolutely didn't get good at central lines until I was a resident. 

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It would be a rare thing that an FM resident (except in very small centres) would ever have that responsibility!

 

As for intubation, the first step is being able to utilize positioning and other techniques to get a Grade 1 view in patients who have "easy" airways. The next step after that is using bougies and stylettes well when you have some partial view. After that (and alongside that) you can learn video techniques (Glicescope, CMAC), and maybe fibreoptic bronchoscopy too. But that would be well outside your scope. 

 

The major thing you can take away for FM or most specialties is getting good at basic airway management, which is to say ventilating with a BVM, use of oral and nasal airways, and, again, positioning. 

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Thanks guys!

I guess that my staff and my R2 want me to take the most out of this rotation. Those anesthetists do love their profession :)

It was a difficult day with all the critiques, but I think that it will push me to do my best and put all those central lines, and intubate more difficult patients :)

Gas is life! :P

It would be a rare thing that an FM resident (except in very small centres) would ever have that responsibility!

 

As for intubation, the first step is being able to utilize positioning and other techniques to get a Grade 1 view in patients who have "easy" airways. The next step after that is using bougies and stylettes well when you have some partial view. After that (and alongside that) you can learn video techniques (Glicescope, CMAC), and maybe fibreoptic bronchoscopy too. But that would be well outside your scope. 

 

The major thing you can take away for FM or most specialties is getting good at basic airway management, which is to say ventilating with a BVM, use of oral and nasal airways, and, again, positioning. 

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Agree with everything A-Stark said :)

 

Thanks guy I really appreciated it!

I was very down today, because my staff and resident kept saying that I would be a bad FM resident during my night calls, if I don't know how to intubate patients quickly and doing central lines, because often not able to reach the other senior residents quickly. I hesitated a long time between psychiatry and FM, and decided to rank FM first...

It were central lines and arterial lines. I guess that my staff and resident wanted me to be a future autonomous FM resident.

I am not the best person with my hands, but I will do my best and aiming just to pass my anaesthesia rotation :)

 

That sounds like some very non-constructive criticism. I reserve comments like that for learners who are lazy and have a bad attitude; neither of which it sounds like you do, at all. Furthermore, 1) you're a med student, and 2) you're going into Family, so that just seems way too harsh. I don't think it's crucial to be able to intubate as an FM R1, it's just crucial to know how to oxygenate well, ie. with BMV or possibly an LMA. That's what's usually going to save a patient. Frankly I'd be concerned if an R1 FM resident tried to intubate a patient "quickly" on their own on the ward or wherever. The wheels can fall off pretty fast if someone's inexperienced and overconfident with an airway. Better to just recognize your limits and call for help early. 

 

They really expected you to be proficient with lines at your stage? Good grief...some attendings just have unrealistic expectations. Apparently some PGY-2 residents do too! I was gunning for Anesthesia as a student and I didn't put in any central lines during all my electives - no one let me - and only got to try a couple of art lines. That's the way it is for a lot of students. Residency is the time to get proficient at those skills, and even then, only if you're going to need it in practice. 

 

Good luck, don't let them get you down 

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I've never done a central or an art line in my life (partly because I never wanted to, but certainly nobody presented it to me as a core competency).  And as a PGY1 on GIM, at least, there was always a senior in house and reasonably available, plus we had critical care outreach who would come SUPER fast and take care of anybody who was crumping.

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I loved doing central lines and art lines when I was on ICU as a resident (I learned to do femoral art lines at one point and I used to get asked to stick them in deteriorating patients if they couldn't get a radial. As a result I got to do a ton of procedures). I hated tubing.

 

If you couldn't tube, or weren't confident you could tube a person you always could call anesthesia and the resident or staff would come back you up. The last thing they wanted was for you to spend 10 minutes mashing a difficult airway and bugger the whole situation up for them.

 

I only learned to do all of those things as a resident. At my center we never would have expected a med student to know how to do either.

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Hey guys, a quick date for my anesthesia rotations so far!!!

I got a super laid-back and chill staff today (no resident), he let me did 2 endotracheal intubation with Glidescope, grade 2 +

I successfully put in a laryngeal mask airway. I was very grateful that I got a nice staff, who told me not to stress and take my time.

He also told me that unless I want to be an anesthetist, I would never put IV or arterial lines again lol! :)

 

Could I finish my last week of anesthesia rotation with Glidescope?? I still feel not prepared to intubate in the old classic way :(

I am reading the Old Classic 1999 Ottawa Anesthesia pRimer, and checking out all the Youtube videos!!!

Thanks so much for all your feedback and help, it really helped me to overcome my fear of intubating, and gaining more confidence in myself!

Next week, I will try to put in central lines if I could! :P

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i learned to tube, a/c-line, do spinals, etc as a med student. I find that as a med student you can get a lot of procedures if you look confident and eager. Watching NEJM videos is helpful to train your mind but you really need to master the technique manually. 

The key to procedures is knowing that the principles underlying the techniques are the same.

 

 

Intubation with direct laryngoscope: Position, position, position. You need to either 1. get down to the patient's head level or 2. bring the patient up (I usually choose the latter). You can elevate them with headrest, or just elevate the bed.

-- essentially you want their head to be at your chest level (upper chest if you have good upper arm strength) (This prevents the typical hunching over position of most novice intubators) (This also aligns the orotracheal line the best).

----- Remember that in Germany, anesthesiologists intubate sitting - same principle

-- as you insert the direct laryngoscope with your left hand, use your right hand on the back of the patient's head to lift it and position the airway so you can visualize it (essentialy do a head-tilt lift and sniffing position).

-- if you do the above, 100% you will see the cords unless patient has anteriorly positioned trachea, retrognathia etc. 

-- If you still don't see it, take your right hand (while keeping tension on your left hand/laryngoscope to keep the head 'lifted up' and perform a BURP to visualize the cord. Then ask the RT/assistant to keep the BURP in position while you intubate.

 

 

2. Central lines: ultrasound-guided is a complex maneuvre. Why? With the left hand, you're moving the probe to visualize the IJ while with your right hand you are 1. holding the syringe/needle 2. holding the plunger with your thumb.

-- The actual maneuver is this: Once you visualize the IJ, you keep your left hand steady while with your right hand you insert the needle while at the same time keeping negative pressure on the syringe (i.e. you're using your thumb, finger to pull back on the plunger as you're pushing the syringe/needle through the skin using your forearm/wrist). As you're doing that you're moving the US probe to do the 'creep' technique.

-- Essentially, when i was a clerk, I took a central line syringe home and practised doing that maneuver of inserting the needle while pulling on the plunger to get my muscle memory entrained. 

-- Once you get that maneuver down, inserting a central line is dead simple. It's just poking the black spot.

 

3. Other procedures (e.g. thora/para/LP/spinal anesthesia, joint injection). Essentially you need to master holding the needle properly. If you know how to hold it properly then you can do any procedure with confidence.

-- You must remember that the art is maintaining a specific angle of insertion. This requires dexterity to stabilize the needle

-- Whenever I am penetrating the skin space to reach a deep space (unless it is just freezing the skin), I use the following hand technique to stabilize the needle/syringe.

-- With my left fingers (usually the index and thumb), I hold near the tip of the needle as much as I can without hurting myself (typically 3-4 cm away from the tip of the needle). This helps stabilize the insertion angle and prevents me from moving as I insert the needle.

-- With my right hand, I use the same technique that I use for central line insertion. You are again inserting the needle and aspirating at the same time.

-- With these maneuvers, you can stabilize the needle throughout the insertion and be sure of the angulation of the needle. The angulation is particularly important when inserting long needles because even subtle movements at the site of insertion could create significant deviations at the tip if the needle is long (think about the arc created by long needles)

 

 

I find that the above skills can be applicable in essentially all non-surgical procedures requiring needles (aspiration, injections, insertion using seldinger technique etc).

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Hey guys I have heard from my friends, that in major academic teaching hospitals, Glidescope has become the mainstream, even for patients Mallampati 1?

I suppose that the anesthetists staff want to see clearly what we are doing, and insist on med students intubate with Glidescope?

I don't know if in practice, Glidescope will become the mainstream even for patients with easier airway?

Thanks for your feedback!

I still have 2 days left looking at the screen, bothering my staff with bradycardia of 48 lol

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Hey guys I have heard from my friends, that in major academic teaching hospitals, Glidescope has become the mainstream, even for patients Mallampati 1?

I suppose that the anesthetists staff want to see clearly what we are doing, and insist on med students intubate with Glidescope?

I don't know if in practice, Glidescope will become the mainstream even for patients with easier airway?

Thanks for your feedback!

I still have 2 days left looking at the screen, bothering my staff with bradycardia of 48 lol

At my residency center the glidescope was a second line tool. Most still intubated the old fashioned way.

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Hey guys just a quick update!

I successfully passed my anesthesia rotation yeah!!! I got a surprisingly positive evaluation and was very very happy!!!

Thanks for all your help and advices, it would not have been possible without your sincere help!

I don't think that I will miss my anesthesia rotation, I do miss the patient contact. It is very useful to learn how to intubate, and put arterial lines! I found that most of the anesthesia staff are very easy-going and very funny lol :P

Heading to my last clerkship rotation!!! :)

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