Why can't nurses intubate?

MereSanity · Nov 2, 2014

I think there was a young girl that died recently due to an intubation gone bad. Tragic, sad story.

PedsED-RN · Nov 4, 2014

Granted, I have been an RN for decades, but, I intubated neonates and children pretty regularly in my years as an NICU, PICU, and critical care transport nurse. As has been previously mentioned, intubation is (or was anyway) one of the skills required for ACLS or PALS certification.
In addition, many of us were trained in providing intraosseous and cricothyroidotomy access for our critical care transport patients, at that time. Is that still in practice?
Times have changed for certain, but RNs still have plenty of opportunity to participate in advanced skills in the acute setting. It really depends upon your practice setting, your experience, the policy of your employer, and your training.

I know for our Transport team (peds hospital), they are all trained in IO, intubation, etc. I know they maintain tubing skills in the OR each year to keep current, not sure about the rest though?

NickB · Nov 14, 2014

You have a middle ground. It's called an LMA.

GrannyRRT · Nov 14, 2014

You have a middle ground. It's called an LMA.

Why would a hospital want to rely on LMAs?

They are great for the OR where the patient has been NPO prior to procedure or for EMTs to get the patient the hospital if they have no other options. If you have ever worked in an ER you will see how many times ambulances bring patients in with temporary devices like LMAs, Kings and Combitubes who have aspirated from the insertion. But, a hospital should be held to a higher level when it comes to intubation. There should be people who are well trained and educated not only in DL but also on the advanced devices which are now affordable for even the most rural hospitals. The good ole' BVM is also an option until those who are well trained in intubation arrives.

We also carry LMAs in our pedi and neo transport team bag. But, in 20 years and thousands of thousands of transports, our teams have not had to use one. The team members do extensive training and retraining on intubations and also the use of an LMA. If you have a few hundred nurses in the ER, it is doubtful they will be able to get the same number of tube to stay proficient.

In other words, you shouldn't just do something to say you can and do it "in a middle ground" if you are in a hospital. Even the small Critical Access hospitals shouldn't be using excuses for not having professionals (Doctors, RTs, PAs, NPs) available to do intubation in the year 2014. It is also a lot more than just the act of inserting some tube but the whole pharmacology thing to enable the patient to tolerate the tube (ETT, LMA) and reduce the risk of aspiration. This is why new and improved approaches to RSI and DAI are always being studied and scrutinized.

NickB · Nov 18, 2014

That's funny that you make the points you do. My RRT and I arrived to an outlying facility last Friday and walked in on an extreme Pierre Robin term baby who had an LMA inserted. This was after two RTTs and an anesthesiologist tried multiple times. We have these devices for a reason. They are a middle ground for pt's who cannot be intubated. This pt would not have survived without an LMA. And let's not forget that highly trained personnel are not always "around". On a side note, my RT intubated this pt on his first attempt. But he has been an RT for 25 years, 15 of them in nicu and I also sedated this pt prior to his attempt. He said it was one if his top 5 most difficult intubations. Middle ground airways have there place in healthcare.

GrannyRRT · Nov 18, 2014

But should the LMA be the standard because some want to intubate but probably won't get the tube time? The LMA is not sufficient for the long term. Would you feel comfortable with a ventilator patient in ICU with an LMA? Didn't you and the RRT feel the need to secure the airway with an ETT?

You described a difficult situation. Luckily there was an anesthesiologist around who has 1000s- of intubations including many with the LMA. Having a tight group who is well versed in several intubation devices is still best. Even the LMA requires a little skill.

But most importantly from your example, those at that facility knew when to stop butchering the airway. That is the most important thing to learn but some still fail at it.

NickB · Nov 19, 2014

I think you misunderstood my first posts. I was responding to someone at the beginning of the thread questioning why they didn't have a middle ground available, regarding some nurses being able to intubated instead of no nurses ever being able to intubate. My point wasn't that nurses should be trained in intubation, my point was that if they find themselves in a situation where a nurse would need to intubate with no one trained, their middle ground is something like an LMA. I've been trained to intubate but would always defer to my RT.

GrannyRRT · Nov 19, 2014

Are you talking about a nurse be a first responder or at a clinic?

I would advise doing BLS_ after calling 911.

If this is at a very rural hospital where there are no RTS and the doctor in the ER is not capable of intubation, I would suggest they contract with 911 EMS for emergent intubation. Hopefully they will be there in 4 minutes.

Yes in those situations an LMA could be used but it would still be better to have someone who is very skilled at intubation. If not, you would have to do competencies on every nurse for the LMA or have staffing issues if someone doesn't have the checkoff. It would be easier to just train the ER doctor to do the LMA until the Paramedic arrives.

Anyone can be trained to intubate but you must do it alot to be competent. Ask the CRNAs_ how many they must do or someone who is on transport. Those transport RTS usually have hundreds of intubations prior to making the team.

NickB · Nov 23, 2014

Here, this is the quote that my original response was for. I think you and I are making the same argument. "Completely true, but in some instances you can't maintain an airway without the intubation. It's a slippery slope, but we need a middle ground"

My response to this is if they find themselves in the situation, they have a middle ground and that would be an LMA.

Guest849204 · Feb 14, 2016

Certain RN's can intubate. It depends on your state board of nursing and hospital policy. When allowed, individual nurses must be trained and certified in some way. The procedure itself is not that risky or technically challenging but it requires training and ongoing practice because when a patient needs to be intubated, time is a major factor so the person doing the intubation needs to be relatively well practiced. Its kind of like how technically nurses aren't trained to place IV's in school but most are taught on the job and do it everyday. Intubation is just more complicated and less common so usually its not necessary to start training nurses.

Learning how to intubate is not that hard, its just not taught to nurses because in most cases there is a doctor, CRNA, or paramedic around to intubate. In some rural areas however that is not true so they teach nurses to intubate.

AZQuik · Feb 16, 2016

Advanced practice nurses do tube pts all the time. When I did NICU, it wasn't all that uncommon for the NNP to grab the laryngoscope out of the resident's hands if they were struggling to get the tube in while we have a premie who needs an airway. As far as staff nurses intubating, we have enough to do already! However, I must say that in all of my years in nursing, we have picked up so many functions that only the docs used to do. I remember when nurses never touched the lines. I used to have to call the doc to come draw a gas! Even worse, when I started in nursing I remember setting up for an IV start and assisting the doc put it in. I didn't start my own until the mid/late 1960s. Maybe the day will come when staff nurses do intubate routinely as they are always adding new things for us to do and be responsible for. Now that I'm retired, there are some days that I really miss working in critical care. When I think about having to be responsible for intubating my 28 weeker when he pulls out his tube not realizing that it keeps him alive.....no thank you....any illuisions that I have of working one more day in the unit are completely shattered...give me my rocking chair...and maybe in a few months I'll start to rock!

Awesome perspective in this post! Thanks! Enjoy the rocking chair. Here's hoping my retirement allows me to use all the fly rods I'll have collected while working. Maybe teaching a future grandkid (both female and male) to fly fish

nicksavage · May 19, 2018

In Texas we cannot intubate. As a Paramedic / Nurse I can on a wagon while out in the field.

Some said why would you want to?, because the faster we get oxygen to them the better the chance. If your working trauma an you have a couple of ICU's and ER and only one Respiratory therapist on duty (if they even let them, some do not), as well as not having a qualified Doctor there to do it then you want to be ready. As well you have the small hospitals where you have one Doctor on staff at night and sometimes they are in an emergency.

There are many risks involved though some are Airway obstruction, laryngospasm, and aspiration as well as harming the vocal chords.

The person that said nurses do not do it enough. True but how often do some nurses use their ACLS, especially at the larger medical facilities with more than one code team. It's all about training and mock drills. Education usually though barely have enough time to train and do very few Mocks on anything. So that person is right in that most nurses wouldn't do it enough not to cause harm.

So why not have the necessary equipment to help out such as a light wand? Would it make it easier yes. I have seen Doctors though that have perforated going in with a light wand and other methods.

I am one that thinks we should not be able to intubate. As well I think unless Respiratory therapy does it enough they should not either, it is best left to an anesthesiologist.