RNs intubating

Geeg · Dec 8, 2003

When medicare decides not to reimburse Docs for intubating then the nurses, heck , even the unit clerks will be intubating.

XIGRIS · Dec 10, 2003

In Texas, the only RN i know that can intubate are advance practitioners: CRNA, ACNP.

Not until I get the CRNA initials after my name will I attempt to intubate.

Besides, there are some ways to maintain a patent airway while waiting for help.

I am an ACLS instructor and the airway part of the program is nothing compared to the "real" intubation.

stevierae · Feb 1, 2004

Originally posted by gotosleep
You do not need to intubate someone to ensure an adequate airway. This is a major misconception among medical professionals. A bag-valve mask with or without an oral airway generally will suffice. Intubating is a skill that requires intensive instruction and continuing education and practice. There is a lot of liability associated with this procedure and the failure rate is fairly high among the inexperienced. So don't do it unless you are credentialed.

Just my thoughts....

I agree. Although I recertify in ACLS every 2 years, I think if I was the only one that stood between a patent airway and death, and AFTER trying a nasal or oral airway, I would do a stab trach--this is a technique I leaned as a Navy hospital corpsman during the Vietnam era--all corpsmen learned it--I am certain they still do--and it has saved many a life. I would never attempt an endotracheal or nasotracheal intubation.

14 G Jelco (or other brand of IV catheter) is what you use for the stab trach. If you have an ET tube close by--don't remember the size; just experiment in a non-emergent situation so you will remember in an emergent one--take the adapter that gets connected to O2 tubing off the ET tube--hook the small end to the intracath--hook the big end to O2 tubing and turn on the O2--you've saved a life.

This is what I would do--I am not insinuating anybody here should do it if they are not comfortable, or if the facility where you work frowns on the practice. However, I would rather face discipline than explain"why" to the family of an unnnecessarily dead patient on my watch.

athomas91 · Feb 1, 2004

the only people who should be intubating in a hospital setting are md's and crna's.....i don't care what kind of airway training video's you have had - you are crossing a line and setting yourself up for a lawsuit...i agree w/ go2sleep...if you need an airway - use an oral airway and bag em...if you can't do that...they are going to likely be very difficult to intubate anyway....

i know medics are trained to intubate and i agree w/ that in the field...but not in the hospital...i am speaking of maryland now..in that if you are a medic and a nurse...you can be a medic outside of the hospital only and a nurse inside the hospital only..there is no crossing-over and you are not covered by liability for that.

as for the NICU nurses intubating...make sure you are covered by the hospital...ususally you are told ok...but if you check the books - you are not covered....but usually bagging is sufficient...

it is just my 2 cents...and i know i will peeve some people off...but i thought the way you did prior to beginning CRNA training...so let's just say I have learned enough now to know better....

EastCoast · Feb 1, 2004

HI,

I am in a little disagreement with the above in that I think it should be that only those 'trained' should be intubating. There are MD's who shoud never hold an ET tube and there are some advanced practice PA's/NP's who have repeated experience that far surpass a lot of docs. I have also seen people extubated post op on a friday afternoon prematurely only to be reintubated by non -anesthesia people hours later.

I will say again that 'airway management' needs to be your philosophy. That is making a thoughtful decision about medications and if you are in fact going to use any pharmacologic paralytics or not. I am in strong agreement that people too often run in like idiots wanting to stick a tube down someone's throat and the patient would be better served with strong BMV technique (another thing that many people can't do properly).

As a CRNA your enviroment will be many times more controlled than the airway management problems on the wards. On the wards you are seeing the airway for the first time, the patient may have a full gut , someone may be doing CPR...you get the picture. I had to learn intubation primarily in the OR because it was a controlled enviroment and then after my course work i did supervised intubations on the ICU. They were 2 different worlds.

NeuroNP · Sep 25, 2004

I had an anesthesiologist tell me once, "it doesn't matter what letters you have after your name, it's experience that counts." This is very true when it comes to intubation.

Obviously, there are legal issues involved, but I totally agree with the poster who said there are many MDs who should never intubate. When I was in school, I originally was pre-Med and got the fantasic opportunity to do a summer internship with Anesthesia. I took ACLS and got to intubate like crazy. I got 13 successful intubations and 1 successful fiberoptic endobronchial intubation (I think that's pretty crazy for an undergrad!). It's WAY different than on that dummy in ACLS. All of mine were in the OR under the supervision of an Anesthesiologist. And while I feel that I could do it if there was no one else around, I wouldn't be quick to grab that scope and dive in. I've found that there is almost NEVER going to be a situation in a hospital where someone with more experience isn't around.

I worked for a while as a Tech in a private hospital where there weren't always docs around (except in the ED and the Cardiologists usually were around if for no other reason than we had a busy heart service and there was usually one in the hospital answering a call 24/7!) and our RTs did all the inutbating in codes. Our House Administrator (the RN running the house, not a HOSPITAL Administrator!) was also allowed to intubate. But I was told in ACLS that they spent time in the OR (like CE time) practicing and you had to do at least 10 a year before the hospital would let you do it for real.

Unless I was a CRNA or ACNP with lots of experience, I wouldn't want to do it without having anesthesia standing by in case something went wrong. The only reason I say anesthesia is not because of those letters, it's because of that experience. I know MDAs who do 5-7 cases a day every day. That's tons of intubations!

My $0.02

bryan

Trauma Columnist · Sep 25, 2004

Very interesting thread - I agree that with this skill it is experience and training that count. One must never go beyond their scope of practice.

apaisRN, RN, CRNA · Sep 29, 2004

I wouldn't touch it with a ten-foot pole. The law is that you are held to the standard at which you practice. That means if you intubate you must be as good as a trained provider (MD, CRNA etc) and if you screw up you get no help at all from the fact that you are untrained and "you were just trying to help."

Honestly, I'd rather bag someone forever. If I was in the unlikely position of being the ONLY person around who knew anything about intubation, I'd still bag. You can do some serious damage trying to intubate, and I wouldn't risk it. If the patient dies because I don't try to intubate, well, I don't think my attempts to intubate would have changed anything.

hotrodrn · Oct 1, 2004

the only people who should be intubating in a hospital setting are md's and crna's.....i don't care what kind of airway training video's you have had - you are crossing a line and setting yourself up for a lawsuit...i agree w/ go2sleep...if you need an airway - use an oral airway and bag em...if you can't do that...they are going to likely be very difficult to intubate anyway....
i know medics are trained to intubate and i agree w/ that in the field...but not in the hospital...i am speaking of maryland now..in that if you are a medic and a nurse...you can be a medic outside of the hospital only and a nurse inside the hospital only..there is no crossing-over and you are not covered by liability for that.
as for the NICU nurses intubating...make sure you are covered by the hospital...ususally you are told ok...but if you check the books - you are not covered....but usually bagging is sufficient...
it is just my 2 cents...and i know i will peeve some people off...but i thought the way you did prior to beginning CRNA training...so let's just say I have learned enough now to know better....

You forgot about D.O.'s those are mainly the docs I work with at our hospital and frankly I would rather work with a DO instead of an MD just because they have a better bedside manner and they are generally more curtious to the nursing staff.

mattsmom81 · Oct 4, 2004

I know a few RN's who have intubated in a pinch but most of these were paramedics or RRT's along w RN's and they had a comfort level with it.

I've seen too many botched intubations with patients looking like Jabba the HUT w SC air(and family that never forget that vision of their loved one). I don't care to take on that liability myself.

I worked agency at a chain of LTAC's where a scary policy stated RN's must intubate...ACLS qualified them all. Yeesh... RRT's are much more qualified than I!!

ACLS emphasizes only the most experienced should attempt it if I remember correctly. I too will BVM forever if its working...and will ask about CPAP rather than attempt an intubation on my own.

BeenThereDoneThat74, MSN, RN · Oct 4, 2004

The only time an RN should be intubating is if:
1 - They are trained to do it (ACLS does not train you to intubate in any way, shape or form. It at best will make you a better assistant for the person doing the intubating. Same for PALS Speaking as an instructor for both)
2 - Your job allows/expects you to do it.
I am an RN but also a Paramedic and am allowed under my dual title to intubate in the hospital. If I ever lost my medic license (God forbid) I would no longer be able to intubate legally even though I would still have the competency and experience to do so.
Intubating is a fun and rewarding skill but a skill that takes practice and dedication to learning the little tips/tricks and nuances of not only when to intubate but also when not to (especially if needing to paralyze to do it).

How does being a Paramedic (a pre-hospital care provider) entitle you to use those skills in the hospital setting). While I'm cerntain you have the ability to perform the task, becuase of you Paramedic experience, are you covered legally inside the hospital?

BeenThereDoneThat74, MSN, RN · Oct 4, 2004

I agree. Although I recertify in ACLS every 2 years, I think if I was the only one that stood between a patent airway and death, and AFTER trying a nasal or oral airway, I would do a stab trach--this is a technique I leaned as a Navy hospital corpsman during the Vietnam era--all corpsmen learned it--I am certain they still do--and it has saved many a life. I would never attempt an endotracheal or nasotracheal intubation.
14 G Jelco (or other brand of IV catheter) is what you use for the stab trach. If you have an ET tube close by--don't remember the size; just experiment in a non-emergent situation so you will remember in an emergent one--take the adapter that gets connected to O2 tubing off the ET tube--hook the small end to the intracath--hook the big end to O2 tubing and turn on the O2--you've saved a life.
This is what I would do--I am not insinuating anybody here should do it if they are not comfortable, or if the facility where you work frowns on the practice. However, I would rather face discipline than explain"why" to the family of an unnnecessarily dead patient on my watch.

So, you would rather poke a hole in someones throat, risk hemmorage, infection etc, rather than intubate? Seems a tad extrem. I know of very few hospitals that will let RN's intubate and none that would tolerate an RN performing a skill that is clearly out of thier scope. I could understand performing a surgical trach in the case of a FBAO that could not be removed via a Magil but short of that if your not going to intubate the Pt. then....