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Intubation Should Be A Nursing Skill, Especially Now

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Specializes in ED/EMS. Has 9 years experience.

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When I was in high school, I worked at an animal sanctuary/wildlife park. They wanted me to be a vet tech, so I was going to a vet tech program at the community college during my senior year in high school. That program wasn't even 2 years, so I was working as an active vet tech at the aforementioned wildlife park before I was even 19 – and I had some degree of exposure to the vet field as early as 14 years old, from being in the volunteer program at that park. 

While I was working there after my vet tech licensure, I got the opportunity to do all sorts of intubations (yes intubation is within a vet techs scope). I got to tube all sorts of animals ranging from large mammals to small reptiles & birds. It's definitely a perishable skill, but it isn't super difficult. I had double digits successful intubations before I got to medic school. Aside from that fact, paramedics can intubate (and I completed medic school & my first 2 years of nursing school together while working part time). 

I don't understand why intubation isn't a nursing skill. Nursing school is 4 years, there's plenty of unnecessary nursing theory fluff that could be replaced by clinical skills like intubation. If nurses can manage a ventilator (which is 100x harder than intubation), or titrate critical care meds, we should 100% having intubation included in our education and scope of practice. Especially when COVID-19 is running rampant, hospitalists should be doing much more ventilator management and nurses should be doing way more intubation. 

Just a rant post. 

GrumpyRN, NP

Specializes in Emergency Department. Has 39 years experience.

7 hours ago, ErikWeeWoo said:

It's definitely a perishable skill,

You said it yourself, how often do nurses need to intubate? 

ErikWeeWoo, RN, EMT-P

Specializes in ED/EMS. Has 9 years experience.

1 minute ago, GrumpyRN said:

You said it yourself, how often do nurses need to intubate? 

Given how medicine works right now, never because it's usually considered an MD skill - however, once upon a time in history even IVs were considered an MD only skill. If it was a nursing skill though (both in the eyes of legal scope of practice & culturally), I'd be fairly regularly in some areas. Specifically ED or ICU - we have intubations in the ED on a regular basis around here. I could also see it being quite useful in surgery environments, or for rapid responses. 

GrumpyRN, NP

Specializes in Emergency Department. Has 39 years experience.

39 minutes ago, ErikWeeWoo said:

however, once upon a time in history even IVs were considered an MD only skill.

Once BP measurement was a medical skill, times change.

39 minutes ago, ErikWeeWoo said:

Specifically ED or ICU - we have intubations in the ED on a regular basis around here.

I spent 25 years in an ED. I am TNCC, ATLS and ALS qualified, I have never intubated a patient. I have lost count of the number of intubations I have assisted at but I have never done it myself.

Again, why teach a skill that for the vast majority of nurses will never be used. ED and ICU are very different from the rest of the hospital.

Don't know about US but in UK if a nurse was to intubate a patient in an emergency and no one else was available then there would be no comeback.

I have found that the biggest problem with in-hospital cardiac arrest calls is to stop people arriving, as you invariably end up with far too many people.

 

First, endotracheal intubation has been within the registered nurse scope of practice in all five states (NC, OH, PA, VA, and WV) in which I have been licensed.  

8 hours ago, ErikWeeWoo said:

[...]

I don't understand why intubation isn't a nursing skill. Nursing school is 4 years, there's plenty of unnecessary nursing theory fluff that could be replaced by clinical skills like intubation. ...

I agree that the curriculum could be tweaked.  However, rather than adding advanced skills most nurses will never use, this time could be used to teach basic nursing skills (IV starts, NG and Foley catheter placement, etc.) that a growing number of nee nurses seem to be lacking.

12 minutes ago, GrumpyRN said:

Again, why teach a skill that for the vast majority of nurses will never be used. ED and ICU are very different from the rest of the hospital

Completely agree with this.  Aside from my time doing transport, I've never seen a time that a physician wasn't readily available to intubate.  And in 3.5 years with a high volume, high acuity transport service I've only had to intubate one patient. 

TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience.

OP, I agree with you, this could be a valuable skill for RN's to learn in certain settings. Having worked in rural hospitals where there can be a delay in intubation due to the only physician in house being an ER doc who may or may not WANT to come to the floor/unit to intubate, it would be helpful for a nurse to be able to do so. I have been in situations where the Respiratory Therapist had to intubate due to lack of physician presence. And while they are the experts when it comes to the lungs, I think nurses could swing it as well. I worked at one rural hospital that trained nurses to establish IO access on the floor in case of emergencies and that came in handy a couple of times while I was there. 

ruby_jane, BSN, RN

Specializes in ICU/community health/school nursing. Has 10 years experience.

On 1/10/2021 at 10:35 AM, chare said:

I agree that the curriculum could be tweaked.  However, rather than adding advanced skills most nurses will never use, this time could be used to teach basic nursing skills (IV starts, NG and Foley catheter placement, etc.) that a growing number of nee nurses seem to be lacking.

We had all that. On manikins, on computer, or if we were lucky enough and our preceptors in clinicals let us, in a patient. I think you might mean that we need actual time doing these skills with patients, not in a skills lab.

Nurse Trini

Specializes in LPN School Nurse. Has 4 years experience.

I spent two days running round doing IV starts and drawing blood.    Foleys, not so much.   I got to do one on a real patient just because I happened to be there when someone needed one placed.    I didn't expect to end up needing that skill, but got surprised when I started at the job at the school.

 

cynical-RN, BSN

Specializes in ICU. Has 11 years experience.

Nurses intubate patients more than any other profession in the country. Learn about CRNAs. 

Edited by cynical-RN

subee, MSN, CRNA

Specializes in CRNA, Finally retired. Has 49 years experience.

On 1/10/2021 at 2:06 AM, ErikWeeWoo said:

When I was in high school, I worked at an animal sanctuary/wildlife park. They wanted me to be a vet tech, so I was going to a vet tech program at the community college during my senior year in high school. That program wasn't even 2 years, so I was working as an active vet tech at the aforementioned wildlife park before I was even 19 – and I had some degree of exposure to the vet field as early as 14 years old, from being in the volunteer program at that park. 

While I was working there after my vet tech licensure, I got the opportunity to do all sorts of intubations (yes intubation is within a vet techs scope). I got to tube all sorts of animals ranging from large mammals to small reptiles & birds. It's definitely a perishable skill, but it isn't super difficult. I had double digits successful intubations before I got to medic school. Aside from that fact, paramedics can intubate (and I completed medic school & my first 2 years of nursing school together while working part time). 

I don't understand why intubation isn't a nursing skill. Nursing school is 4 years, there's plenty of unnecessary nursing theory fluff that could be replaced by clinical skills like intubation. If nurses can manage a ventilator (which is 100x harder than intubation), or titrate critical care meds, we should 100% having intubation included in our education and scope of practice. Especially when COVID-19 is running rampant, hospitalists should be doing much more ventilator management and nurses should be doing way more intubation. 

Just a rant post. 

Intubating dogs and cats is a breeze compared to humans because of anatomical differences.  One can't become a successful intubator unless you do it often (almost daily) because most young people are easy but there is a HUGE number of difficult intubations that require someone skilled and who can get the tube in the first time - especially in a Covid situation.  Let the people who do it well do their job and you do yours.

I would be incompetent in an ICU (haven't worked in one since the early 80's) but I can intubate a pumpkin head with caps on the front teeth with ease.  And we had to do 500 intubations as a student in the 15 month clinical portion and some of those patients were awake, squirming, or very obese and 9 months pregnant.  And you have to know who can be sedated and who can't.  It's not just sticking a tube in a hole.

londonflo

Specializes in oncology. Has 44 years experience.

On 1/10/2021 at 1:06 AM, ErikWeeWoo said:

I had double digits successful intubations before I got to medic school.

I think I want someone with triple digit success! Just kidding! My last two intubations did not go smoothly although I did not know until I woke up. 😧, a temporary filling (put in the day before) and a broken tooth after the second had disappeared. I went from inpatient to dentist on the way home because of a cut tongue. 

I remember a family member/Paramedic with the same argument as you in the 80s. He really was great at focusing on his skills but I don't think he really understood what floor nursing was all about.

ErikWeeWoo, RN, EMT-P

Specializes in ED/EMS. Has 9 years experience.

1 hour ago, subee said:

Intubating dogs and cats is a breeze compared to humans because of anatomical differences.  One can't become a successful intubator unless you do it often (almost daily) because most young people are easy but there is a HUGE number of difficult intubations that require someone skilled and who can get the tube in the first time - especially in a Covid situation.  Let the people who do it well do their job and you do yours.

I would be incompetent in an ICU (haven't worked in one since the early 80's) but I can intubate a pumpkin head with caps on the front teeth with ease.  And we had to do 500 intubations as a student in the 15 month clinical portion and some of those patients were awake, squirming, or very obese and 9 months pregnant.  And you have to know who can be sedated and who can't.  It's not just sticking a tube in a hole.

I don't have that many intubations, but I have more than most of my EMS coworkers and I'm pretty comfortable with it, I'm not doing it daily either. I'd agree with you that normal canid anatomy is generally conducive to a relatively easy intubation as far as the "mechanical" part of the intubation, however there's a very high incidence of preexisting cardiac disease in many breeds which can make maintenance of anesthesia pretty interesting as well as a pretty high occurrence of upper airway obstructions and deviations from normal anatomy. 

Cats are a whole different ballgame though entirely - feline airways are extremely fragile in general, harder to visualize, very high incidence of laryngeal spasm in cats, very high incidence of regurgitation, anesthesia tolerance is lower, moderately high incidence of sudden hypotension (60% if I remember correctly). Hypothermia is also frequent, and temperature management is harder in cats than dogs. 

Ruminants, small exotics, reptiles, and birds are almost universally pretty difficult to intubate but maintenance of anesthesia is a breeze, aside from horses which the entire thing is pretty scary. Crocodilians are actually very simple minus their tracheal rings, but it's pretty objectively terrifying that your forearm through a PVC pipe is the laryngoscope. 

Our NPs in critical care intubate all the time.  As do our RTs.  As the bedside nurse, I push meds and monitor vitals.  I don’t know that I could throw intubation on top of that.  
 

I’ve assisted in probably well over a hundred.  I could technically probably do it myself, I much prefer doing the other things.  It’s my patient so I need the control over those vital signs!

TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience.

3 hours ago, ErikWeeWoo said:

I don't have that many intubations, but I have more than most of my EMS coworkers and I'm pretty comfortable with it, I'm not doing it daily either. I'd agree with you that normal canid anatomy is generally conducive to a relatively easy intubation as far as the "mechanical" part of the intubation, however there's a very high incidence of preexisting cardiac disease in many breeds which can make maintenance of anesthesia pretty interesting as well as a pretty high occurrence of upper airway obstructions and deviations from normal anatomy. 

Cats are a whole different ballgame though entirely - feline airways are extremely fragile in general, harder to visualize, very high incidence of laryngeal spasm in cats, very high incidence of regurgitation, anesthesia tolerance is lower, moderately high incidence of sudden hypotension (60% if I remember correctly). Hypothermia is also frequent, and temperature management is harder in cats than dogs. 

Ruminants, small exotics, reptiles, and birds are almost universally pretty difficult to intubate but maintenance of anesthesia is a breeze, aside from horses which the entire thing is pretty scary. Crocodilians are actually very simple minus their tracheal rings, but it's pretty objectively terrifying that your forearm through a PVC pipe is the laryngoscope. 

Interesting and informative post. I can't imagine intubating a bird, yikes.

ErikWeeWoo, RN, EMT-P

Specializes in ED/EMS. Has 9 years experience.

51 minutes ago, TheMoonisMyLantern said:

Interesting and informative post. I can't imagine intubating a bird, yikes.

I'm going to geek out a bit if that's okay, hopefully others find this interesting. Basically everything about the avian respiratory system is really cool and unique. The avian respiratory cycle actually consists of 2 inhalations and 2 exhalations. 

On the first inspiration, fresh air is pulled through the trachea down to air sacs around their bum. On that first exhalation, the fresh air is moved into the lungs where the air exchange happens. On the second inspiration the now "stale" air is pulled into air sacs around their head/neck/chest,  then on the second exhalation the stale air actually leaves the body. They have no diaphragm, it's the muscles around those air sacs that control inspiration or exhalation. As you might imagine, they get a lot more oxygen in air exchange from one respiratory cycle. 

Intubation can be a pretty difficult, but it's mostly because more things have to happen in a smaller space - pull the tongue out, pressure like a lever on the beak (it's like head-tilt chin-lift with cricoid pressure in one movement), and pass an uncuffed ET tube through the syrinx (birds don't have a larynx). Downside is that pneumonia can get bad, because it can spread from the air sacs into the bone very easily. 

Initial induction isn't that hard. Gas anesthesia is preferred in birds, usually isoflaurane in my experience. They don't really do IVs as much in birds, usually it's IOs. Ketamine, midazolam, and propofol are the common anesthetics. Opioid analgesia. 

Edited by ErikWeeWoo
Phrasing

TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience.

16 minutes ago, ErikWeeWoo said:

I'm going to geek out a bit if that's okay, hopefully others find this interesting. Basically everything about the avian respiratory system is really cool and unique. The avian respiratory cycle actually consists of 2 inhalations and 2 exhalations. 

On the first inspiration, fresh air is pulled through the trachea down to air sacs around their bum. On that first exhalation, the fresh air is moved into the lungs where the air exchange happens. On the second inspiration the now "stale" air is pulled into air sacs around their head/neck/chest,  then on the second exhalation the stale air actually leaves the body. They have no diaphragm, it's the muscles around those air sacs that control inspiration or exhalation. As you might imagine, they get a lot more oxygen in air exchange from one respiratory cycle. 

Intubation can be a pretty difficult, but it's mostly because more things have to happen in a smaller space - pull the tongue out, pressure like a lever on the beak (it's like head-tilt chin-lift with cricoid pressure in one movement), and pass an uncuffed ET tube through the syrinx (birds don't have a larynx). Downside is that pneumonia can get bad, because it can spread from the air sacs into the bone very easily. 

Initial induction isn't that hard. Gas anesthesia is preferred in birds, usually isoflaurane in my experience. They don't really do IVs as much in birds, usually it's IOs. Ketamine, midazolam, and propofol are the common anesthetics. Opioid analgesia. 

Very cool! Thanks for sharing!

0.9%NormalSarah, ADN, RN

Specializes in ICU. Has 2 years experience.

5 hours ago, LovingLife123 said:

Our NPs in critical care intubate all the time.  As do our RTs.  As the bedside nurse, I push meds and monitor vitals.  I don’t know that I could throw intubation on top of that.  
 

I’ve assisted in probably well over a hundred.  I could technically probably do it myself, I much prefer doing the other things.  It’s my patient so I need the control over those vital signs!

Yeah seriously, I’m busy pushing pain meds and paralyzing, and always on guard for immediate hypotension, and of course the occasional cardiac arrest. I don’t want to be doing anything other than managing my patient’s systemic response to the procedure. I’ll let the physician and RT manage that airway. Besides, once they’re done they get to leave and I have about 30 minutes to get my sedation in order, drop an OG or NG, get a foley placed, restrain the patient, all while maintaining those vitals. I guess I wouldn’t mind intubating if another nurse agreed to do all that other crap for me! 😜

akulahawkRN, ADN, RN, EMT-P

Specializes in Emergency Department. Has 6 years experience.

It's not that endotracheal intubation is or isn't a "nurse" skill, it's that most nurses don't have a need to perform this particular skill so it's not something that is taught generally to nurses. Paramedics do learn this skill as does the CRNA because it's part and parcel of what they do and what they're expected to do. It has been years since I've done ETI myself but I do very clearly remember how to do it. Would I be anywhere near as competent as I was when I did my last one? Heck no!! I was initially trained to do it back when VL was just getting started in the field (it was used in the OR for years before that) and was also getting going in the ED as well, so I do have quite a few "other" techniques (and backup/rescue techniques) in my own toolbag. 

What's keeping me from stepping in and doing it where I now work? I'm not accredited to do it and the people that do the accrediting only accredit medical providers (and possibly NICU RN staff). This means that the RN and RT staff are unable to do it. In a way, that's "nice" because I'd probably get a couple tubes per year at most and I'd need way more than that to maintain some semblance of decent competency, same with most of our RT's. Since we aren't doing that stuff, we can focus on other stuff. Personally I wouldn't mind being at least backup airway accredited so that I could drop an LMA or something like that if necessary... but then again, that's all part of what I already know. OPA, NPA, EOA/EGTA, LMA, Combitube, ETT (both OTI and NTI)...