Intubation Should Be A Nursing Skill, Especially Now

[ErikWeeWoo, BSN, RN, EMT-P]

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]

7 hours ago, ErikWeeWoo said:

It's definitely a perishable skill,

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

[ErikWeeWoo, BSN, RN, EMT-P]

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]

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.

 

[chare]

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]

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]

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]

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.

 

[Guest856929]

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

[subee, MSN, CRNA]

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]

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, BSN, RN, EMT-P]

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.