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.
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!
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.
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.
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.
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! ?
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)...
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.
I have intubated many cats in a volunteer clinic . If a cat goes into laryngospasm during intubation, they just aren't deep enough. But, you're not even included in my argument because you are an EMT and get to use your skills more frequently than RN's on the floor who have other more experienced people available to call on. I thought this started as a nursing thread, not an EMT thread.
Specializes in orthopedic/trauma, Informatics, diabetes.
Def part of the "use it or lose it" skills. I used to intubate horses (no scope needed LOL).
On my unit, we don't even do IVs. I would suck if I had to do one. We usually don't have chest tubes or trachs. Not part of our skill set. Now I can set traction up like nobody's business or fit an ostomy pouch. Those are things that are common.
I want someone who does this day in and day out on the first attempt where the skill is commonly employed, more than once week. Get to be an expert on patients you care for everyday. Want more? go onto school, but do not expect the whole care Nurses programs to change because you learned this skill, once upon a time.
I want someone who does this day in and day out on the first attempt where the skill is commonly employed, more than once week. Get to be an expert on patients you care for everyday. Want more? go onto school, but do not expect the whole care Nurses programs to change because you learned this skill, once upon a time.
Indeed, repetition is the key to excellence. You also want someone who knows what to do once the patient is intubated. Additionally, you want someone who knows what to do when the proverbial ish hits the ceiling. One must be able to progress through the difficult airway algorithms sequentially, timely and safely. EMTs might know the skill of intubation, but they fall short on the patho/physiological and intervention aspects of managing the difficult away. A surgeon once quipped that he can teach a monkey where to cut in order to perform a cholecystectomy, and the monkey might become proficient in doing so but the difference between him and that monkey is that he knows what to do when something goes wrong, and that's precisely why he gets paid the big bucks.
LovingLife123
1,592 Posts
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!