Intubation

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Why aren't nurses trained to intubate? I know other health care professionals are there to do it, but I am just curious why nurses were never trained.

Intubate? If I am required as a nurse to take on this (risky) procedure and add it to my other requirements, what tasks do I get to give up?

Nurses can do more and more things that doctors pass along once the tasks become considered routine. Where does it end? At least in intubation I have the rare chance to say "not my job".

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Telling people that "intubating a dude" is easy, is not informative. For people who do not know better, it is dangerous. Why does every well known airway pathway go to a failed airway after three attepts without success? Why are companies making money on supraglottic rescue airways? Why do most experts recommend people who perform advanced airwa management have access to back up devices? Why are people spending hundreds of dollars to take airway management courses such as SLAM?

I also disagree that a monkey will get the tube given enough attempts. Typically, your success rate falls with each attempt. This is part of why most people say move on to rescue after three attempts.

In addition, the liability is high and the complications many. I really do not care about a character from a book and how that persona interacts on a forum. I can watch SCRUBS if I want that kind of humor. What I do care about is when people take lightly one of the few times where you have a good shot at getting the "clean kill'" if things do not work out.

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In the "old" days of ACLS, nurses were taught to intubate and were graded on their skill on intubating during the class. Taking to long to intubate, cracking the mannequin's teeth, intubating the esophagus, etc. was grounds for failing ACLS.

The hospitals I worked in during that time period would allow nurses to intubate if an RT was not around. The rationale for nurses not intubating is/was because they do not do it often enough to keep up their skill in it. Improper/complications from intubation is a big liability issue for facilities.

These days, with ACLS being much of a joke and everyone being passed regardless of how they perform on skills, it would not be safe for a nurse to be intubating even if the hospitals allowed it.

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Specializes in HEMS 6 years.

Originally Posted by CHATSDALE

in a hospital where i work the resp therapist would call in nurses to perform intubations on deceased patients before the funeral home came to pick up the body

Is that ethical?

No , that is not ethical.

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Specializes in HEMS 6 years.

"If you're going to pick up a Laryngoscope, you better be prepared to pick up a scalpel."

(within the context of emergent airway, i.e. surgical cricothyrotomy)

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Specializes in CRNA.
Telling people that "intubating a dude" is easy, is not informative. For people who do not know better, it is dangerous. Why does every well known airway pathway go to a failed airway after three attepts without success? Why are companies making money on supraglottic rescue airways? Why do most experts recommend people who perform advanced airwa management have access to back up devices? Why are people spending hundreds of dollars to take airway management courses such as SLAM?

I also disagree that a monkey will get the tube given enough attempts. Typically, your success rate falls with each attempt. This is part of why most people say move on to rescue after three attempts.

In addition, the liability is high and the complications many. I really do not care about a character from a book and how that persona interacts on a forum. I can watch SCRUBS if I want that kind of humor. What I do care about is when people take lightly one of the few times where you have a good shot at getting the "clean kill'" if things do not work out.

Listen dude, right now I have just over 500 intubations. Some with cool toys such as the glide scope, fiberoptic, fasttrack...most with just straight up DL. I realize that these numbers pale in comparison to dudes/duddettes who have been practicing at it for longer than me. What is important however, is that this is a skill mastered with repetition, doing it over and over again day after day. Yes, I really think a monkey (probably a chimp) could do this if they had the same opportunity. Didn't we send one of them into space during the Mercury Program? Rescue devices are important, but the most basic task essential to master is mask ventilation and I really think it is more difficult in most situations than laryngoscopy. A lot of times after being called to the floor for intubations gone bad when the airway has been bloodied by other providers; the 400lb edentulous dude with the ZZ top beard is being "masked" by someone ineffectively. Once we take over and throw in an oral airway mask ventilation suddenly improves.

I think nurses who learn how to properly BVM when the guy first starts to decompensate are providing a service that is much more important in prolonging the lives of their patients than that of the person called to the floor to put the snorkel in. Unfortunately this too, is a skill mastered through repetition, and if you are not doing it on a regular basis, it is difficult to master.

Finally, what is so bad about using a corpse to further your knowledge base. For example, doing crics on pig tracheas and sim men is useful, but getting a chance to do it on a real person is much more beneficial. Granted the blood will not be there, but at least you get the experience with real anatomy. A lot of people where I am at go to the morgue routinely to practice this once being cleared through the pathology attending.

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Specializes in Acute care, Community Med, SANE, ASC.

I was trained to intubate as an EMT-basic and an EMT-paramedic. So, unless things have changed, which I don't believe they have, an EMT-basic can technically intubate in the state of Ohio. Of course, paramedics can intubate as well. I would like the opportunity as an RN to be allowed to intubate and would not mind getting a special certification or something that would allow me to do so. I find the scope of practice between RNs and medics quite different and I think nurses would be surprised what paramedics are able to do and successfully do in very uncontrolled environments. In the area I live there is one local fire department where the medics are allowed to perform pericardiocentesis for cardiac tamponade, which blows my mind--not in a bad way--good for them--don't think I would have the guts to do it.

Another comment I have is that as a fairly new nurse in neuro ICU I'm seeing a lot more intubations and it kind of surprises me what a big deal it can be. It's not that I don't think intubating is a big deal it just surprises me how many people are in the room with the glidescope, the drapes, the special intubation drug box, the intubation cart, the respiratory therapist, etc. when I know medics are performing the same procedure in much less controlled environments with a whole lot less equipment and support personnel, etc. Just an interesting difference I have observed.

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I have woundered that for years, an EMT can do it , with special cirtification an RN should be able to as well. Who better to do it than an experienced ICU, ER RN. Go figure.

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Specializes in Acute care, Community Med, SANE, ASC.

In my EMT basic class--I think it was a couple of hours a night, 2 nights a week for 5-6 months--we were trained to intubate but cannot start IVs.

Medics can do all manner of things. They give paralytics, versed, cardiac meds and drips--all without orders from a physician. I can do all those things with my medic license but I can't give Tylenol at the hospital without an order. Just different.

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Actually, you do have physician orders in the form of protocols/guidelines. Your physician medical director dictates your companies guidelines.

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You'd understand RedCell if you had read House of God. It seems his persona is an extension of the Fat Man's, and I'm personally loving it. Very informative.

I tried, I lasted abut 30 min. before I fell asleep. You want informative? Read Egan's fundamentals of respiratory care. Far more informative than some self-proclaimed cowboy SRNA. He does however make some good points; procedure practice on cadavers is quite ethical and done routinely in most hospitals, especially post mortem intubation.

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Specializes in HEMS 6 years.
In my EMT basic class--I think it was a couple of hours a night, 2 nights a week for 5-6 months--we were trained to intubate but cannot start IVs.

Medics can do all manner of things. They give paralytics, versed, cardiac meds and drips--all without orders from a physician. I can do all those things with my medic license but I can't give Tylenol at the hospital without an order. Just different.

So how many live intubations in a controlled setting (ie: OR) were you required to complete before credentialed to intubate in the field ?

This is getting off topic from the OP question. However there is considerable evidence mounting to stop prehospital endotracheal intubation. Instead the argument is for the existing back up devices LMA, Combi-tube etc to be the first line intervention for airway management. One study of pediatric TBI showed no benefit in longterm outcome comparing prehospital ETI and BVM during transport.

Here are a few references:

Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000;283:783-90.[Abstract/Free Full Text]

Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med 2001;37:32-7.[iSI][Medline]

Timmermann A, Russo SG, Eich C, et al. Out-of-hospital esophageal and endobronchial intubations performed by emergency medical service physicians. Anesth Analg 2007;104:619-23.[Abstract/Free Full Text]

von Goedecke A, Keller C, Voelckel WG, et al. [Mask ventilation as an exit strategy of endotracheal intubation.] Anaesthesist 2006;55:70-9.[iSI][Medline]

Scott DB. Endotracheal intubation: friend or foe. BMJ (Clin Res Ed) 1986;292:157-8.[iSI][Medline]

Schmid MC, Deisenberg M, Strauss H, et al. [Equipment of a land-based emergency medical service in Bavaria: A questionnaire.] Anaesthesist 2006;55:1051-7.[iSI][Medline]

Gabrielli A, Wenzel V, Layon AJ, et al. Lower esophageal sphincter pressure measurement during cardiac arrest in humans: potential implications for ventilation of the unprotected airway. Anesthesiology 2005;103:897-9.[iSI][Medline]

Konrad C, Schupfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998; 86:635-9.[Abstract]

Gries A, Zink W, Bernhard M, et al. [Realistic assessment of the physican-staffed emergency services in Germany.] Anaesthesist 2006;55:1080-6.[iSI][Medline]

Helm M, Hossfeld B, Schafer S, et al. Factors influencing emergency intubation in the pre-hospital setting-a multicentre study in the German Helicopter Emergency Medical Service. Br J Anaesth 2006;96:67-71.[Abstract/Free Full Text]

Keller C, Brimacombe J, Kleinsasser A, Brimacombe L. The Laryngeal Mask Airway ProSealTM as a temporary ventilatory device in grossly and morbidly obese patients before laryngoscope-guided tracheal intubation. Anesth Analg 2002;94:737-40.[Abstract/Free Full Text]

Kurola JO, Turunen MJ, Laakso JP, et al. A comparison of the laryngeal tube and bag-valve mask ventilation by emergency medical technicians: a feasibility study in anesthetized patients. Anesth Analg 2005;101:1477-81.[Abstract/Free Full Text]

Kette F, Reffo I, Giordani G, et al. The use of laryngeal tube by nurses in out-of-hospital emergencies: preliminary experience. Resuscitation 2005;66:21-5.[iSI][Medline]

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