The intubating PA

[TheDude]

Hello everyone,

 

Wanted to hear from some of the veteran PA's out there as well some of the ones that follow these posts. 

 

How many of you were formally trained in PA school on airway management, other than using a mannequin?  Reason I ask, is that as a PA student, I have not seen anywhere on any syllabus anything that pertains to "airway management" or a formal airway training rotation, other than ED rotations.  I ask this because as I see it, if I am working rurally, I will be up poo-creek if I have had no formal training.  The fortunate thing is that I am a flight paramedic and have had a lot of formal and informal training in airway management and RSI, whereas some of my other classmates and others in different programs have had little to no airway training.  I would like to help implement an airway course at the program I attend, and would like some ideas and/or criticism of what and how I should approach our program director. 

 

Thanks all in advance.

[EMEDPA]

The only PAs I know who intubate are former medics and RTs. we had an em procedures course at drexel and spent maybe 15 min on airway management. I intubate at all 3 of my jobs. anyone without prior experience who wants to learn airway management should take the difficult airway course or something similar and do several days of intensive airway management followed by some time in the o.r.

[jsfelder0417]

I did some intubating as an Army Medic before PA school. During PA school, we had some training in intubation on mannequins, and we had to intubate a mannequin to pass our EM module. Now I am in rotations, and I did an intubation today. I am doing a rotation in Ortho, and I arrived early and asked the Anesthesiologist if I could watch him do it. He talked me through it while I watched during the first two cases, and today he guided me through one. YMMV.

[UGoLong]

As a PA student and a paramedic, I showed some of my classmates how to do it. Intubation is not a core skill taught in most programs, as far as I know. 

[TheDude]

As a flight paramedic, I spent every 6 months in the adult and pediatric OR's doing not just intubations, but also inductions, and the occasional central line with the watchful eye of the attending or CRNA (was a rarety.)  We learned in-depth induction technique along with pharmacology and emergent airway management including crich's, retrograde, video assist etc..  This was just as a flight paramedic, I just wish that airway management was taught other than a basic course prior to ED rotations. 

 

I am wishfully thinking about approaching  an anesthesia attending along with my program director about trying to have a special airway course done, along with clinical training and not just a 2 day stint in the OR.   

 

Whats your take EMEDPA?

[Medic207]

To master the skill you need more than a demo in class. Since the majority of PAs would not be expected to do this skill as part of their job then I'm not sure how much training on this is warranted at the initial school level other than some practice time on a model, and what is shown during ACLS.

 

Then beyond initial training you have the ongoing skill competency aspect to deal with.

 

Any PA that is working solo coverage in a facility where they are expected to do this has it incumbent upon them to learn airway management. Additionally any employer who places a PA in this environment is responsible for that lack of knowledge.

 

You bring up an interesting point; however. Most EM classes in PA school are not "all that." Reason is is that you cannot make Paramedics out of entry level PA students in 1 semester out of many during the program. You cant teach critical care medicine to students who haven't mastered basic medicine concepts. Even entry level paramedics in the field take time to get really good with their focused and guided training.

 

It's easier when and if you have a class full of paramedics in PA school, but it's a whole different story when you have a class full of 22 yr old bio majors who "shadowed" a pa once. Not bashing...just sayin.

 

 

[medic25]

I'll echo what the other have said.  Unless they came from an EMS background, most new grad PA's don't have much exposure to airway management in general.  

 

I teach the introductory lecture to EM/trauma at our university's PA program, and it includes a 5 minute blurb on airway management (including an intubation recorded from one of our ED's Glidescopes).  We cover intubation with the mannequin, and I also make sure that when the PA students rotate through the ED they go through all of the devices in the difficult airway cart.  Outside of ACLS, I'm not sure how much other exposure to intubation the PA students get.

[Medic207]

Medic25, can you message me, I tried sending you a message but it says you can't get any.

[LT_Oneal_PAC]

I'm former anesthesia. Lost count of intubations after 1000. On the ground, in the dark, even lateral on the table once. I tried to put an extracurricular get together where I taught induction techniques, alternative airways, pharm, equipment including VL, physiology, and potential pitfalls. No one cared. I think 7 out of 70 came.

 

To have a really good and in depth experience, you need a week of class. You could do a decent job with 2-3 FULL days. One full day of practicing, then 2 days OR getting as many intubations as allowed. After that, I wouldn't have any qualms about letting a student try on most anyone. Barring loose teeth and the 250+ lbs patients, unless I had seem them previously and was impressed. Obviously no one is going to take the time to do that.

[TheDude]

To master the skill you need more than a demo in class. Since the majority of PAs would not be expected to do this skill as part of their job then I'm not sure how much training on this is warranted at the initial school level other than some practice time on a model, and what is shown during ACLS.

 

Then beyond initial training you have the ongoing skill competency aspect to deal with.

 

Any PA that is working solo coverage in a facility where they are expected to do this has it incumbent upon them to learn airway management. Additionally any employer who places a PA in this environment is responsible for that lack of knowledge.

 

You bring up an interesting point; however. Most EM classes in PA school are not "all that." Reason is is that you cannot make Paramedics out of entry level PA students in 1 semester out of many during the program. You cant teach critical care medicine to students who haven't mastered basic medicine concepts. Even entry level paramedics in the field take time to get really good with their focused and guided training.

 

It's easier when and if you have a class full of paramedics in PA school, but it's a whole different story when you have a class full of 22 yr old bio majors who "shadowed" a pa once. Not bashing...just sayin.

Medic 207-

 

You did hit the nail on the head, especially when a PA is working a solo practice, say rural or small town.  I want to try to start a rotation with anesthesia, not to become a rockstar gas-passer, but to at least be able to become comfortable with airways.  I can remember as a flight medic getting called to rural ED's for interfacility transports and getting there and the pt. was hald dead because the PA or NP did not want to intubate because they were uncomfortable.  I am wanting to turn that "uncomfortable-not confident" into a comfortable-confident airway manager.  Sounds dorky, but I dream big.  Former paramedic or not, I feel with a good training regimen that anyone can become a confident intubator (not sure that is a word, but you get the point.)

[aquafresh11]

I think there is a lack of airway training in PA school for a good reason. Most people simply don't need it. Yeah if you end up working in solo rural ED, you should have some decent airway skills. But how many from school actually do that? Even if you get a weekend or week long course put together, does that really prepare someone for rural ED? It seems to me it would just be playing paramedic.The majority of ER jobs for new grads are in fast track, there just isn't a huge need for advanced airway skills. If your job does require that, they should provide the training, of which there are plenty of good courses available. Learning time in school is limited and if there was a wish list available, advanced airway is not in my top 10. 

[TheDude]

Aqua-

 

I can see your point to some extent, and I do agree that a weeks worth of class and OR time is not sufficient enough.  But I see that it is something that would not only boost the skills set as PA, but make a more confident PA.  Geographical location can delegate if you are working solo, or along with someone, and there is a multitude of different scenarios that could occur where the PA would be the one dropping the tube.  I do not see it as playing paramedic, but being better prepared.  I am sure there are many things that should be taught that are not taught, I just see airway as an important one that can be the difference between life and death.

[medic25]

Medic25, can you message me, I tried sending you a message but it says you can't get any.

Didn't realize my mailbox was full; I just cleaned out a bunch of messages, so give it another shot.

[greenmood]

I was trained on a mannequin in school and then pursued it hardcore on my surgery rotation. I sweet talked the anesthesiologists into letting me intubate elective surgery patients.

 

Then when my ED rota came around I wasn't (as) freaked out by an emergency.

 

 

Sent from my iPad using Tapatalk

[Febrifuge]

Greenmood, that's an example of the kind of initiative and dedication a really good student shows. Nice work. (And hey, I graduated from RFUMS in 2009, so hi there.)

 

I intubated one mannequin - no, two - during school, and I got to intubate the sheep when my ER rotation happened to be somewhere they were doing the sheep lab while I was there. In Urgent Care, thankfully it doesn't really come up. We do have a crash cart, and I'd certainly get something going while the medics were on route, if needed.

[EMEDPA]

As a flight paramedic, I spent every 6 months in the adult and pediatric OR's doing not just intubations, but also inductions, and the occasional central line with the watchful eye of the attending or CRNA (was a rarety.)  We learned in-depth induction technique along with pharmacology and emergent airway management including crich's, retrograde, video assist etc..  This was just as a flight paramedic, I just wish that airway management was taught other than a basic course prior to ED rotations. 

 

I am wishfully thinking about approaching  an anesthesia attending along with my program director about trying to have a special airway course done, along with clinical training and not just a 2 day stint in the OR.   

 

Whats your take EMEDPA?

they won't likely go for it. the goal of most pa programs is to train folks for primary care.

[EMEDPA]

at the very least PA students should know basic airway management well. how to insert oral and nasal airways and use a bvm and king LT airway. if you can bag someone well with a basic airway in place you can wait indefinitely for someone else who can intubate. if you can't bag and can't intubate or pass a supraglottic airway that's crich time....

[GetMeOuttaThisMess]

^^^^^^. Use an OPA and BVM, or look into a combitube/King airway.

[treejay]

For the average PA student, my opinion on  the best way to gain experience intubating is

 

1) at any opportunity in the OR, ask the anesthesiologist to do it.  Of course answers will vary but some are open to it.  And others will be open to it if you've built up a little rapport with them on previous surgical cases.

 

2) do an anesthesiology elective rotation

[EMEDPA]

^^^^^^. Use an OPA and BVM, or look into a combitube/King airway.

I like the king>>>>the combitube. in fact I went so far as to buy a king lt-d just to have one to use when I work at places that don't stock them. size 4 fits most adults 5-6 ft tall.

[GetMeOuttaThisMess]

I COULD see a program incorporating a lecture on airway options and central line placements, but as with everything else, "use it or lose it". When on surgery rotation for example pull the students during a lunch hour and review material.

[EMEDPA]

if i designed a program it would include acls, atls, pals, also, fccs, and difficult airway courses as required 2 day weekend must pass activities in addition to an emergency medicine didactic and skills course that brought everyone to the level of an emt-basic and allowed them to take that exam(don't laugh, some DO schools do this during MS2).

(we would also only accept folks with significant prior hce and a gpa > 3.2). the program would have a focus in underserved, rural, international/global/disaster medicine. it would be advertised as having an "acute care focus" while meetingb the objectives if any pa program.

I expect we could fill a class of 25 every yr with medics, military folks, nurses, and RTs. no candy stripper, scribes, cosmetic derm assistants need apply....:)

[TheDude]

EMEDPA

 

I whole heartedly agree with you.  I fly to many rural places to only find some patients knocking on deaths door with issues that could be solved very easily, ie simple pneumo with a dart, or instead of 50 IV pokes, place an IO or CL.  I spoke to a couple of other classmates that are EMS and we all agree and want to spearhead this.  I am sure we will catch some flack and resistance, as even on some of my posting and points I have made on here, some people see this as a non-important issue.

[GetMeOuttaThisMess]

Again, think of it from the perspective of the generic program director. Not enough students would ever utilize it. EMEDPA, this would be an area where I would actually be interested in getting a MS in PA studies following my lowly BS from decades past. Practicing rural EM while semi-retired, traveling around the country on someone else's dime.

[EMEDPA]

Again, think of it from the perspective of the generic program director. Not enough students would ever utilize it. EMEDPA, this would be an area where I would actually be interested in getting a MS in PA studies following my lowly BS from decades past. Practicing rural EM while semi-retired, traveling around the country on someone else's dime.

an em pa residency would be cheaper than a SECOND program...you would earn a (low) salary instead of paying a tuition.

I had a good em/trauma experience in pa school and was forunate to have several jobs with lots of cme over the years so have taken almost every 2 day "merit badge course" there is at least once. some were great(atls, abls, apls, difficult airway, also) and some I found totally worthless(BDLS, NRP).