12.26.2008

Learning a Craft, Revised

So I suppose to prove I'm not a total grinch I should mention that my favorite Christmas moment is a 3-way tie between watching my one-year old play with his toys before moving on to the next one, building a snow fort and then sheltering from the wind with my middle daughter on Christmas Eve, and playing chess with my oldest daughter for the first time.

But the post is about learning the craft of intubation. Everyone talks about the art of medicine, but the craft is just as important--and, if you look at how we learn procedures, it sure mirrors an apprenticeship. We start off watching, then do it under close supervision for years.

The skill of intubation is by far the most important of all EM procedures. It saves lives and no one else does them like we do; anesthesia has far more repetition but under ideal circumstances (no eating cookies or you wait another six hours for your surgery). This post is about learning the craft with a record of my first attempts, for what it's worth.

I'm in the OR this month learning the craft. Here's a list of my first attempts. DL stands for direct laryngoscopy, which is the way it's done almost all the time. ASA scores range from 1 to 5, with 1 being healthy, 2 being stable minor problems, 3 major problems but controlled, 4 major with threat to life, and 5 not expected to live for 24 hours. By definition all airways in the ED should be 4 or 5. All attempts are first pass only; if I missed, someone else took over.

1st attempt DL: miss, ASA 2, no predicted airway difficulty. Didn't position patient properly.

2nd attempt DL: success, ASA 3, no predicted difficulty.

3rd attempt DL: success, ASA 3, no predicted difficuly. At this point I feel pretty good about myself.

4th attempt DL: miss, ASA 1, great view, couldn't pass tube, no predicted difficulty.

5th attempt DL: miss, grade 4 view, had to change blades, no predicted difficulty. Now not feeling so good.

6th attempt DL: success, ASA 2, no predicted difficulty.

7th attempt DL: miss, no predicted difficulty.

8th attempt DL: success, no predicted difficulty.

9th attempt DL: success, no predicted difficulty.

10th attempt DL: success, no predicted difficulty.

1st attempt glidescope: success, predicted difficult airway secondary to morbid obesity, poor jaw opening, short neck length.

11th attempt DL: success, no predicted difficulty.

12th attempt DL: success, no predicted difficulty.

Tally: 13 attempts, 1 difficult; 4 misses, 9 successes. Rate: 69.3%. An experienced operator in the ED should hit more than 98 or 99% of attempts, but I don't have numbers for first pass success; I think I'd be higher if I had to get the airway and there were no one to back me up. It's a difficult skill.

This is the new world of accountability; you really want to know what your doc knows and can do? There it is. Best I can say is I'm improving, right?

About attempt 8, my body started to know what to do, and I've been successful since. You can describe the procedure in words and it doesn't help--you have to do it. It DOES help to know what you're trying to do so you can, in retrospect, figure out what you did wrong. But in the true sense of a craft, the only way to truly learn it is to do it over and over again.

Before I intubated, there was a sequence to memorize: apart from preparation (which is arguably most important) the motor skill itself involves positioning the head in a 'sniffing' position, scissoring open the lower jaw, placing the laryngoscope just off the midline to the right and slowly advancing down the tongue, sweeping to the left. As I do this I verbalize what I see for the supervisor to know whether I'm lost or found; posterior pharynx with uvula, epiglottis, then, after the blade is placed above the epiglottis and it pulls on the hyoepiglottic ligament, I should see arytenoid cartilage, posterior, and anterior vocal cords. Once in the correct area the laryngoscope, hand, wrist, and elbow are raised 45 degrees towards the feet as a unit without torquing the scope to move the tongue and jaw out of the way of the view. If I'm lost, it comes out as I verbalize; perhaps I only see soft tissue, perhaps I can see epiglottis but not cords. If I can't see at least the posterior portion of the cords, my chance of successfully passing the tube drops to below 1 in 2.

Now that I've done it, even as I type this, I have visual memories for each step and it is much easier to remember. We must read about procedures before we do them but initially it is a memorized scaffold for knowledge; then, the first time the task is performed correctly, there is a sense of recognition as you realize what it feels like to raise the epiglottis. The above paragraph is long and unwieldy; the motion itself, for even a relative novice on an easy airway, is a fluid progression at best, so I'm trying with a thousand words to describe a motion that is best described by doing it.

Language is a poor substitute for the experience but it's a necessary starting point and the best we have to try and get someone ready for 'the show'.

The same is true of confirmation; to carefully watch the tube pass between the cords is the best way and you can look after placement. Before it was memorized; now, when I've passed the tube and that tube stands in the way of hypoxia and death for the patient, looking for fog in the tube, chest rise, CO2 return, listening for breath sounds on both sides--all are almost reflex already.

Now for the long years of solidifying and refining the skill; working with more and more difficult airways, worse situations, even cementing the initial knowledge.

How this is learned is an ethical question these days--is it OK to learn on patients? After these few weeks, I would ask, how can I not? If I were to be intubated, I would not want someone who had only learned on simulators. It's different. Simulators are great and they help make rote the preparation, the scaffold of knowledge I was speaking of above that is required for analysis and learning of the skill. But there's no substitute for actually doing it live.

3 comments:

medicine girl said...

"About attempt 8, my body started to know what to do, and I've been successful since"

Thanks for bringing encouragement & inspiration to those of us who will follow in your steps!

Recruit Hospital Executives said...

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PJ Geraghty said...

Got here from Whitecoat.

Intubation is one of my favorite skills. As paramedic trainees, we practiced on recently-pronounced-dead patients as well as in OR rotations. As you mention, repetition is the key. I also had a very good anesthesiologist for my OR rotations (thanks, Dr. Herrangozo, wherever you are) which made me much more confident. People are terrified of intubation, but I've taught many to do it.

After I (mostly) left EMS, however, they introduced now many more airway choices. Intubation is no longer the only way to secure an airway. There are many other choices for the short-term, until an anesthesiologist can get to the ED.